Will Missouri’s mental health treatment innovations survive federal budget, health-care reform fights?

March 24, 2017 | By Chuck Raasch

Missouri is one of eight states about to launch pilot programs significantly changing the way mental health is treated and paid for.

But the reforms in the programs that mental health professionals say are necessary to expand, improve and standardize treatment are vulnerable in the tectonic battles over the federal budget, which is still running large deficits. They also may be threatened if another effort begins to replace the Affordable Care Act.

The pilot-program changes are the result of the Excellence in Mental Health Act, which became law last year after being shepherded through Congress largely by Sen. Roy Blunt, R-Mo. Besides Missouri, Minnesota, New York, New Jersey, Nevada, Oklahoma, Oregon and Pennsylvania are involved.

The pilots themselves are not endangered. But expansion of the innovations they contain could be, depending on how Congress resolves its current fiscal and health care battles.

Missouri is considered an innovator in many of the reforms included in the pilots. They include setting minimum treatment standards, coordinating responses to mental health emergencies with law enforcement, treating mental health and physical health simultaneously and more holistically, and moving away from fee-for-service billing to a system based on average costs for services provided.

About 70 percent of Missouri’s population will be covered under the pilot through community health networks that operate around the clock. Nationally, the initial cost to the federal treasury, primarily through increased Medicaid payments, is estimated to be $1 billion annually.

But Blunt and mental health advocates say better access to treatment and innovation will save money through fewer emergency and hospital visits and reduced incarceration of people who may need treatment rather than jail time.

Too often, advocates say, those suffering from mental illness have not gotten the physical treatment necessary for diseases compounded by a patient’s inability to cope.

“If you treat mental health like all other health, your total costs go down,” said Blunt. “So whether you are putting a state Medicaid [budget] together or whether you are putting an insurance policy together, if people have the right kind of access to mental health treatment, their other health care costs are likely to go down.”

He said that many people with mental illness didn’t get treatment because of a lack of access to services.

“I think access is at the end of the day the most critical question, and coverage doesn’t always result in access,” he noted. “So I am going to continue to be more focused on access.”

Heading off crisis

Almost one in every five Americans suffers from some sort of mental illness, according to mental health officials. At a recent congressional hearing convened by Blunt, Donald DeLucca, chairman of the International Association of Chiefs of Police, said that about 25 percent of people who died in encounters with police suffered from mental illness.

That’s where the pilot programs come in. Part of its goal is to build a standardized treatment network in which police and emergency rooms can more proactively connect patients with mental health professionals.

St. Louis County and the St. Louis-based Behavioral Health Response recently announced it had been awarded a $1.1 million Missouri Foundation for Health grant to set up a Virtual-Mobile Crisis Intervention program that allows police to connect people they encounter who appear to be in mental health crises with on-call treatment professionals via iPad video.

The mobile intervention program is separate from the pilot Missouri is participating in, but it’s indicative of the broader innovations going on in the field.

The National Alliance on Mental Illness estimates that about 2 million jail bookings a year involve someone with mental illness. DeLucca told Blunt’s committee that untreated mentally ill people who continually ended up in jail or in emergency rooms was “the cycle that never ends.”

“There are a lot of factors here that come together to make it attractive,” said Dorn Schuffman, director of the pilot program for the Missouri Department of Mental Health. “It is not just the mental health community, it’s the law-enforcement community, the courts. They see it as important, as well, because of the problems they are facing.”

A more holistic approach that includes mental and physical care providers’ coordinating treatment of patients “clearly has shown it reduces days of hospitalization and ER,” Schuffman said.

A GOP proposal to repeal and replace Obamacare led to a Congressional Budget estimate that as many as 24 million people could eventually lose insurance coverage. The GOP replacement plan was withdrawn Friday before a vote was taken, and it was unclear whether another effort to replace the ACA would follow.

Mental health advocates say that Medicaid expansion under the current law, and targeted grants set up through the law, have helped states such as Missouri get more people treated, reducing stress elsewhere in the health care system. In 2014, mental health treatment cost Americans about $186 billion, about 6.9 percent of all health care spending, according to the Substance Abuse and Mental Health Services Administration.

Removing Obamacare could hurt “people with serious mental health and addiction” problems, said Rebecca Farley, vice president of policy and advocacy at the National Council for Behavioral Health.

She pointed out that about 25 percent of the cost of mental health treatment in the U.S. is now covered by Medicaid, and that the CBO projections of $880 billion in reduced Medicaid spending over the next 10 years in the GOP reform plan “is going to put extraordinary fiscal pressure on states that they have never had to face before.”

But Republicans say states are better innovators and can do more with less Medicaid funding if fewer federal strings are attached.

“Only in Washington do you literally judge the success of something by how much money you throw at the problem, not actually whether it’s solving the problem,” White House press secretary Sean Spicer said.

In jeopardy

Still, the innovators in Missouri remain concerned about what will survive the budget and health reform fights here.

“Effective evidence” shows that early intervention, coordinated and more standardized treatment of mental health — the goal of the pilots in the eight states — saves strain on many institutions, said Brent McGinty, president and CEO of the Missouri Coalition for Community Behavioral Healthcare.

“We know what happens otherwise — they are going to be in jails and prisons,” he said.

Pat Coleman, the CEO of the St. Louis-based Behavorial Health Response, whose organization will help expand 24/7 access to crisis hotlines, agreed.

“The more access that people with mental health issues have with our type of organization — it definitely can help to increase the diversion from hospitals, from jails,” she said.

“So now all of that is in jeopardy right now,” Coleman said. “We will actually have to see what comes down, but definitely there is a concern.”

ST. Louis Post-Dispatch