Report Ties Hawaii Youth Suicide Rate to HSTA Grab for HGEA Positions
by Andrew Walden
Hawaii has one of the nation’s highest youth suicide rates. The reasons why have been a mystery until now.
Stung by the HSTA’s defeat of their Hanabusa, Hawaii legislators are retaliating by exposing the DoE’s years-long failure to collect federal Medicaid reimbursements for special education services. In exposing the information, they also implicitly admit to covering this up for over a decade.
But at least the story is finally out. And, as usual, it begins with money and ‘positions’.
According to Rep Sylvia Luke, quoted in the Star-Advertiser, August 19, 2018, the DoE has been missing out on $50M to $100M annually for years. The DoE is budgeting $367M for SPED for FY2018. A list of annual Medicaid reimbursements to the DoE 2008 to 2018 shows none of them exceed $1M. Public school parents are not being given the reimbursement application form and DoE bureaucrats have slow-walked a revision of the form for years.
Why would the DoE leave so much money on the table? Here are three clues:
“…states can seek repayment for the cost of certain school-based services, such as hearing, speech and physical therapy, as long as the 1) services are deemed medically and educationally necessary, are 2) performed by a licensed provider and are 3) properly documented. The expenses are divided into two reimbursement categories: services and administration. The latter can include partial salaries….” (Star-Advertiser, August 19, 2018--numbering and emphasis added)
Hawaii’s very limited pool of state-employed ‘Licensed providers’ are represented by the HGEA, not HSTA and are mostly employed by the state DHS or DoH, not DoE. Others are employed in the private sector.
The HSTA-controlled DoE has passed on $1B in federal money in order to keep jobs in the HSTA and away from the HGEA. In doing so, they are endangering 1000s of mentally ill young K-12 students statewide.
The evidence is in a DoE report written by William Dikel MD, of the University of Minnesota. The 2006 report, “Program Evaluation: Hawaii Department of Education School-Based Behavioral Health Program,” is available online only because it was posted on Dr Dikel’s professional website in 2016.
Hawaii has a major shortage of mental health providers and the DoE’s self-centeredness is contributing to the lower pay scales which are keeping psychologists away from Hawaii. As Dr Dikel explains:
“Contracting out for School Based Behavioral Health (SBBH) activities creates a vicious cycle, as professionals who are hired by contracted programs are generally paid higher salaries than DOE-hired employees. Thus, DOE is indirectly paying higher salaries for the same service anyway, but is providing disincentives for professionals to work for DOE rather than for contracted programs, and increasing the likelihood that, for example, psychologists will leave DOE for better paying jobs once they have their necessary supervision requirement hours met.”
Dr Dikel’s report was apparently written with the idea that the DOE was going to begin billing Medicaid for direct treatment reimbursement. But 12 years later it still hasn’t happened. Why? The akamai reader can see how the necessary steps in Dr Dikel’s report would negatively impact HSTA/DoE employment in favor of private sector and/or HGEA employment in DoH or DHS.
Here are a few quotes:
In the last few years (before 2006), most of the outpatient services funds and personnel were transferred from the Department of Health (DOH) to DOE….
Accompanying the transfer of outpatient services to DOE was the conceptual reframing of the nature of these services. There was a perception that the medical model had disadvantages, being diagnosis-based….
DOE has attempted to address the dichotomy of the educational model vs. the medical model by defining SBBH services as educational/behavioral interventions for students with behavioral difficulties, rather than clinical/treatment interventions for students who have disorders. In fact, this approach is the norm in school districts across the U.S. The difference in Hawaii is that SBBH, by taking over outpatient mental health services from DOH, has the added responsibility of clarifying what happened to these mental health services now that they are under DOE’s purview….
SBBH is in the midst of identity confusion, and this situation has significant potential for legal and financial liability, as well as potential for “Felix, Part 2”, if it is not effectively addressed….
