Ohio House Republican press release: Proposal to restructure public mental health

Editor’s note: This appears to be just a proposal, at present, as I do not yet see a bill listed on the General Assembly website. State rep David Burke represents the 83rd Ohio House district, which includes Logan County, Union County, and most of Marion County.  This press release was issued 1/21/2011. After reading through the press release, you are welcome to read my further editorial comments (below the fold).


Will introduce bill to identify cost-savings, structural improvements

COLUMBUS—In order to improve the efficiency and effectiveness of Ohio’s mental health services, State Representative Dave Burke (R-Marysville) intends to propose legislation that calls for a review of Ohio’s behavioral health system. The goal of this legislation will be to identify potential reforms and cost-containment opportunities within the system, which will not only improve state health services but also rein in costs.

“The current system is crumbling and fragmented,” said Burke, who serves as chairman of the Health and Human Services Subcommittee of the Finance and Appropriations Committee. “There is no transparency with regard to costs, and oftentimes there is no coordination of services. With numerous tragic events that have happened over the last few years that have involved behavioral health system issues, it is important that Ohio make a comprehensive review of the system.”

More than 340,000 Ohioans received community mental health treatment during fiscal year 2009. Starting in 2014, the Ohio Medicaid program expects that more than 550,000 new enrollees will be added to the system, about one-third of whom will require mental health treatment. However, the current system leaves significant gaps in coverage for individuals who need behavioral services, which in fiscal year 2009 left more than 22,000 mental health patients without Medicaid coverage.

According to Burke, a lack of coordination between departments often leads to inflated costs or flawed patient care, which not only strains the state budget but also puts vulnerable Ohioans at risk. Many mentally ill Ohioans end up institutionalized in prisons and nursing homes, when in reality, a number of these individuals require more intensive behavioral treatment.

“It is extremely important that we don’t let Ohioans who depend on state services fall through the cracks or be subjected to inadequate treatment,” said Burke. “We will soon have an opportunity to improve Ohio’s mental health system while at the same time reduce inefficiency. This is a standard of excellence that we owe to those who elected us to lead this state.”

More notes from the editor:

Personally, I think the public mental health system is so broken in Ohio that it should be totally eliminated if it doesn’t get fixed. Taxpayer dollars spent on public mental health would be well worth it if the public mental health system in Ohio actually worked. It doesn’t. What would happen to the lives that are crumbling right now if the system was eliminated? Not a whole lot worse than what already happens. What about public safety if the system was eliminated? Wouldn’t it be dangerous? The public safety is already jeopardized, but perhaps you weren’t aware of it. If you’re reading this, you are now aware of it. Be careful out there.

Beyond the Medicaid issues (both eligibility and spend-down requirements), the lack of mental health parity with physical health in terms of medical coverage, the destitute who might not qualify for Medicaid but still have no money to access the system, and the co-pays (a co-pay for the psychiatrist at least once every three months, a co-pay for each of the quite frequent counseling sessions with a psychotherapist, a co-pay for the case management, and a co-pay for the medication) even if there is some medical coverage, the service delivery stinks.

Access is a huge issue.  Actually, in the public mental health system, you might have to wait two months to even get an intake appointment. Then you have to wait for maybe another two months before you see the psychiatrist, which means no medication until then. You can get in to see the counselor sooner–maybe within the same month of your intake, maybe not–which means no case management until after your first session of therapy. Once you are in the system, you might get to see the case manager each week, you might get to see the counselor twice a month, but don’t bet on seeing the psychiatrist once every three months, even if you scheduled an appointment three months out. You’re likely to get a call from the receptionist that all appointments are canceled that day due to an emergency that called the psychiatrist away to the hospital. That’s what it’s like. Because of a scarcity of preventive care in the public system, the otherwise manageable cases become emergencies, land people in the hospital, and that’s when they get to see the psychiatrist.

