ENID, Okla. — The latest in the ongoing round of cuts to state services affects some of the state’s most vulnerable people, and is leaving some professionals worried the move will cost the state far more than it will save.
At issue is a proposed cut in Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) that virtually would eliminate case management services for low-income mental health patients.
Case management is a broad term for services that help connect chronically, severely mentally ill patients with community services outside of, and often after, inpatient treatment. It’s a field that employs more than 3,000 professionals in Oklahoma, overseen and regulated by ODMHSAS.
The proposed cuts
Currently, case managers can be paid for up to six and a half hours per month, per patient, to assist mental health and substance abuse patients with tasks such as accessing aid programs, making sure they’re taking their medication, and tending to basic needs like food and shelter.
ODMHSAS long has advocated for case management as a means to improve outcomes for behavioral health patients, and to reduce reliance on more-costly public services like emergency rooms, inpatient treatment and incarceration.
But now, facing a budget shortfall amidst the state’s fiscal crisis, ODMHSAS has proposed to cut the allowable units of case management from six and a half hours per month to four hours per year — an almost 95 percent reduction in billable case management services.
According to a public statement filed by ODMHSAS with the Oklahoma Healthcare Authority (OHCA), the cuts to case management services are necessary “in order to meet the balanced budget requirements as mandated by state law.”
The least bad option
The ODMHSAS public statement notes the cuts will affect low-income patients: “SoonerCare members who currently receive case management services in excess of what would be authorized by the proposed rule will be affected.”
The alternative, the statement contends, is to reduce provider reimbursement across the board, “to an extent that would in all probability reduce the behavioral health provider network.”
ODMHSAS lists the savings from cutting case management services at $3.5 million this fiscal year.
ODMHSAS director of communications Jeff Dismukes said the department knows the case management cuts will affect patients and other state agencies, but in the current budget shortfall has no other option.
“As is true with any cuts made to behavioral health services, it is expected that these cuts will impact services delivered by other state agencies along with community-level services including hospital/emergency room care and law enforcement,” Dismukes said.
“In addressing this year’s budget shortfall, the agency looked first to administrative costs,” he said. “Unfortunately, there was no way to avoid an impact on treatment services. The focus was to make service cuts in a way that preserved as many critical services — such as crisis and hospital care, outpatient treatment services and medication assistance — for the most seriously ill throughout the state. This cut was the ‘least bad’ of nothing but bad choices.”
The potential long-term costs of short-term savings
Some providers worry the cuts will only result in mental health patients falling out of their treatment, eventually requiring more expensive intervention in the emergency room, inpatient treatment centers or in law enforcement custody.
Dr. Jahangir Ghaznavi, medical director for Resilience Behavioral Health at St. Mary’s Regional Medical Center, said outcomes for behavioral health patients largely depend on how much help they have after leaving inpatient care.
“These patients, either they forget or they feel good when they get out of the hospital, and they don’t follow through on their treatment,” Ghaznavi said.
That problem is exacerbated, Ghaznavi said, when patients suffer from both mental illness and substance addiction — that’s about 60-65 percent of the patients Ghaznavi sees at Resilience.
“We educate the patient not to get off their medication, why to stay on their medication, and what the benefits are of staying on their medication,” Ghaznavi said. “But, especially with the dual-diagnosis patients, we run into problems with their drug and alcohol addiction. We treat their mental acute crisis, and they’re ready to go, but they also need a little help after they leave.”
Ghaznavi saw the impact of ongoing case management when he worked at Red Rock Behavioral Health Services in Oklahoma City.
There, ongoing case management was achieved by case managers working alongside a coalition of professionals from a wide variety of social service agencies and nonprofits in a Program of Assertive Community Treatment (PACT) Team.
Ghaznavi remembers one patient who had been admitted to inpatient care more than 40 times, with some stays lasting up to a year.
Once that patient’s ongoing care was overseen by a case manager in the PACT Team, “amazingly in 12 years we were able to keep the patient from needing to be admitted to inpatient,” Ghaznavi said.
He said that turnaround in outcomes was possible because the patient was receiving regular follow-up by someone checking on medication and helping them connect with needed social services.
And that, Ghaznavi said, saved a tremendous amount of money over constantly readmitting the patient through the emergency room.
“If we have prevention, and ongoing care, in the long run it will save a lot of dollars in our state,” Ghaznavi said.
That concern over cost was echoed by Sean Byrne, policy chair of the mental health committee of Human Services Alliance (HSA) of Greater Enid.
“One full year of case management costs less in the state of Oklahoma than one day of inpatient care,” Byrne said.
A 2015 study published by Becker’s Hospital Review, a hospital industry publication, listed for-profit hospital inpatient costs at $1,883 per day in Oklahoma. Adjusted for inflation to 2017, that number would be more than $2,000.
“We know without case management these individuals are going to go off their medication, they’re going to stop making their appointments, they’re going to deteriorate, and eventually end up in inpatient treatment or jail,” Byrne said. “We’re not providing the basic, most effective — and cost-effective — services, and now we’re creating demand for the more expensive levels of care.”
“This cut is going to cost the state way more than $3.5 million,” Byrne said.
The future of local care
The HSA mental health committee has been working on establishing a PACT Team, much like the one cited by Ghaznavi.
But, without case management, all the good recommendations of a PACT Team will have little effect, said committee chair Taylor Randolph.
Randolph acknowledged ODMHSAS’s need to preserve clinical care, but he said that care does no good if the patients don’t have ongoing case management.
“If their basic needs aren’t met, counseling isn’t going to do them any good,” Randolph said. “That’s what case management does: It establishes the base before you start working on issues like self esteem, depression or anxiety.”
He said the long-term effects of the case management cuts will impact the community’s most vulnerable people.
“This really won’t impact folks who have mild depression or situational anxiety,” Randolph said. “This is going to hurt the most vulnerable people — they’re the ones who utilize case management.”
He said the case management cuts are contrary to what ODMHSAS has long required of behavioral health providers.
“This flies in the face of what the Department of Mental Health has done for years,” Randolph said. “They have stressed case management, they have required it. For them to cut it now — it’s very confusing, honestly. It seems counter intuitive.”
Without effective case management, Randolph predicted worsening outcomes and increasing costs for behavioral health treatment in the community.
“For the severely mentally ill, the case management process keeps that person with us here in reality,” Randolph said. “Without someone to check up on them on a regular basis, these folks will deteriorate, and they may be the folks you read about in the paper the next day because law enforcement had to pick them up.”
That, Randolph said, is a step in the wrong direction in a state that already has the second-highest rate of mental illness in the nation and ranks 42nd in access to care.
Byrne said the cuts to case management would effectively remove a critical layer of care in the state’s mental health treatment system — a move that could have effects long after the current budget crisis.
“What they’re doing is destroying the sustainability of our mental health system,” Byrne said. “That’s harsh, but it’s the reality.”
Byrne urged concerned members of the public to contact their legislators and voice their opinions on the case management cuts.
The proposed policy change will go before the OHCA medical advisory committee on Thursday, and the full OHCA board on Aug. 10.
The public also can comment on the proposed case management cuts through July 28 on the OHCA website at tinyurl.com/OHCAPolicyChange.