Statewide, systematic changes in the mental health service industry are in full swing. Our once stigma-steeped culture of cornering mental health as segregated psychiatric services has shifted to team-based care models. Now, around 90% of Oregon Health Plan (OHP) members are enrolled in Coordinated Care Organizations (CCOs). CCOs administer cherry-picked nets of professionals—physical, mental, and sometimes dental—in cahoots to holistically heal clientele.
These changes are founded in good intentions and said services are evidently paying off, but the majority of those benefiting from mental health care in Benton County and beyond are Medicaid-covered youths and severely suffering adults. Private insurers offer a shortage of services, and the uninsured are unlikely to seek help—although, when they do, they are assisted efficiently.
Over half of the insured and uninsured Americans surveyed by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2011 reported lack of affordability as the number one reason their mental health needs went untreated. Other answers were fear of negative consequences such as stigma in the neighborhood or workplace, or of being forcibly medicated or committed.
Benton County’s mental health professionals, at large, are aware of our system’s reach and those prone to fall out of arm’s length. And beyond decreed duties, they’re participants to new preventative grounds, circulating free public educational trainings, reformed primary care practices, and campaigns aimed at destigmatization.
Given that annually one in five Americans will suffer from a mental illness or that suicide remains the third leading cause of death in 15- to 24-year-olds, it is crucial to cement systematic fault lines, and that takes a competent and sensitized community. Importantly, systematic inclusivity reaps socio-economic success, so adequate care and coverage is essential in a progressive society. Contrarily, coverage is controlled and our taught reaction is to avoid those that appear symptomatic.
Medicaid’s Got You Covered, Unless You’re Moderately Suffering
Of Benton County’s 5,032 youth and 9,175 adult Medicaid members, 15.4% and 39.9% respectively were identified as having mental health needs which would benefit from treatment or services, according to the newly released 2015 Oregon Health Plan Behavioral Health Services Gap Analysis. Results conclude there are more youths served than needing service, approximately 16.9%. Adult members, however, saw a served rate of 18.4%, less than half the amount identified.
The apparent over-service of youths yields a 0% gap overall; however, 98 Medicaid youth in Benton County, needing two or more services, went unserved. This means that those seeking services any one time are pretty much guaranteed to be seen. However, those in need of further treatment are more prone to fall through the cracks. Data representing severely suffering adults mirror these results.
Of Medicaid recipients, results go on to prove the most underserved populous is adults with mild to moderate mental health needs. Such moderate cases made up 2,919 of the 3,659 adults analyzed as needing services in Benton County.
Most deficiently, 68% identified mild to moderate adult members’ needs went unserved by any services and 82% identified as needing at least two. The cost to fill these gaps, to serve our county’s 1,992 mild to moderate Medicaid sufferers, is estimated at $1,992,000, figuring on $1,000 funding per client, plus an equivalent of 16.6 full-time employees (FTEs) to facilitate. Oregon overall would need $200 million annually to mend the 50% gap of OHP Medicaid members identified and unserved statewide.
“We just can’t grow big enough to serve that middle gap,” said Mitch Anderson, head of Benton County Health Department, in reference to those milder cases. Anderson understands how situational hardships, “left unattended, can be really debilitating, too.”
In light of our finite funds and FTEs, of our system’s rigid skeptics, Anderson asserted, “You can have a very effective mental health system, but if it doesn’t meet the demand, people on the outside are going to say it’s broken.”
OHP: Outside Looking in
OHP’s tiered system prioritizes health care codes by highest degree of cost to clinical effectiveness, draws a line at its budget and covers all above. The idea is that successful treatment over time generates prevention, allowing that line to plummet and cover more codes. Codes are evidence-based, scientifically proven, and analyzed every two years by the Oregon Health Evidence Review Commission (HERC).
The percentage of Oregonians of all ages enrolled in Medicaid and receiving mental health services is 16.3%. Now, consider for a second those that are unserved, unrepresented, and uncovered, privately insured or otherwise.
