Mental health care: Not enough money, even less trust

In the good old days, if you just wanted to see spit fly from the mouths of normally calm mental health care professionals you simply had to talk to them about Maine state government and how it funds (or doesn’t fund) mental health care for the mentally ill poor. These days the show is even better – dangle terms such as “Baldacci administration” or “Maine Department of Health and Human Services” in front of them now and their eyes will bug out; feral snarling replaces coherent speech, and many will start frothing at the mouth.

That’s because the Baldacci administration’s recent decision to cut Medicaid funding for mental health care by perhaps $100 million (one-third in state funds, two-thirds in matching federal funds) over the next two years heaps fresh salt onto the wounds of more than 40 years of inadequate funding.

The state says the cuts are fat-cutting efficiencies, while providers say they amount to amputations that will leave the poor with inadequate care. The state says Maine pays more for these services than other states do, while providers say mental health care everywhere is inadequately reimbursed so external standards that are too low are useless benchmarks. The state says we have too many hospital beds for the mentally ill, while some wait hours and even days to get into those beds. The state says its proposed changes in services management will improve coordination of services, while the providers of those services say state government never coordinated anything in mental health and the state’s proposal to “manage care” is simply a money-saving measure meant to cut costs and drive many of them out of business.

The cuts, and transition of mental-health services management for Medicaid patients to a managed-care model, have further poisoned an already acrimonious relationship between state officials who administer Maine’s reimbursement bureaucracy and the mental-health professionals who deliver services to mentally ill Medicaid patients. In some provider circles, they believe virtually nothing of what state officials say about policy issues, never mind what officials say about cost issues.

It will therefore be difficult for state legislators and others to make policy based on what either side says about the status of mental-health needs in the years ahead as these budgetary and management changes are implemented. Are the cuts and the managed-care model helping or harming patients? Is money really being saved, or will we yet again see reductions lead to mental-health service reductions that result in higher costs for the mentally ill by police, emergency departments, prisons and courts?

Maine’s mental health patients and caregivers, its legislators, state government, and the larger community of health-care providers, need a standard set of measures of the quality of mental-health care for the poor that can be followed as the cuts and managed care are implemented. If nothing else, mental-health caregivers and state officials should be able to agree on a report card of quality indicators.

These quality indicators should be easily understood, and include such measures as the number of mentally ill Medicaid patients who need hospitalization, but for whom there are not enough hospital beds, the number of emergency department visits by Medicaid patients in mental-illness crisis, the number of involuntary commitments, police arrests, homelessness, patient satisfaction scores, children admitted to psychiatric hospitals, etc.

Together, these measures should comprise an official report card – developed and maintained by an independent organization such as the Muskie Institute, published on the Web and to the Legislature – which would grade the state on the success of its mental-health-system delivery changes for poor patients.

The report card should not be confused with the reams of data produced by state government and others about mental-health services. We are drowning in data used by one side or another to prove its case; what we need is specific data that we all agree is designed to demonstrate whether services that should help keep mentally-ill Medicaid patients well are adequate, or whether the services are inadequate, so patients are ending up in crisis.

If state officials are right, and their cuts and managed-care plans will not adversely affect these patients, those kinds of numbers should improve or remain stable. If they are wrong, and multiple indicators of the mental health of poor Mainers worsen, these budgetary and program management changes will represent yet another instance in which mental-health-care patients and providers got stiffed with an undelivered promise while the state took money out of mental-health care and spent it somewhere else. It has happened before; we should not let that happen again.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.