A History ofBehavioral Health Policy in America

“Policy” Webster's Dictionary 1966

“Prudence or wisdom in the management of public affairs”

“A definite course or method of action and selected from among alternatives and in the light of given conditions to guide and determine present and future decisions”

“Policy” Thomas Fuller 1608-1661

“Policy consists in serving God in such a manner as not to offend the devil”

Policy According to Broadway

“Money makes the world go round.”Song Line from musical Cabaret

“I'm just a girl who cain't say no,I'm in a terrible fix” Song Line from musical Oklahoma

1700’s

Family’s, Poor Houses, Jails

1840’s

First wave of Public Hospital Development

1880’s

Second Wave of State Hospital Development Shifts Cost and Responsibility to State Level

1920 & 1930’s

Departure of SyphiliticsDeparture of Epileptics

Post World War II

MI Begin to Depart to Community

1950’s

Arrival of Effective Antipsychotics and Antidepressants

State Hospitals Develop Outpatient Medication Clinics

Arrival of Child Guidance Movement

1960’s

Medicaid/Medicare Shift Many Costs to Fed

Persons with Dementia (and many MI) Depart to Nursing Homes

Growth of General and Private Acute Inpatient

Growth of OutpatientCMHC Movement and Federal Grants

1970’sIMD Exclusion Exemptions

- ICF MR created and MR/DD population Departs- Persons under 21 y.o.

Commitment Limited to Dangerousness

Harsher Drug Laws Increase number of MI in Jail and Prisons

First Presidential Report on Mental Health

1980’sIMD Exclusion Exemption for facilities of less

than 16 beds

Fed Block Grants CMHC Funds to States

States Retarget CMHC’s to SMI

TEFRA Stimulates Private Sector Inpatient Growth

States Take Advantage of DSH to Shift Costs to Fed

1990’s

Medicaid Waivers Allow States to Increase Federal Share of Funding

Behavioral Managed Care Causes Loss of Private Sector Inpatient

2956

1757 1762

3877

270 216 118 113 128 128 106 65 112 140 143 143

2341

1946

1725 1754 1841 1808 18631760 1828

1662

1320 1383 1323 1337 1356 1311 1295 1276 1253 12391089

4888

3447

3161 32193325

3225 3223 3148 3150 3144 3060

0200400600800

1000120014001600180020002200240026002800300032003400360038004000420044004600480050005200

1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 Current

Federal Private DMH All Beds

2000

Second Presidential Commission on Mental Health

2000 Up to 2008

Bed capacity fairly stable Stigma much reduced Increased Medication Usage Increased MH prescribing by PCPs Emergence of EBP Integration of BH and Medical Care

Overall

Treatments get continually better

Financing and Administration has become ridiculously complex

Community Focus and Locus Increases

“Better But Not Well”Richard Frank, PhD

Improvements in Care to MI due to: Disabled income and housing

supports Newer medications easier to

prescribe correctly Many more persons with SMI treated

by PCPs with medication

2008 through 2010Suddenly A New Environment

2008 - MH and SA Parity Act 2009 – Economic Crisis 2009 – HIT Act 2010 – Health Care Reform

Public Sector Mission

To Care for Persons whose behavior is so dangerous or socially unacceptable that their communities cannot tolerate their presence and no other entity can or will work with

Public Sector Goals

Treatment and Recovery Public Safety

Public Sector Admission Criteria

The facility or program is the least inappropriate currently available.

Missouri DMH Serves - 36% of persons in Missouri with

SMI5% of persons with a non-SMI

psychiatric need

Try to serve as many as possible with limited resources

Breadth vs. Depth

Everyone’s Choices

Give the best to a few

Give minimally adequate to many

Give something to everyone

Politically Viable Choices

Winners: Medication Access, Kid Services

Losers: Provider Rate Increases, Rehab Programs,

Psychotherapy, Dental Services

Our ChoicesMaximize Minimize

Case Management Therapy/CounselingMedication Services InpatientMedicaid Uninsured

AmbivalentHousingEmploymentCrisis

Mo National Per Capita Rank 2007 – Psych Bed Resources

All Inpatient 20th

State Hospital 14th Forensic Beds 8th Residential Services 31st

DMH Beds by Category

Type 2007 2010 PercentAcute adult 279 86 7.1 %Acute child 48 28 2.3%Intermediate 25 62 5.1%MIDD 20 20 1.6%LTC (88% forensic) 918 893 73.4%SVP 133 128 10.5%

Totals 1423 1217 -14.5%

States with No DMH Adult Acute Beds

Arizona PennsylvaniaFlorida OregonHawaii MarylandIndiana MichiganDistrict of Columbia