…the situation has gone to such an extreme in Hawaii that “the cart is driving the horse”; i.e., services won’t be provided unless they are on an Individualized Education Program (IEP), resulting in services that would be very unusual on IEPS (e.g., foster care) to be listed as either related services or supplemental services. I would encourage DOE to obtain legal counsel on this issue from the Attorney General’s office or, if necessary, from a more specialized school-law attorney….
1) Services deemed medically necessary?
…the major psychiatric disorders (ADHD, Depression, Bipolar Disorder, Schizophrenia, Panic Disorder, Obsessive Compulsive Disorder, etc.). … are essentially medical/biological disorders, and are often minimally responsive to behavioral interventions….
…if a student has a psychiatric disorder that would respond to treatment, it is problematic to have a model whereby behavioral interventions must fail before a referral for a diagnostic evaluation is requested. I recognize that early referrals may occur for more severely disturbed students, but it is my understanding that, in general, referrals for diagnosis and treatment generally only occur after school-based behavioral interventions are unsuccessful. Ideally, there would be a method of screening and triage, separating individuals who require diagnosis and treatment early on in the process. It is inappropriate to assign clinical services to the more severe cases, and behavioral services to the less severe ones, because some of the less severe situations are at risk of becoming more severe without clinical interventions. (This model is equivalent to providing a humidifier to a patient with mild tuberculosis, and antibiotics to a patient who has severe T.B.)…..
The model of IEP-driven services, and of services that focus solely on students who are having problems in the classroom can lead to significant liability claims of negligence. One behavioral specialist described a situation where a student reported having auditory hallucinations to her. However, because the student was not having problems in the classroom, no referral for an evaluation was made. I would note that Paranoid Schizophrenia is a psychiatric disorder that carries a significant risk of harming others, and is a disorder that can manifest with auditory hallucinations and, at times, minimal or no obvious problems at work or at school….
2) Performed by a licensed provider?
Ideally, a school-based approach has the following components … The school system partners with other systems (Public Health, Social Services, Juvenile Corrections, community physicians, community mental health providers, health plans, etc.), and each system takes responsibility for their share of addressing students’ and their families’ mental health needs….
…since few of SBBH interventions at this time are diagnosis-based (Medicaid requires a diagnosis for reimbursement for direct services), and since few of the SBBH providers are qualified to bill Medicaid, that the amount yielded in reimbursement for direct services may be helpful, but not as high as expected….
At this time, funding is not sought from non MedQuest third party payers for services provided by contracted providers…. Even IDEA-based services could theoretically be billed to a third party, with the parent’s permission…. I am not familiar with the relationship between DOE and families who have military insurance coverage, but this would be an example of potential billing, if it is not already taking place….
If a DOE staff refers a Special Education student for a mental health evaluation and/or treatment, the District is the payer of last resort for those services. This may not be the case if the referral is made by a professional working for another system (e.g. a County public health nurse).
DOE-provided services results in a disincentive for the development of a community mental health infrastructure, resulting in DOE services, by default, becoming the major provider of children’s mental health services in the state.
If a decision is made that SBBH staff will only provide educational interventions, then it will be necessary to create an infrastructure of expanded outpatient services, and a method of paying for those services beyond the funding already allocated to the SBBH program. In my opinion, this might be able to be done with funds gained through billing of indirect/administrative Medicaid. Otherwise, it would be necessary to reduce SBBH staff….
…students are rarely referred for mental health diagnostic evaluations until they already are receiving special education services….
Behavioral specialists even raised concerns about potentially unethical practices- including lack of qualifications to work with severely mentally ill students and lack of adequate clinical training and supervision to assure that appropriate behavioral and clinical decisions are made.
Need for clarification of roles re: behavioral vs. clinical interventions. Many behavioral specialists believe that they are providing therapy, despite DOE assertions that they are providing behavioral interventions. For example, the issue of cognitive-behavioral therapy provided by behavioral specialists had arisen. This is clearly a mental health therapeutic service….
