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Nearly one in five children in the United States has a mental, emotional, or behavioral disorder, according to the Centers for Disease Control and Prevention. That suggests some 80,000 children and adolescents in Bexar County have mental health issues.
Clarity Child Guidance Center in San Antonio is the only nonprofit mental health treatment center in South Texas specializing in services for children ages 3 to 17 who are experiencing behavioral and emotional difficulties. In 2017, Clarity CGC served more than 8,000 children, of which 3,000 required hospitalization.
Fred Hines has served as CEO of Clarity CGC for the last 20 years, overseeing a $25 million annual budget while working to expand the organization’s service capacity and reduce stigma surrounding mental health treatment through community and provider education. On Thursday, he announced he will be retiring at the end of the year.
Hines sat down with the Rivard Report recently to discuss how access to mental health treatment has changed over the last 20 years, what is working, what is not, and what needs to change to increase access and improve care for those who need it most.
Rivard Report: Has there been much progress in improving access to mental health treatment over the last 20 years?
Fred Hines: Access to mental health treatment has become more complicated over time. Mental health has been severely underfunded forever – certainly for as long as I’ve been at Clarity GCG. One of the biggest barriers to access for people who need it the most is greed – a lot of the world’s problems revolve around greed and whether companies and shareholders are making a profit.
As health care gets more and more expensive, there is a limit to the funds out there, whether it be through traditional insurance, Medicaid, Medicare, and charities. When a child is hospitalized, first we have to call the insurance company (if they are insured), present the case that a patient needs care, and have a physician prove that there is medical necessity to continue care. The insurance company then plugs this information into a computer with an algorithm that says whether a patient needs to stay at the hospital. We fight those on a daily basis – computers deciding whether someone needs to stay in the hospital or not.
On average, the length of an acute care stay is about five days, with the average cost at about $1,000 a day per patient. We spend that time figuring out what is wrong with someone, stabilizing medication, and formulating a plan, but the length of stay is so short that we often see people coming back on a readmission.
When I first started here there was one person working in the billing department and one person working with people as they discharge to make sure they have a continuation of care plan. We now have a more than 12-person team of people completing case reviews for insurance companies, billing, and organizing financials, and in the end, we might get paid out half of what it cost us after 20 pages of paperwork.
RR: It seems like more and more young people are experiencing mental health crises that require treatment; does it seem like children today have more mental health issues than generations past, comparatively?
FH: It seems like a combination of things. For one, we hear more about it. When there is an issue or emergency involving a mental health crisis, the response is instantaneous; a bad situation will be all over TV, social media, and as a result we hear about it more and kids are under more stress. At the same time, there is a shortage of physicians, psychiatrists, and healthcare providers who are able to help those with mental health concerns. When you look at physician projections for the future it looks the same – there are not enough to treat those who need help.
RR: How has the stigma surrounding mental health diagnoses and treatment changed since you have worked in the field?
FH: It feels like the last 15 years I have been working in mental health have been spent fighting stigma, and still one in five children need help, but only one in 20 get help of any kind. It’s a sad situation. People are afraid to admit that they or their child has some type of psychological illness or health issue, and parents are afraid that their children will be stigmatized for the rest of their life if they get treatment since it will be on a medical record.
On that same token, it seems that in the last five years, people have been opening up to treatment more; the problem is that they wait a long time to get care. When kids come in to Clarity CGC they are typically in a drastic situation, severely depressed, and often suicidal. People understand the need for treatment better, but they are still not accessing services quickly. This delay in seeking treatment may be just as much a financial barrier as it is a lack of information.
RR: What needs to take place to improve mental health treatment and access for future generations?
FH: Health care – both access and treatment – is better when it’s not for profit. If I had to guess where things are going, I think we are going to move to a type of single-payer system. There is only so much money to go around. How are we going to deal with all of these significant issues going on without resolving the conversation of profit?
A lot of European countries seem to be doing health care better than we are; costwise, it’s not as high, and the cost of drugs are regulated differently. If other places can do it, why can’t the United States?
As it stands, Clarity CGC has at times operated at a loss, and over time it will become more and more difficult for healthcare nonprofits to continue covering these costs. Even with 80 percent of revenue coming from Medicaid, when a child gets approved for only five days of treatment, they often come back as a readmission soon after; five days is not enough time to learn how to change your behavior.
Medicaid and Medicare penalize hospitals for readmissions, so we are getting less money back than we spend, even in these cases, because a readmission can cost you up to 4 percent of your funding. We have learned to deal with it, but there might be a time when we can’t do that simply because there isn’t enough money.