Fighting to make sure New York’s community-based mental health providers have the resources they need

Recently, the Legislature and Gov. Kathy Hochul enacted a mandate in the newest state budget saying that mental health and addiction service providers statewide must be reimbursed by private health plans at rates at least on par with Medicaid reimbursements. The mandate was the culmination of a decade-long fight for the mandate on the part of the New York State Council for Community Behavioral Healthcare, an advocacy group for community mental health and substance treatment providers statewide, who've long said that the paltry reimbursement on private plans forces them to turn away needy patients. 

The mandate, say the providers, will help expand care and treatment for countless New Yorkers experiencing opioid addiction – particularly in New York City, which reported an all-time-high for overdose deaths in 2022. And according to the council, the mandate is also good news for the one in three residents of New York state facing a mental health issue.

New York Nonprofit Media spoke on May 23 with Albany-based Lauri Cole, executive director of the half-century-old , about the long pathway to victory on the mandate, the other things that the council does, and the personal experiences that drive her work.

Thanks for talking to us today. Can you start by saying what you'd tell me about the council if we were seated next to each other at a dinner party and I asked what it was?

Sure. The NYSCCBH, which we just call "the council," is a 50-plus-year-old membership organization that is composed of both mental health and substance abuse prevention, treatment and recover providers, including harm reduction. These are community-based agencies in all areas of the state. The council started as an informal advisory group working with the New York State Office of Mental Health to help them achieve the expansion of community mental health centers,  based on legislation from the 1960s. But over time they wanted to make it more formal, so it incorporated and became what you would now think of as a trade organization, even though we don't call ourselves one. When I took the job 21 years ago, we had only 28 members across the state, but right now, we have 150, largely because we've achieved the types of outcomes that providers need to do their jobs.

Such as?

I do some education and advocacy at the federal and local levels, but primarily I represent providers' needs to Albany. I interface with regulators and oversight agencies, like the Office of Mental Health and the Office of Addiction Services and Supports. We do a lot of business with the New York State Department of Health and Department of Financial Services.

So you basically represent community-based nonprofits that run mainly on public funding?

Correct. They're 99% nonprofit charitable organizations that have state permission to offer a broad array of programs and services designed to assist New Yorkers in achieving their recovery goals. They're funded primarily through the state's Medicaid program, or through contacts with the state or counties in cases where the provider is offering services that are not Medicaid-reimbursable.  Two of the big providers in New York City, for example, are the Jewish Board of Family and Children's Services and Services for the Underserved.

Can you explain the win you just had regarding reimbursement from private plans?

The services that our member agencies offer are overseen by the Office of Mental Health and the Office of (Addiction Services and Supports) and paid out to providers as reimbursement through Medicaid as well as through commercial health plans. Several years ago, the state set a minimum rate on reimbursement of services for Medicaid beneficiaries. But it didn't also set a minimum rate for patients with private plans, who make up about 20 to 25% of people who use the public mental health system in the state. That's a lot of people whose providers were receiving about only half of the reimbursement received via Medicaid plans. So if someone went into a clinic on Long Island as a Medicaid beneficiary, the likelihood that they'll be served is far higher than for someone with commercial insurance. 

So we've been long arguing that those New Yorkers deserve the same access to care as those with Medicaid. 

What did your efforts that finally came to fruition look like?

We've been at it ever since the state set a minimum rate for Medicaid but not private plans, escalating our advocacy to point out the grossly inadequate rate of reimbursement on private plans. I've testified at many hearings over the years. But the state's Department of Financial Services said that this had to go to the Legislature, so we spent a lot of time educating lawmakers on this disparity and what it means on the ground for people in their districts. And it was ironic because, across healthcare in New York City, usually it's the Medicaid reimbursement rate that is lousy and the private plan rates that are decent. Mental health and substance use is the only area where it's the reverse. 

We had real allies in Assembly Health chair Richard Gottfried and Senate Health chair Kemp Hannon [both now retired from the Legislature]. It wasn't a hard lift to explain the situation to them, to show that this disparity was creating waiting lists, especially with all the publicity about the lethal overdose rate. It finally sunk in for state leaders that the mental health system was overwhelmed – and that, without decent reimbursement rates across the board, providers can't hire the workforce they need, leading to tremendous shortages. 

So the upshot of the mandate is?

On January 1, 2025, as contracts are renewed between health plans and purchasers, the state will let private health plans know that they must pay the Medicaid minimum rate that is established on April 1 of each year. This means that providers will happily be in a more stable and viable position to go back and contract with private plans whose reimbursement rates were previously too low for them to contract with. Which hopefully means that care recipients will not have to go from clinic to clinic looking for a provider that can afford to serve them.

With that matter resolved, what are a few other ongoing priorities for the council?

