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HomeMy WebLinkAbout2002-12-HSC-rpt-Mental Health Services in Lexington.pdf MENTAL HEALTH SERVICES IN LEXINGTON,MASSACHUSETTS: A REPORT TO THE BOARD OF SELECTMEN By The Human Services Committee Stephen Baran, Social Services Coordinator and Staff to the Committee Robert A.Dentler,Chair William L.Blout Sarah B. Conklin Steven Kelly Mary M.Rommell Russell Schutt Christine Yedica December,2002 TABLE OF CONTENTS 1.Purpose of the Study 2.Mental Health Service Providers in Lexington and the Sample 3.Agencies and Organizations 4. The Individual Professional Providers 5.Interpretations and Conclusions 6.Recommendations Appendix A.Tables 3 MENTAL HEALTH SERVICES IN LEXINGTON 1.PURPOSES The Human Services Committee study of professional mental health service providers began to take shape in 2001,when representatives of the Middlesex branch of the National Alliance for the Mentally Ill met with the committee to present their current needs and concerns.We decided to conduct a study of the services available in Lexington for citizens, including children and youth,of the town. Our primary purpose was to inform ourselves and the Board of Selectman about the nature,extent,and levels of activity of all types of mental health services by Lexington agencies and solo practitioners.We sought to identify and describe the availability and provision of psychotherapeutic,sociotherapeutic,counseling,and medical services to clients suffering from psychoses,psychoneuroses,related cognitive or emotional distress, and difficulties associated with alcoholism,substance abuse,and the like. Our aim was to gather,interpret,and report on evidence of unmet needs.We believed that subgroups who were found to be under-served should be identified and that the Board of Selectman would entertain ways of strengthening the scope and quality of future services. A report published by the Boston Globe on December 4,2002,found"Growing numbers of adults and children in Massachusetts are visiting mental health professionals, and are spending far longer in therapy. .Americans generally are seeking more therapy,but this trend has turned out to be particularly pronounced in Massachusetts."Harvard Pilgrim Health Care said the number of talk therapy visits among its members increased 4 22 percent in 2001,and will grow another 17 percent in 1002.This trend intensified our concern. The project was planned during the spring and summer of 2002 and carried out during the fall. Committee members interviewed solo practitioners face to face and one on one and gathered information and interviewed two or more members of the four principal service providing agencies in the town. 2.MENTAL HEALTH SERVICE PROVIDERS IN LEXINGTON AND THE SAMPLE We pooled information from several sources,including HelpPro.com on the Internet, to develop a master list of professional service providers based in Lexington.The total number of private practitioners is 173.These include therapists who have an office in Lexington, even though their primary office is located elsewhere,as well as professional providers on the staffs of RePlace,Eliot Community Health Services,the Edinburg Center Inc. (formerly the Center for Mental Health and Retardation Services Inc.),and the Lexington High School Guidance Department. The Massachusetts Board of Registration informed us of how many licensed therapists-36 psychiatrists, 179 psychologists,425 social workers,and 86 allied mental health professionals-list their addresses in Lexington.Many of these individuals reside in Lexington but practice elsewhere.And many people are licensed but do not practice privately.Committee member William Blout,who has expertise in this domain,estimates from these data and from his knowledge of turnover and other changes,that at least 200 professional mental health service providers work in Lexington.We used our list of 173 5 names and office addresses to draw our sample,taking every sixth name from that list. We are grateful to the many practitioners who gave us their time and shared their expertise. Lexington's population in 2002 was 31,122,with 6,655 of this number under 17 years of age.The hypothetical ratio of providers to citizens was thus 155.6,an exceptionally high ratio compared to communities elsewhere in the nation and in the Boston metropolitan area. If we take the often-utilized proportion in mental health literature of ten percent of a population in need of services,there may be about 3,000 citizens at risk of mental and emotional distress in Lexington,and on this estimation,the residential hypothetical ratio is 1 provider per 15 residents.There is,we believe,an indisputably high number of mental health service providers working in Lexington. Our study interviewed 28 solo practitioners for a sample of 16 percent of this group. In addition,we interviewed from two to five professionals in each of four agencies and organizations.Within the 28, 17.9 percent were psychiatrists,42.9 percent were psychologists with PhDs,25 percent were psychologists or counselors with PsyD or EdD degrees,7.1 percent were social workers with MSW degrees,and 7.1 percent came from other professions.We did not sample pastoral counselors. 85.7 percent of our solo practitioners had 15 or more years of professional experience. 