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NAMI 6/02

Olmstead 10/02. NAMI 6/02. Mental Health Reform; The View from 30,000 Feet . Mike Hogan, Ph.D. Director, Ohio Department of Mental Health Four County ADAMH Board: Oct. 2002. The Context of our Conversation. Different perspectives and knowledge Recovery is Real

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NAMI 6/02

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  1. Olmstead 10/02 NAMI 6/02

  2. Mental Health Reform;The View from 30,000 Feet Mike Hogan, Ph.D. Director, Ohio Department of Mental Health Four County ADAMH Board: Oct. 2002

  3. The Context of our Conversation • Different perspectives and knowledge • Recovery is Real • Great needs, new national attention • State MH budgets in trouble • The bad side effects of good reforms

  4. Recovery is real: PET scans of a woman with treated depression. The scan on the left was taken when she was on no medications and very depressed. The scan on the right was taken several months later when she was well, after medication had treated her depression. Note that her entire brain is more active when well, particularly the left prefrontal cortex. Depression With Successful Medication Treatment Pre Treatment

  5. Recovery is Real Positron emission tomography (PET) scans show that successful medication or behavior therapy treatment of obsessive-compulsive disorder (OCD) reduces excess brain activity. OCD Pre Tx OCD Pre Tx OCD--Medication Tx OCD--Behavioral Tx

  6. Significance of Mental Health Issues • Great needs... • High prevalence (“one in five…one in ten”) • Significant clinical impact, burden • 4 of 10 most illnesses causing most disability (WHO) • depression alone causes 80 M lost work days (US) • fastest growing cause of disability • Treatments are quite effective for most conditions • Most get no care; most care is suboptimal • Mental disorders unique: costs due to burden of illness are greater than treatment costs • Since 1999: White House Conference, Surgeon General’s Reports, President’s Commission

  7. Perspectives on Mental Health Care • The “dynamic complexities” of mental health care • Commercially funded care An example of patterns: Care for depression --Effective Rx, most get no care --Primary Care roles: providers, gatekeepers --Many efforts to change this... A case study: 1987-1996: Treated prevalence doubles (to 50% of those with depression). Most of the increase is in primary care. Why?

  8. Perspectives on Mental Health Care • The “dynamic complexities” of mental health care • Commercially funded care • The reformed “public mental health system” • It is high time we thought about our successes, failures, and especially about the unintended consequences of reform...

  9. Good Reforms With Some Bad Side Effects: Themes of Mental Health Reform • 1--Local “systems of care” • 2--From institution to community • 3--Reliance on “natural” or “less restrictive” supports and services • 4--A focus on the “most needy” individuals with serious and persistent mental illness • 5--If it moves, “Medicaid it”

  10. Major Themes of Mental Health ReformAnd Possible “Side Effects” • 1--Local systems of care: the theory --Bedrock of public mental health policy for 40 years: local ownership, manageable system scope, citizen involvement in governance, alignment with community care… --In Ohio: county based Boards with significant powers/flexibility (control all state MH GRF$ including state hospital care), manage Medicaid, local levy authority, contracting, etc.

  11. Major Themes of Mental Health ReformAnd Possible “Side Effects” • 1--Local systems of care: the right thing to do; bad side effects ? Has the move to local responsibility reduced the “ownership” of mental health funding by budget bureaus and legislators? An analog: What trends do we predict for federal TANF funding levels following devolution of welfare responsibility?

  12. Major Themes of Mental Health ReformAnd Possible Side Effects • 2--From institution to community: why? Institutional care: ineffective, inhumane, expensive, restrictive… Community care: preferred by consumers, more effective and efficient, less depriving of liberty, etc.

  13. Major Themes of Mental Health ReformAnd Possible Side Effects • 2--From institution to community: a possible side effect--when we took the money out of the hospital “bank,” we stopped getting “interest” on government’s investment in mental health...

  14. ODMH Funding (GRF Services Line Items: Constant $ at 3%) Shows major budget accounts of the ODMH from ‘92 to ‘03, adjusted (3%) per year for inflation. Dark portion of each years’ budget is for community care, light portions are for hospitals. Note trends pre-, since ‘97 Community Services Civil & Forensic Inpatient Care

  15. ODMH Funding (GRF Services Line Items: Constant $ at 3%) During reform (and a period of steady state revenue growth), ODMH GRF funding increased with inflation. Hospital cost containment allowed increased community care, within a level budget. Following reform, funding has declined against inflation, eroding care. Funding erosion accelerated after successful reform (community care & control) and coincides with state budget pressures of Medicaid, corrections, schools. Community Services Civil & Forensic Inpatient Care

  16. These are National Trends:SMHA Inpatient and Community Expenditures FY'81--'97 Successful Reform: SMHA Systems ARE Community Based

