School-Based Mental Health Clinics Play a Critical Role in Addressing the Behavioral Health Needs of NYC Children
Testimony & Public Comments
April 17, 2024
On Wednesday, April 17, Associate Executive Director of Policy and Advocacy Alice Bufkin submitted testimony at an NYC Oversight Hearing on school-based health centers and school-based mental health clinics. On behalf of CCC, the testimony speaks on key considerations related to Article 31 school-based clinics and recommendations for improving their sustainability and enhancing access to their services.
Read the Testimony Below
Testimony of Alice Bufkin, Associate Executive Director of Policy and Advocacy
Citizens’ Committee for Children of New York
Submitted to New York City Council Committee on Health, Committee on Mental Health, Disabilities and Addiction, the Committee on Hospitals, and the Committee on Education
Oversight Hearing on School-Based Health Centers and School-Based Mental Health Clinics
April 17, 2024
Since 1944, Citizens’ Committee for Children of New York has served as an independent, multi-issue child advocacy organization. CCC does not accept or receive public resources, provide direct services, or represent a sector or workforce; our priority is improving outcomes for children and families through civic engagement, research, and advocacy. We document the facts, engage and mobilize New Yorkers, and advocate for solutions to ensure that every New York child is healthy, housed, educated, and safe.
Thank you Chair Schulman, Chair Lee, Chair Joseph, Chair Narcisse and all the members of the Committee on Health, the Committee on Mental Health, Disabilities and Addiction, the Committee on Hospitals, and the Committee on Education for holding today’s hearing.
In 2013, Citizens’ Committee for Children published a report entitled, A Prescription for Expanding School-Based Mental Health Services in New York City Public Elementary Schools, informed by local school principals and clinicians. Though more than a decade old, many of the challenges and recommendations identified in the report are still relevant today. In particular, the report draws attention to the critical role Article 31 school-based mental health clinics play in supporting students’ behavioral health; the administrative and funding challenges that make it difficult to open and operate these clinics; and opportunities for the city to bolster the ability of these clinics to stay open and provide high-quality services.
Below, we offer an overview of key considerations related to Article 31 school-based clinics, and recommendations for improving their sustainability and enhancing access to their services.
The Value of School-Based Mental Health Clinics
Throughout New York, families are sitting on waitlists for weeks, months, and even years for behavioral health services their children urgently need today. These challenges are borne out in New York City, where.15.6 percent of adolescents report seriously considering suicide and 36 percent of high schoolers report persistent feelings of sadness and hopelessness.i In February 2021, youth advocates launched a Voicing Our Futures survey that collected responses from more than 1,300 young people across New York City. More than a third said they wanted or needed mental health services from a professional, but only 42 percent who needed services reported receiving them.ii
As a result of a lack of adequate care, children are cycling in and out of emergency rooms and hospitals. In 2019 32% of young people discharged from a psychiatric stay at a general hospital in New York City ended up back in an emergency room within 90 days; 22% end up back in an inpatient bed. Parents are left desperately searching for services that just aren’t there.iii
Article 31 School-Based Mental Health Clinics (SBMHCs) play a critical role in addressing the behavioral needs of children in our city. SBMHCs operate under the auspices of independent, licensed not-for-profit health care institutions (e.g. voluntary community-based providers or local hospitals). These sponsoring agencies contract with participating schools to provide services through satellite clinics located on school grounds. Sponsoring agencies are responsible for staffing these clinics with medical and/or mental health professionals, as required, and for developing the clinics’ billing infrastructure. In return, school principals are responsible for providing a safe and secure space, in accordance with State regulations, to administer services to students.
An Article 31 SBMHC is a comprehensive model of mental health care delivery in a school setting, with on-site mental health clinicians providing a wide array of services. These clinics offer students and families assessments and evaluations; individual, group and family therapy sessions; service coordination; case management; and crisis intervention. Aside from offering standard assessment and treatment services, school-based mental health clinics also focus on the following prevention services:
- Classroom observation;
- Participation in school-based committee or interdisciplinary team meetings;
- Consultation with school staff (e.g. principals and teachers) regarding the social, emotional, and behavioral needs of children;
- Trainings to school staff on various mental health topics, including classroom management, bullying prevention and conflict resolution; and
- Parent outreach and workshops on various mental health topics, including parenting skills, conflict resolution, bullying prevention and domestic violence.
