2013 News Releases

The Impact of Strengthening Medicaid on Missouri's Mental Health System

Updated DMH Statement 4-15-13

Last week, President Obama released his 2014 budget proposal. The President’s budget includes proposed legislation to delay for one year the reduction in disproportionate share hospital(DSH) payments to hospitals that was scheduled to begin in Federal FiscalYear2014.

DMH’s recent report, “The Impact of Strengthening Medicaid on Missouri’s Mental Health System,” is still accurate.

If the proposed legislation passes, DSH payment reductions will still begin in 2015, and the reductions originally scheduled for 2014 would be spread over 2016 and FY 2017.

Therefore, DMH’s original projections that DSH payments to Missouri hospitals will be reduced, ultimately reaching about 50%, is accurate. Though the start is delayed one year the reduction is accelerated to achieve the original deadlines for both dollars and full implementation date, thus only delaying the initial impact by a year.

It is also significant that for each year Missouri does not expand eligibility for Medicaid to 138% of poverty it will lose one year of 100% federal funding of the expanded population, $62 million in state tax revenue from new jobs generated, and 90,000 Missourians in need of mental health, substance abuse, and developmental disabilities services will not have health insurance coverage.

Executive Summary

As the state’s public mental health authority, the Department of Mental Health (DMH) is responsible for overseeing, operating and funding much of the mental health system in Missouri. It is a complex system that requires close collaboration with community partners to maximize resources and provide effective treatment to some of the state’s most vulnerable citizens.

Strengthening Medicaid by extending eligibility to 138% of the federal poverty level, through federal funding available under the Affordable Care Act (ACA), has major implications for Missouri’s mental health system. This analysis compares the major changes that will occur in community mental health and psychiatric inpatient services if the state extends eligibility or if it maintains current eligibility levels.

Four community hospitals have participated in this analysis. They include CoxHealth-Springfield, SSM St. Joseph Health Center-St. Charles/Wentzville, Truman Medical Center-Lakewood and Twin Rivers Regional Medical Center-Kennett. They are typical of most hospitals in Missouri.

In summary, the major findings of the report are as follows:

• If eligibility is extended, nearly 50,000 of the 300,000 newly eligible Missourians would receive behavioral health services through DMH-funded community treatment and support programs.  Many will be young adults, between the ages of 18-30, with developing mental illness such as schizophrenia or bipolar disorder.  Missouri’s public mental health system does not now serve them well because they are generally uninsured and have no means to pay for their treatment.
  
• Through extended eligibility, Community Mental Health Centers (CMHCs) and other DMH-contracted community behavioral health providers will engage individuals earlier in the onset of their mental illness or substance abuse.  DMH and MO HealthNet (Missouri’s state Medicaid agency) have already proven that early intervention and treatment result in better health outcomes at lower costs through recent pilot programs focusing on high-cost Medicaid recipients with co-occurring mental illness and chronic medical conditions.
  
• Missouri hospitals, that deliver inpatient services to uninsured and indigent patients, receive over $500 million annually through a federal reimbursement mechanism called Disproportionate Share Hospital (DSH) payments.  Under ACA, all hospitals receiving DSH reimbursements will ultimately lose approximately 50% of this funding, since many individuals who are now uninsured or indigent will become Medicaid eligible if states extend eligibility.  Missouri hospitals will lose about $250 million in federal reimbursements for the charity care they provide, whether or not the state chooses to extend eligibility.
  
• Missouri already has limited availability of acute psychiatric inpatient beds statewide. Community hospitals now operate a total of 2,168 acute psychiatric beds, or about one psychiatric inpatient bed for every 2,800 Missourians.  For comparison, community hospitals now operate one general medical bed for every 300 Missourians.
  
