Friends and Colleagues:
As I announced last week to our members, it is time for me to pass the torch to my successor, Le Ondra Clark Harvey. She began working for California Council of Community Behavioral Health Agencies in January as the new Director of Policy and Advocacy. That is the position I had filled for the past 31 years.
After just two months on the job, it is already clear she has the capabilities to most effectively represent the nonprofit behavioral health provider community, building on her years of experience both as a licensed psychologist in Los Angeles County, and as the chief consultant to the Business and Professions Committee of the California State Assembly. As I have gotten to know her and see her in action with legislators and key staff members, it is clear she has stronger relationships than I do among key legislative staff and members, and has all the skills necessary to be an effective advocate with a strong and growing base of knowledge on our issues.
She also benefits from the fact that there are now many other people and organizations to do this advocacy work, in support of our mission of getting everyone the right care, at the right place, and at the right time. So, I leave with confidence that the foundation we have built over the past three decades will lead to much greater success in the coming years.
When we wrote Proposition 63, we thought we were creating a system that would be adequately funded and staffed to meet all the important needs. Clearly, we are not much closer than we were 15 years ago when we wrote the act. The principles and programs needed and potential funding are there, if we can find a way to get all the major institutions inside and outside the public behavioral health system to work together; strategically to do the things we already know are the most cost-effective in terms of utilizing limited resources.
As I leave, I want to make a few comments on some of the key questions that people continue to ask me on a regular basis.
Will the County Run System, The So-Called Carveout Continue?
I was recently meeting with a private sector consultant who reminded me that the trend across the country is for the elimination of carveout programs and the placement of all behavioral health under commercial managed-care companies. He added that he had heard Jennifer Kent speak in favor of such a change within the past year and wanted to know what I thought would happen in California.
I told him I did not see any way the state of California would ever propose such a change. I noted the state constitution now includes the realignment of behavioral health funding to the counties. Proposition 63 does the same thing for the Mental Health Services Act funds, meaning that it would take a vote of the people to take control of those funds – out of the hands of counties, and give them back to the state.
Moreover, the realignment shifts all the financial risk from the state to the counties. I am not aware of the state Department of Finance ever wanting to take back that type of financial risk. Similarly, this financial structure makes California’s behavioral healthcare system somewhat unattractive to managed-care companies because the revenues are limited by the realignment and ballot measure revenues (soon to be augmented by Proposition 64 revenues); they would not have the ability to easily obtain approval for increased rates as the service demand and costs go up as they seem to be able to do now with the state for physical healthcare. My sense is that they already have the main carve in that works for them which is the so-called mild moderate mental health care. I’ve been told that that program has grown from $100 million to $700 million. It will be useful to see what difference that is making, how many people it is serving, where the penetration rates are the highest, and how it might be reducing the pressures on the public system.
Nonetheless it seems likely there will be some changes when the current federal waiver expires in 2020. At that time or soon thereafter we will see a change in how federal funds are received in the current fee-for-service system, with its daunting
paperwork documentation requirements, will give way either to capitation or some type of performance-based system at least in part.
We Don’t Have Enough Money and Prevention and Early Intervention Is the Key
Logically the focus of most providers and county staff is on the high-end population that already has a serious emotional disturbance or severe mental illness. Unfortunately, it seems that we will never have enough money to serve all of them if we don’t reduce the growth in that population through effective prevention and early intervention programs.
The primary purpose of the prevention and early intervention program was to reduce the number of new cases where people had mental health problems that progressed over many years without treatment and where the cost and duration of care would be not have been nearly as great had the problems been identified and treated early in the onset. The funding for that program began in the worst possible year of 2009 in the depth of the recession. It caused counties to see that new money as a way to avoid cuts it would otherwise have to make in current services instead of planning strategically about how to use that money for the intended purpose.
Even in that difficult time most of the larger Counties started early psychosis programs which have the greatest potential to help the people who are most likely to be the most expensive get in and out of the system quickly and lead productive lives living with schizophrenia as programs around the world have been demonstrating. Now it seems every county is including one of these programs and the only challenge is taking it to scale. We’re also starting to see efforts to rethink the use of the rest of that money.
With the state and county leadership working together there is hope that we will be able to get it right. The other challenge besides having to rethink the original spending plans is that the most effective strategies require partnerships outside of the behavioral health system.
Schools, primary care, workplace, and technology are the places where we can most easily reach people as mental health and substance use challenges are first emerging.
There are many pilot projects reflecting the types of partnerships needed for these programs to succeed. The recent Oversight and Accountability Commission RFP for school/County partnerships represents the type of strategy that will help address the challenge of how to design them in the best way so that we can take them to scale and generate the long-term savings not just in behavioral health but also to the benefit of each of these other systems. Schools save money when fewer kids have serious emotional disorders.
Employer save money when fewer workers become disabled or less productive due to untreated mental illness or substance use. The physical healthcare system has far fewer high cost patients when everyone is getting their behavioral health needs met.
