Mental Health Access to Care in Missouri

Abstract

Mental illnesses are a significant cause of morbidity and mortality in the United States, affecting, in some estimates, up to one in four adults or 57.7 million people. Severe psychiatric disorders, like schizophrenia, bipolar and major depression occur in one in seventeen Americans. Moreover, serious mental illnesses affect children at rates approaching 10%.^1,2 Addictive disorders co-occurring with other mental illnesses affect over five million adults.³ The direct cost of these illnesses is high, totaling 16 billion dollars per year; dwarfed by the indirect costs of loss productivity which is four times as much. Individuals diagnosed with mental disorders have significantly higher rates of school dropout, homelessness, incarceration, and suicide. Embedded in these statistics is a concerning fact; access to care for those with psychiatric disorders is poor, with only one-third of adults and half the children diagnosed receiving care in any given year.² These numbers are worse if the person is a racial or ethnic minority.⁴ This paper hopes to highlight the state of mental health treatment first in the United States and then in our state of Missouri. The news is sobering but there are pockets of good news as well.

Mental Health Services in the United States

There is an estimated shortage of about 45,000 psychiatrists in the USA.⁵ A 2006 study showed that 96% of counties nationwide had an unmet need for mental health prescribers.⁶ Two out of three primary care physicians reported that they could not obtain mental health services for a significant number of their patients.⁷ A survey of federally funded U.S. Community Health Centers providing direct clinical services within the 50 states and the District of Columbia conducted in 2004 showed that, although staff physician positions for several major clinical disciplines remained unfilled, (13.3% of family physician positions, and 20.8% of obstetrician/gynecologist positions) the percentage of unfilled psychiatry positions was higher (22.6%).⁸

The statistics for child psychiatry are even more troubling. A 2006 study estimated a national need for 30,000 child psychiatrists, but found only 6,300 in practice.⁹ According to the Department of Health and Human Services, the demand for child and adolescent psychiatrist services will double between 1995 and 2020, and there will be a need for 12,624 child psychiatrists by 2020, whereas only 8,312 will be available based on today’s statistics. This situation is expected to be exacerbated by diminishing numbers of International Medical graduates being accepted for training in child psychiatry.¹⁰

Missouri State General Health Statistics

The state of Missouri spends approximately $5,500 per person on health care per year, ranking it twenty-first among all U.S. states.¹¹ Despite health care spending in the top 50%, Missouri continues to be ranked in the bottom third of states nationally on many health indicators. The 2009 America’s Health Rankings, prepared by the United Health Foundation,¹² (“The Commonwealth Fund’s State Scorecard”),¹³ and Kaiser Family Foundation rankings,¹⁴ placed in Missouri thirty-eighth and thirty-sixth places in the bottom quartile respectively on national measures of coverage, access, quality, and equity. In 2011, Missouri was ranked fortieth by the United Health Foundation on health measures set forth by the Agency for HealthCare Research and Quality (AHRQ).

In spite of these sober facts, Missouri is at the national forefront on two general health indicator measures, placing third on percentage of women receiving prenatal care in the first trimester and twelfth in percentage of ninth-graders graduating high school. Furthermore, in 2009, Missouri ranked twenty-eighth on avoidable hospital use and cost, and thirtieth in use of preventative, recommended, and patient-centered care.

Missouri Mental Health Data

Of Missouri’s approximately six million residents, close to 223,000 adults live with serious mental illnesses and about 65,000 children live with serious mental health conditions. Missouri ranks forty-fourth on a mental health quality-of-life indicator.¹⁵ In 2010 36% of adults within the state reported having poor mental health between one and 30 days in the past 30 days, compared to the national rate of 34%. In 2006, 1,293 children were incarcerated in Missouri’s juvenile justice system. Nationally, approximately 70% of youth in juvenile justice systems experience mental health disorders, with 20% experiencing a severe mental health condition. According to the Kaiser Family Foundation report¹⁴ for 2010, Missouri had a higher death rate by suicide than the national average (13 vs. 10 per 100,000). In 2009, 16.8% of the population admitted into the Missouri correction system was considered mentally ill. Statistics from Boone County in which the University of Missouri is located is illustrative. From 2005 to 2009, 15% (204) of offenders released in Boone County on probation and parole had a mental illness. In the July 2010 Point in Time Count, 39% of the homeless individuals counted in Boone County were severely mentally ill, the majority of whom were sheltered.

