Why can't we... be the first state in the union to follow through... and not let the [President's New Freedom Commission on Mental Health] gather dust in this state.
(J.C.)
Ohio's behavioral health system includes publicly funded mental health services and alcohol and drug addiction services. Many persons with serious behavioral health care needs experience long term but episodic illness. The episodic nature of their illness is quite different from the disability experienced by people with mental retardation and many frail elderly persons. Acute care situations tend to be short (less than a week), but a small number of admissions for acute stabilization of psychosis or addiction last for weeks or even months because treatment proves elusive. The mixture of short-term and long-term treatments (e.g., medication, therapy) and supports (e.g., case management, supported housing) vary over time.
Approximately one in ten Ohioans experience behavioral health care needs at some point in life and, due to a lack of overall insurance or parity for behavioral healthcare, many people are unable to access the services and supports that they need via a private insurance plan. The publicly funded behavioral health system in Ohio functions as a safety net, providing acute care services and supports for indigent and working poor persons and virtually all long term care for persons with serious disorders, since private insurance often does not cover these services.
Ohio's behavioral health system faces unique financing challenges. A longstanding federal policy excludes federal Medicaid reimbursement for inpatient psychiatric hospitalization for individuals aged 22 to 64. This means that, unlike other delivery systems related to Ohio Access, the behavioral health system is unable to use Medicaid home and community based waivers to "refinance" and generate additional federal funds for expanded services.
Ohio is recognized as having one of the strongest community behavioral health systems of any large state. It mirrors the state's general preference for local control with state direction and, through a local board system, allows for a unique level of local feedback and decision-making. Yet, that success is tempered by the reality of emerging crises in communities across Ohio.
The Ohio Access cabinet recommends focusing on behavioral health to:
- Increase community based services;
- Maintain public/private inpatient capacity;
- Strengthen behavioral health Medicaid administrative processes;
- Provide access to better care for children; and
- Implement the President's New Freedom Commission recommendations.
B.1 Increase Behavioral Health Community Based Services
Behavioral health community care is managed and governed by local Boards, many of which have multi-county jurisdiction, and most of which have combined responsibility for mental health and alcohol and drug services. Community care is provided by community agencies that are certified by ODMH and ODADAS and under contract with Boards. That system of community care is under extraordinary financial stress brought about by a number of factors, including:
- Erosion in the strength of state funding for the community system (Ohio's ranking among states in terms of per capita spending for mental health dropped from 17th in 1981 to 34th in 2000;
- Matching funds for Medicaid behavioral health benefits are provided by local boards using ODMH, ODADAS and local levy resources. Increasing Medicaid costs, coupled with below-inflation GRF revenue increases, are causing reductions in services for the many individuals who need services but are not Medicaid eligible;
- Reductions in private mental health spending, closure of private hospital psychiatric units, and a corresponding shift of costs to the public mental health system;
- The downsizing of state psychiatric hospitals has been completed, resulting in very low levels of institutional beds compared to other states and other long term care systems in Ohio. This means that savings in institutional costs are not available in behavioral health, as they may be in other systems, to cover the costs of current or expanded community care;
- Inability of boards to gain public support for new or increased levies; and
- Increased demand for behavioral health services.
The financial stress on the community system is most directly affecting poor adults who are seriously mentally disabled but not eligible for Medicaid. Without the support of the community system, these persons may fail at parenting, become homeless, enter the criminal justice system, or worse. They will face lives of despair and hopelessness. This is particularly tragic for people who, with proper treatment and supports, could be active and contributing members of society.
| B.1.1 | ODMH and ODADAS will seek additional funding in the SFY 2006-2007 budget to increase behavioral health community based services. |
B.2 Maintain Public/Private Inpatient Capacity
Since 1997, Ohio's mental health inpatient system, both public and private, has lost 13 percent of its capacity to serve some of its most needy citizens. Many hospitals have "downsized" their psychiatric units and at least 22 have closed their units entirely. This downsizing followed the dramatic reduction in ODMH facilities in the mid 1990s, with five institutions closed, and a 60 percent reduction in ODMH beds from 1990 to 1998. The reasons behind this erosion of inpatient capacity are complex, but include a lack of adequate fiscal resources and reimbursement, reorganization and mergers of hospital systems, and shortages of skilled professionals including psychiatrists and registered nurses. These changes have intensified the pressures on an already fragile mental health system:
- Average length of stay decreased approximately 12 percent in private settings and eight percent in public settings from 1997 to 2002.
- The number of admissions and discharges increased 40 percent in private settings and 10 percent in public settings from 1997 to 2002.
- Total charges for inpatient services increased 12 percent from $9,700 in 1993 to $10,888 in 2001 while charges for all other major diagnostic categories increased nearly 55 percent over the same period.
- The number of patients admitted from overcrowded emergency departments increased 20 percent from 2000 to 2002.
| B.2.1 | B.2.1 ODMH will continue to monitor access and adequacy of hospital and community acute care in the public and private sectors, and recommend changes in policy, rates, or budgets as needed in order to sustain access to acute inpatient behavioral health services. |
B.3 Strengthen Behavioral Health Medicaid Administrative Processes
The Medicaid benefit for community behavioral health in Ohio is managed by ODMH and ODADAS, with responsibility delegated from ODJFS. ODMH and ODADAS are committed to jointly improving administration of the Community Medicaid Behavioral Health Program at the state and local level. Each level of administration must perform essential activities to assure the community Medicaid behavioral health program meets consumer needs and complies with federal and state Medicaid requirements. The two departments, supported by ODJFS, developed a Medicaid Business Plan early in SFY 2004 that describes the scope and sequence of work necessary to achieve proper, efficient and statewide administration. The Plan addresses standardized Medicaid contracting, dispute resolution, auditing and compliance, rate setting, reimbursement and cost reconciliation, claims processing, clinical system improvement, implementation of Assertive Community Treatment (ACT) and Intensive Home and Community Based Services (IHCB) and Medicaid Administrative Claiming (MAC) for boards.