3.AGENCIES AND ORGANIZATIONS Four agencies and organizations serve Lexington,apart from solo practitioners.They include Wayside RePlace,Eliot Community Human Services,the Edinburg Center Inc., and the Department of Guidance Counseling at Lexington High School. 6 Wayside RePlace.RePlace has been in Lexington since 1970 when it began as a youth drop-in center which provided counseling,supervised emergency foster homes,peer counseling,and a child assault prevention program and hotline. In the 1970s, 1980s and until the 1990s, it was identified with the Hancock Church and was housed in the church building.(For the period from November 1994 until late 1995, Eliot Community Health Services took over from RePlace and offered drop-in services and peer counseling for youth from a clubhouse in Depot Square. It proved difficult to reconcile the activities of youth at that location with the business interests of merchants based on the Square.The contract reverted to Wayside RePlace). The present day RePlace,with local headquarters on the second floor at 4 Muzzey Street, retains a tradition carried over from the old Replace of working to be identified with Lexington,carrying on advocacy for youth and families,and empowering youth as well as being prevention-oriented.It differs from what it was in its earlier decades: it is more bureaucratically organized and professional with a higher level of staff training, documentation of services,and reporting. Since 1996,it has had a solid relationship with its parent agency,the Wayside Youth and Family Support Network,with headquarters located in Framingham,which serves a large,multi-suburban range of communities. In addition to programs of youth skill building,and efforts at bullying and violence prevention which complement the Domestic Violence Task Force work of the Police Department,and health education, RePlace provides counseling and crisis intervention services for emotionally distressed children and youth. In the fiscal year that ended June 30,2002,the agency provided 459 hours of counseling sessions to 119 Lexington residents 7 and their families on the contract with the town.They also offered group and individual counseling to a few groups of children and middle school youths at Fiske,Harrington, and Clarke schools. Issues addressed in some of these settings included social skills,teasing and bullying,grief and loss,and anger management.The annual operating budget for the year was$108,000,which included$74,087 awarded by the Town of Lexington.This funded the work of five part-time and fee for service staff workers with 1.5 full time equivalents. RePlace generally sees higher functioning youths. It does not treat those with psychotic or mood disorders or psychoneuroses. Some individual youths have been referred to RePlace staff by the guidance counselor at Clarke.The high school staff could use RePlace as a referral resource but does so very rarely. In the judgement of two senior administrators at Wayside Replace,Lexington youth should be involved more in community governance.Adults should reach out to them for their views and recommendations.This was attempted at a youth"summit"meeting in March,2002,with some success,according to both adult and youth participants.The youth at the summit recommended that efforts should be made to make shops and restaurants youth-oriented, and there should be a mobile youth center Events should be held in different places and oriented to the middle school students especially. Lexington needs to adopt community mental health and environmental strategies,the youths said. The clinical administrator at RePlace believes that the most serious impediments to adequate mental health services include insufficient funding,limited access to hospitals,and incomplete emergency response capabilities. Many RePlace clients come to RePlace after their HMO insurance benefits have been exhausted. Some never had insurance in the first 8 place.There is also a lack of collaboration among service providers.A provider needs to be known for a long period of time in Lexington before gaining the trust of other providers. They also believe that the quality of services in Lexington is excellent but that there is an inability to meet rising needs. Eliot Community Human Services.This agency serves a sizeable range of suburbs in Middlesex County The Lexington branch located at 186 Bedford Street was at one time a substantial unit but services have recently been concentrated in Concord and reduced in Lexington. For instance,there had been a psychiatrist in the Lexington office one half day a week,but this has been discontinued. Eliot serves clients with significant mental illnesses, particularly schizophrenia and bipolar disorders,but medication provisions,outreach, and case management services are concentrated in the Concord office. Eliot maintains a 24-hour beeper system and assists parents who phone regarding runaway teenagers or those for whom medication balances get out of control.Psychotherapy is provided at the Lexington office for a few clients. From the point of view of the clinical administrator,there are not enough mental health services to meet needs in our region.Eliot, among others,has recently done little with outreach efforts in Lexington,after making a valiant effort in earlier years.Rates of reimbursement for mental illness and emotional distress are significantly lower than rates for physical illnesses.The state's new mental