When government officials issued stay-at-home orders to limit the spread of the coronavirus, Community Care Alliance bought about 150 flip phones with unlimited minutes to hand out to their patients.
The organization, a healthcare nonprofit with several locations in Rhode Island, helps people with mental illnesses and addictions, many of whom are homeless or living in group homes. Because Community Care Alliance had to limit in-person therapy visits, it had to find a way to reach patients who don't own phones or have limited minutes on the devices they do own.
In some ways, providing care over the phone has worked well. Patients who have children don't have to arrange for childcare, and the clinics can set up calls for the same times they used to hold therapy sessions.
But Community Care Alliance can't hold group sessions anymore and has stopped a couple other programs in which patients would stay for the day or overnight. It has also seen a drop in the number of patients referred for substance abuse treatment.
All of these services used to be a major source of revenue. CEO Benedict Lessing estimates the organization, whose annual budget is $33 million, is losing about $150,000 a month.
Despite the financial troubles, Community Care Alliance has tried to adapt and says it doesn't see itself shuttering, because Rhode Island officials made it possible to get paid quickly for phone visits and because it has adjusted in other ways.
Its workers visit patients who need someone to make sure they're taking their medications. They provide rides to the grocery store, where a case worker can help with shopping from at least six feet away. They've brought people exposed to the coronavirus to testing sites.
"We have had to be very creative in making sure these folks stay as well as possible," said Mary Dwyer, the organization's senior vice president of community support and recovery services.
But many providers who treat addiction and mental illness, a specialty known collectively as "behavioral health," are in much worse financial shape, and not all can do appointments remotely.
An online survey conducted in early April of 880 behavioral health facilities found that 62.1% believe that they can survive financially for only three months or less under current conditions.
Already, 61.8% closed at least one program, and organizations have cancelled, rescheduled, or turned away 31% of patients since the pandemic started, according to the survey from ndp | analytics and the National Council for Behavioral Health.
"It's pretty clear that we are at a moment in time where we are worried about losing a significant number of mental health providers and group homes," said John Snook, executive director of the Treatment Advocacy Center, which advocates for treatment of people with severe mental illness.
Shortages of workers and funding have plagued US mental health and addiction services for decades. According to the National Institute of Mental Health, 7.5 million out of the of 11.2 million adults with serious mental illness received treatment in 2017.
People with serious conditions with nowhere to get care can become homeless and cycle through the criminal justice system, show reports from the Treatment Advocacy Center. Mental health advocates say the pandemic will make the behavioral health crisis even worse.
"We were already in crisis," said Paul Gionfriddo, president and CEO of Mental Health America. "We already had inadequate services for people with psychosis. Now it's worse."
Before the pandemic the US was already facing an opioid overdose crisis that killed 46,802 people in 2018. That same year, suicides climbed to 48,344.
Making matters more difficult now, advocates expect flare-ups in mental health issues and substance misuse in the general population related to the pandemic. They expect to see grief, trauma, anxiety, and depression following job losses, tens of thousands of deaths, and people being alone at home.
"We know that the advent of a new medical crisis unfortunately does not replace the ongoing mental health and substance abuse crisis our nation faces daily," Dr. Elinore McCance-Katz, who oversees the government's Substance Abuse and Mental Health Services Administration, or SAMHSA, said in a recent statement.
Even more people are expected to start seeking help. SAMHSA recently reported that calls to its hotline increased 891% from March 2019 to March 2020. A recent Gallup poll found more people say their mental health is suffering as a result of social distancing than say the same of their physical or financial health.
Despite the indications that more people need mental healthcare, demand for appointments appears to have gone down by about 30% because people aren't leaving their homes, Gionfriddo said.
"That's a tremendous shift that is hampering the ability of a lot of traditional behavioral health providers to keep the door open and stay in business," he said.
Mental health providers aren't the only caregivers struggling. Almost every part of the healthcare industry has taken a financial hit because of shut-down orders and higher expenses in parts of the US facing a surge in coronavirus cases.
Congress allocated $175 billion to healthcare providers through two different bailout packages. The money is supposed to go to medical providers across the board, regardless of specialty.
So far, behavioral health hasn't gotten a specific allocation from the Department of Health and Human Services, or HHS, which has authority over how to distribute the money, in the way that rural providers or coronavirus hot spots have. The agency hasn't yet announced plans for about $75 billion of the funding.
Healthcare providers who get a large share of revenues from Medicare received the fastest infusion of funds. But mental health providers were on the losing side of that formula because they tend to get a larger share of their services paid for by Medicaid, a government program that covers the poor, many children, and some people with disabilities.
Secretary Alex Azar, who oversees HHS, told reporters last week that a portion of the relief funding would be sent specifically to providers that only take Medicaid, but didn't specify how much.
Several advocacy groups told Business Insider in interviews that they aren't optimistic the federal government will allocate the $38.5 billion they think will be needed to rescue behavioral health providers. They calculated that figure based on forgone revenue as well as increased costs from providing patients with phones, paying out overtime to staff, conducting visits to patient homes, and paying more for protective equipment.
So far, federal rescue packages have only allocated $425 million for behavioral health, $250 million of which was set aside for clinics.
"We got 1% of what we needed," said Gionfriddo from Mental Health America. "That's still better than getting 0% of what you need, but it's not what you need."
Advocates have also brought attention to administrative changes such as allowing more people to get therapy over the phone.
Angela Kimball, national director for advocacy and public policy at the National Alliance on Mental Illness, said the federal government still hasn't made clear to states that Medicaid and other insurers should pay for mental health visits done over the phone, leaving lots of variation in terms of reimbursement rates, whether patients can call a provider out of state, or whether a visit is covered at all.
"This administration needs to remove each and every barrier to telehealth, because if we don't do that then we are not leveraging the current capacity that we've got," Kimball said.
Mental health and addiction specialists already have turned to phone and video appointments to help patients wherever they can, but the technology won't work well for every patient.
Paul Johnson, a counselor with a private practice in Bryan, Texas, has been seeing patients exclusively through phone and video chats since April 1. He provides therapy sessions for children and teenagers, getting referrals from pediatricians, juvenile services, and Child Protective Services.
Johnson won't use telemedicine to see patients he hasn't already met with in person, and in some cases the technology can't replace in-person visits. Patients referred to him through Child Protective Services, for example, don't always have a private place to talk. For others, age is an issue.
"Conversation with audio or video with a 3-year-old is going to last about two minutes if you're lucky," he said, explaining that therapy visits with young children are supposed to be more interactive.
His work with patients relies on watching body language, including small cues such as avoiding eye contact something that's hard to observe through video chats.
"It's kind of like doing therapy without all the tools that would be helpful to do my job," Johnson said.
About 70% of the patients Johnson sees are covered by Medicaid, and the rest are covered by private health insurance.
Texas officials recently announced Medicaid would pay for phone and video visits through the end of May, at the same price as an in-person visit. Until just a few days ago, officials had only announced they would cover telehealth through April. Johson said he's able to keep his practice afloat but admitted it worries him.
"It is nail biting at times," Johson said. "I'm set up at home and I'm surviving. I think there are people in the world that need it much more than I do. It's really a dicey thing. It seems to me that the small guy is going to kind of get overlooked."
If you're having trouble finding a behavioral healthcare provider that provides residential treatment, and are willing to share your story with Business Insider, you can contact senior healthcare reporter Kimberly Leonard at firstname.lastname@example.org.
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