Behavioral Healthcare in Rural Settings

1. Behavioral Healthcare in Rural Settings Climbing Mountains, Fording Streams

2. A Brief History of the Public System • The California Community Mental Health Services Act 1969 “deinstitutionalized” mental health services, serving people with mental disabilities in the community rather than in state hospitals.

3. A Brief History of the Public System • The mental health system was never conceived as an “entitlement.” • Mental health services were to be provided “to the extent resources are available.” • The Short-Doyle Act was the funding mechanism intended to build the community mental health system. • Adequate funding was never transferred to communities

4. A Brief History of the Public System • In 1990, California faced a $15 billion state budget shortfall which would have resulted in drastic cuts to mental health • “Realignment” was enacted in 1991 with passage of the Bronzan-McCorquodale Act • It represented a major shift of authority from state to counties for mental health programs • 2004 Prop 63 passage provided dedicated funding for high priority populations

5. Current System Design • Now managed by each county, which is a mental health plan (or PIHP) unto itself • Services provided either by the county, contracted providers, or some combination • Rural counties served primarily by the county, though starting to change

6. Current Funding • Realignment Revenues • Medi-Cal Specialty Mental Health Managed Care SGF Allocation • Medi-Cal EPSDT SGF • State Mandate Reimbursement (AB 3632) • Federal Funding (SAMHSA, Medi-Cal FFP) • Mental Health Services Act (Prop. 63)

7. Healthcare Reform and Parity: Why Do We Care People diagnosed with depression have nearly twice the annual health care costs of those without 49% of Medicaid beneficiaries with disabilities have a psychiatric illness 52% of those who have both Medicare and Medicaid have a psychiatric illness

8. Healthcare Reform and Parity: Why Do We Care • 11% of Californians in the fee for service Medi-Cal system have a serious mental illness. • Healthcare spending for these individuals is 3.7 times greater than for all Medi-Cal fee-for-service enrollees: $14,365 per person/year compared with $3,914 • Many studies demonstrating cost savings

9. Healthcare Reform in CA • Medicaid Expansion • 3.3 million plus by 2014 • CA Waiver as Bridge • CEED basic benefit for SPDs includes minimal MH • Healthcare homes as base • Primary Care Integration w/focus on prevention, care coordination, stepped care

11. Impact of Parity • Applies to Medicaid and Medicare • Most people will be covered • Movement toward managed/coordinated systems • Mental Health and SU needs will have to be included – only way to bend the cost curve

12. Information Technology • State-level initiatives – Stimulus $$ • EHR Technical Assistance - RECs • Health Information Exchange • Behavioral Health in the mix • Critical to include • Federal legislation to broaden scope • Staying in the game in CA

13. No Mountain Top • No system is perfect • The process is most important • Prime opportunity to collaborate • Consider the whole person

14. What We Know* • Behavioral Health is part of health • Prevention works • Treatment is effective • People recover *From Substance Abuse & Mental Health Services Administration

15. References • “The Business Case for Bidirectional Integrated Care” by Barbara Mauer & Dale Jarvis; 6/30/2010 • “CA Mental Health Funding Evolution & Policy Implications Pre- and Post- MHSA” by Pat Ryan; Sept 2010 • “Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence - Based Practices” Revised February 2006; by Barbara Mauer for the National Council of Community Behavioral Healthcare