Overview of Behavioral and Mental Health in Alaska · “The economic cost of mental illness will be more than cancer, diabetes, and respiratory ailments put together.” Thomas Insel

Overview of Behavioral and Mental Health in Alaska

Gregg Knutsen, MSChair, Planning and Community Relations Committee, Anchorage/Fairbanks Community Mental Health Services Board of Directors

Jerry Jenkins, M.Ed., MACChief Executive Officer, Anchorage/Fairbanks Community Mental Health ServicesPresident, Alaska Behavioral Health Association

Mental Illness, Substance Abuse – Behavior Health

Will pay for services somewhere – direct, indirect

Identifiable Life versus Statistical Life

Recovery and Growth

Investing in programs during a recession

Government’s Role versus Government Efficiency

Access and Intensity of Services: Unable to see costs rise significantly

Early less cost better out

Continuum of Care

June 2, 2017Jenkins/Knutsen 2

Concepts and MessageHow do we deal with the inner drama of being human?

Mental health is “a state of well-being in which the individual:

Realizes abilities,

Cope with the normal stresses of life,

Can work productively and fruitfully, and

Able to make a contribution to his or her community.”

It is estimated that only about 17% of U.S adults are considered to be in a state of optimal mental health.

Definition: Mental Health


Behavioral medicine is an interdisciplinary field combining both medicine and psychology

Concerned with the integration of knowledge in the:

Biological,

Behavioral,

Psychological, and

Social sciences relevant to health and illness.

There is emerging evidence that positive mental health is associated with improved health outcomes.


Definition: Behavioral Health

Mental Health

All mental disorders are behavioral disorders

Not all behavioral disorders are mental disorders.

Behavioral Health

Downstream of Mental Health

Behaviors may contribute like lack of exercise, diet, habits


Mental and BehavioralHealth Differences

Usually psychological factors (internal factors) dominate in mental disorders

Behavioral disorders physiological and sociological factors (external factors) may dominate.

Marriage/family counseling

Addiction treatment

Services providers: social workers, counselors, psychiatrists, neurologists, or physicians

Continuum of prevention, intervention, treatment and recovery support services


Behavioral and Mental HealthCommonality and Overlap

Mental Health Triad


Many elements affect over-all mental health

Not shown is socio-economic factors

Not shown are interventions & services

There is feedback: positive and negative

Social & Economic Impacts


Social & Economic Factors


As with general health care, social & economic factors matter

Social: Longevity


2012 Economist Report

United Kingdom

Comparison of years lost due to various conditions

Mental health highestnegative impact

Men die 20 years earlier causes other than suicide

Partly because: tougher to treat, and

often live less healthily


Social: Mental WellbeingNovember 2007

Estimates from several rich countries put the economic cost of mental illness at 3-4% of GDP.

Economist, 2012

“The economic cost of mental illness will be more than cancer, diabetes, and respiratory ailments put

together.”

Thomas InselDirectorNational Institute of Mental Health, USADavos, 2015


Estimated Total Costof Mental Illness

Comparison of Severe Mental Illness (SMI) and no SMI (National Institute Mental Health) SMI episode serious impairment at least 30 days

Without SMI ≈ $38,853 annually

With SMI ≈ $22,545 annually

Societal loss estimated $192.3 Billion

The total loss is combination of: 75% income income reduction

25% no income


Earnings Impacts (2008)

Intervention and Treatment: Location & Timing



Comparative Cost of TreatmentOKPolicy.org - February, 2011


Timing of InterventionMental Health America


Care Options CostsFinancial and Human Toll, Liz Szabo, USA Today


In-patient Care OptionsFinancial and Human Toll, Liz Szabo, USA Today

Alaska Specific Information


± $260 Million

(2013)

Federal

State


Funding SourcesRelative Size ≈ Amount of Dollars

“Remember, we will pay for untreated mental illness and substance use disorders somewhere!”

So sayeth Jerry Jenkins – 2 June 2017


Funding -What are we buying?









Gaps in system are resulting in additional utilization of more intense services.


Funding Sources

Indian Health Services (IHS) 100% Federal Medicaid Assistance Percentage (FMAP) -Matching) Rates adjusted annually – encounter rate – D. Morgan is the resident expert. State regulated under auspices of Medicaid and state grants - “Self-determining” in

light of proposed administrative support organization (ASO) – aka managed care Grants: Federal and State including IHS funding. Third party insurance including Medicare; self pay

VA/DOD

Non-IHS (private for profit and non-profit; government; schools)

50% FMAP since 2010 88% Denali Kid Care (DKC) negotiated No regular rebasing of Alaska Medicaid rates. State regulated Grants: Federal and State Third party insurance including Medicare; self pay


Funding Sources

Federal Sources: Indian Health Services

Federally Qualified Health Clinics

Medicaid (TEFRA, CHIP/DKC), Medicare, Tricare

Grant Funding for Specific Programs (HUD; HHS; USDA, DOJ, etc.)