This was the challenge recently issued during Albany’s Behavioral Health Town Meeting, one of many statewide, held by Senator Sara Gelser and Oregon Health Authority (OHA). Attendees were divided into tables and asked three rounds of questions, the first of which prompted people to reveal their current challenges as well as the “best thing in their lives.”
Among the crowd of families, professionals, and advocators sat Mary Buzzell, Family Partnership Coordinator at Trillium Family Services. Buzzell understands the crucial need for people like her who can offer peer support, backed by common experience, as she confronted the system herself, suddenly, when her son began showing signs of mental deficit. Buzzell was stranded in that long waiting line, her private insurance offering zero relief.
Presently, private insurance patients with insufficient mental health coverage can visit Benton County’s website, call its CCO-provided phone number for assessment, and if deemed eligible, get one same-day appointment. In some cases, CCOs could issue what is referred to as an Early Psychosis and Early Assessment and Support Alliance (EASA), an extended two-year wraparound support service for 12- to 25-year-olds. However this is unlikely, given that Benton County currently lacks funding for an EASA program.
Under-Insured and Uninsured
The Congressional Budget Office predicts that 30 million Americans will remain uninsured in 2016, a modest comparison to the 50 million reported by Kaiser in 2010. Since health care coverage was made mandatory by the Affordable Care Act (ACA), polls show the bulk of those remaining uninsured are 19- to 25-year-olds, and they are often either unemployed or devoid of benefits and confused as to where to go for coverage. They are dubious of qualifying for subsidies to reduce monthly premiums, rates so unaffordable they’d rather face the fine.
Among those encountered at Good Samaritan Regional Health Center are some of the uninsured in Benton County, last documented at 18% in 2013. Caroline Fisher, Vice President of Mental Health at Samaritan Health Services, mentions OHA campaigns for training social service employees to assist in signing people up for insurance. This allows ease of access for uninsured patients admitted to Samaritan’s Emergency Room (ER), Mental Health (MH) units, or other inpatient units.
Fisher details how adequate care becomes most problematic for those privately insured, because employers control options and most likely aren’t focused on mental health coverage when choosing which plan to sponsor. Coverage likely varies between outpatient, inpatient, and intermediate services. One private insurer might offer ample inpatient coverage but zero funding for intermediate services such as sub-acute or short-term residential rehabilitation. However, such differences are not apparent even on fairly close inspection.
Dishing further difficulties, Fisher explained, “You can think you have coverage in that your policy will say they cover mental health inpatient X amount and outpatient Y amount, just like it goes through coverage for pregnancy or hospitalizations. However, if the insurance company is not willing to pay fair market rates, providers won’t agree to contract with them. If you can’t find a provider who accepts your insurance, you effectively have no coverage.”
One suggestion Fisher shares is contacting your insurance company and requesting they help you find a provider, since insurers are contracted with a specified number of providers to provide covered services. If the insurer is unable to find a contracted provider, they may be willing to agree to contract with someone out of network.
“You pretty much have to say, ‘I have a provider and now you need to be willing to contract with that person.’” Fisher recommends being sure such outlying providers are willing to negotiate with the insurance company, because sometimes insurers offer insufficient rates for covering the cost of providing the service. Though not affordable for most individual providers, providers may be prompted to help pay for care, as well as non-profit organizations with private donations, sometimes able to subsidize care.
One way to avoid systematic co-pays is to seek out local group therapy sessions, offering out-of-pocket payment. Psychology Today lists over five pages of therapeutic practitioners within Benton County. Currently ongoing are Dialectal Behavior Therapy (DBT) group sessions, hosted every Tuesday or Saturday by Licensed Professional Counselor Nancy A. Olsen.
DBT is a cognitive-behavioral psychotherapy offering detection and support over deficits in vital developmental categories such as emotional regulation and social skills. It’s utilized in our area by Trillium Family Services.
