Montana’s mental health safety net is full of holes.
Stigma, lack of insurance, Medicaid restrictions and a shortage of mental health professionals all contribute to the “state of despair” that reporter Cindy Uken has been detailing in a Billings Gazette series on suicide. The state’s suicide rate — the highest among the 50 states and double the national average — is cause for alarm. Yet it isn’t the only terrible symptom of Montanan’s mental health care gap.
Let’s start with stigma. The “cowboy way,” is toughness, independence and not “talking about it.” More public awareness and education is essential to help all Montanans understand that mental illnesses are diseases of the brain. Like people who have heart disease or other illnesses, people with mental illnesses need effective treatment. They can recover.
Barbara Mettler, executive director of the Mental Health Center in Billings has only been on the job for two months. Already she’s learned that some folks from small towns choose to drive to another town for their mental health care. They are concerned about protecting their privacy.
Not everyone who needs mental health care is able to travel long distances. Most of Montana is designated as Mental Health Care Professional shortage areas by the federal Health Resources and Services Administration.
The shortage of mental health professionals is nationwide, said Mettler, who has worked in community mental health in Colorado for three decades. Too few young people are entering mental health care professions because compensation is lower than for other health specialties. Psychiatrists are at the low end of the doctor pay scale, along with primary care practitioners, who also are in short supply. About 75 percent of the Mental Health Center’s revenue comes from Medicaid. Most of the rest comes from the Mental Health Services Plan, a program that provides limited care to seriously mentally ill Montanans who don’t qualify for traditional Medicaid. Medicaid doesn’t cover all who are poor and the MHSP has limited funding.
“We have a whole lot of folks who aren’t getting treatment,” Mettler said last week. “As a community, we need to get our ducks in a row to meet the needs of the community.”
Here’s an example of how Medicaid restricts care: More than 40 percent of all babies born in Montana are covered by Medicaid because their mothers have no health insurance and their incomes are less than 133 percent of poverty level (less than $25,389 annual income for a family of three). However, most of these women weren’t eligible for Medicaid before they became pregnant and lose Medicaid two months after their pregnancy ends.
Postpartum depression diagnoses spike nine months after delivery, according to Karen Kietzman, a clinical psychologist in Billings. At a December legislative forum on children’s health, Kietzman said she has continued to see patients who lost their Medicaid and can’t pay, but a lot of clinicians don’t.
Uninsured in Glendive
Glendive Medical Center admitted 101 patients to its new inpatient mental health unit in 2011. A quarter of those patients were covered by Medicaid, a quarter paid out of pocket. The rest were uninsured and couldn’t afford to pay, according to CEO Scott Duke. The hospital treated them anyway as part of its mission to serve the community.
Billings Clinic provided $14 million in charity care in 2011, much of it to patients receiving mental health care.
The clinic saw a gap in care for indigent adults being discharged from its psychiatric hospital, so it created the Bridge Clinic to provide short-term outpatient services.
The purpose is “to ensure people stay on their treatment plans and medications,” said Kristianne Wilson, executive director for health policy.
Billings Clinic’s Bridge
Designed in collaboration with RiverStone Health, the Bridge Clinic receives no government funds. It has reduced re-admissions and cut the average time that adults are hospitalized in the psychiatric center.
Medicaid accounted for 41 percent of 1,700 psychiatric inpatient admissions last year while Medicare accounted for 27 percent. About 10 percent had no payment source. Psychiatric treatment is the No. 1 reason for Billings Clinic emergency visits, hospital admissions and re-admissions.
The numbers of emergency and short-term psychiatric patients were larger before the Community Crisis Center started diverting people from the emergency department, providing immediate care at lower cost.
The crisis center was launched by Billings Clinic, St. Vincent Healthcare, RiverStone Health and the Mental Health Center. The majority of needy people walking through its door are homeless and few have Medicaid or insurance, according to manager Marcee Neary.
The crisis center operates with funds from the two local hospitals, from a voter-approved countywide levy and from a state program created by House Bill 130 that was established to support community crisis services.
The crisis center helps keep mentally ill people out of trouble and out of jail. Crisis center staff members work with the jail’s professional counselor, Terry Jessee.
Montana’s mental health system has some good services, but not enough. The gaps demand urgent responses.
We call on Montana lawmakers to support legislation this session that will:
- Raise public awareness of mental illness and treatment.
- Encourage early intervention.
- Encourage mental health professionals to practice in Montana.
- Cover the cost of quality mental health care for Medicaid and other indigent patients.
- Require care providers to demonstrate that their treatment is effective and base future payments on outcomes, such as reduced hospitalization.
Montana’s suicide toll won’t be reduced without concerted, long-term efforts. It’s time to strengthen Montana’s mental health safety net.