Monday, November 16, 2015

Michigan: Washtenaw County's Mental Health Mess

The Ann Arbor News featured a long article about the decrease in funding for Community Mental Heatlh (CMH) services in Washtenaw County: "Analysis: Where has all the money gone? Washtenaw County's mental health mess" by Ben Freed, 11/15/15.

Kudos to Ben Freed for figuring this out and analyzing  a mess similar to the results of Humpty Dumpty falling off the wall in the nursery rhyme.  Freed has unscrambled the egg and now I am trying to understand and translate his analysis, so that us ordinary people dealing with the mental health system can at least have a clue as to what happened.

The CMH system provides services primarily to people with developmental disabilities, mental illness, and drug abuse problems. For individuals who are eligible for Medicaid and are developmentally disabled, Washtenaw County CMH still has a responsibility to provide them with all services that are deemed medically-necessary through a person-centered planning process that results in an Individual Plan of Services (IPOS). Most people with developmental disabilities fall under this category. This has not changed, but many other people who were previously covered by CMH who do not fit that category, have found themselves with greatly reduced services or none at all. This is bound to affect the entire system.

What Happened?

Washtenaw County's mental health services budget was $80 million in fiscal year 2012 and has fallen to $66.7 million in Fiscal Year 2016. 

Where has the $14.3 million gone? Freed breaks it down into several categories to account for the lost funds.

$3.86 Million: The WCHO deficit

The Washtenaw Community Health Organization was formed in 2000 in partnership with the University of Michigan and was designated the Prepaid Inpatient Health Plan (PIHP) for a four county area as well as the CMHSP (or what had previously been called the CMH ) for the County. The PIHP is a regional administrative agency that distributes Medicaid funding to the counties belonging to its affiliation and the CMHSP provides the services. 

Within the WCHO, Medicaid funding and the number of people served would fluctuate over the course of a year and deficits in one county, usually Washtenaw, would be plugged by surpluses in other counties. This practice was not hidden and it was the accepted way of balancing the budget.  Sometimes infusions of state funding would also fill the gaps. 

By 2014, it became clear that the gap had reached unmanageable proportions and a Washtenaw County Behavioral Task Force recommended dissolution of the WCHO and a takeover by Washtenaw County government to provide better oversight and monitoring of CMH. There were also changes in state funding and the PIHPs that eventually led to substantial changes:

“A new organization, the Community Mental Health Partnership of Southeast Michigan, was formed to take over PIHP duties from the Washtenaw Community Health Organization, which was eventually phased out as an entity in 2015. Its county functions were absorbed by the CSTS [Community Supports and Treatment Services], which took on the name Washtenaw County Community Mental Health.”

Cuts in services to offset the deficit have been the source of controversy and have led to devastating results for some County residents.

$8.5 million: Medicaid and carry over

Medicaid funding accounts for 80% of the Washtenaw CMH budget. Medicaid funds can only be used for certain services for Medicaid-eligible individuals and cannot be used for other services or for those who do not qualify.

Here is where you have to watch the bouncing ball to understand what is going on with Medicaid:

If the economy improves, as it has in the last couple of years, fewer people qualify for Medicaid and funding to CMH goes down:

“As of June 2015, there were 3,333 fewer total Washtenaw County residents on Medicaid than the previous June—that number includes all Medicaid enrollees, not just mental health patients. In FY 2015, Washtenaw County received about $1.4 million less than was budgeted for that year and in the coming year the county's Medicaid payout will be down by $2.5 million.”

In previous years, any Medicaid money that was not used up could be rolled over into the next year’s budget: 

In 2012, the WCHO had $8milliion to carry over to its next fiscal year. “By FY 2014 the carry forward had shrunk to $6 million and four months into the following fiscal year, it was gone. This year there is no carry forward money to help supplement the Medicaid dollars. At the same time, community living support costs grew from $10.4 million in FY 2010 to more than $22 million by FY 2014. Core provider costs had grown from $25.8 million to nearly $30 million over the same time period.”

Also, “Three of the four counties in Washtenaw County's PIHP region did not receive enough Medicaid dollars to fully fund their programs in FY 2014 and the $1 million surplus from Lenawee was distributed to help the other three support their deficits.”

$2.2 Million: The State of Michigan

Although the State Budget Office tells us that the state's total mental health budget - including the Healthy Michigan Plan (Medicaid expansion) - grew by 9 percent to a total of $2.8 billion in 2015, local CMH agencies are struggling with financial problems not addressed by the state or exacerbated by state funding decisions.

Michigan introduced its Healthy Michigan Plan (Medicaid expansion), in 2014, and more than 600,000 people signed up who had previously not had Medicaid coverage:

“Because enrollment was higher than expected, the state had less money to pay per patient than they had previously estimated. Approximately 15,000 people enrolled in the program in Washtenaw County, but the per-patient rate was adjusted down by $10 per month mid-year by the state.” This resulted in $1million less revenue than expected for Healthy Michigan Plan CMH consumers that will carry over into 2016.

Then, “with the new federal funding coming into mental health services, the state also took the opportunity to cut general fund allocations to county mental health agencies across the state.” Because this money had been used to fill in gaps for County residents who did not qualify for Medicaid or were on the borderline of qualifying, services that were once provided with general fund money, are the most adversely affected by the state’s decision.

As a result, “’You're starting to see those people in the ER, you're going to start seeing them in the justice system, people who had been under our care,’ Cortes said. ‘These are people we've been serving for more than a decade.’”

“…Washtenaw County's general fund allocation for FY 2012 was $8.36 million. In FY 2016 it is $2.8 million, but the state is also taking on about $1.9 million payments to state hospitals that previously came from the general fund allocations.”

What happens next?

There are state-level discussions going on to request an increase in general fund dollars for county CMH agencies. Washtenaw County Board of Commissioners has stepped up to continue funding of the county’s vocational training program. The County has also added a “structural $400,000 allocation to mental health from its general fund that will be paid for through the anticipated increases in taxable value in the county.”

“…St. Joseph Mercy Hospital and University of Michigan Health System have each pledged more than $100,000 to Community Mental Health and the Washtenaw County Health Plan is adding an additional $150,000. Those funds will all go toward direct services for people not covered by Medicaid.”

In addition, “The county is also in negotiations with the unions about maintaining staffing and pay levels for county employees”.

The article also covers the programs that are likely to be most affected by the changes in Washtenaw County and the services that will likely be dropped. 

Read the full article here...

Another article, "What the mental health funding cuts mean for one woman's struggles" by Ben Freed, 11/15/15, follows the day-to-day changes in the life of a woman with severe mental illness whose services have been reduced or eliminated.

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