• Only 1,174 (or 54%) of Missouri’s 2,168 acute psychiatric community hospital beds are for adults between the ages of 18 and 65, even though the onset of serious mental illness usually occurs during the early and mid-adult years.  While child and geriatric inpatient beds have lower percentages of indigent patients and have other funding streams, such as Medicare, to cover their costs, adult psychiatric inpatient beds do not.
  
• If Medicaid eligibility levels remain the same, Missouri hospitals will be forced to reduce services to indigent patients to make the necessary budget reductions.  While the overall percentage of a hospital’s indigent patients may be small, the percentage of indigent patients served in its acute psychiatric units is much higher.  Among the four hospitals participating in this analysis, only 7-18% of all patients served by the hospitals were uninsured, but the acute psychiatric units of the hospitals provided 24% to 58% of all indigent care days.
  
• The hospitals included in this study will lose between $1.0 million (Twin Rivers-Kennett) and $10.6 million (Truman-Lakewood) in federal indigent care reimbursements annually under the DSH reduction, depending on the hospital’s size.  Since a very high percent of the charity care they provide is in their inpatient psychiatric units, the hospital will be forced to cut adult acute psychiatric beds as the DSH cuts take effect.
  
• Individuals who are seriously mentally ill and in crisis are often involuntarily committed to acute inpatient care for diagnosis and treatment by Missouri’s courts.  The additional loss of acute psychiatric beds will create even greater problems for county sheriffs and city law enforcement departments that must transport these patients, often for long distances, in search of a psychiatric inpatient bed.  Local law enforcement officers already stay at the hospital emergency rooms and inpatient units for many hours as these patients are admitted to care.  This situation will worsen.
  
• If community hospital psychiatric beds close, there will be increasing pressure on elected officials to open state acute psychiatric beds.  The operating costs for state-operated acute beds would average approximately $850 per day, or about $31 million per year for every 100 beds, not including capital costs.  Reduced federal DSH payments for state hospitals means that the costs of opening acute psychiatric inpatient beds would be borne primarily by state general revenue funding.

Specific information on the impact of strengthening Medicaid as it relates to individuals with developmental disabilities (DD) has been added and can be found at the end of the report in Addendum A. The below points provide a summary of the addendum:

• DMH estimates that extending Medicaid coverage to Missourians with incomes at or below 138% of the federal poverty level means that over 40,000 Missourians with DD will have health insurance to help them remain healthy and continue working.
  
• Providers of healthcare services for the newly eligible Missouri Medicaid population will be reimbursed at commercial rates that are higher than traditional Medicaid reimbursements rates, promoting broader and easier access to healthcare.
  
• Approximately 5,000 of the 15,000 adult Missourians under age 65 now receiving services from the DMH-Division of Developmental Disabilities (DMH-DD) have a dual diagnosis of DD and mental illness (MI).  Last year 1,778 of these adults were hospitalized in a psychiatric inpatient unit for their mental illness condition.
  
• With only 1,174 adult acute psychiatric hospital beds remaining in Missouri, it is already difficult for persons with dual diagnoses of DD/MI to be admitted due to the small number of beds and unique characteristics and communication difficulties of these dually diagnosed individuals.
  
• As mentioned earlier, there is a great risk that more psychiatric hospital beds will close and therefore patients with a DD/MI condition, needing psychiatric inpatient care, will not be able to access it.

Strengthening Medicaid in Missouri will enhance public safety and improve public health by providing earlier intervention for people developing serious mental illness and substance use disorders as well as cover working individuals with developmental disabilities. Not extending Medicaid eligibility will have a significant negative impact on Missouri’s mental health system, particularly on psychiatric inpatient services.

Click here to read the full report including Addendum A

Click here for the DMH Medicaid Impact Powerpoint Presentation

Click here to view a one page summary with graphics

Click here to read only Addendum A

Click here to read the Saint Louis University School of Law, Medicaid Expansion FAQs

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2013 Mental Health Champions and Lasting Legacy Award

[Jefferson City, MO] - Three remarkable Missourians who have overcome mental health challenges to make life better for others and their communities have been chosen as 2013 Mental Health Champions by the Missouri Mental Health Foundation. The Champions are Ms. Bobette Figler of St. Louis, Mr. Tim Boyd of Nevada, and Mr. Garrett Lawrence of Hannibal.

