I am launching a local and national peer provided services advocacy campaign to let people know how we can fund mental recovery instead of systems that keep people dependent and ill for the rest of their lives. The Substance Abuse and Mental Health Services Administration blog predicts that by 2020 psychiatric diagnoses will be the leading cause of disability in our country, more than any other physical disability. But if you could please cut our budget, this doesn’t have to come true – people can completely recovery from mental health labels and move on with their lives. Here are seven funding suggestions for how to please cut our budget to reduce the growth in psychiatric disability. This is an expansion of my previous blog about mental health advocacy priorities.
Wellness Wordworks is doing a local event kicking off August 17th at the Medicaid Reform forum in Overland park, KS. Click here to RSVP for it or call, email, or text me via my contact info page. We’ll have T-shirts that say:
Please cut our budget! We’ll tell you how.
This is a designed to be a provocative message that legislators, media, and other advocates are not saying. Everyone else is trying to ask for more funding, so by asking to please cut our budget, we hope to get consumer priorities truly heard. We are trying to promote ways to help mental health service recipients with ideas from people who have themselves recovered from mental health diagnoses. We know what works because we have done it.
The back of our T-shirt will say:
1. Fund local peer run crisis alternatives NOT state hospitals: 1/10 the cost and better outcomes.
This is based on studies done by the National Empowerment Center and outcome results of other existing peer run crisis respite care. These are locally based programs that give people a chance to work through their main issues of housing, relationships, jobs, trauma, or spiritual sources of crisis. People in hospitals typically only get medication adjustments and often additional labels. People using respite typically do not need nearly as much re-hospitalization and the programs are much less costly to run. Furthermore, these can be run locally instead of requiring people to travel halfway across the state for treatment where they are isolated from support from family and friends.
SAMHSA just completed a 90 minute national conference call on the topic that drew over 300 participants. This call will be archived on their training teleconference page when they have fully processed it. Many of the participants asked the question, “Why aren’t there more of these programs? They make so much sense.” If you could could please cut our budget and let us help each other recover in safe, effective local programs, it would save a ton of money.
These programs also reduce stigma by showing that people in crisis do not have be isolated in huge state institutions. Furthermore, Medicaid funds may be available as there is a cutoff for hospital funding for hospitals that have more than 17 beds. Another problem with hospitals is that many of the 50 or 80 year old buildings have lots of safety and hygienge problems inherent in the architecture that can’t be fixed. So many staff were being injured in Missouri’s Fulton state forensic hospital that staffers tried to introduce a bill where they could fight back and injure residents without retribution based on a “self-defense” exemption. All this could simply be eliminated by moving residents to smaller, local, less traumatic, more affordable, and more recovery friendly environments.
Another problem with state hospitals is that many of the beds are being filled by sexual predators who have served their prison terms but are not deemed safe to return to the community. This is essentially a second prison term that may or not not be a violation of their rights. These people should either be recovered and released, or returned to prison. Currently up to half of the psychiatric beds in Missouri are taken up by sexual offenders, taking badly needed help away from people in psychiatric “crisis”. The current “shortage” of hospital beds is really a bad misallocation of resources. My source for this is Edward Duff of the Missouri Governor’s Council on Disability.
All state officials should please cut our budgets with huge reductions in hospital costs. We should immediately issue requests for proposals for non-profits interested in starting local peer run crisis alternatives. This can reduce hospital expenses hugely, while also being very important for rural communities by increasing local jobs, providing local access to care, and increasing recovery. Please cut our funding by reducing hospital expenses.
2. Fund community mental health NOT treatment in jails. 1/3 to 1/16th the cost.
Jails cost housing, meals, supervision, and other costs that are much higher than community mental health treatment. Furthermore, people in jail are rarely given rehabilitation opportunities, and jails greatly increase people’s exposure to trauma. Most public officials, however, see jail funding as a fixed cost since the jails are already built, and mental health funding as a variable cost because costs change with the number of people served. However, this five page cost savings model shows how to calculate a community’s potential savings by keeping people out of jail.
State officials please cut our budgets by shifting funding from jails to community mental health centers and funding additional jail diversion programs. State officials should also look to replicate California’s recent decision to reduce prison populations by releasing some of the 95% of people where were scheduled to get out sooner or later anyway, saving $48,000 per person per year. Please cut our budget, especially, the prison budget.
3. Supported employment and peer support centers NOT adult day cares: 4X more people employed.
Many studies like this first research article, this second research article, and this literature review of supported employment show better outcomes when mental health centers convert their day programs which teach “psychosocial rehabilitation” to programs helping people immediately to get jobs of their choosing. Most of these studies found that people had better or the same recovery outcome measures, but around four times as many of them were working in competitive employment. They also found that costs to provide the service are about the same. However current Medicaid reimbursement is set up where supported employment is usually provided as a one on one service whereas day programs do lots of groups and combined activities which still bill for each individual participant. Day programs are not in existence because they work all that well, they are in existence because they are cash cows for community mental health centers.
However, another alternative is local consumer operation organizations or peer support centers. These provide many of the services of day programs without delaying recovery by keeping people isolated in the mental health center. All services in these programs are provided by people who themselves have benefitted from recovery. The state of Missouri has been recognized nationwide for replication of a program created by Dr. Jean Campbell and other people in recovery evaluating these programs and showing their effectiveness. Dr. Campbell found that people who attended these programs more had a greater increase in well-being. This information can now be downloaded for free as national toolkit to promote more consumer operated programs.
The state of New Hampshire evaluated their Medicaid data for high service users, medium users, and low service users against surveys of people who attended peer support centers. They found that people who attended peer support centers had much lower medicaid utlization rates and many fewer hospitalizations than people who didn’t use each other for support. Source: Ken Braiterman, who can be found @KenBraiterman on Twitter.
