New Law Impacts Day In The Life Of School Therapist
A little known law may have big consequences for schools, families and people struggling with their mental health although whether it will help ease the day in a life of school therapists like Peggy remains unclear. Peggy’s day (captured below) went sideways pretty quickly last week when a student interrupted her at 7am to tell her a classmate wanted to kill herself. These interruptions are more the rule than the exception in schools these days so if health insurers are to start paying for in-school therapy sessions as one law requires, designing the right approach will likely be difficult.
Starting in 2024, California will require its health insurers to pay for mental health services inside schools whereas today schools like the one we highlight below have to pay for this out their own budgets. This has been increasingly difficult given the cost to recruit and the effects of social media on students, effects from the pandemic and difficulty hiring counselors away from their more lucrative “cash paying” panels.
But this law may be the beginning of a solution - an early footprint. Health insurers after all have experience with adapting to policy mandates, social change and national behavioral health crisis. Nearly every state, for example, now requires insurers to pay for services for children on the autism spectrum. More insurers are also adapting to new ways to deliver mental health therapy. Some will pay for swimming and painting if it’s “therapy” and a few, like the Blue Cross Blue Shield insurer in Texas, pay for up to 11 horseback riding sessions for certain low-income children. Insurers pay for all sorts of things in all sorts of places – hospitals, homes, the outback and the back of the office – and while they have rules for what they’ll pay and how often, there is an ever-evolving undercurrent of health insurers finding ways to pay for things we need to get better.
But up until now and with very limited exceptions they do not really pay for therapists to handle behavioral health care inside schools. There’s a potential blueprint now with California’s law. The law (California law, AB 133) directs the state to develop a statewide minimum fee schedule for “school-linked” outpatient mental health or substance use disorder treatment services for students age 25 or younger. Each health plan regulated by the state, including Medicaid plans, will be required to reimburse providers of school-linked behavioral health services at least the minimum amount, regardless of whether the provider has a contract with the plan. The reimbursement will come from payers based on their terms of coverage.
But the question will be how this plays out nationally and what parameters will come with it. “I think this has a lot of potential but there will be lot of challenges around implementing it - figuring out how to price it since I know it’s not as clean as 1 hour sessions,” says retired school counselor Sandra Mensner.
Health insurers tell us they would want to put controls in place to ensure there isn’t duplication in services that becomes counterproductive and may just add cost, such as an in-school therapist giving therapeutic advice to a teenager at noon, the student’s psychiatrist giving another set of conflicting instructions at 5pm that same day and neither talking to the pediatrician. “I’d worry about overpaying, duplication, differences in treatment or advice but also the importance and challenge of collaboration,” a national payer said. “There’s a cost to that that I’m not sure we’d want to be taking on - even if forced. I think figuring out how to pay and manage could be very difficult, but I’m open to it …. and may not have choice.”
In our recent poll of stakeholders, there’s support for school based therapy, just no consensus on how to pay for it:
Poll of 568 readers of The Behavioral Hour, May 2023
Personally, I’m not arguing for change one way or another but I am a part-time gym teacher for much of the school year in Hartford where I see the value of mental health care and the challenges facing family, teachers and the kids. Take it from the lens of another middle school with basically 1 full time master’s trained mental health therapist for 675 students.
Day In The Life
On a recent Wednesday, the therapist, Peggy, showed me her schedule from the day earlier and her “log” of how they day unfolded. I’m sharing it here as a bit of window inside school mental health, circa 2023:
Morning
7-7:30: Begins to draft email letter to parent but interrupted to meet with student and parent about the student recently telling other students she wanted to kill herself
7:40-7:45: Meets with principal to discuss that meeting
7:45-8: Calls DCF on a former student situation
8:00: Sits down to write the email letter to the parent
8:05: Called down to classroom to help with fight between two students, met with one student who has had anger outbursts - her mom was jailed and dad left the week before
9:00: Sits down again to write the letter, called down to meet with teacher and student about student crying due to kids making fun of her weight
9:25: Heads out to hospital where one student was overnight due to unknown psychiatric episode at home
11:15: Returns to school for meeting with staff – agenda turns into discussion about how to motivate kids with anxiety
11:55: Returns to desk to take phone call with parent about a student’s recent switch to higher Zoloft dose and how it’s impacting homework ability
Afternoon
12:25: Begins again to write letter to the parent but interrupted by two students who come in and say that they heard a 7th grader talk about being raped. After 2 hours of meetings and calls and discussions with staff and parents and other students, a call is placed to the police
1:46: Talks with pediatrician about a student exhibiting depression and anxiety who is complaining of “feeling very fatigued” due to stresses and pressures, and suggests to the doctor to consider possibility of Lyme disease
2:58: Eats a snack at desk and sits with a student who is complaining about feeling anxious with her classmates
3:30: Holds a separate meeting with a transfer student who is scared to go on the bus but is afraid to walk home – Peggy determines the student has a phobia due to an incident with her step dad several years ago. “Have you ever told anyone about this,” she asks. “No. Not til today.”
4:45: After helping make temporary arrangements for the student, Peggy opens up her laptop to finally type that letter….
“Dear Mr. and Mrs. Collins – I know it’s been a difficult year for you and your family navigating your daughter’s return to school. You are not alone in having a child with anxiety and I am so happy she is starting to do well and for all your support and patience. I also wanted to be the first to formally let you know that your daughter has been accepted into college on a scholarship. I know it has been a long road for her and you but you persevered and she did as well and you should be awfully proud. I know we are. I will be available to her and you throughout her transition to the college. I’m also happy to speak to the college counselor to help make her first months there a success.”
Evening
6:15: Peggy goes for walk around her block with her 8 year-old and their puppy Roger, then is happy her husband has cooked chicken and broccoli with that creamy sauce she loves
8:06: Peggy falls asleep (or so she’s told the next morning)
Stay tuned for the next edition in our series on schools and mental health policy. To weigh with suggestions or comments, click here.