health parity law makes it sound to the public as if more services will become available,but the law requires proof that the illness being addressed constitutes a "medical necessity,"a standard that is very difficult to meet. In fiscal year 2002,Eliot provided 771.5 hours of services-a total of 791 sessions or 9 appointments-to 21 residents of Lexington.The services ranged from individual therapy to family and couples therapy,to family and case consultations,diagnostic evaluations of clients,and medication management. Edinburg Center Inc. Edinburg,known until 2002 as the Center for Mental Health and Retardation Services,has a large headquarters building located at 1040 Waltham Street in Lexington.It is a private,not-for-profit corporation funded by the Massachusetts Departments of Mental Health,Mental Retardation,and Public Health,foundation grants, HMO's and other third party payers. Its director,Ellen Attaliades,is a licensed clinician in psychology,and has 22 years of professional experience,nearly all of them with Edinburg. This agency employs about 300 professionals and support staff who work in the Lexington headquarters and clinic and in clinics in Waltham and Arlington. It serves 18 towns and villages in the immediate county.In addition to providing diagnostic, evaluative, and case management treatment and support planning services,Edinburg maintains these types of services: • Round-the-dock crisis psychiatric intervention services for all persons over 13 years of age. • Adult day treatment services,including two different group programs. Intensive support for daily living assistance,short term psychotherapy, vocational and housing assistance,medication monitoring, and linkages with other service providers. • Outpatient clinics focusing on treating the whole person in community settings. Charles Webster Potter Place,a clubhouse for pre-vocational,social 10 experiences,and psycho social rehabilitation for 40 to 60 members. Five community treatment programs for 39 clients,one of them based in Lexington,and supported housing for 68 adult clients in individual living arrangements. • A variety of programs and services for mentally retarded adults,including two group homes in Lexington. During fiscal year 2002,Edinburg provided mental health services to 96 residents of Lexington.While 82 were whites,the remainder were truly multiethnic.The group included youths from 14 to 20 years of age as well as some adults. The principal services rendered to these 96 included crisis interventions and outpatient counseling. Edinburg collaborates with Emerson Hospital,Eliot Community Mental Health Center,Wayside/RePlace,and a range of individual mental health service providers. It bid,incidentally,on the service contract funded by the Town of Lexington that went to Eliot Community Health Services before it reverted to Replace.Its collaboration with the Lexington Police Department has been especially fruitful in recent years.Typically,a local police officer phones and brings in a person referred by family or friends as in an emotional crisis.Edinburg gave an award to the Lexington Police for the dedication and quality of their services this year. Agency professionals evaluate the client's problems and capabilities,utilizing placement at Emerson Hospital if necessary for the immediate short term.They assign a case manager, create a team of staff,and begin a program of therapy,medication, and day program participation. 11 Edinburg copes as well as it can with what it deems to be a number of serious impediments to the provision of adequate services.These impediments include the difficulty of achieving coordination between the many towns and jurisdictions they serve; seriously insufficient funding for outpatient services; and very inadequate transportation services-no public buses operate between Lexington or Waltham and the Center. In addition,this large and bustling professional center has no budgeted resources for research and development, program planning,or staff training and development.The director also noted that the Center's overall annual funding is not growing. Lexington High School Guidance Department(LGD).LGD consists of eight full time professionals,a psychologist,counselors and social workers,and a director.The director referred us to his staff because he was new to the town and the school in 2002.We interviewed five members. LGD serves a caseload of 200 students per staff member.About 80 percent of their time is devoted to college and job placement counseling. Social adjustment and mental health issues received 20 percent or less of their time.The mental health service provided by staff in LGD is of an emergency kind-disruptions and episodes that come up unexpectedly during the school day in particular- and is devoted to very short term problem solving. The Lexington school district does not permit professional staff to engage in therapeutic counseling.This is part of the district's risk management strategy as devised by the legal counsel for the school committee.As part of the same strategy,LGD members cannot refer or make related arrangements with outside mental health practitioners.They 12 are permitted only to lend a student or a parent or guardian a notebook listing names, specialties, and addresses and phone numbers.Their book of listings contains numerous solo practitioners but very few clinics,group