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Uneven Efforts, Part Four: Mental Health Care: ‘A Very Difficult System to Navigate’



Monday, July 27, 2015
When serious mental illness occurs, finding care and making choices can be daunting. Families of the mentally ill frequently find themselves the first responders to health emergencies. And they may be unprepared.

“When you have a child or a sister or a brother or an aunt or an uncle who starts displaying weird behavior, you have no background for integrating that information into your world view, your life scheme,” said Claire Munat, a leader of support groups sponsored by Vermont advocates for the mentally ill.

And families have limited tools to address mental illness, said Marjorie Mathews, a support group leader with the New Hampshire chapter of the National Alliance on Mental Illness. “What can you do as a family member? You cannot compel someone to treatment. You cannot compel them to take medication. Absent threats to themselves or others, you cannot engage the police or get commitment.”

Munat, Matthews and other leaders of support groups run by advocacy organizations know of the considerable challenges of addressing mental illness that face patients and their families. That knowledge is drawn from direct observations as well as from hearing of the experiences of others.

Often confused, desperate and without training or adequate tools, the mentally ill and their families also face the task of trying to find a way through the mental health care system — or, rather, a not very systematic array of social services mixed in with encounters with law enforcement.

Donna Stamper, a support group leader with NAMI New Hampshire, noted the frustrations of dealing with “the waits, the access to getting care (and) the police being involved in the processes.”

In the midst of a crisis and in its aftermath, she said, the mentally ill and their families may have “to understand the mental health system and then understand the criminal justice system.”

Patients and families aren’t the only ones who see it as daunting.

“It’s a very difficult system to navigate,” said Christine Finn, a physician and director of the crises and consultation service at Dartmouth-Hitchcock Medical Center in Lebanon.

To describe the complexity of mental health care services, the authors of a January 2014 report on violent incidents in New Hampshire’s mental health system resorted to this delicately mixed metaphor: “Components of our mental health system are woven into an intricate mosaic.”

Vermont’s mental health care is also complex. “Getting tangled up by a system that can’t seem to get it right?” is the invitation that Counterpoint, the quarterly newspaper of Vermont Psychiatric Survivors, an organization for mental health patients, uses to solicit letters from readers.

Adding to the tangle is the existence of neighboring and sometimes cooperating systems that provide care that complements or overlaps the care from mental health providers.

Distinct care-giving networks and organizations address the needs of some seniors, veterans, individuals with developmental disabilities, emotionally disturbed children, prisoners, students and the homeless. The terminology and content of diagnoses, treatments, ground rules, funding sources and other elements of patients’ experiences may vary among networks and organizations. Identifying and understanding barriers and boundaries can also be tough.

And even when patients and families solve the system’s complexity, they may discover that the quantity and quality of mental health care in the Twin States falls short of what is needed. Shortfalls exist in Vermont as well as in New Hampshire — even though on a per capita basis Vermont’s spending on mental health care is more than double New Hampshire’s.

More budget battles

Throughout five decades of efforts to move mental health care out of large hospitals and into communities, in the Twin States and elsewhere, new budget cycles have regularly presented fresh challenges to reforms and reformers.

Yet some see progress being made.

Vermont’s newly enacted fiscal 2016 budget treated mental health care “reasonably well,” Frank Reed, the interim commissioner of the Vermont Department of Mental Health, said in an interview in late May. “We did not see reductions in major areas, especially in community-level programs.” The department’s budget last year was about $220 million. While that number ticked down to $217 million this year, much of that reduction resulted from the shift of small line items to other departments, he said.

But Sen. Claire Ayer, an Addison Democrat, said that mental health care finances “may have lost ground” in the latest budget. “If you consider the designated agencies and Medicaid mental health providers as part of the system, and I do, we were unable to add the money to provide raises for staff,” she said. “Because of that we’re falling behind.”

Anne Donahue, a Republican state representative from Northfield and mental health care advocate, said that cuts to vocational rehabilitation and peer support services had hurt mental health care, as had an 0.25 percent increase in the reimbursement rate for community mental health agencies. That was less than the rate of inflation, and difficult for those agencies because they lack alternative sources of revenue, she said.

In New Hampshire, budget winds are blowing even more harshly. In February, Gov. Maggie Hassan promised to “continue our efforts to address our strained mental health system, which remains a pressing challenge facing our families, health care providers, police officers, and communities across the state.” She noted that her proposed budget included funding for a new, 10-bed inpatient stabilization unit at New Hampshire Hospital and “the funds necessary to maintain our commitment to our landmark mental health settlement.”

But funding for mental health has become a point of contention in an ongoing budget face-off between Hassan, a Democrat, and the leaders of the Republican-controlled Legislature.

A budget passed by the Senate would have trimmed $6 million from Hassan’s request for funds to implement the agreement that settled the 2012 lawsuit that alleged that the state had violated the civil rights of some patients with serious mental illness. The budget passed by the House would have kept the new inpatient stabilization unit at New Hampshire Hospital sitting unused after the completion of construction, which is expected soon. The unit, which is designed for patients in crisis who can recover through an intense but short course of treatment and avoid admission to the larger hospital, would save money in the long run, hospital officials said.