Substance Abuse in Missouri

One-quarter of Missouri adults smoked cigarettes in 2008, ranking the state forty-eighth in the nation. This low ranking is partly accounted for by the state’s very low cigarette tax rate, currently the lowest in the nation. Although national rates/prevalence of illicit drug use increased between 2008 and 2010 (SAMHSA), rates of illicit drug use in Missouri are generally equal to, or in some cases lower, than the national average. The National Survey on Drug Use and Health (NSDUH) provides national and state-level data on the use of tobacco, alcohol, illicit drugs (including non-medical use of prescription drugs), and mental health in the United States. In the most recent NSDUH Survey, 7.38% of Missouri residents reported using illicit drugs in the past month. The national average was 8.0%.¹⁶

Access to Mental Health Care in Missouri

In 2009, Missouri’s per capita expenditure on mental health was $86.15, compared with a national average of $122.90. Missouri spent $2.104 billion (9.11%) of the state budget on mental health in FY2010. ¹ In the same year, Missouri spent more on in-hospital care in general (not specific to mental health) and less on other aspects of clinical care. Missouri ranks sixth nationally in providing access to needed mental health care for children. Seventy-four percent of children in Missouri aged 2 to 17, with emotional, mental or behavioral health needs, received mental health care or counseling in 2007 compared to the U.S. rate of 60%. An estimated 49% of Missouri’s population lives in a mental health underserved area, compared with 29% nationally. Thirty-eight percent of Missouri’s population (nearly 2.4 million individuals) is underserved with regards to mental health compared with 21% nationally. Missouri needs to recruit/employ more than 200 psychiatrists in order to achieve the target practitioner -population ratio.

Missouri had lower rates of uninsured compared with the rest of the U.S. (15.3% vs. 16.7%), and ranked twenty-fourth in the nation with regards to overall insurance coverage. These figures may reflect the higher rates of employer-based coverage in Missouri compared to the national average (57.1% vs. 55.8%).¹⁷ Approximately 13.1% of Missourians are enrolled in Medicaid. Fifteen point three percent of Missourians are uninsured, ranking the state twenty-fourth nationally in percentage of uninsured overall.¹⁸

Uninsured rates are higher for the non-elderly adult population than the general population in Missouri, rendering access to needed health care difficult, particularly for adults who are uninsured. This population is at a relative disadvantage because Medicare provides universal coverage to individuals age 65 and older. Uninsured rates are lower for children because of access to Medicaid, the federal-state low-income insurance program, and the Children’s Health Insurance Program (CHIP) for low-income children who do not qualify for Medicaid.

While a similarly low percentage of adults with insurance in Missouri and the U.S. could not see a doctor in the past year because of cost (9% vs. 8%), a higher rate of uninsured adults faced financial barriers to care in Missouri compared to the U.S. (50% vs. 42% in 2006–2007). At-risk, uninsured adults in Missouri were also much less likely to have obtained a routine checkup than uninsured adults in the U.S. (50% vs. 38%).

These statistics do not exist in a vacuum, and must be put in the context of other characteristics. For example, the median household income in Missouri is $46,408, about $6,000 less than the national median household income. In Missouri, 13.3 percent of people live below the federal poverty level nearly identical to the national average of 13.2%.¹⁹ The average rent for a studio apartment in Missouri is 76% of the average Supplemental Security Income (SSI) payment, making housing essentially unaffordable for adults living with serious mental illness who rely on SSI.