treatment resources,or networks and agencies. The zero tolerance policy of Lexington High School concerning drug and alcohol use and threats or instances of weapons or violence has the effect,in the judgement of those we interviewed,of"killing the possibility of preventive work with students" Students who have these and related problems now tend to avoid the staff of the LGD,whom they know to be obliged to report student suspects to the administration.Health education about these behaviors is worked upon by the High School Health Department with state grant resources. The theme of the LGD is"coordinative communication" This includes intramural advocacy for students,a parent information and support group which convenes weekly and is open to all interested parents, and assistance to the special needs educators and administrators working the school. Lexington High School faculty in general give very major attention,as do many parents,to time on academic tasks in the classroom and to homework.Time out for counseling or for work on mental health challenges is frowned upon by most faculty and parents.An important exception to this pattern came in 2002 with the death of two students,one a murder victim and one an auto accident victim. On that occasion,LGD and other school staff devised a time of support,counseling,and group grieving. The greatest unmet need in Lexington,in the judgement of the staff members we interviewed,is the need for group counseling and group therapy sessions for adolescents. We should also mention the work of the Health Protection Advisory Council 13 (HPAC).This group of more than 20 health educators,special educators,social workers, public health specialists,work on a number of funded projects to improve drug and alcohol awareness and prevention concerns among parents and youth.They work through a special health unit at Lexington High School and through health educators at the middle and elementary schools.HPAC also works on preventing bullying and harassment and related improvements in interpersonal relations among students. 4.THE INDIVIDUAL PROFESSIONAL PROVIDERS Most of the service providers in our sample work with 15 or more clients a year. See Appendix A.All but a very few of them practice alone and are not part of an agency or group of colleagues.Adults and married couples are the clients of concern to 59 percent of the providers,while 15 percent serve children and 26 percent serve youth.All of the providers serve white clients,but many of them have a multiethnic clientele as well. Most of them treat more than one type of problem,of course.The providers include clinical psychologists who specialize in psychological diagnoses(25 percent). Many of the counselors and therapists work on neuroses and general anxiety disorders(31 percent)while a smaller proportion focus on eating and sleep disorders(16 percent).Marital and parenting problems are primary challenges for 30 percent of the providers. We asked each provider to give us a case illustration of how they go about their work as solo practitioners.The responses varied greatly,of course. Some typical illustrations included the following: • A two hour psycho-educational testing and diagnostic session. 14 • Talking therapy,with time given to listening to what the client is in pain about,for instance,grieving over a father's death. • Mine is a psychoanalytic approach,with an emphasis on emotional,affective life. • Providing psychotherapy for a seven year old who was having difficulty with the aftermath of a parental divorce. • Probing in sessions twice a week to try to learn the causes of death threats and violent outbursts by an adolescent. • Play therapy with children and verbal discussions with adolescents,following the taking of medical histories. • Receives a referral,has an initial session for intake of history, scheduling of future sessions,payment terms,and then a period of talking therapy plus medications lasting from 2 to 9 months. • Gets a referral to a boy who appears depressed and uses lots of marijuana. Meets with the youth and sometimes includes the parents. Contacts the school for details,often visits school for a professional meeting. Takes a day to day approach rather than an analytical or historical one. We also asked an open-ended question about whether there are better practices for service and treatment now in use,or better practices from state or local agencies than there were some years ago. Some of the typical responses to this question were as follows: My experience with the state is one of movement toward privatization through agencies which operate like private practices.The state seems to support large corporate institutions. Fewer people are going to work in community agencies. Social and political change has led to lots of isolation for those who are practitioners. No better practices: we're going backwards.Neuropsychiatric rates have gone down.Now,under state laws,parents can no longer get a second evaluation paid for.The state used to 15 pay for an independent evaluation if parents were not satisfied with the one provided by the school. There need to be more connections between services. In some ways,this is improving.HMO referrals,for example, now require a contact with a primary care physician. Employee assistance programs of today are helpful. Replace is a good community resource but is underutilized.It is not