State officials should please cut our budgets by working with Medicaid officials to shift funding from day programs to supported employment and peer support centers. Please cut our budget by not billing Medicaid for services that keep us dependent.
4. Peer/doctor evidence based medication reduction teams NOT preferred drug formularies: 10X lower med and hospital costs
In November of 2007 the President and CEO of Eli Lilly pharmaceutical company gave a speech to a conference about tailoring medication to individual people, called pharmacogenomics. He showed that 38% of people are not helped at all by antidepressants and 40% of people are not helped at all by antipsychotics. He said that these medications may instead by harming the person. He was making the point that maybe we should be using pharmacogenomics to test whether or not people would respond to a medication before we give it to them. This would save huge costs and human suffering. Other researchers have suggested not all people need medications in early psychosis and that giving everyone medications may in fact be lowering recovery outcomes for a huge pool of people.
Many other researchers have suggested while medications may help some people, for others they may cause harm, and meds may be increasing disability in our country. Robert Whitaker, the keynote speaker at last years national Alternatives conference, said that “The best way to predict who will respond to medications is who says their medications are helping them and who likes taking their medications. If people tell you that their medications are not working, then in the long term they tend to not show a response to them, either.” So, helping people reduce their medication use may both reduce their treatment costs and improve their recovery outcomes. A careful, slow, considered medication reduction is absolutely necessary and support from both peers who have been through it and doctors who are aware of medication problems are essential. Here is the Icarus Project’s exellent Harm Reduction Guide to coming off psych meds.
Cost savings estimates: If 40% of people are not helped by medications, and many other people could reduce medications, then addressing their needs efficiently would both save medication costs and reduce their hospitalizations, disability rates, and long term care costs. This is where I get a 10 fold cost savings.
State officials should please cut our budgets immediately by asking each community mental health center to ask for individuals on their staff who would have enough knowledge and interest to help people use good evidence based medication withdrawal techniques. Each mental health center should have at least a few people who know about this material. Then any time a person asks about reducing medication use, they should be referred to this team, which would not incur any additional costs and would save money immediately.
5. Medicaid good prescribing limitations as in Texas and Missouri NOT repeated violations by out of date doctors: 3X lower medication costs
Both Missouri and Texas have put in limitations to Medicaid drug costs where doctors who prescribe medications outside of evidence based practices have to explain the exception to a pharmacist before the prescription is filled. The prescription is not blocked, but just delayed until the doctor provides a justification. These are not conservative limits. In Missouri the clinical edits are things like:
- 6 or more psychotropic medications at once
- greater than 2 SSRI antidepressants
- SSRI antidepressants in children under 5 years old
- use of multiple atypical antipsychotics at the same time
- use of atypical antipsychotics in children under 5 years old
- use of SNRI antidepressant for more than 30 days in children under 18 years old
- More than two tricyclic antidepressants at the same time
Texas also cut their medication costs in half according to this PBS video when they added in these kind of evidence based limitations. North Carolina has similar limitations, with a table showing that even the FDA and the drug manufacturers do not recommend prescribing certain antispychotics off label to children. If the drugs have so little effect that even these people do not recommend them, then would be an excellent place to please cut our budget.
The reason limits like that are important is that there is no evidence base for any of the above prescribing practices. None of the atypical antipsychotics have an indication in children under 5, and only two of them have an official clinical indication for children under 10. However, in Missouri, the HealthNet Psychology Program Unit collected data on atypical antipsychotic use in children 6 years of age and younger for the full 2007 calendar year. They found that 443 kids under age 7 were given antipsychotics during the year at a cost of $1.4 million to the state. Again, keep in mind that this would fund 28 peer support centers of 15 respite care homes, and that’s just one drug category for one age group.
Rhonda Driver, the director of Missouri’s Medicaid monitoring program, said, “What we’ve found is that there is just a small number of doctors violating these practices, but…. they are kind of like…frequent flyers. Often they don’t even bother to put in a justification when the prescription is denied.”
Cindi Keele, the director of NAMI Missouri said, “Well, maybe we can reach out to the people whose prescriptions have been denied.”
I said, “Well, maybe we can reach out to these doctors who don’t seem to understand evidence based medicine.” These clinical edits are not very conservative. If a doctor repeatedly violates the guidelines, either they are trying to heroically rescue a lot of people with huge doses of medications, or they have not kept up to date with medicine.Removing these doctors from the Medicaid prescribing pool should produce the following cost savings:
Est. 2000 clinical edit violations per year X $300 per psych med prescription X 2.5 factor for giving someone a better chance at recovery X 2 for reducing hospitalization needs due to overmedication = $3 million dollars per year.
State officials should cut our budgets by immediately questioning doctors who repeatedly violate evidence based prescribing practices and remove them from Medicaid prescribing eligibility.
6. Peer supporters as 10% of staff in mental health centers to build wellness strategies NOT risk avoidance measures. 3X the recovery rates.
Peer support has a huge evidence base of effectiveness and the staff costs much less than academically trained professionals. This is a research article showing that peer staff is less invalidating than traditional staff, and when people need to be challenged, peers can often do this in a way that is not invalidating to service recipients. Here is another research article showing that peer support helps avoid hospitalization. This is the literature review of peer support evidence. I published a research article showing that the lack of peer support is a real rift between science and current practice.
State officials should immediately cut our budgets by implement policies boosting the number of peer supporters in mental health centers.
Summary: Please cut our budgets. We’ll tell you how.
These solutions will save tons of money, increase real recovery rates, ward off the spread of disability, and help many of my brothers and sisters in the mental health system to become full, productive, tax-paying citizens.