By CHARLES M. JOHNSON
CHARLESTON -- In today's world, if an investment advisor told you that you can leverage your initial investment of $1 million with a return of an $3 million in gains guaranteed within a year and that you also will likely receive dividends of $1 million at the end of same year, you might check his credentials to see if his last name is "Madoff."
This certainly sounds too good to be true.
For our investment as West Virginia taxpayers in the behavioral health delivery system, it actually seems that West Virginia has "made-off" with our money. The economic aspects of the current crisis pale in comparison to the human impact on those needing services, but may serve as the linchpin for fixing the system.
A human tragedy of epic proportions is playing out in our communities daily as a result of the recent crisis in the behavioral health system. Due to the axing of community-based services, the number of commitments in State hospitals has increased 233 percent from 2001 through 2005.
On July 3, 2008, David Sudbeck, Ombudsman for Behavioral Health, issued a report that identified the horrible conditions at Mildred Mitchell-Bateman Hospital in Huntington ("Bateman Hospital") due to persistent over-crowding , including patients being placed on three cots in make-shift rooms with no private bathroom facilities, a lack of daily access to decent personal hygiene, a lack of privacy, a lack of adequate staff and lack of adequate services. As a result of the report, Judge Bloom of the Circuit Court of Kanawha County decided to have an evidentiary hearing to consider whether the West Virginia Department of Health and Human Resources ("DHHR") was violating the patients' rights guaranteed under W. Va. Code 27-5-9 and the Courts previous orders in E.H. v. Matin.
DHHR vigorously opposed the evidentiary hearing , and sought emergency relief from the West Virginia Supreme Court of Appeals to prohibit Judge Bloom from taking evidence as to the overcrowding issue and other pending issues. DHHR argued Judge Bloom was overstepping his authority by having a hearing to consider whether DHHR was following previous consent decrees.
On Feb. 6, 2009, the West Virginia Supreme Court of Appeals denied DHHR's request to prohibit Judge Bloom from holding an evidentiary hearing to consider whether the overcrowding at Bateman Hospital is due to a failure of DHHR to provide adequate case management services and other community-based services. The West Virginia Supreme Court of Appeals stated, "In general, the portrait that emerges from the Ombudsman's reports is that of a hospital that is overcrowded with patients, most of whom are frustrated by living on top of each other, being denied privacy and not having daily access to basic grooming needs…..the term 'Dickensian squalor' ... used to describe the hospital in 1981 is an apt description of the hospital that emerges from the July 3, 2008 report."
On Feb. 7, 2009, behavioral health advocacy groups conducted an emergency meeting lamenting the lack of community services and the crisis of care that results.
This current crisis is not a new phenomenon. In January 2000, Hansine Fisher, an expert in Medicaid funding with the Institute for Human Services Management, drafted a public report entitled," Publicly-Funded Behavioral Health Services in West Virginia: A System in Crisis." In this report, Hansine Fisher states that, "The real problem behind this crisis is a government that works at cross purposes to its own mission. The State has legal mandates to maintain a seriously ill population outside institutional settings.
The availability of Medicaid funds has helped the State to achieve this goal at a reasonable cost. Yet ... state government ... cut Medicaid spending for behavioral health services, even though there is a high likelihood that these actions will ultimately increase State spending for the population now served by the 'safety net' providers and result in more people being institutionalized."
Instead of fixing the problem over the past decade, the State of West Virginia myopically made further cuts in community-based services.
West Virginians have a right to receive behavioral health services in the least integrated environment under various State and federal mandates, including the Olmstead Plan recently adopted by Governor Manchin by Executive Order on October 12, 2005. If a consumer can properly be treated in the community, he has a legal right to do so. It is not only cheaper to treat patients in the community if it is appropriate, the experts have determined it is also better from a treatment perspective.
Despite the constant drumbeat from providers, patients and advocates witnessing firsthand the unnecessary suffering caused by the impact of these cuts, efforts over the past decade have not lead to permanent solutions. Once again we face a crisis in the behavioral health system. If we do cannot agree on the need to fix the behavioral health system or even the best way to do so, we can certainly all agree that current economic times require us to use all of our State dollars wisely to avoid huge increases in the State budget. It is critical that we understand this is an economic as well as a human tragedy.