Jeanie Forester, chair of the Senate Finance Committee, said in a June 22 interview that a budget agreed to by both chambers would restore all but $1 million to the $22.9 million in settlement agreement funding sought by Hassan. The Republican budget also would allow the new state hospital unit to open and preserve several nursing jobs that had been on the chopping block, she said.

But Hassan and the Republicans continue to disagree about whether to include in the new budget money to keep alive beyond 2016 the New Hampshire Health Protection Program, which tapped Affordable Care Act funds to expand low-income individuals’ eligibility for Medicaid coverage that includes mental health care. “I would find it difficult to tell 40,000 people you don’t have health coverage anymore,” Nick Toumpas, the commissioner of the New Hampshire Department of Health and Human Services, said of the impact of shutting down that program.

Forrester said that the future of the program, which is sometimes referrred to as Medicaid expansion, is “a policy issue and needs to be dealt with separately.”

Mental health providers are also carefully watching carefully how the settlement agreement is implemented.

Suellen Griffin, the West Central executive director who also serves as president of the New Hampshire Community Behavioral Health Association, expressed concern that the settlement agreement’s promise of improved local services would prove illusory. Griffin noted that while the state has committed to spend about $90 million to implement the deal over four or five years, she and other local mental health leaders are concerned that some of that money would be raised by cutting the rates at which community mental health providers are currently reimbursed for services.

That manuever would be a sort of “shell game” in which no new money would be spent on mental health care, but only shifted from one account or service to another, she added.

Beyond the current budget cycles, the financial foundation for mental health care reform remains uncertain in both states.

New Hampshire has pinned its near-term hopes on a waiver of Medicaid rules that would allow the state to spend more than $200 million to improve mental health care and further integrate it into the general health care system.

The 213-page application, filed May 30, 2014, details how the state wants to use Medicaid dollars, which match state spending with federal contributions, to pay hospitals and clinics to maintain and expand mental health care capacity, implement new and expanded services called for by the settlement agreement, expand mental health and related services for children and youth, and train and retain mental health and substance abuse caregivers. The waiver would also permit Medicaid money to be spent on programs to promote physical fitness and smoking cessation and to provide dental care to pregnant women and mothers with small children.

That application looks promising to some local health care leaders. Peter Wright, the chief executive of Valley Regional Hospital in Claremont, said that he believed the waiver could generate $250 million in revenue for the state over five years. Valley Regional has so-far unsuccessfully sought state financial backing for a plan to spend $1.5 million to add 10 psychiatric beds for patients who pose a danger to themselves or others.

But Toumpas cautioned that the fate of the waiver application remains in doubt. A waiver is granted “solely at the discretion of the (U.S.) Secretary of Health and Human Services,” he said. “It is not a slam dunk. It is not a done deal.”

Vermont already has its own green light for innovation. “We have an 1115 waiver currently,” Reed said. “That does allow us a good deal of flexibility currently for both the work that we’re doing (to improve) inpatient care and (for) investments in the community.”

But more will be needed. Right now the state is preparing to apply for a grant from the U. S. Substance Abuse and Mental Health Services Administration to support the development of “certified behavioral health clinics” that would focus on integrating care for physical and mental health and substance abuse.

Vermont hopes to be one of the 22 states that get planning grants worth up to $2 million. Those choices are expected before the end of this year. Vermont also hopes to be among the eight states that will receive implementation grants, Reed said.

But even with waivers and grants in hand, mental health care in the Twin States will continue to face financial challenges. So Jeffrey Rothenberg, the chief executive of Vermont’s new state hospital, thinks it’s time to end the “poor relation” status that behavioral health providers have among caregivers. “I think it’s important for mental health care to be part of health care,” Rothenberg said.

He noted that even as “hospitals are getting 4 percent increases each year, and it’s a decrease from their usual increases,” community mental health providers frequently scramble to get any increases in their budgets. Community mental health would be better off, he added, to “be part of that overall health care budget.”

But cost-cutting pressures are mounting inside and outside the health care system. That is likely to dampen the reception that mental health caregivers will receive if they try to tap into existing revenue flows.

In the end, only the federal government has the deep pockets to fund concerted reforms or expansion of care for mental health and other separate but related maladies, such as substance abuse.

But such programs historically have been the responsibilities of the states, albeit shared substantially in recent decades through the complex and evolving federal-state marriage called Medicaid.

But with health care reform enmeshed in the seemingly perennial partisan disputes about Obamacare, the political formula to increase the federal role in funding mental health care, inside or outside of Medicaid, remains, at best, elusive.

Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229. Today’s story is part of a project that is supported by a Health Care Performance Reporting Fellowship from the Association of Health Care Journalists and by The Commonwealth Fund.