This article was supported by a grant from the Fund for Investigative Journalism.
By Taylor Knopf
Decades ago, North Carolina legislators sought to change the way mental health care is delivered. They closed psychiatric hospitals arguing that patients would be better treated in the community, in less restrictive settings.
Mental health experts agreed that the deinstitutionalization of mental health — a movement taking place across the country in the early 2000s — was a good idea. But in North Carolina, state lawmakers never fully followed through with the money for it. This left the state with an inadequate supply of both inpatient beds and community care options.
Twenty years later, North Carolina is reaping the results of that chronic underfunding. Over time, the number of people showing up at emergency departments has swelled into a deluge of patients in mental health distress, leaving hospital emergency rooms increasingly unable to care for the crush of patients.
In the wake of the pandemic —with more people than ever experiencing mental health issues — the state’s mental health system is buckling under the weight.
Read the first part of this story: New mental health data show ‘unsustainable’ burden on NC hospitals
There’s been a cycle of funding in North Carolina where the dollars first flowed to psychiatric hospitals and then to more outpatient mental health services. Now, as ERs flood with patients, the funding pendulum is swinging back toward the creation of inpatient beds with hospitals scrambling to build psychiatric treatment facilities all over the state.
The reality is that there will always be a need for both inpatient and outpatient options, mental health leaders say. The solution to North Carolina’s mental health woes would be fully funding both.
Mental health, hospital and state leaders agree that a well-balanced system would include an array of services: from readily available therapy appointments to community wellness centers to intensive outpatient treatment centers to psychiatric hospitals and everything in between.
These same experts say that to help turn the tide of the current mental health crisis North Carolinians need affordable access to readily available mental health services so they don’t have to resort to the emergency room.
For that to happen, a cascade of changes need to take place: patients need health insurance, services need to be paid for, and insurance companies must be made to pay for those services at the same rates they pay other health services.
Meanwhile, to retain mental health providers and entice more practitioners to the field, they must be fairly compensated for their work.
More services earlier
For example, someone with symptoms of depression may progress from withdrawing from family, friends, and work to engaging in self-harming behaviors to thinking about suicide to making a plan for ending their life. A person with a psychotic disorder may go from experiencing an occasional visual hallucination to a delusion to a full-blown psychotic episode. These episodes can lead to the actual loss of some cognitive function, whether it’s memory, processing speed or concentration.
“What we see is that when individuals have serious psychosis, or more aggressive, serious mental illness situations, is that each progressive crisis moment, drives them downward,” said North Carolina Department of Health and Human Services Sec. Kody Kinsley during his cabinet seat confirmation hearing in June. “And getting them back to a higher level of stability is incredibly hard.”
It’s also very expensive. The average cost of a hospital stay in North Carolina is $2,528 per day, according to 2020 data collected by the Kaiser Family Foundation.
“This truly is where an ounce of prevention is really worth a pound of cure,” Kinsley said.
Programs that provide comprehensive interventions earlier — meaning more than simply providing medications — have been shown to keep people out of psychiatric hospitals while setting them up for lives where they’re able to be productive and participate in their communities.
The North Carolina Healthcare Association, which advocates on behalf of the state’s hospitals, included “expanded access to community-based behavioral health services, with an emphasis on early intervention and treatment” as one of its top three legislative requests for mental health this year. The association is asking state lawmakers to allocate federal funds from the American Rescue Plan to do so.
But the barriers to treatment are many. They can include hours spent on the phone to find a local provider who takes a specific insurance plan who is also accepting new patients. If someone is lucky enough to land an appointment, health officials have said available appointments are often several weeks or months away.
Not only do patients need better access, but there needs to be more collaborative care, such as mental health screenings embedded in primary care offices, said Samantha Meltzer-Brody, chair of psychiatry at the University of North Carolina – Chapel Hill school of medicine and director of the UNC Center for Women’s Mood Disorders.
“If you can’t easily get into an initial outpatient psychiatric evaluation, or the reimbursement is not there, or you’re having to pay out of pocket, those are barriers,” Meltzer-Brody said.
Last year, 27 percent of mental health patients discharged from a hospital emergency department in North Carolina were uninsured, according to the NC Healthcare Association. Those people often end up in a hospital emergency room because, according to federal law, the ER is the one place that cannot refuse someone care, regardless of their insurance coverage.
