Kids are getting stuck in Minnesota’s mental health care pipeline. Lawmakers are weighing a fix

By Dana Ferguson, Minnesota Public Radio News

Jade Miles and David Sabotta took a pause between therapy sessions on a recent Wednesday morning to decompress in Miles’ softly lit office.

Both have full caseloads counseling kids in their community. They, along with their colleagues, see as many people as they can but acknowledge they don’t have enough counselors to meet the need in the region.

Like many community mental health providers, Fernbrook Family Center, where they work, has to turn some families down or put them on a wait list when they call.

“There are times across our agency where we stop taking names for the wait list, because if it’s going to be six months or a year or question mark, you know, it feels cruel to keep people on this indefinite wait list,” Sabotta, a clinical training specialist at Fernbrook, said. “Those are really the hardest phone calls I’ve ever had to make here.”

Across the state, an increasing number of children are being held in Minnesota hospitals and – in some cases — detention facilities as they await mental health care in their communities. Without a step-down service they need, some children get stuck for days or weeks. It’s known as boarding.

It’s an issue that families, providers and lawmakers hope to address this year at the Minnesota Legislature. But with a rapidly approaching deadline, it’s not clear that they’ll reach an accord in time.

A rate mismatch

For years, mental health advocates have pressed the state for more resources to build out the state’s mental health infrastructure. This year they hope that a proposal to gradually increase rates for Medical Assistance — Minnesota’s version of Medicaid — to align them with Medicare could offer some relief.

Medical Assistance reimbursements are around 70 percent on the dollar compared to Medicare reimbursement rates and about 30 percent on the dollar when compared to what’s covered by commercial insurance plans.

A quarter of Minnesota’s population is on Medical Assistance. Among Fernbrook’s patient population, it’s higher, close to 50 percent, Sabotta said. Those low Medicaid reimbursement rates make it tough to balance a budget, he said.

“The rates that we use for reimbursement are fixed. You know, if I ran a burger joint and the price of a burger goes up, I could charge more for the burger,” Sabotta said.

“Costs are going up across the board. We cannot increase the cost of therapy,” he continued. Those rates are set by the state and by the government, and they’ve not been adjusted in like, 12 or 14 years.”

Sabotta said the lower funding rates make it tough to attract and maintain providers. They might be able to find higher salaries in other lines of work, he said, and might not experience burnout from an emotionally grueling job.

As community and residential treatment centers scale down or close their doors, hospitals that provide acute and emergency mental health care are having a harder time creating a discharge plan for children.

“It’s really hard when we’re telling families like, ‘Okay, this is the program you need. This is what your child needs. But there is a five-week wait list,’” said Jessica Brisbois, the manager of acute mental health services at Children’s Minnesota.

Without the step-down service they need, Brisbois said some children get stuck. Last year, Children’s reported more than 1,200 instances of children boarding in the hospital, and roughly 77 percent of those patients are on Medical Assistance.

The impact of being stuck can exacerbate kids’ mental health conditions, she said.

“We’re pulling them out of school, we’re pulling them out of their day to day life,” Brisbois said. “And so for a kid to just be repeatedly hospitalized because they’re not getting the appropriate level of care, or they’re not receiving the help that they need is really, really hard on families and the kid as well.”

Jennifer Gustafson, clinical supervisor at the Dakota County Juvenile Service Center, said several children and adolescents are boarding in the facility because step-down treatment programs won’t take kids who’ve acted out. She said one child will surpass the one-year mark there.

“I think it’s been important to me to give voice to the fact that there are children in the state of Minnesota who are suffering from significant mental illness that are boarding in a jail,” Gustafson said. “No one that I’ve talked to thinks that’s a good thing.”

Stuck on how to help

At the Capitol, late-in-session debates could determine whether additional funding measures pass this year. The goal is a solution that allows community-based centers to hire more mental health providers and keep the ones they have.

Minnesota lawmakers are mulling proposals to do that but have different ideas about who should foot the bill. Both chambers have a provision in their health bills that would boost Medical Assistance rates to bring them in line with Medicare rates if the federal government signs off. But a separate bill is needed to explicitly adjust rates for mental health services.

A Senate proposal would impose a new assessment on health insurance plans to bring Medical Assistance rates for mental health services in line with Medicare rates over two years. A report from the Department of Human Services recommends bringing the rates up to increase mental health staffing and reduce instances of patient boarding. The federal government would then provide 99 percent in match funds that could then be returned to the health plans.

“We know that our system has reached a breaking point. Too many children and families are waiting weeks, months, or in some cases, years, to access the care they need,” Sen. Melissa Wiklund, DFL-Bloomington, said during a committee hearing earlier this year. Wiklund is sponsoring the bill. “We can fix this by increasing reimbursement rates while simplifying payment structures.”

Lucas Nesse, president and CEO of Minnesota Council of Health Plans, said the organization is supportive of efforts to increase funding for mental health services. But he said placing an assessment on insurance plans could force them to pass on the cost to consumers.

“No one’s arguing that health insurance is, you know, extremely affordable already,” Nesse said. “So we’re very protective of trying to make sure that health insurance continues to be as affordable as possible.”

Republicans have a similar view. They’re concerned about putting more costs on insurance providers. They’ve suggested turning to existing state health funds to make up the difference.

The House considered the fee bill but ultimately didn’t include it in its health budget proposal. Rep. Dave Baker, R-Willmar, signed on as a co-author. He said funding is important but some in his caucus are worried about taking steps that could increase costs for Minnesotans.

“Anything we put on whether it’s a tax on health care plans, whether it’s more increases, if we’re increasing the cost of health care, that is a really big reason to be concerned about this bill,” Baker said. “This is not an easy bill to pass.”

House Health Committee Co-Chair Robert Bierman, DFL-Apple Valley, said he would keep fighting for the Senate language as lawmakers move into a conference committee. There they will iron out differences between the proposals and adopt a negotiated package.

“That’s still a work in progress. It’s not out of the picture,” Bierman said. “And we’re looking forward to getting that one in, because if we have both, that’s going to be the full package.”

In a narrowly split Legislature, a final bill could come together soon. But time is running short to fashion an agreeable solution to a complex problem — and do it by May 19th, when lawmakers must adjourn.

Providers said the reimbursement rate increase could help them drop second or third jobs they have and pay off student loans.

“We have a passion for this work. We want to help people,” Miles, a licensed professional clinical counselor at Fernbrook Family Center in Rochester, said. “And we also have to live at the end of the day.”