Racial Disparities in Specialty Mental Health Services Programs
By Stacey Wittorff and Gillian Sonnad
1. Introduction
Minority patients in need of mental health services face unique challenges in seeking such services. In 2001, a Supplement to the Surgeon General’s report was issued which focused directly on racial disparities in mental health treatment. The main findings of the study were first that, “minorities have less access to, and availability of, mental health services.” The study also found that “minorities are less likely to receive needed mental health services; minorities in treatment often receive a poorer quality of mental health care, and that minorities are underrepresented in mental health research.”[1] The study also points out that it is far easier to identify the disparities themselves than the reasons or causes for them.[2]
Legal Services of Northern California has identified such disparities in the County mental health program. The Yolo County Department of Alcohol, Drug, and Mental Health (“County”) administers the Medi-Cal Specialty Mental Health Services program (“Program”) in County. The Program provides eligible low-income persons with mental health services including assessment, therapy, and rehabilitation. The Program is designed to “reduce mental disability and improve and maintain Program beneficiary functioning consistent with the goals of learning, development, independent living, and enhanced self-sufficiency.”
We will examine here (1) how the Program was administered by the County, (2) how Program beneficiaries of color are underserved and are thus disparately impacted by the Program’s administration, and (3) possible causes of the identified disparities in services.
2. Background
In mid-2007, LSNC obtained information showing a gross disparity in the average dollar value of approved claims for Latinos and Whites, $1800 for each claim for Latinos and $4217 for each claim for Whites. This disparity is four times larger than the average statewide disparity.
Based on the documents provided to LSNC by the County regarding the claim approval and denial rates by race and ethnicity, LSNC determined that the disparities in Program claim approval and denial rates likely implicated institutional bias in the Program administration.
3. Program Administration
The unit within the County responsible for the authorization of Program services is the Access Coordination Team (“AC”). The County requires the AC exercise its discretion in approving or denying claims in accordance with the Medical Necessity Checklist tool (“Checklist”). The Checklist allows the AC to exercise substantial discretion in determining whether a given claim meets the required criteria. For instance, the Checklist requires the AC to determine, among other things, whether a treatment is focused to address the condition diagnosed by the client’s medical practitioner or a treatment will benefit the client by significantly diminishing the condition. If the AC determines that any of these conditions are not met, the AC must deny the treatment request.
However, the Checklist does not offer guidance on how the AC should apply the Checklist criteria to a given claim. Thus, the criteria may be applied in a subjective fashion. Additionally, the AC has knowledge of a client’s race and ethnicity when approving or denying a claim as a client must submit demographic information to be eligible for Program services
4. Disparities in Services Provided
The data LSNC reviewed suggested that the County administered the Program in a manner that had a disparate impact on Program beneficiaries of color. In particular, the available data suggested that (1) the dollar value of approved claims is substantially higher for Whites than Latinos and (2) the claim approval rates for Whites was substantially higher than the claim approval rate for various racial and ethnic minority groups. If this data is accurate, Program beneficiaries of color were receiving, as a group, substantially inferior mental health services.
a. Disparities in the Average Dollar Value of Approved Claims for Whites and Latinos
According to the Quality Review, there was a large disparity between the dollar amount of claims approved for Whites and Latinos.[3] In Yolo County, the average dollar amount of claims approved for Whites ($4,217) is more than two times the average dollar amount of claims approved for Latinos ($1,880). Statewide, the dollar amount of approved claims for Whites ($4,161) is only 16% more than the average dollar amount of claims approved for Latinos ($3,580).
b. Disparities in the Claim Approval Rate for White and Racial and Ethnic Minority Groups
According to the Quality Review, the County’s claim denial rate was more than twice that of the statewide averages. A sample of claim denial rates by beneficiary rates and ethnicity revealed significant disparities.
Based on the sample, claims of White beneficiaries were approved at a higher rate than claims of Latino, Black, and Filipino beneficiaries. Claims of White beneficiaries were approved at a rate of 98.72%.[4] Claims of Latino beneficiaries were approved at a rate of 96.77%.[5] Claims of Black beneficiaries were approved at a rate of 69.23%.[6] Claims of Filipino beneficiaries were approved at a rate of 66.67%.[7]
5. Possible Sources of the Disparities
Several factors could account for the disparities in the dollar value of approved claims and the Program’s claim approval rate. Possible causes could include the Program administrative processes, physician bias and cultural competency, as well as cultural stigma that different beneficiary populations attach to reporting mental health issues to physicians. The County is obligated to select service providers whose practices and training mitigate the detrimental impact of physician bias, poor physician cultural competency, and cultural stigma on the level and quality of care Program beneficiaries receive.
6. Strategies and Potential Remedies
LSNC engaged in dialogue and negotiations with the County on the issue of disparities in the specialty mental health services. We sent several letters which made extensive recommendations for the County to monitor the appropriate data and techniques to start addressing the disparities and hopefully reduce them.
LSNC also engaged in several attempts to determine if this disparity was directly reflected in the relevant client community. We multi-lingual targeted outreach and advised people of their rights and how to contact us if they were having trouble receiving mental health services.
7. Recommendations
In dealing with this particular case we were able to learn much about how these disparities can be formed and what programs can do to identify and start to remedy them. First and foremost, legal services agencies should find out what their local programs are doing, which includes getting the relevant data and looking through it carefully. If the program does not keep this type of data you should focus on advocacy efforts which will encourage and perhaps motivate them to start keeping such information. The data necessary to identify the disparities which often occur should be kept for multiple years and be easily accessible to Program staff and advocates. Advocates should also provide and promote cultural competency training for Program and Provider staff as this is one the biggest areas in which the disparities can be directly addressed. Finally, advocates should encourage their Programs to hire and retain diverse and multi-lingual staff.
[1] U.S. Department of Health and Human Services. (2001). Executive Summary of Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. SMA-01-3613. http://download.ncadi.samhsa.gov/ken/pdf/SMA-01-3613/exec_summ.pdf Last accessed May 21, 2010.
[2] Id.
[3] The Quality Review does not provide the average dollar amount of claims approved by race or ethnicity for groups other than White and Latino. The California Health and Human Services Agency Department of Mental Health (HHSMH) collects and makes publicly available statistical information about how counties administer Medi-Cal specialty mental health service programs. The most recent data available from HHSMH for County administered Medi-Cal specialty mental health services is for fiscal year 2002-2003. The average expenditure per non-SSA eligible client by race and ethnicity was: White $3,282.30, Hispanic $2744.26, African American $1,951.54, Asian/Pacific Islander $2,180.31, $2,285.73, Other/Unknown $1,717.00.
[4] 77 out of 78 claims submitted by White Program beneficiaries were approved.
[5] 30 out of 31 claims submitted by Latino Program beneficiaries were approved.
[6] 9 out of 13 claims submitted by Black Program beneficiaries were approved.
[7] 2 out of 3 claims submitted by Filipino Program beneficiaries were approved.
* Stacey Wittorff is a staff attorney at Legal Services of Northern California and works at the Health Rights Hotline. Gillian Sonnad is a staff attorney at Legal Services of Northern California and works at the Yolo County field office.