The cost of ignoring needs of mentally ill
By JODI SMITH
Special to The Press
As the country faces an economic crisis that has not been seen since the Great Depression, our state is in the midst of determining ways to manage the budget. Medicaid, which faces somewhere between a $35-$185 million deficit depending on which report you read, is likely to experience the most drastic cuts. Current estimates have the deficit at somewhere around $92 million, yet that could change as new data is received. Proposals have been made to eliminate entire Medicaid programs, including community-based services for adults with developmental or mental health disabilities and dental care for adults with the exception of pregnant women.
Currently, less than 8% of all health spending is attributed to behavioral health spending. While this may seem like a good place to make cuts, we must take into account the domino effect of doing so. People who live with conditions affecting their behavioral health are at a much higher risk of physical illness and disability than others. Medicaid recipients with behavioral health disorders are less likely to seek preventive care for physical concerns that may arise and are 30-60% more likely to suffer from preventable conditions such as pulmonary disorders, hypertension, diabetes, and heart disease. A report by the United Hospital Fund found that “Mental health beneficiaries spending on physical health services was 32% higher than comparable spending for non-mental health beneficiaries.” Additionally, links between Medicaid spending and the co-occurrence of severe physical health and behavioral conditions have been made. A study by the New York Community Trust found that 60% of all Medicaid spending in New York is for 10% of the beneficiaries and that most did not get adequate health care until their physical conditions became critical and that this resulted in long, costly hospital stays.
These findings indicate the message that Idaho consumers of behavioral health services and providers of these services have been echoing for some time………eliminating vital community-based programs to our most vulnerable citizens will only serve to increase Medicaid costs. While our legislature has asked for suggestions as to how to cut costs, some continue to be unwilling or uninterested in taking these suggestions to heart. Prior to the state-wide Medicaid Matters rallies held on February 19th over 15,000 signatures had been obtained on petitions in support of increased beer, wine and tobacco taxes as a way of increasing revenue to save programs from elimination. This number can reasonably be anticipated to increase by at least 50% over the next couple of weeks due to efforts made by those in support of this option.
What other options are there? Well, plenty have been suggested by provider networks and advocates. It’s clear our behavioral healthcare system is in need of restructuring, the question is, how to go about this without completely dismantling the current system? There seems to be a clear consensus that early intervention with this population could reduce health care spending by averting health crises. Those of us in the field know that those at highest risk must be identified BEFORE they are in crisis. Not only is aggressive outreach necessary to identify these individuals, just as important is the opportunity to engage these persons at high risk before they are in critical need. When individuals are not identified until they arrive at emergency rooms, as frequently happens, there needs to be an avenue to link them to community-based services/supports immediately or the pattern will be repeated.
Our current system includes services such as Psychosocial Rehabilitation (PSR), a community-based skill building program designed to teach persons with severe and persistent mental illness coping skills and strategies to avoid higher cost services and become integrated into their community of choice. PSR provides only a part of the overall continuum of care, and has been deemed by some as ineffective and costly. This is far from the case and as many consumers of this service will state…..far from true. Persons living with mental illness across the state have shared stories with legislators of how PSR services have helped them remain in their homes, achieve educational and vocational goals, and become active members of their communities. PSR is a program that instills HOPE and promotes RECOVERY and COMMUNITY INTEGRATION to over 6000 people in Idaho. Many of these Idaho citizens are now living in fear that the supports that have helped them manage the symptoms of their mental illness will be stripped away with nothing there to replace them. Sure, some can say these individuals have family members, churches and neighbors willing to help out, but the truth is most don’t. Many of these adults have been living with mental illness most of their lives they find themselves alienated and stigmatized, due not only to the devastating effects of mental illness, but also a lack of education and support for their families and the community at large. This community-based service assists consumers to achieve their stated goals, on their terms. PSR is a voluntary service, and those electing to receive this service have the ability to determine what they want, when they want it and how they want it, thus empowering them to guide their journey of recovery based on what it means to them, not what it means to you, me or anyone else. Without this service, these individuals face having their right to choose taken away because there will be very few remaining options for support. No longer will they be able to call their PSR provider at 1am when they are hearing voices telling them to hurt themself and have a caring, trained person on the other end who can guide them through the steps of their personal safety plan. I shudder at the thought of what someone in this situation may do when they can no longer access this support, and so should you. This is but one scenario of what will happen if PSR services are eliminated.
Idaho Medicaid put into rule in 2009 that all qualified PSR providers, not already licensed by the Idaho Bureau of Occupational Licenses as a social worker or counselor, obtain the Certified Psychiatric Rehabilitation Practitioner (CPRP) credential. This was a bold and controversial move as it requires that a number of individuals in the field obtain specialized training and experience to apply for and pass a nationally administered examination. While the PSR program was simultaneously facing cuts and future funding uncertain, there was much concern over the additional required credential and the significant associated cost. The United States Psychiatric Rehabilitation Association (USPRA) administers the CPRP program. In 1975, the U.S. Psychiatric Rehabilitation Association and its members developed and defined the practice of psychosocial/ psychiatric rehabilitation, establishing these services as integral to community-based treatment and leading the recovery movement. Today, with nearly 1,400 members, USPRA is the preeminent association advancing the practice of psychiatric rehabilitation and recovery. Established PSR providers in Idaho are feverishly working to get the training and log their work experience hours to apply for and take the exam before the January 1, 2012 deadline. Many have already acquired the CPRP credential and scores more have submitted applications to USPRA to sit for the exam. The national pass rate of the CPRP exam is around 70%, yet the Idaho pass rate is above 80%. That says something about the quality of the workforce and the integrity of the program. Still, we can all agree improvements can be made.
Eliminating community-based services, such as PSR that serve some of Idaho’s most vulnerable citizens is not the answer to the budget crisis. Yes, it may result in initial cost savings, but it won’t take long to experience the devastation of the increased cost shift to other Medicaid and non-Medicaid programs. Not only that, but we will effectively rewind to the days when people were institutionalized due to lack of any other viable options. If community-based services are eliminated, we will all miss out on the opportunity to experience and learn from these individuals who have so much wisdom and talent to share. We will be throwing them away as if they mean nothing. We ALL have meaning and purpose, and we ALL should be entitled to all supports necessary to fully experience this meaning and purpose.
Jodi Smith, CPRP, LPC
Chair
Idaho Psychiatric Rehabilitation Association (state chapter of USPRA)
Coeur d’Alene, Idaho