While there was much to criticize in the final report of the President’s New Freedom Commission on Mental Health, the basic observation that the “mental health system is in shambles” seems spot on. Further, the recommendation was not for marginal, around the edges kinds of changes, but for fundamental reform. “Knowing the complexity of the mental health system, the commission realized that the incremental reform that has brought us to this point cannot move us forward. What is needed, we concluded, is a transformation in our approach to care. The “mental health mess” cannot be fixed via reorganization or by adding new programs – our conventional tools. The concept of transformation – implying many changes, at every level, over time – emerged as a necessity.”
We are going on ten years now since the report’s final recommendations, and like many pieces of policy reform, it has largely gathered dust.
Nevertheless, in Ohio, local mental health and substance use authorities (“Boards”) are in a unique position to bring about the kinds of fundamental change Dr. Hogan recommended. Beginning in State Fiscal Year 2013 (SFY 13) which runs from July 1, 2012 thru June 30, 2013, local Boards are no longer “in the Medicaid business.” In Ohio, Medicaid is the most common insurance for persons receiving services in the community mental health/substance use system. Those with private insurance and/or ability to pay out of pocket rarely seek services from the community system (that’s a separate blog).
Local Boards are now primarily funded thru non-Medicaid State funding, federal drug/alcohol funds, grants/foundation and local mental health/substance use levies. Medicaid brought with it a far larger bottom line, but it also required Boards to match at 40 cents on the dollar without any meaningful controls to keep providers from overbilling or billing inappropriately. This arrangement actually limited Boards from developing non-Medicaid reimbursable services as they were unsure from year to year what their Medicaid match obligations would be.
[Curious side note here: Some of you in other states may be thinking, why would providers want to do so much Medicaid business? In Ohio, we have separate rates for mental health and substance use services under Medicaid (“Behavioral Health Carve Out”) versus mental health and substance use services under the larger primary Medicaid benefit. Carve out rates are actually so high that providers have a developed a vibrant “business model” taking advantage of high rates and a fee-for-service reimbursement environment.]
So you see the trade-off, the loss of Medicaid passing thru the Boards but the gain of funding flexibility and certainty. Boards can begin or enhance non-Medicaid programming without the perpetual risk of worrying about “Medicaid match overages”. In some respects this is very freeing. Moreover, this freedom allows Ohio’s Boards a chance to transform the local non-Medicaid community system of care to reflect principles of recovery, trauma, medication optimization, peer respite, informed consent, etc.
For example, the Ashland County Board has for ten years allocated local levy funding to the ‘School-Community Liaison Program.’ The services are extremely flexible (limited paperwork, no cost to families/youth, individualized response). The goal is to act as a resource to both school administration/staff and youth/families that may be struggling with a myriad of life issues affecting school performance. Liaisons aren’t the same as mental health workers. The emphasis is not on “pathologizing” or “medicalizing” the challenges youth/families face, but building relationships, providing information, and facilitating referrals that assist the youth and family both at home and at school. Regular readers of MIA will see some opportunities here. By intervening early with the school, youth and family we can begin to turn off the spigot of diagnosing young people with so-called mental illness. We can impact the number of young people being exposed to dangerous psychiatric drugs.
The School-Community Liaison Program is just one example of the kinds of flexible programming now available to Ohio Boards. Peer-Respite, I-Wards and other non-medication based recovery centers? Fund them. Create a local trauma-informed system of care? Yep, you can do that. Throw out the devilishly incentivized fee-for-service paradigm? You bet you can do that now. Work out arrangements to pay for exercise in lieu of medications? Now we’re talking! Of course these non-Medicaid funds are limited, but sufficient enough to impact a community if invested in the right kinds of programming.
So what will Ohio Boards do with this opportunity? Too soon to tell, but I am more optimistic than I was a few years ago. The success of Bob’s book, this website and the general change in “tone” makes me believe that the public will demand better of those responsible for making policy and funding decisions in their local communities. I urge all those bloggers and commenters of MIA to get involved with your local mental health/drug and alcohol authority. By volunteering your time and ideas, you will become a key piece of the transformative change called for by the New Freedom report ten years ago.
*This blog is particularly oriented to readers interested in local governmental mechanics and policies needed to bring about humane reforms in our community mental health and substance use systems of care.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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