  17. Total SMHA Controlled Expenditures as a Percent of Total State Gov't Expenditures This Trend is Due Primarily to Lost “Budget Clout” of SMHA’s-- not Reduced State Spending Generally. And, it “Tipped” Following Reform

  18. Major Themes of Mental Health ReformAnd Possible “Side Effects” • 3--Reliance on “natural” or “less restrictive” supports and services: the theory... • Housing • Employment Supports • Income Supports • Families “Generic” services: less stigmatizing, less expensive, more integrative…likely to better facilitate recovery and inherently preferable

  19. Major Themes of Mental Health ReformAnd Possible Side Effects • 3--Reliance on natural/generic/less restrictive supports and services: side effects • “Less restrictive” housing means relying on the private housing market, your local Housing Authority, HUD funding • Employment Supports brought to you by Voc. Rehab…with mental health agencies taking a walk... • Relying on Income Supports (SSA) creates incentives to stay “disabled” for life • Families are the primary, unfunded caregivers for people with serious mental illness

  20. Major Themes of Mental Health ReformAnd Possible Side Effects • 4--Focus on “most needy” populations: the theory In an earlier era of deinstitutionalization, CMHC’s focused on revenue generating services, not people discharged from state hospitals….the core responsibility of government should be on those most in need…the CSP vision defined practical approaches needed to sustain people with serious disabilities in community life.

  21. Major Themes of Mental Health ReformAnd Possible Side Effects • 4--Focus on “most needy” populations: possible side effect Has a legitimate focus on more needy people labelled “SMD” or “SED” weakened the “budget relevance” of mental health… in an era when state capitols (indeed, the global economy) are focused on competitiveness, economic development, and education?

  22. Major Themes of Mental Health ReformAnd Possible Side Effects • 5--If it moves, “Medicaid it”: theory --No mental health benefit when Medicaid created… ”IMD’s” excluded from coverage… reimbursement for NF care encouraged “transinstitutionalization”; $ for general hospital units encouraged “substitution”…these policies had more impact on state institutions than community mental health (Gronfein) --Following 1977 GAO study, National Plan for Chronically Mentally Ill leads to creation of (optional) benefits for clinic and rehabilitative care --States seek to “maximize reimbursement” via Medicaid for CMH services

  23. Major Themes of Mental Health ReformAnd Possible Side Effects • 5--If it moves, Medicaid it: results In 1997, for the first time, total mental health expenditures in Medicaid (not including medications!) exceeded total GRF expenditures of state mental health agencies. Medicaid is now the biggest “mental health program” in the country…(following Social Security disability payments).

  24. Major Themes of Mental Health ReformAnd Possible Side Effects • 5--If it moves, Medicaid it: side effects? Now that mental health relies so heavily on Medicaid, problems are evident: --Eligibility Limitations (e.g. being “not disabled enough” for eligibility) --Coverage Limits (e.g. housing, job support, consumer operated services not easily covered) --The “Pac-Man” effect of providing match funds --Discriminatory exclusions: IMD’s vs. ICF’s… means Home & Community Services waivers are essentially infeasible in mental health --Fragmentation of services, leadership, accountability

  25. An Example From the State of Oregon 1995-1996 Mental Health Budget by Fund Source: State GRF/indigent care= 32% of funds * Data Source: 1996 Block Grant Report of Activities

  26. State of Oregon 2000-2001 Mental Health Budget by Fund Source State GRF/Indigent care = 19.5% of funds * Data Source: FY 2001 Block Grant Application

  27. Major Themes of Mental Health ReformAnd Possible Side Effects • 3--Reliance on natural/generic/less restrictive supports and services: side effects…. • Federal “mental health” programs: Medicaid (ABD, CHIP, TANF and other eligibles, basic benefit, optional benefits, HMO’s, carve outs, waivers), Medicare, SSI, SSDI, VR, HUD (vouchers, construction support, public housing), Title XX, Special Ed, Child Welfare, etc. • Have we introduced unmanageable complexity?

  28. Coordinated Mental Health Services in Theory SAMHSA-CMHS Federal level SMHA State level Local level CMHC Case Mgt. M.H. Care Housing Coordinated Care Job Support Consumer M.D. Meds Income Support

  29. Coordination of Mental Health Services in Reality Medicare Medicaid CMHS HUD Education SSA SMHA V.R. State Medicaid Agency CMHC PHA Case Mgt. M.H. Care Housing Job Support Consumer M.D. ? Meds Income Support

  30. How Do We Continue Mental Health Reform,Manage “Side Effects” and Face New Challenges? • Can the force of recovery become dominant? • Can local “systems of care” be sustained with Medicaid as the dominant funder? • Can community care be budgeted for as “solidly” as institutions? • Can our ideological reliance on “natural” or “less restrictive” supports and services be matched with the discipline to make them work, and back them up? • Can we maintain our focus on the “most needy” individuals while recognizing the need for early intervention? • Can the dominant “mental health programs” (Medicaid, Medicare, VR, SSA, HUD, corrections) do the right thing? • Can the President’s New Freedom Commission on Mental Health help with these challenges?

