Background: Mental health treatment facilities that offer services at no cost to clients or use a sliding-fee scale are an important safety net for individuals to access needed services. This report examines the availability of uncompensated care or services using a sliding-fee scale in mental health treatment facilities. Method: The 2010 National Mental Health Services Survey (N-MHSS) is a survey of all known mental health treatment facilities in the United States, both public and private. Data from the 2010 N-MHSS were analyzed to assess the extent to which mental health treatment facilities in the United States offered payment assistance to those who are in need of care but who cannot afford to pay for services. Because N-MHSS is a census-type survey and collects actual counts rather than estimates, statistical significance and confidence intervals are not applicable. Differences in the proportion of facilities offering payment assistance were assessed using Cohen’s h. The results described in the text have a Cohen's h effect size ≥ 0.20, which indicates that there are meaningful differences between the groups. Results: About 4 in 5 mental health treatment facilities surveyed in 2010 offered services at no charge or used a sliding-fee scale for patients/clients who could not afford to pay for services. These types of payment assistance were available across a variety of facility types, including psychiatric hospitals (76.6 percent), outpatient mental health centers (88.0 percent), and multisetting mental health facilities (86.2 percent) but were offered less frequently in residential treatment centers for adults (69.5 percent). In contrast, slightly more than one-third of residential treatment centers for children offered payment assistance (38.3 percent). Conclusion: Availability of affordable services will remain a critical part of the mental health care delivery system along with efforts to improve the coverage and affordability of mental health services.

Introduction

Approximately 1 in 5 U.S. adolescents experience mental disorders with severe impairment,¹ and 1 in 5 U.S. adults (excluding adolescents) had mild to severe symptoms of mental illness in the past year.² However, every year, many adolescents and adults with mental illness go untreated.^3,4 Recent data suggests that half of adults who felt the need for mental health treatment but did not receive it within that year reported not being able to afford treatment as a major reason for not receiving care.⁵ However, this data collection occurred before the implementation of the Affordable Care Act, so the number of adults who feel the need for treatment but do not receive it may be reduced in the future.

Mental health facilities that offer services at no charge or use a sliding-fee scale serve as a safety net for those individuals who need but cannot afford to pay for these services. Although the literature in this area is sparse, a few studies have examined the availability of free general health clinics and the organizational structure of these clinics. In general, free clinics were defined in the available studies as nonprofit entities that offer uninsured and underserved individuals access to reduced cost or free health care services.^6,7,8 One available survey of free general health clinics found that about one-third of these clinics also offered mental health treatment.⁸ However, mental health services may be provided not just in free general health clinics, but also by specialty mental health facilities. Studies that focus on the national availability of mental health facilities that provide mental health services either for free or with payment assistance are limited. Estimates of the number of mental health facilities nationwide that provide mental health services without charge or with some financial aid are not available. This knowledge is important because the affordability of mental health services may be a factor in individuals' willingness to seek treatment, and the availability of a wide range of different health care settings for mental health service delivery may improve access to treatment.⁵ This report examines the availability of mental health treatment services provided at no charge or using a sliding-fee scale in U.S. mental health treatment facilities.

The National Mental Health Services Survey (N-MHSS) is an annual survey of all known mental health treatment facilities in the United States, both public and private. The N-MHSS is conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and is designed to collect data on the location, characteristics, and use of mental health treatment facilities throughout the 50 states, the District of Columbia, and other U.S. jurisdictions.

The 2010 N-MHSS is the most recent available analytic data file and is used in this study. The final 2010 N-MHSS facility universe included 16,197 mental health treatment facilities, of which 12,186 were eligible for the survey. Of the 11,118 (91.2 percent) eligible facilities that responded to the 2010 N-MHSS, 10,374 were included in the N-MHSS main findings report and data files. The 10,374 facilities included 1,235 facilities that completed an abbreviated follow-up questionnaire (basic facility information and client counts) and 9,139 facilities that completed all sections of the questionnaire, including basic facility information, services characteristics, and client counts. This report focuses on the 8,938 facilities that completed all sections of the survey questionnaire and responded to the two items on payment assistance. Because the N-MHSS involves censuses and actual counts rather than estimates, statistical significance and confidence intervals are not applicable. The differences between proportions mentioned in the text of this report have Cohen's h effect size ≥ 0.20, indicating that they are considered to be meaningful.