We're co-leading an ongoing campaign seeking reform of the Medicaid audit process. The Office of the Medicaid Inspector General has a responsibility to root out Medicaid fraud, which we completely support, but over time, as the Medicaid program in New York state has grown, the office has come to penalize providers for technical minor mistakes. Like if one signature is missing, the Medicaid Inspector General will assume that the same mistake was made across an entire field of records. That can add up to a very expensive penalty for a minor mistake. I know of a hospital in New York City that made a minor mistake that should've been penalized at just $400 but which was blown up to a fine of over $1 million, and the program had to close.

So the last few years, we've been coordinating a campaign of more than 50 healthcare associations, seeking legislation that injects fairness and balance into the audit process. The most recent bill was introduced this year. Two years ago, a bill passed both the Assembly and the Senate, but Hochul vetoed it.

Can you talk about the opioid crisis a bit and how it relates to your work?

The situation of every New Yorkers struggling with an addiction is unique, so providers offer a broad range of services, from traditional counseling combined with attending outside groups to harm reduction options for those who aren't ready for recovery. But what the state has invested in fighting this crisis is a pittance. So we're calling for a far quicker pace to the RFP [request for proposals] process that puts new funding and programming on the ground, including harm reduction options, which currently are funded far below traditional treatment options. Every time the state's Opioid Settlement Fund Advisory Board has tried to push more money to harm reduction the past few years, such as making [the overdose reversal inhalant] Narcan more available, the governor and the legislature have rejected it. 

My fear is that, at this point, the opioid problem is seen now, rather than as an emergency, as more of an ongoing crisis that to some extent we've accepted. I myself have lost two immediate family members to overdoses. The reality is that, 20 years ago, the drugs on the street did not cause immediate death [because they did not contain fentanyl, as they often do now]. So the idea of letting people hit rock bottom first [before they are offered help], or waiting for people to have a sentinel moment – those types of traditional interventions are really failing us now because of the lethality of today's drugs. There needs to be an absolute swarming of resources statewide, and access to on-demand care.

Okay, thanks for that. So what is a typical workday like for you?

I'm the executive director of an organization with a staff of 2.5 but with 150 members – so the day is busy. I'm sitting in front of my computer by 7:30 a.m. As an organization, we pride ourselves on having the most accurate, timely and detailed information available for our members statewide, so we provide them a lot of education and context, political and otherwise, often as soon as what happened overnight. They'll hear from me almost every day. Twice a week I run a morning meeting for them. One meeting is on public policy. The other is on billing. We've learned that the people working the back offices of our member agencies, the billing coders and reimbursement specialists, need a lot of assistance in seeking reimbursement and dealing with managed care. There's a long tradition from both Medicaid managed care as well as commercial plans of failure to pay providers on time or in full. Those back-office workers really are the unsung heroes.

Then I'll personally return calls from providers seeking assistance. I'll call various state offices to try to fix a problem for them. If the legislature is in session, I may go downtown to talk with lawmakers.

I also write a lot on the job, explaining the political environment to our members or analyzing regulations and guidance. 

Do you take breaks?

I'll go for a walk or do an errand when I can in the middle of the day. I usually stop working around six, do some form of mild exercise and walk the dog. Sometimes I'll go swimming. Maybe I'll get a bite to eat with a friend. I also read a lot. 

What do you read?

Politics. I'll read The New York Times and the local paper. Sometimes I'll turn my brain off and watch reality TV, like Vanderpump Rules.

How did you get into this work?

I went to SUNY Albany and majored in psychology. My first job out of school was with the rape crisis center in Rensselaer County. My job was to intervene in emergency rooms and accompany my clients through the judicial system. After doing that for three years, I ran a homeless shelter for two years, during which I decided to get my Master of Social Work, which took a while because I was working part-time the entire time. After school, I worked for 11 years for the Association for Community Living, which represented housing providers within mental health services. I liked it. It was incredible to represent providers who needed more of a voice, more power. And I've been representing providers ever since.

What do you like most about your current job?

I've become a political animal, which not every social worker does. I learned that not only can you make change at the micro level, one on one, but also at the macro level, via changes to policy that hopefully improve care.

What's the most challenging part of the job?

I'm not an incrementalist by nature. I have a lot of idealism and I think that everything should move much faster than it does. But I've learned that you have to persevere, and be willing to accept small changes. With the fight for the reimbursement mandate, we just kept going. It was our top priority for several years.

What is a top skill of yours?

I was not a very skilled writer early in my career, but I had a mentor or two who brought me along and now I feel very capable and our members tell me that my writing is clear and  concise and that it simplifies complex topics.

What is something you struggle with?

I mentioned that I had two overdose losses in my family, so when I talk about the issue in public, I tend to get anxious. But it's not debilitating. I can be a very passionate speaker.

I would think that bringing in the passion of your personal experience could be an asset.

Yes – I'm told that it is. It takes a lot out of me because I’m revisiting trauma, but I know I’m not the only one who’s suffered these losses.