SBMHCs have the benefit of being available to students outside of school hours, including after school and during the summer, as well as for weekend crisis support in many instances. Clinicians are also available for emergency risk assessments for students who express suicidal ideation, homicidal ideation, or self-harm, and are often able to reduce the need for hospitalization or 911 involvement because they are able to respond immediately on-site.
Given the depth of mental health needs facing New York’s young people, it is urgent that the city identify ways to enhance access to services in school-based mental health clinics.
Financial Barriers to Operating a School-Based Mental Health Clinic
SBMHCs are primarily funded by a reimbursement model by which they claim payment from a mix of third party payers, including Medicaid managed care, Child Health Plus, and commercial (or private) insurers. Medicaid is the single largest third party payer for services in school-based settings.
Unfortunately, SBMHC are only able to recoup a fraction of the total cost of care from third party payers, even after all efforts to maximize claims have been exhausted. This is a result of two main factors: 1) Current reimbursement rates remain too low and do not match the cost of care, and 2) Many of the vital populations SBMHC serve, and the services they offer, are not reimbursable, and therefore clinics take a financial loss whenever they provide this care. Key non-reimbursable scenarios include the following:
- Services provided to a student who does not have any form of health coverage. A clinic is obligated to see a student presenting for a service, even if that clinic is not recognized as a participating provider in their health plan or if the student is Yet these services will not be reimbursed if the student does not have health coverage. This challenge may disproportionately impact clinics serving large immigrant populations, who are less likely to have health coverage in New York, even if they are eligible.
- Services provided to a student who does not have a Without a diagnosis, the clinic cannot bill Medicaid or any other third party insurer. Yet many students who need mental health supports do not have a diagnosis, nor should having a diagnosis be a requirement for receiving services.
- Services not deemed billable. Many of the most essential supportive services SBMHC clinics can offer are not technically reimbursable. These include services such workshops/trainings for school staff, consultation with teachers regarding children who lack parental consent to be treated, crisis services for children who are not already admitted to the clinic, case management, referrals and parent outreach. For instance, if a clinician were to spend several hours helping de-escalate an emotional crisis with a student and prevent school staff from calling EMS or the NYPD, that would not be
As a result of these financial limitations, SBMHCs cannot remain operational if they do not find funding sources to supplement their reimbursement. Some clinics rely on philanthropic dollars to make up the difference between reimbursement and costs. Other SBMHCs survive because they are partnered with another school-based program, such as a Community School or a Prevention and Intervention Program (PIP). These programs have their own independent funding, and may be able to route some of this funding to help sustain their on-site clinic.
However, many schools with SBMHCs do not have philanthropic resources, or may not be part of a Community School or other program with independent funding. And even those with these resources may find them insufficient. As a result of insufficient funding, providers report clinic closures every year.
Recommendations
- Provide wraparound city funding to all existing school-based mental health clinics to help finance preventive and essential administrative services that are not billable. Medicaid does not cover services to children without a diagnosis, and clinics are not reimbursed for services provided to children without health coverage. Other essential supports that clinics can offer schools – such as workshops/trainings for school staff, consultation with teachers regarding children who lack parental consent to be treated, crisis services for children who are not already admitted to the clinic, case management, referrals and parent outreach – are not Collectively, these reimbursement limitations have placed an enormous strain on the ability of clinics to remain solvent.This is where the City can step in. Wraparound funding for existing clinics – specifically $75,000 per clinic – will enable clinics to offer a more comprehensive and inclusive array of services, including for uninsured children and children without a diagnosis, as well as trainings and support for school staff and the school population more broadly. It will, in short, help ensure the financial stability and effectiveness of these important community clinics.