Prevention Pays for Itself… Eventually
Richard Blum, Vice President of Business Development at Trillium’s Farm Home, foretells of the Corvallis’ Boys & Girls Club’s anticipated addition, which will offer outpatient mental health services to all OHP eligible families.
According to Blum, they could be “building a whole generation of kids who don’t view mental health help as a stigma.”
Centralizing the team of professionals, bringing them straight to the kiddos is what Blum believes will eliminate no-shows and transportation cost, as well as normalize the need for mental health help. He backs up the financial and social benefits with the success of contracted professionals first implemented in Corvallis and Philomath public schools and now employed throughout the county. Both districts were considered most at risk after the tragic spike in suicides over a year and a half ago, inciting the state to funnel them money.
These districts have seen what Blum believes to be a drop in overall completion and attempts, proof that early intervention and prevention via on-site, eye-peeled professionals are key to student thrival and survival, that the skills vital to well-being are best taught early on.
Regarding this seeming success, Fisher said, “The problem with suicide is we really won’t know until the preventative and intervention measures pay off in the long term.” She notes the cyclic rise and fall of suicides and the fact that they often happen in clusters. One cause could be contagion effect, as it spreads suicidal ideation in its wake. Such tendencies further highlight the necessity of implemented safeguards.
The Vulnerable Age
Fisher admitted, “When they hit 18, it’s a bit of a desert,” confirming that 75% of all mental health disorders typically emerge before a person’s early 20’s, and noting a marked decrease in the variety of services available for young adults, an age where, as noted, a person is most likely to be uninsured.
Already tasked with establishing one’s life trajectory, there is traditionally much less support from school, home, or the mental health system. Options such as wraparound services and residential step-down units become much less available after the age of 18. Sometimes adolescents who had made progress or been successful with early support face adulthood untethered.
The wait for seeing a private psychiatrist can take months. Inpatient beds are limited, too, and for a person reaching crisis state—where every second matters—the wait can sometimes take weeks. Samaritan has 24 beds and, depending on rate of discharge, one could expect anywhere between a few hours to a four-day delay at their facility.
On a more positive note, psychiatrists, psychologists, therapists, and primary care providers are now teaming up to improve mental health treatment in primary care offices. Primary care docs now screen for common mental illnesses like depression using simple screening measures that patients fill out at their regular visits. Plus, docs are speaking with patients about how to improve their emotional well-being. Patients may be referred to a psychologist or therapist on site to work on emotional betterment, and psychiatrists collaborate with primary care providers to manage patients’ mental illness.
Now, “Instead of mental illness being isolated and stigmatized, it can be normalized,” Fisher explained.
This fairly new, innovative approach not only alleviates stigma and stressors, but is also more effective, relieving an overflow of ER visits and allowing psychiatric professionals to pencil in more urgent cases.
Fisher emphasized, “The number one thing we can do is acknowledge that mental illness is a real thing. This is a biological illness, not a character flaw. It is nothing to be ashamed of.”
Allotted a small margin for success, it is no wonder those phasing out of facilities, especially treatment-focused ones with blanketed support programs, are prone to fall through the cracks. Trillium’s Sender House in Albany, our region’s only residential facility for adults phasing out the children’s mental health system, reiterates our shortage of services. Sender House has only five beds and sits on a massive amount of applications. Its confirmed success in catapulting clients, after facilitating real-world connections, should be cause enough for establishing more of its kind.
Free First-Aid, New Best Practices
Samaritan has breached our public awareness forefront, offering free Mental Health First-Aid, ongoing classes open to the public. The classes offer resources, warning sign detection, general information on trauma and common diagnoses and, most crucially, tips for helping those in need.
Trillium’s tackling normalization, too, now in its second year of Sanctuary, a trauma-based model which focuses on experience rather than diagnoses, on the “What happened to you?” rather than “What’s wrong with you?”
