This February, Alabama Psychiatric Services (APA) announced that it would permanently close its doors across the state, shutting 11 offices that served 28, 000 patients.
A press release blamed the sudden closure on a decrease in funding by Blue Cross and Blue Shield of Alabama.
“This is the most dramatic change I’ve seen in my 20-plus year career, ” says AltaPointe Health Systems CEO Tuerk Schlesinger.
APS’s 300 employees provided a number of client services, including treatment for depression, eating disorders, drug dependency and more.
The fallout between APS and Blue Cross is mainly over a switch from capitated pay to fee-for-service reimbursement for mental health care providers. In the past, health care professionals were paid a specified amount each month for each patient, whether or not the patient sought care. “Without the guaranteed money up front, doctors lost money, ” says Dr. Bruce Atkins, president and CEO of Psychiatric Corporation of Alabama PC.
Atkins believes that managed care companies and health maintenance organizations micromanage mental health care to an extreme. “I don’t blame Blue Cross for the problems we’re facing, ” he says. “Middleman organizations have gotten in the way of providing adequate health care. They can determine who can be seen and when. Some patients can only see a doctor a set number of times.”
Blue Cross and Blue Shield of Alabama has taken measures to help former APS clients find new providers, but acknowledges that things are in flux. “The many changes brought on by the Affordable Care Act, mental health parity laws, and the ever-increasing demand for higher quality health care at lower costs have affected health care providers and insurers, ” says Koko Mackin, vice president, corporate communications and community relations for BCBSA.
By March, many former APS patients had been referred to new providers, including Greyson & Associates, Southern Behavioral Health and AltaPointe’s BayView Professional Associates.
“We began receiving calls to our CarePointe call center and crisis line almost immediately after the public announcement of APS’s closure, ” says Carol Mann, director of public relations at AltaPointe.
While private practices will absorb some of APS’ disbanded staff, other professionals may not feel any incentive to stay in state. “After the closure of APS, assumptions were made that professionals would go into private practice, ” says Schlesinger. “While some will stay in state and join those private practices, others will just move away.”
Schlesinger blames low compensation rates for the lack of mental health professionals across the state. “We would have more mental health professionals in Alabama if we had adequate reimbursement, ” he says. “If professionals aren’t staying in state, it’s because the rates are not competitive. Pay is too low to attract doctors.”
Dr. Sandra Parker, vice chair of the University of South Alabama College of Medicine Department of Psychiatry, attributes the state’s low reimbursement rates in part to a
devalued perception of psychiatric health. “There is no commitment to parity when it comes to behavioral health care, ” she says.
Mental health professionals stand to earn far less than physicians in other fields. “For a new patient visit of high complexity, psychiatrists are paid $101 by Blue Choice versus $154.73 by Medicare, and Medicare has traditionally been considered a low payer, ” says Parker. “Psychiatrists are therefore reimbursed at a much lower rate than other physicians, and this makes it difficult to make a living in private practice while also trying to pay off high medical student loans.”
Schlesinger warns that more professionals may reduce the scope of their practices or even leave Alabama altogether if pay rates don’t improve. “If reimbursement is not increased for the private and public sectors, the state will decline in its ability to care for mental patients, ” he says. “Providers will have to scale back services.”
The closing of APS is not the only mental health cutback that Alabama will see in 2015. Decatur’s state-run North Alabama Regional Hospital is expected to close by late June. This follows the closings of state-run Greil Memorial Psychiatric Hospital and Searcy Hospital in 2012. Bryce Hospital, Taylor Hardin Secure Medical Facility and Mary Starke Harper Geriatric Psychiatry Center remain, but all are located in the center of the state.
These closings reflect a larger issue, an overall dearth in mental health care in Alabama. “We really are short by 30 percent of the number of behavioral professionals we need, ” says Atkins. “The entire country is disproportionate. Bigger cities attract more professionals, but rural areas and much of the South don’t have enough to meet their needs.”
A recent study by Mental Health America ranked Alabama 49th out of 50 states for the accessibility of mental health care. Parker believes that stronger incentives may be necessary to attract professionals. “It has been historically very difficult to recruit psychiatrists to Alabama from other states, ” she says, “so one possible solution would be for the state to pay for an increased number of psychiatry residency slots in exchange for the residents committing to work in Alabama for a certain number of years after completing residency.”
Clinical therapy fares no better. A 2014 report by the American Psychological Association suggests that the distribution of psychologists across the U.S. does not evenly match the distribution of reported cases of mental illness. The South showed the lowest numbers of psychologists per cases of mental illness. There is a drought of licensed psychological professionals in a region that reported mental disorders in more than 17 percent of the population.
“There simply isn’t enough care for mental illness, ” says Jacqueline M. Feldman, professor emeritus of psychiatry in the Department of Psychiatry and Behavioral Neurobiology at University of Alabama at Birmingham. “Hospitals have become the default sources for behavioral care in many cases, and jails are a secondary source. Something should be done before it gets to that point for anyone. We need more specialists throughout Alabama.”
Low compensation may deter some medical students from pursuing mental health fields in the first place. “When you graduate with high debt, mental health isn’t always the most appealing choice, ” says Feldman.
The unique challenges presented by mental health professions may not seem worth the pay to some students. “It’s not a highly sought position, ” says Atkins. “You can’t do a blood test to diagnose these complicated conditions. It takes a very long time working with patients one-on-one.”
Feldman believes that mental health care has been hindered due to common negative misconceptions about the nature of mental illness and its treatment. “These mental conditions are biological, not any sort of choice, ” says Feldman. “The fact that mental care is funded at a lesser rate than other medical treatment shows a lack of understanding.”
The actual number of people living with a mental illness may be higher than reports claim, as public misconceptions can intimidate those who feel that something is wrong. “Some people don’t seek help because of the stigma attached to mental illness, ” says Feldman. “There’s an issue in how we cognitize it. That’s a barrier that we as a society need to work on.”
Thomas Little and Chad Riley are freelance contributors to Business Alabama. Little is based in Birmingham and Riley in Mobile.
text by Thomas Little • photos by Chad Riley