They will be honored on May 21, 2013, at the Sixth Annual Mental Health Champions Banquet to be held at the Capitol Plaza Hotel in Jefferson City. Reservations for the event as well as table sponsorships are available at Missouri Mental Health Foundation.

"These individuals exemplify courage and commitment and serve as an inspiration to others. They help provide motivation to thousands of Missourians facing the challenges of mental illness, addiction disorders and developmental disabilities," said Patty Henry, Executive Director of the Missouri Mental Health Foundation. Not only do these Champions demonstrate personal courage through their actions, they encourage others and strengthen their communities."

Bobette Figler has been in recovery from alcoholism for more than thirty years. Not long after she got sober, she began volunteering at the National Council on Alcoholism and Drug Abuse (NCADA), and many years later became employed there. Her volunteer work at NCADA lead her into a long-standing role of giving back to the community, effectively helping others, which is her on-going goal and purpose. She is incredibly effective in assessing and motivating people to address their addictions and move toward wellness. She has also become an active advocate and volunteer in local efforts, forums and agencies for those organizations providing help to those who suffer from MS and Myasthenia Gravis. She continues to serve as a volunteer and gives of her time to a variety of circumstances for recovery causes, consistently at the table or showing up for any and all recovery events.

Tim Boyd lives with bi-polar disorder, major depression and HIV. His new determination to begin his journey to recovery began in 2005, accelerating as he began volunteering at Nevada Regional Medical Center. He is the Auxiliary President, currently serving his third consecutive year in this capacity. Mr. Boyd is also a RESPECT speaker, passionate about telling his story so others can understand the importance of fighting stigma surrounding mental illness and other disabilities. In addition, he currently teaches others to share their stories as a RESPECT Institute Facilitator. Tim also works in a part-time position with “On My Own, Inc. (Center for Independent Living). He has naturally assumed the role of advocating for others who have a mental illness or disability. His self-worth is no longer based on things that are fleeting, but rather, what he can give back to others.

Garrett has always made an impact where he goes. These past few years, that impact has been felt in ever widening spheres. He has been a Jaycee since 2003, raising money for their annual fireworks display. He is also a member of POPS Club (Participants of Public Service), Aktion Club, and is president of the Board of NEILS; the area Independent Living Center. Currently, Garrett also works for DMH serving as one of the planners for the Real Voices-Real Choices Conference. He was in the first Project STIR class offered in the Hannibal area and is interested in mentoring high school students to learn more self-determination skills. He continues to take advantage of opportunities to develop his advocacy skills for those with developmental disabilities.

This year the Lasting Legacy Program Award will recognize the DM (Disease Management) 3700 Project. This award recognizes a mental health program that transforms the way Missourians are offered or receive services. It represents cutting-edge innovation and collaboration which gives help and hope to Missourians and their families. The DM 3700 Project saves lives and reduces costs by improving the quality of health care of high cost, high risk Medicaid recipients with serious mental illness and multiple medical conditions. The Department of Mental Health in collaboration with the Department of Social Services, Division of MO HealthNet, received the state’s Pinnacle Award for their work on the DM 3700 Project. The prestigious award was part of the 2012 Governor's Awards for Quality and Productivity (GAQP).

For more information about tickets and sponsorship opportunities for the 2013 Champions Banquet, please contact Patty Henry at MMHF@MissouriMHF.org. The Missouri Mental Health Foundation is dedicated to raising awareness and public understanding of issues impacting individuals and families living with mental illness, developmental disabilities and addictions disorders. Our efforts battle stigma and discrimination, facilitate treatment, and foster inclusion in the community and workforce.

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