December 14, 2009
New Hampshire’s public mental health system fell from 2nd best to D-plus in 10 years. When I went to national conferences in the ‘90s, everyone wanted to be like us. In 2006, the National Alliance on Mental Illness (NAMI) gave NH a grade of D-plus in a survey of all 50 states. Our system has gotten much worse since then. The main reasons are change-averse community mental health center (CMHC) chief executives, and gross underfunding for the past 10-15 years.
UNDER FUNDING: When you “level fund” a CMHC, you are really cutting its annual budget 10-15 percent, because insurance, building maintenance, professional staff, and other expenses go up every year. Most years, when we level funded CMHCs, the state made no allowance for inflation or population growth. And we asked CMHC’s to more for us they could not be reimbursed for by Medicare or Medicaid.
For years, the state has been telling them to use Medicaid to subsidize needed services Medicaid does not reimburse. So they pile services on their Medicaid clients, which are often unnecessary, not helpful, or occasionally harmful. Some centers, including Riverbend in Concord, appear to be reviving day treatment, but calling it something else, because it’s been shown that day treatment encourages dependency, and does not help people get well. We now know a lot about how to help clients get well and stay well. Treatment is better than ever, but harder than ever to get from CMHCs.
CHANGE-AVERSE CMHC EXECUTIVES: Many clinicians in CMHCs practice strength-based, recovery-based therapy. But top managers in CMHCs resist change of any kind. They use the language of recovery, but recovery is more than a new vocabulary for the same old thing.
Most of the funding for CMHCs comes from Medicaid. The state and federal government each pay half. They reimburse CMHCs on a fee-for-service formula. Government decides which services, and how much per hour, to reimburse. Naturally, CMHC’s resist doing anything Medicaid will not reimburse.
So when the Dartmouth Psychiatric Research Center developed an evidence-based recovery curriculum for CMHCs, the 10 chief executives became the main obstacles to adopting it, according to a follow-up study by the state Bureau of Behavioral Health. Medicaid does not reimburse the hours of special training, preparation by the clinicians, and specialized supervision the new practices demand.
Two years ago, the CMHC’s pushed a new administrative rule that would have eliminated the right of every client to an annual meeting with his entire treatment team to make sure the client understood why each element is in the plan. Clients could also propose changes and alternative treatments, and bring to the meeting anyone they chose for advocacy and support. Those meetings require a lot of staff time that Medicaid does not reimburse, and reduce the clinicians’ ability to produce “billable hours.”
The CMHC’s proposal would have eliminated what was always considered a basic right. The state Bureau of Behavioral Health supported the CMHC’s, but the client and family organizations, and the Disabilities Rights Center, objected vehemently. The Legislature changed the proposal. Today, clients who ask for a conference can have one, and the CMHC’s must inform their clients of that right. If clients don’t ask for one, their case managers must discuss their plans point by point at least once a year.
When then-Commissioner of Health and Human Services John Stephen proposed a new requirement that doctors in CMHC’s use only cheaper medications, the same three client advocacy groups went ballistic. Requiring a person who is doing well to change medication is very risky. He can relapse, and lose whatever ground he’s gained. Every client reacts differently to every different drug.
The then-Republican Legislature changed that. People doing well on a medicine do not have to change. People just starting on medication start with the least expensive drugs. There is no scientific evidence that new, expensive medicines are more likely to succeed than older, cheaper drugs, so it makes sense to try the cheaper ones first, and move to more expensive ones only when necessary.
The CMHCs’ remained silent. One CEO told me they were afraid to oppose the commissioner, who often took revenge on groups that opposed him on anything.
I believe the CEO’s of the CMHC’s were putting their bureaucracies’ needs ahead of client needs and rights. Why do they need 10 CEOs, 10 CFOs, 10 COOs, 10 offices to bill Medicaid, and 10 liability insurance policies? They claim poverty, so how can they afford to pay a professional lobbyist?
And why hasn’t the Bureau of Behavioral Health, which regulates the CMHC’s and writes their state contracts, ever said “This is how you’re going to do things from now on because science, or good business sense, show it’s the best practice?” It takes a concerted effort to bring a $200 million system down so far so fast, and that’s what we’ve seen in our mental health system.