thought of as a referral by referring parties. The Lexington Police are wonderful; they use their resources to best advantage! The problem is finding a psychiatrist to just do medications,without therapy due to reimbursement rates from insurers. The Council on Aging is a wonderful program. In general,services in Lexington have gotten worse in recent years.Processes are slow and laborious; there is no coordination of services. Replace is still serving youth well,I believe. There are a lot of suffering kids.They have to rely on their parents to access services and pay with their own insurance,but with more complicated cases they don't get what they need unless the family has sufficient funds. School-based mental health services are needed in order to avoid dependence on the quality of their own health care insurance and resources. Lexington relies on a system of private practitioners to provide services to kids,which is inadequate.In Cambridge,there is a citywide crisis team,and counselors in the schools and teen centers.Newton also has a coordinated response. We asked the providers what they believed were the major unmet mental health 16 needs of residents of Lexington.A paucity of youth services headed the list(54 percent), with an additional 14 percent citing a need for more help for children and for parenting. Support groups and group psychotherapy services were mentioned by 9 percent,and another 9 percent cited a shortage of geriatric services. We also asked the providers to identify serious impediments,if any,they met in the course of their work.HMO regulations and related management actions were named by 31 percent,and insufficient state funding was cited by 27 percent.Burdensome amounts of required paperwork was cited by 14 percent and 29 percent identified a variety of other impediments. When we asked whether each provider estimated the conditions affecting mental health challenges for Lexington residents were changing,71 percent said they thought that conditions were worsening,25 percent did not know or were not sure,and 4 percent said they were improving.When we asked whether,in their judgement,mental health services in Lexington are better or worse now than they were a few years ago,54 percent thought they had gotten worse,21 percent thought they were as good now as they were earlier,and 14 percent thought they had improved. 5.INTERPRETATIONS AND CONCLUSIONS Lexington is blessed with a large,highly trained,and experienced corps of mental health service providers. There is of course no restriction on access to services anywhere in the region so Lexington residents may and often do seek help from providers located outside 17 of the community,while many non-residents are clients of providers whose offices are based in Lexington.No one can measure the in-and out-movement demographics,but we know they are substantial. Lexington also hosts four agencies with highly trained, experienced service staffs. Sizeable as they are,two of these-Eliot and Edinburg-serve very few Lexington residents. Together,they diagnosed or treated a total of 117 Lexington residents during fiscal year 2002.The Lexington High School Guidance Department devotes all but a fifth of its professional energies to college and job placement and related academic advising and paperwork.It is also gravely restricted in the range and depth of counseling and mental health assistance work its staff is permitted to do under school committee policies. RePlace is the one agency which contracts with the Town of Lexington to serve youth.The amount of the contract is less than half of the funding made available annually to the Town of Bedford Department of Family and Youth Services. Bedford has a substantially smaller resident population- 12,361 in the 2000 Census-than Lexington. RePlace currently does a lot with the resources it has to work with,but its parent agency Wayside went into the red in fiscal 2002 and may prove unable to supplement the funding of Lexington's program in fiscal 2003. Our evidence suggests that RePlace is well regarded by professionals in Lexington, but that it is utilized as a referral resource by Clarke Middle School primarily,as well as by some physicians and counselors,but not by Lexington High School or Diamond Middle School. Solo practitioners,mental health practitioners within the agencies,and others we 18 contacted in the course of this project concur generally that Lexington,with all of its abundance of helping talent,displays a serious lack of services for adolescents.There is also a lack of collaborative coordination between the solo practitioners and between professionals within Lexington High School and these practitioners. This has been a study of mental health service providers and their knowledge and views.We do not have direct evidence of a shortage of mental health assistance for Lexington youth,only the conviction of providers and counselors to this effect. It could be argued,for instance,that adolescents appear to be"managing"their lives in Lexington rather well now,if the criteria used were youth suicides and incidents of violence.We do not subscribe to this argument in the light of what we have learned from our interviews,but more evidence is needed. We could also ask about the standard that should be used in gauging the extent to which public agencies and especially local government should manage the need for mental health services.We would note that the new state parity law equating mental illness and emotional distress with physical illness and injuries places mental health on a footing identical to that given public health concerns of all kinds. Our view,in addition to supporting the existing commitments of the Commonwealth,is that it is strongly in the self- interest of Lexington's governmental leadership to monitor and foster the availability of mental health services. 