  31. President George W. Bush Announcing the Commission Albuquerque, New Mexico: April 29 2002 • Our fragmented mental health service delivery system is an obstacle to quality mental health care…”Many years and lives are lost before help, if it is given at all, is given.”

  32. President George W. Bush Announcing the Commission Albuquerque, New Mexico: April 29 2002 • “I announce the New Freedom Commission on Mental Health. It is charged to study the problems and gaps in our current system…and to make concrete recommendations for immediate improvements that will be implemented.”

  33. Mission: Conduct a comprehensive studyof the United States mental health service delivery system, including public and private providers, and recommend improvements to the President. President’s Executive Order, April 2002

  34. Goal: “The Commission’s goal shall be to recommend improvements to enable adults with serious mental illness and children with severe emotional disturbance to live, work, learn, and participate fully in their communities.” President’s Executive Order, April 2002

  35. The Commission shall: • Review the quality and effectiveness of public and private providers and Federal, state and local gov’t involvement in services to individuals with SMI/SED and identify unmet needs and barriers • Identify innovative treatments, services and technologies that are demonstrably effective and can be widely replicated in different settings • formulate policy options that could be implemented to integrate effective treatments, improve coordination and improve community integration • President’s Executive Order, April 2002

  36. --How the Commission will gather information: -- Public hearings --Review of reports and documents --Public comment at all meetings --Outreach by members and staff --The Internet Reach us at: www.MentalHealthCommission.gov

  37. Mike Hogan, Ohio Dept. MH Jane Adams, Keys to Networking, Kansas Rudy Arredondo, Texas Tech University, Texas Dan Fisher, National Empowerment Center, Mass. Anil Godbole, Advocate North Side Health Network, Illinois Henry Harbin, Magellan Health Services, Maryland Larke Huang, Georgetown University, Maryland Norwood Knight-Richardson, CareMark Behavioral Health Services, Oregon Ginger Lerner-Wren, Judge, Florida Steve Mayberg, Cal. DMH Bob Postlethwait, retired Eli Lilly Neuroscience, Indiana Wally Prechter, Chair, Heinz Prechter Foundation, Michigan Nancy Speck, Telehealth Consultant, Texas Randolph Townsend, Nevada State Senate Dee Yates, Psychologist, Texas 7 Ex Officio Members Commissioners

  38. Senior Staff and Contact Information: Claire Heffernan Executive Director Stan Eichenauer Deputy Executive Director President’s New Freedom Commission on Mental Health Parklawn Building, Rm. 13C-26 5600 Fishers Lane Phone: 301-443-1545 Rockville, MD 20857 Fax: 301-480-1554

  39. Employment and Income Housing and Homelessness Older Adults Children and Families Evidence Based Practices Cultural Competence Medicaid and Medicare Criminal Justice Consumer Issues Rights and Engagement Rural Issues Medications Interface with General Medicine Suicide Prevention Co-Occurring Disorders Each Subcommittee: supervises development of an Issue Paper which identifies key issues and population affected…analyzes status of issue….identifies federal programs involved and models of excellence on the issue…considers policy options…lists recommendations for consideration Commission Subcommittees

  40. First product: Interim Report “In six months, an Interim Report shall identify unmet need and gaps in service, and identify examples of community based models with success in coordinating…and delivering desired outcomes.” (Executive Order)

  41. Thank You! We need your concerns, your ideas, your high expectations, and your support!

  42. SMHA Mental Health Spending, FY'81 to FY'97 Erosion of Funding Emerged as Issue in ‘90’s: Average SMHA Funding Declines 1%/year 1990-1997

  43. The President’s New Freedom Commission on Mental Health • Background • Mission • Goals • Principles

  44. Cautionary Note #1 • Fundamental, essential reforms in mental health in the U.S. are highly unlikely because there is a profound misfit between the requirements of good mental health care and the nature of the American political/governance structure • (mis)quoted from Ted Marmor and Katherine Gill

  45. Cautionary Note #2 • A review of the history of mental health reform in the United States leads one to conclude that there is really only a single, major, recurrent question. It is: the choice between “inside” and “outside” asylum. • (mis)quoted from Andrew Scull, Decarceration

  46. President George W. Bush Announcing the Commission Albuquerque, New Mexico: April 29 2002 • “Our health insurance system must treat serious mental illness like any other disease…I will work…to reach an agreement on mental health parity--this year.”

  47. Changes in ODMH Inpatient Care From 7/01 to 8/02

  48. Inpatient staff reduced by 13% during FY 02 <------------------- FY 02 ---------------->

  49. 13% reduction from July 01 to August 02

  50. Patient and Employee Trends Since 1988 7,000 6,000 5,000 Hospital Employees 4,000 Patients 3,000 2,000 1,000 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Excludes CSN staff

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