Public Mental Health Health: How We Got Here

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Public Mental Health Health How We Got Here

• Marvin Swartz, MD
• Department of Psychiatry
• Duke University Medical Center

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Franklin Pierce Veto 1854

• Pierce vetoes a bill sponsored by Dorothea Dix
  calling for the sale of federal lands to
  subsidize institutions for indigents with mental
  disabilities
• If Congress has the power to make provision
  for the indigent insane. . .it has the same power
  to provide for the indigent who are not insane,
  and thus to transfer to the Federal Government
  the charge of all the poor in all the States....

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President Kennedys Message

• We must act to bestow the full benefits of our
  society to those who suffer from mental
  disabilities to prevent occurrence of mental
  illnesswherever and whenever possible to
  provide for early diagnosis and continuous care
  in the community, of those suffering from these
  disorders to stimulate improvements in the level
  of care given the mentally disabled in our State
  and private institutions, and to reorient those
  programs to a community-centered approach to
  reduce, over a number of years and by hundreds of
  thousands, the persons confined to these
  institutions to retain in and return to, the
  community the mentally ill and there to restore
  and revitalize their lives through better health
  programs and strengthened educational and
  rehabilitation servicesKennedy, J.F., Message
  from the President of the United States Relative
  to Mental Illness and Mental Retardation,
  Washington D.C. USGPO, 1963.

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Value of Behavioral Health Benefits, 1988-1998
2527
2169
2372
2099
Dollars
6.2
3.2
155
70
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Origins of Reform 1999-2001

• Issues
• Loss of Child services capitated pilot (Carolina
  Alternatives)
• Medicaid paybacks (soft match)
• Area Program financial difficulties
• Staffing and record keeping complaints at Dix
  Hospital
• Department of Justice investigation of State
  hospitals
• Continuous turnover of leadership at Division of
  MH/DD/SAS
• Supreme Court Olmstead decision
• Bad press

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Key Elements of State Plan

• Area authority supplanted by Local Management
  Entity (LME)
• LME role to plan for local MH/DD/SA needs.
• State dollars targeted to provide services ONLY
  to target populations.
• Divests care from public to private providers and
  directs LME to develop provider networks.
• LME may provide services to target populations
  ONLY when providers are not available.
• Eliminate 700 state hospital beds by 7/1/06

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Fate of Area Authority

• State Plan splits area authority into
  administrative/managed care function and divests
  clinical functions to provider network
• The Local Management Entity (LME) is the
  administrative body that develops, implements,
  oversees, monitors, and evaluates system services
  in a specific region or area of the state.

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Target Populations

• State-funded services to individuals with the
  most severe disabilities.
• Non-target population to be served by private
  sector or county funded services.

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Re-investment Strategy

• State hospital admissions not Medicaid
  reimbursable for adults.
• Reduction of State bed dollars can leverage
  Medicaid community-based services.
• Need community capacity to reduce
  admissionsbridge funding needed.

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Implementation

• Counties given several years to develop local
  capacity and divest services.
• Division of MH/DD/SAS to create financial
  incentives to develop new community services
  (defined in service definitions).
• Division to amend Medicaid Plan (and new rates)
  to support new services.
• Saving from State Facility downsizing and MH
  Trust Fund to support new services.
• Division to lead workforce development plan.

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Thats all, folks!