State Sources: CAMA – Chronic and Acute Medical Assistance

Grants (GF, UGF, DGF)

SOA Employee Insurance

Private Sources – 3d party insurance, EAP

No insurance - out-of-pocket or charity care (EMTALA –Emergency Medical Treatment and Labor Act)

Southcentral Foundation– Indian Health Services (IHS)

Peninsula Community Health Services – Fed Qualified Health Clinic (FQHC)

Arc of Anchorage – Medicaid, multiple types (DD; MI), donations

Counseling Solutions of Alaska – Private Insurance, Out-of-pocket

Nugen’s Ranch – Grant Funded (IMD exclusion)

ACMHS/FCMHS – Various, Comprehensive Behavioral Health Treatment and Recovery (CBHTR) Grant – 50 funding streams.

Department of Corrections – State of Alaska – largest provider of mental health services in AK?


60 + Service Providers: Samples

It is complicated trying to describe the Alaska behavioral healthcare system because it is complicated.





Walk-ins – Same day access – very limited in AK.

Referrals

Family and friends,

Employer,

Other providers like API, North Star, DOC

Civil Commitment

Criminal Justice System (DOC; Mental Health Court)

Emergency Medical Services – SB 74 – 5days for either primary care or behavioral health


Access to Services

Stigma

Lack of ‘same day access’ or any access like detox

Lack of information about where to get services (211)

Transportation within local community

Geography and Weather


Barriers to Services

Demand for Services Improving treatment:

Comorbidity is the norm – medically complicated

Resistance to effective clinical management (refuse meds, miss appointments due to limited transportation, don’t follow through on treatment plan) – just like other illnesses.

Acute/crisis focused often versus long-term support

System capacity:

Over capacity resulting in long waits for services and

Limited availability of services within communities

Limited or no same day services except ER

Workforce


Challenges to the System

Workforce: Administrative and Clinical Talent

Recruiting and Retaining

Competitive compensation and benefits help.

High Stress due to nature of the work - It is not for everyone!

Documentation and Record Keeping demands-

Funding required documentation

Regulatory training and record keeping – highly audited

Turnover: train and then brain drain to private practice

Necessity to utilize locum tenens prescribers – migrant workers

Lack of routine rebasing for non-IHS providers.


Challenges to the System (Continued)

Cost of Services


Reimbursement $58,800.00

$79,998.00

Cost of Services

Clinical Associate: $79,998.00 (Hourly rate of $20.20 with benefits, requirements and cost of business.)

Available Hours: 920

Cost per Hour: $86.95

Reimbursement Rate: $64.00

Reimbursement: $58,800.00

Difference: $21,198.00 (Importance of

grant funding.)

Summary



It is complicated trying to describe the system because it is complicated.

And, “Remember, we will pay for untreated mental illness and substance use disorders somewhere!”

So sayeth Jerry Jenkins – 2 June 2017 So sayeth Jerry Jenkins – 2 June 2017

Gaps in system result in additional utilization of more

intense/higher costing services.

Fill gaps and use telephone/technology triage.

Use 211 for steerage.

Supporting Office of Children’s Services

Identifying mentally ill departing Department of Corrections

and linking to services.

Identifying and connecting Division of Juvenile Justice

releases to community services.

(BTW, they normally do a good job.)

Opportunities

This need in Alaska continues to grow

Behavior/Mental Health services cannot fix all of the

“Inputs”; can mitigate and treat

Can positively affect the Outcomes: interrupt the cycle

Universal Concern: the inner drama of being Human

More investment in behavior/mental health services

Saves lives, families, and communities

Improves over-all health and well being – avoids other costs


Summary

How, when and where we address

behavioral/mental health needs matter


Summary (Continued)


Summary (Continued)

To save money – change the De Facto system

Continue to educate and inform Alaskans about the dynamics of behavioral and mental health issues

All service segments are inextricably linked

Swim against the tide and increase funding for all service providers

There are real and measurable economic and financial benefits to gain with improved services


Summary (Continued)

Documents

Overview of Behavioral and Mental Health in Alaska · “The economic cost of mental illness will be more than cancer, diabetes, and respiratory ailments put together.” Thomas Insel