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In this section, data are summarized from three distinct and potentially overlapping sources to help to define the size and scope of the ambulatory mental health system in New York State.
As is often the case with different data sets, the data do not always "cross-walk" between the sets. We have reviewed areas of difference and are confident that, taken together, they help to provide a comprehensive picture of the State’s mental health system.
Total 2004 Spending on Public Mental Health Services is more than $5.5 Billion
It is important to understand how the ambulatory system fits within the total public mental health system in NYS. In 2004, total spending for non State operated adult and child mental health services was more than $3.9 billion (Table 1). [50]
| 2004 Hospital and Community Mental Health Expenditures | ||||||
|---|---|---|---|---|---|---|
| Service | Private Psychiatric | Residential TX Facilities | Article 28 Hospitals | OMH Non-Article 28 CFR Filers | Family Care | Total |
| Emergency | $187 | $23 | $210 | |||
| Inpatient | $180 | $86 | $1,429 | $1,695 | ||
| Outpatient | $5 | $515 | $550 | $1,070 | ||
| Support | $32 | $430 | $462 | |||
| Residential | $15 | $447 | $23 | $485 | ||
| Total | $185 | $86 | $2,178 | $1,450 | $23 | $3,922 |
Table 1 – Mental Health Spending (millions)
In addition to the $3.9 billion in hospital and community services summarized above, spending for State operated services in 2004 totaled an additional $1.64 billion. State operated services are primarily inpatient ($1.2 billion), but also include emergency, outpatient, support, residential and research services (see Table 2).[51]� These services are principally funded from $1.25 billion in State general funds and $406 million in Medicaid funding (for individuals under 21 and over 65 years of age).� Thus, all told, 2004 spending in New York�s mental health system totaled $5.564 billion.
| 2004 State Operated Service Expenditures (Research Spending has been allocated to Program Costs) |
|
|---|---|
| Service | $ |
| Emergency | $24,438,837 |
| Inpatient | $1,196,936,343 |
| Outpatient | $200,240,887 |
| Support | $139,674,275 |
| Residential | $80,952,406 |
| Total | $1,642,242,747 |
Table 2 – Spending (millions)[52]
Adult Ambulatory Mental Health Program Spending Totals Almost $1.4 Billion
Adult ambulatory services include $651 million in clinic spending and $724 million (Figure 1) in non clinic expenditures according to 2007 CFR data.[53]� Thus non clinic ambulatory expenditures are slightly more than 13 percent of the total system expenditures.[54] These services include virtually all of the recovery oriented services that have been developed over the last two decades, including clubhouse, self help services, vocational supports, and ACT. They are described in Attachment B and C in greater detail.
Figure 1 – Statewide Ambulatory Non-Clinic CFR Data
| CFR Expenses by Category: Statewide | ||
|---|---|---|
| Emergency-Comp. Psychiatric Emergency Program | $61,475,009 | 8.5% |
| Emergency – Crisis | $36,512,007 | 5.0% |
| Total Emergency | $97,987,016 | 13.5% |
| Total Day Rehabilitation | $185,770,558 | 25.7% |
| Total ACT | $45,572,105 | 6.3% |
| Support – Care Coordination | $152,858,509 | 21.1% |
| Support – General Support | $67,985,623 | 9.4% |
| Support – Self-Help | $100,950,992 | 13.9% |
| Support – Vocational | $71,931,572 | 9.9% |
| Support – Other | $1,115,492 | 0.2% |
| Total Support | $394,842,188 | 54.5% |
| Total Expenses | $724,171,867 | 100.0% |
Funding from Medicaid provides more than 54 percent of financial support for non clinic, ambulatory services according to the CFR data. The balance is net deficit funding (32.7%) from State and local revenues, Medicare, and third party revenue (11.6% combined).
Adult Medicaid Funding Totals almost $1.8 Billion
Total Medicaid Spending for all adult mental health services in 2007 was almost $1.8 billion (shown in Figure 2). This total includes the following:
Thus, over 50 percent of adult Medicaid mental health spending supported hospital based inpatient, partial hospital and State operated services.
Figure 2 – 2007 Adult Medicaid Mental Health Spending
| Statewide Medicaid MH Adult Services Total | ||
|---|---|---|
| Services | Statewide Medicaid | % |
| Ambulatory | $348,944,245 | 19.9% |
| Residential | $168,761,937 | 9.6% |
| Hospital Inpatient | $669,128,784 | 38.1% |
| Partial Hospitalization | $6,379,884 | 0.4% |
| State Hospital | $90,165,465 | 5.1% |
| PMHP | $125,587,318 | 7.2% |
| Clinic | $347,133,425 | 19.8% |
| Total | $1,756,101,058 | 100.0% |
Of the 39 ambulatory non clinic services tracked through the CFR (see Attachment C), Medicaid pays for only 7 - CPEP, CDT, PROS, IPRT, ACT, Targeted Case Management (TCM) and Partial Hospital services[57]. However, Medicaid funding for these seven services equals 50 percent of the funding for all of the 39 services combined. PROS spending was not reported for 2007.
As shown in Table 3 below, Medicaid funding for CDT and TCM was approximately $160 million and $116M respectively. This is almost 78 percent of total non clinic Ambulatory Medicaid spending.
Large Variation in Per Person Cost Per Service:
Medicaid funding varies greatly on a per person per service basis.
Overall spending per consumer served for Medicaid ambulatory non clinic mental health services (Table 3) was $5,249.
2007 Medicaid Ambulatory Services
| Ambulatory Services | Statewide Claims | $ per Individual Served |
|---|---|---|
| ACT | $51,542,791 | $11,904 |
| CDT | $159,807,146 | $7,784 |
| CPEP | $8,295,211 | $622 |
| IPRT | $13,151,190 | $4,775 |
| TCM | $116,147,907 | $4,991 |
| Partial Hospitalization | $6,379,884 | $1,836 |
| Total Ambulatory Non-Clinic | $355,324,129 | $5,249 |
| Ambulatory Clinic | $347,133,425 | $2,010 |
Note: Medicaid CY 2007 Claims divided by unduplicated recipients served
Table 3 – 2007 Medicaid Ambulatory Services
Regional Variation in Service Patterns:
Patterns of spending vary by program type and region. Access to and utilization of Medicaid mental health care are also widely divergent throughout the State (see Attachment E). Overall adult Medicaid penetration rates[58] vary significantly by region; rates range from 9.5 percent to 17.6 percent. Medicaid recipients in Western New York have the highest penetration rate, almost double the rate of NYC and almost four percentage points higher than the next closest region, Central New York.
Western New York has a dramatically higher overall penetration rate (primarily due to clinic access rates), and relatively low per capita and per recipient costs (in comparison with other regions). New York City has low penetration, low overall per capita costs, the lowest ambulatory costs and highest inpatient hospital costs.
Variations in service access, cost and utilization are the result of historical distribution of State funding and the choices made by individual counties in budgeting, staffing and contracting for mental health services in New York. Ultimately, the factors that drive these differences need to be studied further. Most importantly, local planning must incorporate these data, developing strategies to reduce unwanted variation.