Missouri Mental Health System

The state of Missouri utilizes a State Administrative Agent System to deliver care to the mentally ill. This system has its origins in the late 1970s and early 1980s when the Missouri Mental Health Commission overhauled the state’s mental health statutes in 1980. In that year, the state’s legislature directed the Department of Mental Health (DMH) to identify community-based services in each geographic area of the state to serve as entry and exit points into and out of the state’s system of care for persons with mental illness. DMH was permitted to purchase services from private and public providers with state funds. This led to the development of the Administrative Agent system (virtually synonymous with the Community Mental Health Centers or CMHCs), wherein the state DMH is able to contract directly with private not-for-profit organizations to provide comprehensive mental health care to citizens within the geographical area allocated to that entity. Under the administrative agent system, a single entity within each service area is responsible for providing all care to the population within that locale. Each CMHC is required to have a governing board comprised of local persons, to have completed a needs assessment, and have a plan of service to meet identified local community mental health needs as well as a willingness to work cooperatively with other local mental health agencies to which they might be required to distribute funds. The entire system is designed to provide equal access to comprehensive mental health services nationwide by completing the service arrays designed to designate a service area as a core, intermediate or full service area. There are currently 25 Administrative Agents providing services across the state, organized as the Coalition of Mental Health Centers.

Limits of Missouri Mental Health Access: Qualification

While the Administrative System has functioned relatively well since its inception there are still gaps and concerns in the delivery pipeline. The CMHC Administrative System predominately serves patients with Medicaid but there are state funds for those without a designated public insurer. These funds are limited and prioritized broadly in the order below:

1. Forensic psychiatric patients;

2. Adults, children and youth with severe and disabling mental illness (SMI) being discharged from inpatient facilities;

3. Adults and children and youth being transitioned from residential or inpatient hospitalization;

4. Adults and children and youth with mental illness discharged from the state-operated emergency departments;

5. Adults and children and youth receiving housing assistance from state Community Living program funding authorizations;

6. Children and youth referred through the Custody Diversion Protocol; and

7. Individuals with a DSM IV Axis I or Axis II diagnosis, other than a principal diagnosis of substance abuse or mental retardation, who also qualify as adults with severe disabling mental illness or children and youth with serious emotional disturbance.

As one might conclude, there is an apparent absence of public services for those patients who may indeed have diagnosable psychiatric illnesses but not to the extent of meeting severe criteria. Many of these persons struggle to find care, often accessing primary care providers who perform a crucial role in delivering treatment. Many patients remain untreated or undertreated.

Inpatient Beds

The other glaring area of concern is the reduction of psychiatric inpatient beds in the state. From 1990–2008 there was a reduction of nearly 40% in staffed psychiatric beds (4,888 to 3,144 beds). Since 2008 there has been an accelerated change in psychiatric beds including the state closing acute psychiatric beds in the St. Louis, Mid-Missouri and Kansas City area. Some of these closures were transfers of care from the state to other entities, in Mid-Missouri, the University of Missouri opened a new psychiatric center in the footprint of the previous Department of Mental Health Facility, while in Kansas City Truman Medical Center took on significant clinical responsibilities. However, in St. Louis state acute care beds were closed without another entity filling the void. Recently a partnership of state and private hospital systems is opening a small acute care unit in the St. Louis area in response to the loss access. In the last few years there has been a dramatic reduction in long term state psychiatric beds which has led to some degree of difficulty in finding long term care for psychiatric patients requiring a higher level of care.

Areas of Innovation and Success

We have highlighted the problems in the state of Missouri in terms of availability of psychiatric care for those in need. Some of this scarcity is a direct result of the “Great Recession” of the few years. The state has looked to the large expenditure in mental health care as one of a few areas to reduce. Having said that, we give great credit to the Department of Mental Health who has been subject to the cuts and responded with many innovative approaches, including the facilitating replacement non DMH funded inpatient beds mentioned previously. There have been other notable achievements and we will highlight several.

Housing Programs for the Mentally Ill

Some Administrative Agents have spear headed new programs to augment and enhance routine care. In Central-South Missouri, Burrell Behavioral Health is providing mental health services directly in apartment complexes with high numbers of mentally ill residents. Burrell has also been in the forefront in building and staffing supportive housing in Springfield with the plan to expand housing in Columbia. Another administrative agent, Pathways Community Behavioral Healthcare, has partnered with the state to build and run a transitional housing program based in Jefferson City. This program allows patients to have a therapeutic step down unit either after inpatient discharge or in lieu of a hospitalization.

