Silver linings are seen in mental health care efforts for Oklahomans in the future.
That’s the good news as those receiving effective assistance can be part of the workforce and build the state’s economy.
The bad news is a lot of dialogue and planning as well as depoliticizing the existing system is required.
The challenges and opportunities are among many issues facing various agencies looking at improving mental health care of the many in the state, an effort that could save millions of dollars annually, specifically by lowering the Department of Corrections incarceration rate.
Steven Buck, Oklahoma Department of Mental Health and Substance Abuse Services deputy commissioner, Michael Brose, Mental Health Association Oklahoma executive director, and Joseph Fairbanks, Oklahoma State Department of Health Center of Health Innovation executive director, provided a brief overview of the work being done during the 21st Annual Zarrow Mental Health Symposium.
Susan Dentzer, Robert Wood John Foundation senior policy adviser, moderated the panel discussion.
Oklahoma ranks 46th in the nation in terms of funding for mental health programs, Brose said. Despite the lack of adequate money, the conversation is beginning to move upstream.
“I mean, we are being more assertive in working with people, being proactive and taking steps to prevent deterioration,” he said. “That seems to be an environment, and we are optimistic about that.”
Buck said the state is in the early steps of intervention and implementation. The question is how those services will be paid for. Yet, everyone, health systems and purchasers, are engaged.
Other challenges facing planners is how to have an adequate workforce throughout the state, Fairbanks said. There are 77 counties in Oklahoma and 69 subsets with mental health providers.
There are 571 licensed psychologists in the state with about 60 percent practicing either in Tulsa or Oklahoma City. The rest are in nearby areas, meaning nearly half the state doesn’t have good access to mental health providers.
Oklahoma is one of 11 states awarded a State Innovation Model (SIM) grant to design a new system, he said. That work has been underway since February. It is a work in progress and the grant will continue for years.
“We have a great opportunity to design a completely new Oklahoma specific model,” Brose said. The need is clearly recognized.
Business groups, chambers of commerce, health care providers and others list behavioral health as a priority, Buck said. They recognize the behavioral health costs. Currently 68 percent of Oklahoma adults have some form of mental illness and at least one chronic disease.
Chronic diseases drive costs up. If a mental health issue is involved, then the costs of treating chronic diseases multiplies dramatically.
Programs in Minnesota, Colorado, North Carolina and Oregon are being studied, Buck said, but no answer has been found.
He then invited anyone in the audience with possible answers for Oklahoma to attend and disclose them at a breakout session.
State agencies are in a creative partnership, thinking of ways to be innovative and collaborative in ways not previously considered, Brose said. Even though Oklahoma did not accept Medicare expansion, everyone is moving ahead with a new determination.
Brose cited the Mental Health of Oklahoma’s housing program, noting that many using the facilities are employed by the agency. About 60 percent self report they are in recovery from serious mental illnesses.
Despite having medical benefits, they still use the emergency room, he said. These people do not have the confidence or history of accessing primary care the way many others do who have had that privilege.
The transportation question was raised and Brose noted that Tulsa’s system doesn’t always work for the people the agency serves. Housing is located near public transportation or walking distances from grocery stores and pharmacies. The Zarrow Family Health Care has a bus system for people to use to get rides to services and clinics.
Transportation examples using Medicaid dollars are seen throughout the country, Dentzer said. There are some Medicare advantage plans and Medicaid expansion dollars also would provide funding towards these services as does Medicaid managed care.
Telemedicine technology is being developed to extend mental health services delivery.
Technology issues, particularly in tele-health, are important in the model that is being developed, Fairbanks said. This service can reach someone in a rural community and get them help from a doctor in a metro area. This service is being used and will continue to be expanded.
Telemedicine and tele-psychiatry is being used in Oklahoma.
Buck said the state has one of the best publicly supported systems in the nation, which is something to be proud of.
He cited a psychiatrist in southern Oklahoma who was able to provide services to 500 people from his office because he was able to reduce windshield time driving to communities to meet with patients.
Support should be given to a tele-hub where an iPad and face time could be used to do a brief screening from a centralized location, Buck said. The bottom line is at the end of the day people will have been accessed at their convenience with a high degree of satisfaction and everyone wins.
Technology could be a means of reducing the need for a police officer taking someone to another part of the state to meet a mental health professional.
University of Oklahoma and Oklahoma State University personnel are advising how to develop the tele-health model, he said. The challenge is how to prevent service disruptions.
Just as Uber has disrupted the taxi industry, many people are trying design the Uber version of health care. It would be great because it would expand services to Oklahomans, but it also could become obsolete within three years because some genius comes along and develops something that is not anticipated.
Medical workforce training
Workforce training in healthcare occupations is vital, Fairbanks said. Everyone knows that physicians, psychiatrists and psychologists are needed, but there also is a study to determine future needs.
Graduate medical education programs are being reviewed to teach physicians in rural and underserved areas about the importance of including behavioral health into their practice. Today’s physicians say they want to work with behavioral health, but they were not trained in that area and do not know how to do it.
Oklahoma has had to create its own silver linings playbook since Medicare expansion was rejected, Brose said. Transportation is a public private partnership and Tulsa has received incredible support from sponsors.
Dentzer noted that when states elected not to expand Medicaid that people below 100 percent poverty, mostly adults without dependent children, that an anomaly was created where the poorest of the poor were hurt. Many of the people in this group have multiple morbidities that include mental illness.
A lot of mental illness is concentrated in that area, which creates difficult situation, she said.
Fairbanks said that time has been spent on health care coverage and that a vast majority is determined by health insurance outcomes.
“We must address these issues because the fee for service Medicaid program throughout the country is broken,” he said.
Medicaid costs in 2014 totaled $500 billion nationwide. Oklahoma costs, including the state and federal share, was $5 billion. The state budget is just under $7 billion. A way must be found to get a value-based system instead of a fee for services.
Fortunately, Oklahoma’s innovation model is a state multi-payer system and out-of-state Medicaid involvement is a full participant.
Employment is another way to close gaps in mental health care, Brose said. If people can be helped with substance abuses and difficulties because of incarceration, they can obtain benefits as an alternative.
“As an organization, we are working on that every day,” he said. “People who have never had benefits are working for us and have benefits.”
Possibilities in 2020
Dentzer challenged the speakers to look ahead to 2020 and discuss what they saw for health care in Oklahoma.
Fairbanks hoped that Oklahoma would have a delivery system based on value and outcome and as a result, people would have better care, mental health issues would be addressed and costs would go down.
Buck expects to see the primary care physician talk about behavioral care that would become as common as using a stethoscope to check the heart.
That also would mean the Department of Corrections would not be incarcerating as many people who would be treated for mental illness and addictions and whose crimes were more of a response to their problems than anything else.
Brose hoped the state would move from a politically driven decision making system to a data decision making system.
“I think we as Oklahomans are going to look around and say we are better as a Medicaid state,” he said.