There is a need for more consistent and unified levels of supervision. If a school principal is the supervisor of a behavior specialist, then there may be problems with the specialist carrying out activities in a manner consistent with programming in other areas. This can lead to lack of clear role definitions, potential diluting of roles, and potential legal liabilities.
3) Properly Documented?
There is a lack of confidentiality of very private information, as all records regarding a student’s mental health issues are ultimately school records. These records are private, not confidential; parents have access to information that might be withheld, for clinical reasons, by an independent mental health professional. Parents also have concerns about private family and student information being recorded in school district files….
Behavioral specialists describe the bind that they are in regarding documentation of mental health issues that are addressed in their interventions. Some note that they are reluctant to document the content of their sessions with students, as all information ultimately goes into school records. Some of the information discussed by students is very sensitive, reflecting very personal thoughts, feelings and behaviors, or describes potentially sensitive issues affecting family members. If the student were seen in therapy by an outside professional, these records would be confidential, and only could be available to the school with an appropriate release of information. Also, school records do not have the degree of confidentiality present in clinic records; thus all confidential issues discussed with behavioral specialists and documented in school records are available for parental review as well. School records also may follow the student to other districts if the student moves out of town or out of state, and this could be potentially embarrassing or could have other adverse consequences. As a result, some behavioral specialists write minimal notes describing their interventions with students. One behavioral specialist described a student who was seen in weekly sessions who was presenting with significant depressive symptoms. When asked what was being documented about the student’s self-report and about the content of the sessions, either in school records or in the behavioral specialist’s private notes, the response was that almost nothing was documented.
Behavioral Specialists, by their own report, are seeing students who have potential risks of harming themselves and/or others, or risks of clinical deterioration from disorders if they are not effectively treated. The lack of adequate records that define issues such as changes in clinical symptoms, potential for danger to self and/or others, etc. creates significant liability for DOE. Also, the lack of documentation makes it very difficult to establish the nature of interventions, the students’ responses to those interventions, and the ultimate outcome of the interventions. It also makes transition to another professional difficult, as the new treating professional does not have adequate documentation to clarify the nature and types of interventions that have already been used.
Thus SBBH staff are in a very difficult position in regard to documentation. Being district staff, they face a dilemma of either protecting confidentiality or being potentially negligent in their duties to document.
Harm to Students
SBBH staff who have inadequate training to address the needs of severely psychiatrically disturbed students may not intervene appropriately when clinical symptoms dictate certain clinical responses.
Behavioral Specialists described an alarming frequency of significantly dangerous behaviors exhibited by a number of students, including suicide attempts that were nearly fatal. If there were problems in service provision (lack of documentation, lack of definition of role of the Behavior Specialist, provision of behavioral interventions when clinical interventions were necessary, lack of referral for psychiatric treatment despite evidence of a potentially fatal psychiatric disorder, etc.), the district would be in significant legal and financial liability. If the district remains self-insured, without malpractice coverage, a multi-million dollar lawsuit would be highly problematic.
The IEP-driven model does not address the mental health needs of students who have psychiatric disorders, but whose disorders are not affecting their educational progress. This could include students, for example, who have eating disorders, moderate depression or obsessive compulsive disorder. Girls who have inattentive ADHD also frequently go unidentified in school settings. This is not to say that the educational system should be responsible for treatment of these children and adolescents, but, by default, DOE has become the major mental outpatient mental health provider in the state. An infrastructure will need to be developed for these non-IEP non-504 children and adolescents to receive services….
SBBH staff uniformly reported that, for the high school students who they serve, approximately 75% had drug and/or alcohol abuse problems. This is of great concern, especially since SBBH staff are not providing focused drug treatment for these students, and because many of these students are receiving no services other than SBBH services. DOH will accept referrals of students who have drug and/or alcohol abuse if they also have a co-morbid psychiatric diagnosis. There are some programs that provide chemical dependency treatment, but it is my understanding that there is a significant relapse rate when students finish the program and return to school environments where drug use is the norm. To date, there are no “sober schools” or “sober classrooms” in the Hawaii educational system….