Ohio mental health system on 'brink of failure,' community solutions report says

COLUMBUS, Ohio - With Ohio state lawmakers on summer break, the growing fear that next year's growing budget gap will spread the heartache of fiscal austerity among many undeserving human service sectors, the release Monday of a report by The Center for Community Solutions (CCS) arguing for more funding to keep the state's community mental health system from collapsing, only adds more salt to an economic wound few believe can be stanched anytime soon.

Writing in the CCS's newsletter, Susan Ackerman, Fellow, Public Policy and Advocacy for CCS, The Center for Community Solutions, author of the report "Ohio’s Community Mental Health System at a Crossroads," warns that Ohio's mental health system is collapsing due to a lack of investment over many years, and to keep it from collapsing and forcing higher costs on to other related systems, the state "must actively pursue system reform in order to improve treatment and care for individuals with mental illness."

Among the many factors Ackerman says contribute to pushing the system to the brink of failure, lack of funding, not surprisingly, tops the list.

It should come as no surprise that driving people from less expensive venues like a home to higher priced settings like a hospital, nursing home or even a jail, drives up system costs at a time when reigning in government deficit spending, regardless of whether it adds additional hurt to recipient populations who have the least amount of political pull in the system and who may experience more inhuman treatment in the process, is the political mode de jour.

Hitching its wagon of remedies to the opportunity offered for change as a result of the passage of federal health reform by President Obama and Congressional Democrats over the protests of Republicans who are running to repeal it if they gain control of one or both houses in the November elections, Ackerman suggests four recommendations for state lawmakers, and Ohio's next governor, be it first-term incumbent Democrat Ted Strickland or his
GOP challenge, former Congressman John Kasich, to consider.

Additional investment is critical, given that current funding levels for some local boards will not keep up with Medicaid caseload growth rates, which will result in the addition of 554,000 people beginning in 2014. Moreover, the looming expiration of federal stimulus funds that subsidize Ohio's share of Medicaid costs will only exacerbate a system already in trouble.

The reports second remedy is to create a stand-alone Medicaid agency. By combining what five state agencies do now into one agency, Ackerman says such an organizational move would "help to reduce siloed decision making, increase budget and spending transparency across the whole program, and improve the coordination of health care policy and administration."

By creating a bipartisan commission to reform behavioral health care in Ohio, CCS's report says walking through the door of opportunity for change that was opened by health insurance reforms at the federal level gives Ohio the chance to integrate services, redefine roles and responsibilities, develop ways to reduce inappropriate institutionalization, and refashion financing structures and improve coordination across non-health services as never before.

Lastly, providing additional long-term care options for individuals with severe mental illnesses by offering more home- and community-based alternatives to institutional care for this younger, disabled population (under 60 years of age), that are Ohio nursing homes' fastest growing population.

Names of institutions a progressive society built to accommodate the mentally ill, like Bedlam, the first hospital in London, England, that dates to the 1700s and whose name is synonymous with "uproar" and "confusion," have evolved over time to become pejoratives for going crazy. During these progressive times, it was common in the early 18th century to charge people for a chance to star at the "patients," a new term that displaced "lunatics" who lived in a lunatic asylum.

Ackerman, describing Ohio's system of care for people with severe mental illness that she says is "reverting to something that resembles the system that existed when Dorothea Dix began her raids on jails and almshouses in the 1840s," says the time and opportunity for Ohio to improve the health of its citizens is here.

"Ohio cannot continue down its current path," Ackerman concludes.

Report highlights and facts:

Ohio has 50 county boards of mental health or combined alcohol, drug addiction, and mental health boards use state subsidies, federal reimbursement, and local levies (where available) to pay for treatment and supportive services through state hospitals or the community mental health system.
Created by the Mental Health Act of 1988, Ohio uses a financial incentive to encourage treatment in the lowest cost and least restrictive setting.
Boards receive state subsidies based on a formula that factors in population, prevalence of mental illness, and poverty.
Because state psychiatric hospitals are the most expensive care settings, boards can maximize the dollars available to support community-based services by minimizing inpatient hospitalization.
The average daily population in state psychiatric hospitals declined by 69 percent from 1988 to 1998, from 3,823 to 1,190.
Between 1998 and 2009, the decline in the average daily population in state hospitals was much smaller – a drop of about 15 percent.
The average daily population in Ohio’s seven state psychiatric hospitals today has stabilized at about 1,000 people.
Under current policy, it is not reasonable to expect that state psychiatric hospital inpatient hospitalization rates can be appropriately reduced much more.
Savings from the deinstitutionalization of state hospitals has peaked.
As the number of people in state psychiatric hospitals has decreased, the number of Ohioans served by the community mental health system has been increasing steadily: up 34 percent from fiscal year 2002 to 2009.
The number covered by Medicaid grew even faster – 47 percent.
In FY 2009, more than 340,000 people were receiving treatment in the community mental health system with 68 percent covered by Medicaid.
Children make up more than one-half of the consumers receiving coverage through Ohio’s Medicaid program, they only represent 33 percent of all community mental health system clients.
About 1.9 million people were enrolled in Ohio’s Medicaid program in FY 2009.4
12 percent of them also received community mental health services.
From FY 2003 to FY 2009, Ohio's Medicaid program caseload grew by 21 percent, while mental health Medicaid clients increased more than twice as fast – by 47 percent.
Non-Medicaid services and services to non-Medicaid eligible clients have been reduced or eliminated, many providers are offering care without compensation.
Many clients are waiting longer to see a professional or are receiving services less frequently.
Compared to the general population, individuals with a severe mental illness die on average 25 years earlier from preventable health conditions.
County boards pay for inpatient care in state hospitals and community-based mental health supports.
The Ohio Department of Job and Family Services’ budget pays for physical medical care, prescription drugs, general hospitalization, and nursing home stays.
Ohio's fractured system creates incentives to shift costs between systems which can lead to inappropriate and more expensive patient care.
The average cost of a nursing home stay in Ohio is $168 per day.
The cost of incarceration in a state prison is $69 per day; 16 percent of the nation’s prisoners have a serious mental illness.
Medicaid is now the largest payer of mental health services in the United States, accounting for more than 50 percent of public spending on mental health services.
Medicaid services for mental health in Ohio leave significant gaps in coverage, such as family counseling, intensive home-based services, and supported housing.
Medicaid eligibility is limited to two main categories – covered children and families and aged, blind, and disabled.
Individuals with severe and persistent mental illnesses are more likely to be uninsured.

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