If we simply leverage our investment we can save millions of dollars and restore the quality of life for. thousands of West Virginians. The State has invested unwisely in institutions and cut community-based services, depriving thousands of their rights and wasting millions of our tax dollars.
I have a modest proposal. For each State dollar we spend on Medicaid-funded behavioral health services, the federal government currently contributes three dollars, stretching the total purchasing power to four dollars. Multiplied by a hundreds of thousands or even a million, this leverage gives us great power to right the behavioral health system without a huge increase in the State budget. By investing a million State dollars in Medicaid community-based services, the State can leverage this to $4 million dollars through the federal Medicaid match.
Second, besides the four-fold leveraging of the federal match, it is also cheaper on average to serve those in need of behavioral health services in the community. The average cost of serving a consumer in the community is about $500 per month or $8,500 per year, while the cost of treatment in the State hospital for same period is between $16,000 and $37,000 per month or $200,0000 to $445,300 per year. The costs in private psychiatric hospitals are even higher.
It costs about between $590 to $1,220 per day to direct patients to private hospitals, or approximately $215,000 to $445,000 per year. Based upon the costs for treatment in the State hospitals, it is roughly 23 times cheaper to serve these individuals in our community.
In summary, we can expect to quadruple our investment by using Medicaid-funded community services, and we can expect to further leverage these scarce dollars twenty-fold by treating scores more in the community than in institutions for the same dollar.
Finally, if we are able to decrease the number of people committed to State hospitals, the decreased costs drops to the State's bottom line since this treatment is all funded using State dollars. The State of West Virginia can thusly achieve dramatic leveraging of its State dollars, while managing its budget wisely and decreasing overcrowding in State hospitals. If we can right the system financially, we can save State dollars and adequately serve people in the community. If this were a football game, the odds are one hundred to one in favor of investing in community-based services.
While I am sure the natural reaction of State government will be to study this phenomenon, maybe even form a task force and hire a consultant -- the truth is staring us in the face. A number of groups have already studied this issue. This problem could be fixed with little infusion of capital. If we invest only a fraction of the money we currently waste on unnecessary hospitalizations in a sound community based behavioral health program, the rewards will be dramatic.
The more we invest, the more we can expect in cost-savings to the State and its taxpayers. Not to mention the restoration of thousands of consumers that will receive the help they need to remain integrated in their communities. The tools to fix this problem already lie rusting in disarray across the State.
We do not have to re-invent the wheel to fix this problem. The outcry from the advocacy groups to be heard across the State is real, and should receive our sympathy. However, if past experience is any barometer, usually only those personally invested in the system are capable of the sustained outrage necessary to move this issue forward. We only need to have the fortitude and vision to spend our limited State dollars wisely.
Every West Virginian should be upset at the needless waste of millions of their tax dollars -- we have cut the community-based behavioral health services that are needed to maintain people in their communities, and instead invested our scarce State dollars in institutions which are more costly and less effective.
While there can be little doubt that the Medicaid budget will continue to climb in years ahead for legitimate reasons, if we can leverage our State dollars more efficiently to provide community-based behavioral health services instead of institutionalizing them and diverting them to psychiatric hospitals, we can at least make sure our taxpayer dollars are being spent wisely to care for as many as possible in the best manner possible. By using our Medicaid dollars wisely, we can assure that we can keep health care costs down for West Virginia businesses and families.
The current Medicaid mantra is that we provide the "right care, in the right place at the right time". This is a worthy goal and has met with some success in healthy populations. But, by serving people in need of Medicaid behavioral health services unnecessarily in institutions, the State is missing all three marks and wasting our money in the process.
A recent crisis meeting called by mental health advocates concluded that a portion of the funding to re-build community-based services should provide the $1.5 million (plus the federal match for three consecutive years of equal across-the-board Medicaid rate increases for each of the 33 "clinic" and "rehabilitation" codes is an important first step in re-establishing community-based behavioral health services across the State.
This goal is not only achievable, but will stem the rapid increase hospitalizations and enable the State to re-assert control over behavioral health costs. If we can also drastically cut the number hospitalized on a daily basis in West Virginia, we can save millions of dollars, restore well-being to thousands and fulfill the State's legal mandates without lengthy delays and litigation.
It's an investment that will reap benefits both to the States coffers and to some of our most fragile citizens. The smart money is on increasing the viability of community-based services.
Johnson is a partner in Dinsmore & Shohl, where he practices health care law.