The purpose of the Medicaid Business Plan is to ensure consumer access to services, the quality of those services, and accountability at all levels of administration of the community Medicaid behavioral health program. By better defining and redesigning the reimbursement system to align with statewide Ohio Access principles, and by implementing tools to ensure quality of services and compliance with federal and state rules and regulations, the community Medicaid behavioral health program will achieve additional value from taxpayer investments. For example, the addition of ACT and IHCB services will enhance the options for evidence-based care available to individuals served by the community Medicaid behavioral health program.
| B.3.1 | ODMH, ODADAS and ODJFS will standardize Medicaid payment contracts and uniform cost reporting, and add ACT and IHB as Medicaid reimbursable services in SFY 2005. |
| B.3.2 | ODMH, ODADAS and ODJFS will implement provider-specific fixed rates for community participating providers in SFY 2007. |
| B.3.3 | ODMH, ODADAS and ODJFS will implement other elements of the Medicaid Business Plan during SFY 2005-2008 and finish the project in SFY 2009. |
B.4 Provide Access to Better Care for Children
Child and adolescent behavioral health problems are a significant issue in Ohio's child welfare system (with inadequate access a federally-cited deficiency), the major driver of school failure, a major challenge in juvenile justice, the leading problem in adolescent health, and a leading cause of death among teens.
Ohio is in a strong position to provide access to better care for children and adolescents with behavioral problems: Ohio's Healthy Youth Initiative involves schools to address behavior; evidence-based and best-practice models exist for making positive change; and technical assistance is available through the OSU Center for Learning Excellence, the Center for Innovative Practices, and School Success Networks. In addition, Ohio has several community-based planning processes in place to align these resources, including a comprehensive local planning process sponsored by Ohio Family and Children First called Partnerships for Success.
| B.4.1 | ODMH and ODJFS will work with interested stakeholders in SFY 2004 to identify strategies to expand the supply of behavioral healthcare to priority populations. |
| B.4.2 | ODMH will implement Access to Better Care during SFY 2005 as an extension of Partnership for Success planning through the Ohio Family and Children First Initiative. |
B.5 Implement The President's New Freedom Commission Recommendations
President Bush appointed ODMH Director Mike Hogan to Chair the New Freedom Commission on Mental Health. The Commission reported that recovery from mental illness is now a real possibility, but that for many Americans the services and supports they need are fragmented, disconnected, and often inadequate. The Commission proposed transforming the nation's approach to mental health care to support recovery (See: www.MentalHealthCommission.gov). ODMH with stakeholders will develop a comprehensive strategy to implement the Commission's recommendations, with emphasis on the following actions:
- Create a comprehensive state plan;
- Raise awareness to reduce stigma; and
- Make suicide prevention a priority.
Create a Comprehensive State Plan
The President's Commission recommended creating a comprehensive state mental health plan to reach beyond the traditional state mental health agency to address the full range of treatment and support service programs that consumers and families need. This approach is intended to overcome problems with fragmentation in the system, and to leverage resources across multiple agencies that administer state and federal dollars. Ohio is in a strong position to make quick progress: Ohio Access already coordinates activities across multiple state agencies; the Ohio Commission of Mental Health reported recommendations for system change in January 2001; and ODMH currently has initiatives underway to improve the quality of services for multi-need adolescents, adults with co-occurring mental illness and addiction or MRDD, adults with mental illness involved in the criminal justice system, and children with behavioral disorders in schools.
| B.5.1 | ODMH will initiate a comprehensive planning process before January 2005. |
| B.5.2 | ODMH will release a comprehensive state mental health plan no later than SFY 2007. |
Raise Awareness to Reduce Stigma
The Commission recommended raising awareness about mental illness as a strategy to reduce stigma, which discourages many people from seeking the services they need. Ohio is one of eight pilot states selected to participate in the Elimination of Barriers Initiative, a national anti-stigma effort sponsored by the federal Center for Mental Health Services (CMHS) in the Department of Health and Human Services Substance Abuse and Mental Health Services Administration. Reducing stigma in the general public and business community will increase employment and housing opportunities for people with mental illness and substance abuse disorders, and will enable consumers to participate more fully in the social fabric of their communities. CMHS is developing materials for three primary audiences: the general public through broadcast and print media public service announcements; the business community through educational materials for CEOs and managers with hiring responsibilities; and schools through resource kits for administrators and teachers.
| B.5.3 | ODMH will coordinate distribution of "pilot" anti-stigma public service announcements and materials for the business community and schools in mid-2004 and cooperate in the federal evaluation of the program. |
| B.5.4 | ODMH will coordinate the distribution of final anti-stigma materials in September 2005. |
Make Suicide Prevention a Priority
The Commission also addresses suicide prevention. Suicide is the second leading cause of death among people age 15-19, the third leading cause among persons age 10-14 and 20-24, and the eighth leading cause among males of all ages; and suicide risk for persons 80 or above is three to four times higher than for younger Ohioans. ODMH already has a plan for the prevention of suicide that includes improved tracking of suicides and attempted suicides, targeting intervention strategies to high-risk groups, encouraging communities to adopt prevention and response initiatives, implementing age-appropriate suicide prevention programs in schools, and evaluating the effectiveness of prevention programs.
| B.5.5 | ODMH will join the National Violent Death Reporting System in SFY 2004. |
| B.5.6 | ODMH will implement age-appropriate suicide prevention programs in schools beginning in SFY 2004 using the department's Red Flags and Teen Screen programs as models. |