Health officials have said one way to address the lack of insurance is by expanding North Carolina’s Medicaid program to the hundreds of thousands of low-income workers who currently make too much money to qualify for Medicaid but don’t earn enough to qualify for subsidies to buy an insurance plan on the Affordable Care Act marketplace. North Carolina is one of only 12 states in the U.S. that has declined to embrace expansion.
When state lawmakers asked Kinsley during his confirmation hearing what his priorities were for improving the state’s mental health system, he gave a familiar refrain: “Number one, expand Medicaid.”
“[Mental health] funding, expansion of Medicaid,… those are political issues that shouldn’t be,” said Wayne Sparks, medical director of Charlotte-based Atrium Health Behavioral Health Services. “We’re trying to take care of people and all of those things could be helpful.”
After many years of refusing to consider Medicaid expansion, both NC House and Senate leaders have said they’re finally willing to entertain the idea, but have different ideas on how to do it.
Even when someone has insurance, it can be challenging to find a mental health provider who takes a particular coverage plan or to get treatment covered. Federal law mandates that mental health services must be covered by public and private payers at parity, meaning in the same way all other health treatments are covered.
But this doesn’t always happen.
“We have to work with commercial and state payers to do the right thing, to reimburse — at least at parity — which will enable other health care systems to invest,” said UNC’s Meltzer-Brody. “So that’s another part of the equation is that reimbursement has been so poor, and it is a disincentive for health care systems to adequately invest.”
The NC Healthcare Association this year also made greater state and federal enforcement of parity laws one of its legislative priorities. Insurers must be required “to cover behavioral health services on par as other covered health benefits, including robust provider networks and equitable reimbursement formulas for cash-strapped providers,” the association wrote in a legislative brief.
Part of building a strong mental health system is having qualified, competent workers. Health care staffing across the nation took a hit during the pandemic, with burned-out workers quitting in droves. Better reimbursement rates for mental health providers could incentivize more professionals to enter the field, industry leaders say.
“We have been paying for mental health services in this state, mostly with short-term dollars, Scotch tape and paper clips, for a very, very long time,” Kinsley said during a July town hall in Greensboro on mental health. “We’re going to put our money where our mouth is to try to continue to do that and work to kind of build and grow that workforce further.”
Even private insurance plans often pay as little as 80 percent of what Medicare — a government program — pays to mental health providers.
“If mental health was reimbursed at a higher rate, I think you’d see a lot more people wanting to be part of that solution,” said Paula Bird, vice president of behavioral health services for Novant Health, the Winston-Salem-based hospital network. “We need to make mental health not be sort of a secondary type of service. Really, you can’t have any health without mental health.”
The mental health workforce was already stretched thin before the pandemic even started, particularly in rural areas. There are 38 counties in North Carolina with fewer than one full-time psychiatrist, according to the UNC Sheps Center health workforce database.
There’s a host of other mental health workforce roles to fill as well, from peer support specialists to psychiatric advanced practice nurses.
“Another thing that I think would help is the modernization of the Nurse Practice Act,” said Bird, a nurse. “We talked about those millions of North Carolinians that don’t have access to a healthcare professional. Oftentimes, that’s in the rural areas and nurse practitioners can really help.”
For many years, a bipartisan group of lawmakers have introduced the SAVE Act bill which would allow advanced practice nurses, including psychiatric nurses, to operate with more autonomy from physicians. That bill has never advanced to vote on the floor of the state House of Representatives.
Though the mental health crisis is daunting, it’s caught the attention of lawmakers on both sides of the aisle which leaves some hopeful.
“Most people know someone in their family or social network who has a child struggling with mental health issues,” Meltzer-Brody said. “So I see this as what I’m calling a tipping point. We have this crisis and we have a real opportunity to change the trajectory in a really positive direction.”
In the state senate, Sen. Jim Burgin (R-Angier) has emerged as a leader on this issue for the Republican majority that controls the General Assembly. He’s spent several years participating in mental health forums and town halls around the state. At these events, he almost always shares a different example of a constituent with a family member who experienced a mental health crisis and struggled to get the care they needed.
“We all agree that mental health is a big deal, and it is one of the one of the reasons I even ran for the Senate,” Burgin said during July’s event in Greensboro. “I have always been concerned about what we’re doing in mental health and how we’re taking care of folks.”
Last year, a bipartisan group of lawmakers introduced a package of bills to support alternative mental health crisis interventions. These included non-police crisis response units and more peer support organizations run by people who have a mental illness or have experienced homelessness or incarceration. Though the bills didn’t move during the most recent legislative work session, lawmakers on both sides of the aisle said they would try again in the future.