California’s behavioral health system is in trouble… still.

OPINION – When I was growing up, I was adamant I would never become a mental health professional. My Black, single mother worked tirelessly in private hospitals, her own private practice, and in community-based organizations for more than 30 years. From my perspective, her clients were the “worried well,” a term mental health professionals use to describe those who have the time and luxury to invest in sessions at a therapist’s office. I was not only wrong about this judgment, but I also ended up following in my mom’s footsteps, eventually becoming a psychologist.

Today, as I lead an association of members spanning almost every type of service provider and serving the full spectrum of age groups, I find myself pausing often to catch my breath. We’re treading water, waiting for the flood to happen, as I answer calls, text messages, and emails from agencies who are literally gasping for air. They are grappling with cancelled contracts, plans to shut down programs for foster youth, as well as older adults, and how they are using the last of their savings in the hopes the future is slightly brighter.

But the future isn’t looking any brighter. A 2022 report from the California Health Care Foundation found that the state has less than 12 licensed psychiatrists and slightly more than 44 licensed psychologists per 100,000 people. And, there are wide variations by region, with the Inland Empire and San Joaquin Valley hit the hardest.

How did we get here? California was already experiencing a workforce shortage, and the pandemic accelerated the trend. Those who had solid reserves before 2020 burnt through them to keep serving clients. Then, as those who survived rounded the corner, they were dealt another blow in payment reform — the state’s new project that is designed to change the way services are reimbursed. The idea of payment reform is not a bad one. The current process clearly isn’t working as it should as we continue to lose potential providers to other industries and therefore can’t keep up with demand, but it’s been fraught with challenges.

California has been struggling to close the provider gap for years; we have a massive workforce shortage, particularly in rural areas. Yet, there seems to be a lack of urgency to retain providers.

Typically, counties receive money from the state to provide behavioral health care to their residents. To provide the services, counties contract most of the work out to community-based organizations like the members my association represents. There is no consistency with this contracting process. Many agencies have sites in multiple counties and are contracted for vastly different rates, with no recourse available. Everything is handled via reimbursement, which is why so many agencies were not equipped when the pandemic hit. They just didn’t have enough in the bank to keep the doors open, which, unfortunately, shouldn’t come as a surprise.

However, the new payment system isn’t making anything easier. The rates for service provision are inadequate for the vast majority of organizations, and most counties are no longer reimbursing for travel time. More so, several counties still don’t have functional electronic health record systems, leaving agencies in a lurch and unable to submit timely billing claims. Some agencies are even tracking billing on Excel spreadsheets, an obsolete practice also rife with privacy concerns. Yet, the response I’ve heard time and time again is “there will be loss leaders… it’s going to be bumpy for the first year.” And most concerning, “tell your members to have better business models.”

This payment reform experiment is going badly. If one agency fails, others must step in and absorb their clients. California has been struggling to close the provider gap for years; we have a massive workforce shortage, particularly in rural areas. Yet, there seems to be a lack of urgency to retain providers. The assumptions about the ability to lose providers and keep going are dangerous and, most importantly, they negatively impact some of the highest need clients across the state.

I’m always up for a challenge and believe we must regularly revise and update systems to be more innovative and streamlined. However, we cannot let this change negatively impact the ability for agencies to address the significant behavioral health crisis on our hands. We must ensure that those who are expert at providing services are provided the support needed to actually save the safety net.

But, we need state policymakers to listen to our calls for help. If they don’t, California’s behavioral health crisis and workforce shortage will only get worse, with one continuing to exacerbate the other.

Le Ondra Clark Harvey, PhD, is a psychologist and the Chief Executive Officer of the California Council of Community Behavioral Health Agencies (CBHA).