If you are a stakeholder in someone’s mental health case, perhaps by assisting a family member or by being a patient yourself, watch out for the snafus of the office staff, too. They may lose paperwork which may require a destitute person to reapply for financial assistance from the county ADAMH board each time the person makes a visit. However, the office staff won’t tell the person that the application for assistance went missing. Instead, the staff will not bill ADAMH, so the medical billing company will then mail a hefty bill to the person’s house for the followup visit–a bill that will scare the patient into not ever scheduling again because they are made to believe they can’t afford it. Watch for the multiple billings, too. An account number isn’t assigned to a patient. Instead, an account number is assigned to a visit, thus one patient will have to track down multiple account numbers if that patient wants to question the billing with the office staff. A patient might get two or three duplicate invoices in the mail for the same visit, and if it’s happening to the patient, Medicare or some other medical coverage provider might be getting invoiced just as often (defrauding the Medicare system and the patient, both). If there are questions to resolve about invoices and payments, a patient should be made aware that the billing has been outsourced to some other company hundreds of miles away whose only address is a post office box. The person in the office that provides that information to the outsourced medical billing company (the patient may see 20 staffers behind that receptionist counter, but only one knows anything about the account balances) may be out to lunch or otherwise out of the office. Once the patient manages to meet that staffer, the patient will have to correct the staffer’s math, because they added and subtracted the $$ amounts wrong.

The professional counselors and psychiatrists hate their jobs because of all the crazy paperwork required by both government bureaucracy and insurance bureaucracy. If they could go into private practice in an office that only accepts cash, to be paid at the time of service, and line up enough customers to fill the schedule, they’d jump at it. On a cash-only basis, where no insurance, no Medicaid, and no Medicare are accepted for payment, and the staff will not even process paperwork for reimbursement from coverage providers, the only billing info they need on hand is the duplicate copy of the hand-written receipt given to the customer when cash is received at the time of the visit. Most patients would assume that going to a cash-only office would be too expensive, but, actually, with the lower overhead, the charges for service might be no more expensive than the co-pays in the public mental health system. Though cash-only patients can get much better access to the private-practice mental health care professionals at a reasonable price, what’s unreasonably expensive are the prescription drugs, which can cost hundreds of dollars each month. So, if a patient can’t pay for prescriptions out of pocket, then, to get insurance coverage or government assistance, one either goes to a private practitioner with much more overhead expenses (in which case, it’s much more expensive for psychotherapy there), or one goes to public mental health (which, if you add the cost of psychotherapy and the cost of drugs together, is the lowest cost alternative).

If you’re rich and can afford all the medications and psychotherapy out of pocket, go to the cash-only private practitioners.

Case managers in public mental health also don’t like their jobs. Not only are they swamped with more cases than they can manage, they also know that those who they’re assigned to help aren’t getting effective treatment in such a broken system. Therefore, the case managers feel a dread that they are risking danger whenever they meet up with clients.

The grumpy professionals in the public mental health system will tell you the scarcity of care is due to government cutbacks.  The truth is, even if their budgets were bigger, they’d still hate their jobs, which makes recruiting staff problematic.  Furthermore, the professionals and staffers, perhaps from feeling burnt out or overwhelmed by the backlog, don’t really work that much.  They may spend as much time socializing with each other as they spend on-task.  So the backlog is not just a product of supply and demand, not just a product of government budgets, not just a product of not enough professionals and staff, not just a product of having to put out fires instead of preventing them in the first place, not just a product of mountains of paperwork, but it’s also a product of lack of productivity due to lack of a work ethic.  I’m sure staffers and professionals would protest and act appalled at the allegations I’m making, but when one spends hours in a waiting room, one has plenty of opportunity to observe the staff with one’s own eyeballs.

These horror stories of public mental health don’t just take place in Ohio’s urban areas. They take place in small towns, like Sandusky, Norwalk, and Tiffin, too.

If Ohioans want the mentally ill to have access to treatment, then state rep David Burke is right. The system must be fixed, and the broken system is costing taxpayers too much money for such unacceptable treatment outcomes.  A word of warning:  Truly fixing the system may take much more effort than the state rep ever imagined.

Having been diagnosed with both ADHD and bipolar disorder, I have firsthand knowledge of such service delivery dysfunction. Been there, done that.

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