19 6.RECOMMENDATIONS The challenge facing this study project has been to arrive at recommendations to the Board of Selectmen that do not contradict that body's urgent quest for ways in which to fill the extreme gap between town expenditure requirements and available revenues.We therefore offer just a few no-cost recommendations for the Board's consideration. Our premise is that the well-being of Lexington's citizens,especially the youth who make up so much of its life as a residential community,depends in part on having ready access to mental health services within the town in the immediate years ahead. 1.The Board should make earnest and sustained efforts to encourage the Lexington School Committee to change its current policies of risk management and avoidance of psychological and counseling assistance to students.The change should be strongly toward the provision of mental health services by appropriate staff now employed by the Lexington Public Schools. 2.Lexington school policy makers and staff practitioners should also be encouraged to better utilize the considerable professional resources available within Lexington as part of consultation and training to support their clinical work.We have a clear impression that some local providers might gladly donate their time if they were approached effectively.For instance,during the first two decades of work by RePlace,volunteer participation was very high.A rescue home for runaway youths who needed a temporary haven was one of the features of this approach. 3. The position of Social Services Coordinator for Lexington should be reconfigured. Presently,the Coordinator is spread thin. He provides information and 20 referral,case management and even counseling help for clients, and runs groups and staffs committees for the Board of Selectmen. We recommend that the Social Service Coordinator be charged as a priority with coordinating mental health services for Lexington that involve Eliot,Edinburg, and Wayside/RePlace.In this model, all adult services and most services for youth with serious and persistent mental illness would be the responsibility of Edinburg and Eliot,as coordinated by the Social Services Coordinator. 4.In the course of renewing its contract with Lexington,Wayside/RePlace should revise its proposed program of services for youth,in collaboration with the public schools and including programs directed both to mental health and substance abuse for children and youth. Support of proposed programs such as"Young and Sober"should become part of the collaboration.The Board of Selectmen should work to secure agreement with the School Committee to have Wayside/Replace take the lead in initiating this collaboration. 5.Taken together,recommendations 3 and 4 should be unified into a concerted effort between the Department of Social Services,Wayside/Replace,and the Lexington public schools to collaborate,coordinate,and reach out to children and youth in need of help. Consistent with that aim,we recommend that the Board of Selectmen consider building the provision of youth services into their policies and programs in the future.The Human Services Committee pledges it support and its future workmanship to this objective. APPENDIX A TABLES Table 1 Column Count Valid N% Highest MD 5 17.9% Degree PhD 12 42.9% Achieved PsyD or EdD 7 25.0% MSW 2 71% Other 2 71% Total 28 100.0% Table 2 Column Count Valid N% Years of 15+Yrs 24 85.7% Career 10-14 Yrs 3 10.7% Experience 5-9 yrs 1 3.6% Under 5 Yrs 0 .0% Dont Know 0 .0% Total 28 100.0% Table 3 Column Count Valid N% Number More than 20 16 61.5% of 15 to 20 4 15.4% Clients 10 to 14 1 3.8% Fewer than 10 3 11.5% Dont Know 0 .0% Varies 2 7.7% Total 26 100.0% Table 4 Column Count Valid N% Practice as Part of Yes 3 11.1% Group or Agency No 24 88.9% Total 27 100.0% Table 5 Column Count Valid N % How Are Service Worsening 20 71.4% Impediments Improving 1 3.6% Changing Other or Dont Know 7 25.0% Total 28 100.0% Table 6 Column Count Valid N% How Do Services As Good Now 6 24.0% Compare to Two Gotten Better 4 16.0% Years Ago Gotten Worse 15 60.0% Total 25 100.0% Table 7 Count Column% Groups Children 11 39.3 Served Youth 20 71.4 Adults 26 92.9 Married Couples 19 67.9 Table 8 Count Column% Client White 22 100.0 Ethnicity Black 5 22.7 Asian 9 40.9 Hispanic 5 22.7 Table 9 Count Column% Primary Marital or Parenting Problem Problems 17 63.0 Foci Neuroses.AnXiely 19 70.4 Psycho-diagnosis 15 55.6 Eating,Sleep Disorders 10 37.0 Depression 17 63.0 Other Psych Problem 4 14.8 Table 10 Count Column% Services Therapy, Counseling 25 89.3 Provided Medication 4 14.3 Diagnostic 20 71.4 Other 6 21.4 Table 11 Count Column% Unmet Youth Services 23 85.2 Needs Child&Parenting Help 6 22.2 Support&Therapy Groups 4 14.8 Geriatric Services 4 14.8 Other 6 22.2 Table 12 Count Column% Serious State Funding 13 46.4 Service HMO Regulations 15 53.6 Impediments Paperwork Required 7 25.0 Other 14 50.0