Response to the Joplin Tornado

Last year’s devastating tornado in Joplin posed a nearly unimaginable psychiatric disaster to its population. The destruction left the city without mental health services for those needing help with the traumatic experience, as well as those needing to continue treatment for existing psychiatric illnesses. Two responses to this event are worth noting. First was the School Based Mental Health Program, developed by Dr. Syed Arshad Husain. Dr. Husain has a long career working with international disasters, which he applied to his own home state. Dr. Husain, who has positions both at the University of Missouri and Pathways, brought together a consortium of groups including the Department of Mental Health and the Ozark Center of Joplin funded by the Missouri Foundation for Health. The school-based program had three critical components; needs assessment; training of mental health professionals in disaster psychiatry; and finally training teachers to be therapists. The program has trained 80 mental health professionals and 90 teachers as therapists. The program will screen all 7,500 Joplin students in Kindergarten all the way through twelfth grade, and provide care as identified. The other noteworthy event was the partnership by the University of Missouri-Columbia Department of Psychiatry with the Ozark Center to provide direct psychiatric care via tele-health during the first overwhelming months. The state helped support funding psychiatry faculty and residents who used their own time to see patients via the tele-health system.

The Health Home Project

Beginning in January 2012, Missouri became the first state in the nation to implement the Health Home initiative, a program which targets Medicaid-eligible Missourians with chronic illnesses. The program is collaboration between Missouri Foundation for Health, the Missouri Primary Care Association (PCA), the Missouri Coalition of Community Mental Health Centers (CMHC), and various other stakeholders.

What is a Health Home?

The Health Home is modeled on the Patient Centered Medical Home and has many of its characteristics. However, it is customized to meet the specific needs of low-income patients with chronic medical conditions. Key components include comprehensive care management, care coordination and health promotion, comprehensive transitional care including follow-up from inpatient and other settings, patient and family support; referral to community and support services, use of health information technology to link services. Service centers include selected CMHCs, Federally Qualified Health Clinics, and public entity primary care clinics. At least 25% of a provider’s patient base must consist of Medicaid patients and/or uninsured patients.

What are the Goals of Health Home Initiative?

Persons with serious mental illness frequently have multiple other co-occurring medical problems, have difficulty accessing care, and die an average 25–30 years earlier than individuals without. They often take multiple medications and receive care from many different providers. This can make coordination of care difficult and can expose patient to dangerous medication side effects and interactions.

The Health Home initiative aims to address these problems by using care coordination by care managers using data analytic tracking to find and address care gaps. Missouri intends to use this initiative to reduce inpatient hospitalization and emergency room visits, enhance the amount of primary care nurse liaison staffing available at community mental health centers, add primary care physician consultation, and enhance the state’s ability to provide transitional care between institutions in the community.

In order to be eligible for these services, an individual must be covered by MoHealthNet (Missouri’s Medicaid plan) including those covered through MoHealthNet’s Managed Care Plans; must have two chronic conditions or have one chronic condition, and be at risk for a second chronic condition; and/or persons who have one serious and persistent mental health condition. Qualifying chronic conditions include: serious mental health conditions like schizophrenia, major depression or bipolar disorder, asthma, substance abuse disorders, diabetes, cardiovascular disease, including hypertension, overweight (BMI>25), developmental disabilities, and tobacco use. Health and Fiscal outcomes from this initiative are being tracked.

Conclusion

While access to mental health treatment remains an issue in Missouri, as it is nationally, Missouri has made significant strides in addressing several issues related to accessing mental health care, and is a leader in many respects, when compared to the rest of the nation. There is a potential for the situation to move in several directions. If the planned expansion of Medicaid enrollment occurs in 2014 there could be a great impetus to support a growth in providers. However, if the economic recovery falters, state governments will again be looking to large ticket items to cut, including mental health services. Likewise, more aggressive taxation of cigarettes and alcohol would discourage use and provide much needed revenue for prevention and treatment.

Biography

Sosunmolu Shoyinka, MD and John Lauriello, MD, are with the University of Missouri School of Medicine in the Department of Psychiatry.

Contact: shoyinkas@health.missouri.edu