Position Paper Supporting HB 1089
House Bill 07-1089 will establish a rural and urban pilot program within the Department of Health Care Policy and Financing for a specific mental health quality program. Using technology people using mental health services will either call or be called or will log onto a secure web site to track progress. For example if a person is being treated for depression they might answer questions such as if they slept a normal amount (not too much or too little), if they are able to eat normally, if they feel suicidal, etc. The questions will be targeted to the diagnosis. Then these results will be compiled so that the state, provider agencies and clients will be able to look at the success of provider agencies and individual providers. This will help the state make good purchasing decisions and will help clients in the community mental health program choose effective providers.
Colorado will spend over $200 million in Medicaid community mental health this fiscal year. (2006/2007 budget documents HCPF website) In 2003 the program served approximately 20,000 clients.( Orchid Report) Medicaid clients are approximately 86% of the overall client base for clients served by Community Mental Health Centers (CMHC). These centers are the primary source of care for most Medicaid clients. 67% of patients had previous outpatient mental health care. 11.6% presented with Bi-Polar, 20.2% presented with major depression, 3.2% presented with dysthymia and 10.3 % with anxiety and less than 5% with schizophrenia. (Id.) These are the most serious disorders and disorders where effective treatment makes the most difference.
It is now accepted that people with the most severe mental illnesses such as schizophrenia, Bi-Polar, major depression and anxiety based disorders can live full and productive lives if and only if they get proper treatment. Treatment means a proper combination of medications combined with other types of support services and therapies. Some clients will require services throughout their lifetime so progress should not be measured by discharge percentages, but should be measured by improvement in day-to-day functioning. For example can a person who now has a representative payee learn to manage his or her money over the next year? Can a person who needs to be taken to doctor appointments learn to use public transportation over the next year? If a client is experiencing intolerable side effects are the providers sufficiently open and accessible and are clients reporting this or are they simply going off of their medication? When advocates have filed quality of care complaints the response is always a defense that states that a certain number of units of service have been provided, therefore there is no grounds for a complaint. In the cases we have filed we did not dispute that services were provided, but argued that either the services were the wrong services or were otherwise ineffective.
Having clients answer objective and consistent questions about how they are functioning will give clear guidance to see where clients are not getting better. Not only will this show us how to spend our mental health dollars effectively this tracking will also save money on the physical side of Medicaid. By tracking symptoms an aware provider may notice an adverse drug reaction or drug toxicity and can act quickly. We had a member who recently experience drug toxicity (not due to overdose just an unanticipated reaction) that became so severe that the client required an MRI costing close to $1,000. Had the client had a way to let the provider know daily what was happening that could have been avoided Clients often only see a provider every few months and often see different providers each year due to internship requirements or staff turnover. This system will allow tracking of progress over time.
Often when clients with psychiatric disorders are not doing well their physical health care costs increase. People with acute clinical depression are more clumsy and accident prone. They are more likely to have accidents where they break bones, require stitches, etc. Many clients with psychiatric disorders must take medications that cause severe weight gain and can cause other problems including diabetes and high cholesterol. If a provider is monitoring daily and can look at patterns these items can be addressed. For example appetite will be an item that clients can report on daily. If a provider notices that a client on an atypical antipsychotic is reporting daily severe hunger and increased appetite they can address this with the client, either by adding an appetite suppressant, facilitating enrolling the client in an exercise class, or changing the timing of the medications. If this can happen before the client gains 100 or more pounds and develops a host of physical problems we will see decreased costs throughout the Medicaid program.
More important than cost is the impact of quality on the lives of the people served by this program We have too many people who are in the mental health system for years and years with little or no improvement in their quality of life. For example once someone is determined to require a payee to manage his or her money (a source of income for some providers) it is rare that the client ever regains control of his or her money. Good treatment would help people regain this control. For some clients, such as those with Bi-Polar disorder it might mean adequately controlling manic episodes with proper medication and cognitive behavioral therapy. We have many clients who have been in mental health care for more than a decade but still need their case worker to make and transport them to doctor appointments. If the person does not have an accompanying severe cognitive impairment there is no excuse for this learned dependency. We have too many clients going in and out of hospitals. If someone receives high quality rehabilitation after the first psychotic break followed by high quality maintenance therapy that is closely monitored by the provider they should not need further hospitalizations, at least not until the natural changes of the body that occur at mid-life which often require a medication adjustment. Of course there will be the very rare case of the person who cannot tolerate most medications, but most people with mental illness should be able to avoid repeated hospitalizations after the initial onset of the illness and should be able to avoid institutionalization in the corrections system.
Finally, the federal government, who pays 50% of the bill, is increasing their insistence on real quality improvement programs. Currently we do not have adequate quality improvement programs in our community mental health programs. The quality assessment activities are all paper-based and there is no real inclusion of what clients actually think or feel or how they are doing by their own report. This kind of system will not be acceptable to the CMS in the long-run as CMS is insisting on more direct consumer involvement in all of their programs, particularly waiver programs. Implementing this innovative program now we can get ahead and have a program that is Colorado designed in place.
By comparing different providers the state can set new and improved quality standards. What is the ceiling today will become the floor tomorrow. The significant mental health dollars we spend will be properly utilized to make sure that our citizens who live with mental illness are getting the best possible care and having the best possible quality of life.
Sincerely,
Julie Reiskin
Executive Director