Mental Health Treatment Facilities that Offered Payment Assistance

In 2010, 18.8 percent of mental health treatment facilities offered services with a sliding-fee scale only, another 18.4 percent offered services at no charge only, and 42.7 percent offered both types of payment assistance (Figure 1). Approximately 1 in 5 facilities offered neither type of payment assistance (20.0 percent).

Figure 1

Mental health treatment facilities by type of payment assistance offered: 2010 N-MHSS

Description of Mental Health Treatment Facilities that Offer Payment Assistance

The availability of payment assistance (i.e., services available at no charge or with a sliding-fee scale) differed by type of treatment facility. Payment assistance was offered in 88.0 percent of outpatient mental health centers, 86.2 percent of multisetting mental health facilities,⁹ 76.6 percent of psychiatric hospitals, and 71.4 percent of general hospitals with separate psychiatric units (Figure 2). Multisetting mental health facilities are "facilities that provide outpatient and residential mental health services and are not classified as a psychiatric or general hospital with a separate psychiatric unit or as residential treatment centers (RTCs)."⁹ Among residential treatment centers (RTCs) for adults, 69.5 percent offered payment assistance. In contrast, slightly more than one-third of RTCs for children offered payment assistance (38.3 percent).

Figure 2

Mental health treatment facilities offering payment assistance, by facility type: 2010 N-MHSS

More than three-fourths of facilities operated by private nonprofit organizations (79.6 percent), and almost all facilities operated by state mental health agencies (94.9 percent) or local, county, or municipal governments (94.7 percent) offered payment assistance (Table 1). In contrast, about half of the facilities operated by private for-profit organizations offered payment assistance (49.6 percent). Of the facilities that offered services in Spanish or other languages, 85.4 percent provided payment assistance. Payment assistance was available across a majority of U.S. regions, but was available in more facilities located in the most rural, or "noncore," counties (89.0 percent) than facilities located in more urban counties (range of 77.4 percent to 81.6 percent).

Table 1

Characteristics of mental health treatment facilities offering payment assistance: 2010 N-MHSS

Treatment Approaches Provided in Mental Health Treatment Facilities that Offered Payment Assistance

A majority of the facilities that offered payment assistance (either services at no charge or with a sliding-fee scale) provided cognitive/behavioral therapy (89.6 percent), individual psychotherapy (87.2 percent), group therapy (85.5 percent), and psychotropic medication therapy (83.6 percent; Figure 3). More than half of facilities that offered payment assistance provided couples/family therapy (68.4 percent), behavior modification (64.5 percent), and integrated dual disorders treatment (56.7 percent).

Figure 3

Mental health treatment approaches provided in facilities offering payment assistance: 2010 NMHSS

Discussion

Data from the 2010 N-MHSS indicate that about 4 in 5 mental health facilities offered payment assistance for those who cannot afford to pay, either by providing services at no charge to the client or by using a sliding-fee scale. The availability of these affordable services varied by type of facility, facility operation, and whether the facility was located in an urban or rural area. Payment assistance was less prevalent in RTCs, especially those for children, in private for-profit organizations, and in more urban areas. The relatively lower use of a sliding-fee scale or free care by facilities in urban areas compared with more rural areas may point to a possible unmet treatment need, especially in low-income communities of the inner city. Slightly more than one-third of RTCs for children offered payment assistance, which raises concerns regarding the accessibility of services for children in need of residential care who have no means of paying for treatment.

Health care reform may address some concerns regarding affordability by expanding insurance coverage for individuals and by including treatment for mental health and substance abuse as 1 of the 10 essential benefits eligible for coverage.¹⁰ The Mental Health Parity and Addiction Equity Act implemented in 2010 has also been shown to decrease out-of-pocket spending for certain mental disorders.¹¹ The greater availability of payment assistance in rural settings coincides with higher uninsured and underinsured rates noted in rural than urban areas.¹² However, as shown by a recent national survey that found cost as a major barrier for receiving mental health treatment,² availability of affordable services will remain a critical part of the mental health care delivery system along with efforts to improve the coverage and affordability of mental health services.

Individuals in need of mental health services and payment assistance may find more information using the SAMHSA's Behavioral Health Treatment Services Locator (https://findtreatment.samhsa.gov/).

Suggested Citation

Smith, K. E., Kuramoto-Crawford, J., & Lynch, S. Availability of Payment Assistance for Mental Health Services in U.S. Mental Health Treatment Facilities. The CBHSQ Report: March 23, 2016. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Rockville, MD.