We recommend that the City begin with the 50 SBMHCs that have the fewest financial resources to make up for insufficient reimbursement. The City should consider identifying legacy clinics – those that never received state startup funding and are not partnered with a school program such as Community Schools – as a potential priority for additional funding. Ultimately, we recommend a long-term goal of expanding funding to all SBMHCs in the city.
- Protect and Expand Community Schools. SBMHCs are frequently partnered with Community Schools, as the holistic nature of Community Schools and the clinical care of SBMHCs provides a comprehensive support system to meet students’ behavioral health needs. Community Schools have been shown to lead to improved student attendance, academic achievement, family engagement, improved child physical and mental health outcomes, and increased community iv They are also crucial to helping many SBMHCs remain financially viable. Unfortunately, funding for Community Schools is threatened in the City Budget year after year. This year, Community Schools are facing significant budget reductions both from city budget cuts and one-year funding, as well as from the anticipated loss of federal COVID-19 relief funding. We therefore urge City leaders to protect funding in the FY25 Budget for Community Schools, including $55 million in expiring federal funding, $8 million in November PEGs, and $14 million in one-time city funds.
Moving forward, we urge City leaders to maintain and expand Community Schools funding. This will not only help strengthen the sustainability of SBMHCs located at Community Schools, but will increase the number of students able to access the essential wraparound supports offered through the Community Schools model.
- Advocate with State leaders to enhance Medicaid behavioral health outpatient reimbursement rates. The primary hurdle facing school-based mental health clinics is the same hurdle facing all children’s outpatient behavioral health providers: a deeply insufficient workforce driven largely by inadequate Medicaid reimbursement Inadequate rates statewide have led to high vacancy rates and turnover, and ultimately to children and families waiting months or even years to find services.Though Medicaid reimbursement decisions are made at the state level, City leaders have an important role advocating with state elected and agency leaders to reform Medicaid rates. We urge the City Council and Administration to uplift the challenges providers face in finding staff, and the crisis of waitlists confronting families as a result.
At the State level, CCC is working closely through the Healthy Minds, Healthy Kids Campaign to advance a series of rate reforms to the children’s behavioral health outpatient system. These reforms would transform the children’s outpatient system, helping address the waitlist crisis confronting families in New York City and across the state. We hope City leaders will help support and uplift these recommendations with State leaders, as they will result in improved rates of reimbursement necessary to attract and retain the community-based outpatient behavioral health workforce needed to increase timely access to care for children and adolescents in New York City.v
- Work with state leaders and state agencies to ensure implementation of last year’s state mandate requiring commercial insurers to reimburse school-based mental health clinic services in the same rate as Medicaid. Historically, commercial insurance rates for children’s outpatient services have been significantly lower than Medicaid rates. In fact, commercial insurers pay on average half of what Medicaid pays in New York State for outpatient behavioral health This has contributed to the workforce capacity crisis, ultimately increasing the number of families on waitlists and children sent to emergency rooms and hospitals because their families cannot find or cannot afford providers who take their insurance. A recent report by the NYS Attorney General demonstrated that New York’s health insurance companies are failing to offer adequate mental health care, highlighting the central role inadequate reimbursement rates play in this failure.Last year’s state budget took an important step to combat this inequity by requiring commercial insurers to reimburse school-based mental health clinic services at at least the same rate as Medicaid. While this was a critical policy advance, it is clear that implementation is not currently occurring. SBMHC providers are overwhelmingly reporting that administrative and contracting barriers are preventing their sites from implementing and enforcing this change. We urge city leaders to partner with state elected and agency leaders to identify and immediately address the barriers preventing enactment of this crucial policy change.
- Enhance DOE reimbursement rates for Prevention and Intervention Program (PIP). PIP schools are a DOE-funded model that provides counseling, educational workshops, crisis management, and case management to students. Like Community Schools, they are often partnered with SBMHCs, and help support their sustainability. However, reimbursement for PIP services is inadequate, and has not been raised since 2017/2018. We urge DOE to raise PIP reimbursement rates to the same rate as Medicaid to help ensure the sustainability of both PIP models and SBMHCs that partner with them.
Thank you for your time and consideration.