We Must Stop Taking Everyone to Jails and Hospitals. Create the Full Continuum of Care When They Leave
When there is a psychiatric crisis or a homeless person picked up on the streets who is in a similar crisis, the police seem to have only two choices: jail or hospital. They know neither is the right place for most. We started with SB 82 in 2013 to create incentives for counties to create alternative systems through mobile crisis outreach, crisis stabilization and crisis residential. The governor’s proposal of over $100 million to reduce the number of people ‘incompetent to stand trial’ creates an additional financial incentive to expand these programs. But I don’t believe we will get the programs taken to scale if we don’t create broad-based local partnerships that bring together the sheriffs, hospitals, city police, Medi-Cal managed care plans, housing providers, and other community leaders. This is what it has taken in other communities to take these programs to scale and I’m hopeful that this next round of state funding will create the incentives for counties and their partners to build a full-scale system.
In doing so, it should free up money away from institutions and make it possible to provide more slots in intensive outpatient program such as Full-Service Partnerships so we can end the revolving door of people being discharged from jails and hospitals right back to the street without the support they need
We Must Expand the Workforce by Investing in Academic Program Expansion
CBHA’s top state budget priority is to extend the current workforce program for one more year to allow time to complete a new five-year plan, see what emerges from the healthcare workforce commission, and work with a new administration. For now, the focus has been on short-term solutions: loan forgiveness and stipends to attract more students into the public system. However, very little has been spent to expand the number of slots available in academic programs. Those don’t provide short-term solutions but they are the only way to increase the total number of behavioral health professionals, otherwise we’ll continue competing with each other and with the private sector for a pool that is too small.
Clearly, we need to find ways to fully utilize and recognize non- licensed bachelors level rehabilitation specialists and peer support. Technology is also a key part of these efforts as there is evidence many mild and moderate problems can be addressed without seeing an in-person clinician with appropriate online support. We also need to work outside of the public system to create a reimbursement arrangement for private clinicians that will cause them to come back into the commercial insurance marketplace; too many have opted out due to limited reimbursement rates and extensive paperwork documentation requirements.
About a year ago, I heard the president of the California Association of Health Plans say that clinicians were simply asking for too much money. My immediate reaction was he wouldn’t have said that if there was a shortage of surgeons or other health care specialists. Insurers would recognize they have to pay whatever the market rate is for highly skilled professionals. The option of not having enough people available to meet everyone’s needs would not be the policy which it appears to be in behavioral health. It appears as though our state regulators understand the problem and are committed to pressuring the plans to expand their network adequacy. Hopefully, this will happen to increase reimbursement rates that draws more people back into the system and makes behavioral health professions more financially rewarding, leading more young people to see careers in this field. Of course, none of this works if we don’t expand the number of slots in graduate school programs.
When I started representing mental health providers 30 years ago, it was generally estimated that paperwork accounted for 20 to 30 percent of the cost of services. It seems to grow every year and has exceeded 40 percent many years ago and probably is closer to 50 percent now for most providers. Obviously, the more time a clinician has to spend on paperwork the less time they have to provide clinical care which significantly compounds our workforce challenges.
Government officials seem to be especially reluctant to make changes to make anything easier. I fear that things will only get worse as we hear about a new federal audit that suggests that hundreds of millions of dollars of services have either been improperly or inadequately documented which usually leads to more requirements and more paperwork. We know that our fee-for-service federal payment model creates requirements that don’t exist in the Medi-Cal managed care plan for the mild to moderate component of care. When we are ready to change that payment model perhaps that will create the impetus to rethink all of the documentation requirements and try to streamline and standardize these so that they are more performance oriented.
All of Us Need to Work Together
In the exact month I started working in mental health, there was a cover story in a magazine devoted to California public policy known as the California Journal. It described the mental health community as a circular firing squad. It suggested that a major reason why mental health was so horrifically underfunded was the advocates spent all their energy fighting each other on various philosophies and approaches in care rather than working together to address the unmet needs.
Those days seem to be long gone. We worked together to create commercial insurance parity, build systems of care, and of course wrote and passed the Mental Health Services Act (Proposition 63) of 2004.
The level of consensus appeared to be in the room at Google’s Verily campus for the Innovation Summit; suggesting we are largely on the same page in recognizing the current challenges and identifying some of the most promising approaches.
I Feel Confident in The Next Generation of Leaders
Nearly everyone knows I retired a year or two before I had planned to do so. I might have wanted to because I am now facing a very challenging and life-threatening medical condition known as ALS. I have received an outpouring of support and acknowledgment from so many of you that I appreciate greatly.
Those who said my retirement will be a big loss are undervaluing the talent that has emerged in the next generation of leaders, both for statewide advocacy and local system development. Equally important, is the interest coming from physical
health and hospital leaders who recognize that success in behavioral health is essential to overall healthcare. Similarly, as Darrell Steinberg likes to say, behavioral health is the second issue directly related to every other major issue that people care about. So, whether it is education, public safety, or homelessness, these problems can’t be addressed without addressing behavioral health.
I have always been an eternal optimist. Perhaps my glasses are too rose-colored. However, I feel quite confident we are making great progress that we will soon begin to see dramatic improvements in addressing all of our unmet needs.