According to Terrence Killian, Vice President of Operations, Sanctuary is “a big bite to take.” Killian has incorporated additional holistic measures like hiring a physical fitness coordinator plus dietary options such as vegetarian meal alternatives and a salad bar.
Killian is also responsible for Trillium’s ongoing advocacy campaign, Keep Oregon Well, aimed at raising awareness via online registry or booth sign-ups. Those entered pledge to combat mental health stigma by being socially aware and empathetic, by modeling self-control and coping skills, and by offering non-judgmental support. The campaign urges us to recognize how mental health affects everyone.
Homelessness and Incarceration Exacerbates
Severe or serious mental health sufferers are two times more likely to become violent and, sadly, less likely to detect their deficits. They will commonly resist treatment and wind up re-hospitalized or incarcerated.
Imprisonment and impoverishment are especially exacerbating as mental health victims are already dealing with deteriorated rational capacities. An estimated 46% of shelter-inhabiting homeless Americans suffer from severe mental illnesses or substance use disorders. Annually, 50% of male and 75% of female state-prison inmates are expected to experience issues requiring mental health services. Percentages are leveled among jailed females but heightened to 63% of jailed males.
A recent OSU study proves an increase in Corvallis’ police confronting mental health concerns, as call time over subjects believed to be in crisis or experiencing mental health issues nearly doubled between 2007 and 2012, from 248 to 489 annual hours.
It’s unclear what educative extent Crisis Intervention Training (CIT) breaches. A dispatcher of the Corvallis Police Department revealed a basic level of required mental health training and the option for more. Our county’s policemen often rely on mental health professionals called in to assist during escalated confrontations.
Given the recent failure of Benton County’s proposed jail levy, which would have offered crucial rehabilitation services for successful inmate re-entry into society, our county’s citizens can’t be too surprised when those being released don’t meet their standards.
Confront Your Conditioned Incompetence Before Condemning
Everyone can conjure the image of an estranged wanderer speaking erratically into thin air. And what’s the usual onlooker’s gut reaction? To maximize the distance between them. Anderson calls on this analogy with the added scenario of a scraped knee, which would likely result in quick public care and concern.
Recently in downtown Corvallis, a homeless man approached me, for the second time, seeking soup or spare change. I remembered a small change-purse in my pack and fished it free for him. He reached in for a hug and introduced himself. I felt immediately both scared and ashamed, of never even thinking to ask his name. I hadn’t harnessed much hug-power either, I’m sure because of the associated and sometimes valid danger of getting close to the less sane. Most of us don’t know the proper response.
Psychosis is most scary, given tragedies as close to home as the Umpqua Community College shooting. We often fault the system and fail to realize the public’s part. But once educated in detecting the warning signs—irregular behavior or sleep patterns, low energy, mood swings, hopelessness—we can more confidently expand our minds and extend our arms to reach people in need.
Alongside police and medical personnel, most vital to public competence is an understanding that those confronted with mental health needs, whether they be friends, family, or streetside strangers, have a name and a history and deserve careful consideration.
On a federal level, Pennsylvania Representative Tim Murphy (R) is sponsoring the Helping Families in Mental Health Crisis Act. It proposes the termination of SAMHSA, referencing what he believes to be a corrupt and redundant use of federal dollars, and instead appointing an assistant secretary for mental health. The bill envisions the assistant secretary offering programs such as assisted outpatient treatment, known to reduce violence and repeated hospitalization and incarceration, as well as dependency on drugs and alcohol. The act also aims to revise HIPAA laws, allotting less restrictive family involvement in mental health cases, which current privacy rules blur and bar.
As Anderson said, “Emotional problems and issues, the solutions to them are by our connection with other people.” The whole team-netted philosophy of CCOs reflects a standard of spread-armed vigilance desperately needed both within and outside the system, inclusive of all.
By Stevie Beisswanger