Presentation on the Future of Mental Health Services in N.C.

32nd Annual Legislative Breakfast“The Future of Mental Health Services in NC”

April 17, 2010

NORTH CAROLINA CENTER FOR PUBLIC POLICY RESEARCH

by Mebane Rash, Attorney and Editor of North Carolina Insight

Joshua:The

Public in

Public Policy

Mental Health Reform in NC:Key Dates

Olmstead: A 1999 U.S. Supreme Court decision 2001 State Law on Mental Health Reform 2008 Investigative Series in The News & Observer Deaths of Patients in State Facilities 2008 Gubernatorial Election 2009 Budget Shortfall

1.27 million North Carolinians need MH/DD/SA services, 14% of NC’s population560,000 need MH services106,000 need DD services606,000 need SA services

306,000 children are in need of services

The System of Care

N.C. Population 9,380,884

Total # in Need of MH/DD/SAS Services 1,274,193

Total # Served by the State 343,607

# Served in 14 State Facilities 17,044

# Served by LMEs 326,563# Unserved 930,586

State-Operated Facilities

Mental Health Services Funded by Medicaid

1. Intermediate care facility services for the mentally retarded (ICF-MR)

2. Inpatient hospital and nursing facility services for individuals 60 years of age or over in an institution for mental diseases

3. Inpatient psychiatric services for individuals under age 21

4. Outpatient prescription drugs

5. Physical therapy and related services

6. Personal care services

7. Diagnostic, screening, preventive, and rehabilitative services

8. Case management services

9. Other medical or remedial care

10. Home and community-based services to individuals with mental retardation or developmental disabilities

Medicaid: The Largest Funder of Mental Health Care N.C.’s Medicaid budget already is $250 million over

budget for the fiscal year ending June 2010. The federal government has been picking up an extra

portion of state Medicaid costs with federal economic stimulus dollars. This subsidy will end in December 2010.

The number of those eligible for Medicaid increases as unemployment rises and as the number of elderly grow because Medicaid pays for long-term care for the elderly.

The Cost of Medicaid: % Paid by Federal and State Government

Percentage of Costs Paid Normally

Percentage of Costs Currently Paid Due to

Federal Economic Recovery Funds

Federal Government 65.13% 75.59%

North Carolina 34.87% 24.41%

1915(b)(c) Innovations Waivers

Pros: Control Medicaid costs LMEs pick providers, set rates Better use of data Hopefully, improves quality of services

Cons: Waiting lists? Caps on services? Risk for LMEs, counties?

Lawsuits Shape Public Policy

Lawsuit #1: Reverse-Olmstead lawsuits to prevent the state from cutting off services that allow clients to live in the community

Lawsuit #2: Challenging the state’s budget cuts and new independent evaluations of whether personal care services are needed for 40,000 clients

CABHAs:Critical Access Behavioral Health Agencies

Pros: Appropriate medical and clinical treatment Reduce unnecessary services Approved by federal government Need ability to control costs

Cons: Enough psychiatrists for medical director positions? Consumer choice? Small providers?

Mental Health Study Commission

Stakeholder Inclusion Independent StaffingStrong Leadership 7 Long Range Plans

Four Systemic Questions That Need To Be Answered for Successful

Mental Health Reform

Governance – What is the responsibility of each level of government (local, state, and federal) for the welfare of those with mental illnesses?

Coverage – Which individuals and disabilities should be included in government-provided mental health care, and what services should be paid for by the government?

Work Force – Is there an adequate supply of trained workers who can care for the mentally ill and provide treatment?

Funding – How will the necessary services be paid for?

Part II of the Center’s Study Mental Health, Developmental Disabilities, and Substance Abuse

Services in North Carolina: A Look at the System and the Numbers

The Privatization of Mental Health Services in North Carolina

Mental Health and Medicaid in North Carolina: Services and Support Under Federal Law

The Genesis of Community-Based Mental Health Services in North Carolina: The History, Structure, and Accountability of Local Management Entities

The North Carolina Mental Health Study Commission: A Better Model Because of Stakeholder Inclusion, Independent Staffing, and Strong Leadership

Using Local Hospital Beds for Short-Term Inpatient Psychiatric Care: Background and Issues

Part III of the Center’s Study Work Force Needs: Update research on the available work force for mental health

services. Will include future projections of shortages.

Sidebar: The need for Transition Services for Juveniles, and whether this is connected to rising suicide rates in ages 16-20 as adolescents transition to adult services in North Carolina.

50-State Research: We will examine mental health reform in all 50 states – including an in-depth look at 3 states where mental health reform has worked and 3 where it hasn’t worked.

Qualitative Research with Policymakers, Providers, and Consumers in North Carolina: Interviews of legislators, executive branch officials, LMEs, providers, advocacy groups, and consumers. We will visit all four state psychiatric hospitals, as many LMEs as possible, providers, and key advocacy groups.

Findings and Recommendations: Based on our research on the needs of the patients, the funding streams, experiences in other states, and interviews with those in the field, we will make findings and recommendations designed to improve the provision of mental health services in North Carolina.

Mark Long

Contact Information

Mebane Rash

Attorney and Editor of North Carolina Insight

NC Center for Public Policy Research

PO Box 430

Raleigh, NC 27602

919-832-2839

[email protected]