Mental health cuts just cost more later

The next legislative session is more than half a year away, and already the in-box is starting to fill up. One of the jobs that should be near the top of the pile is the way mental health services are delivered.

Cuts that were made in the depths of the budgetary crisis have had ripple effects that, down the line, cause increased costs and avoidable patient distress. Given improvements in the state’s economy and fiscal health, that needs to be readjusted now.

State health officials should be acknowledged for the efforts they’re already making to reinforce the programs now. These gestures will need to be amplified through action by lawmakers holding the state’s purse strings.

The problem was highlighted last week when the Hawaii Health Information Corp., a private nonprofit research service, released new figures showing statewide rising counts of emergency room visits, hospital admissions and charges related to mental illness.

The increases, tallied between 2009 and 2012, are more than substantial. Visits to the ER, which are known to generate higher costs than treatment in a non-emergency, clinical setting, jumped by one-fifth, to 13,666. Admissions to hospitals rose 14.3 percent. All of this adds up to a 30 percent increase in costs, from $76.1 million to a staggering $98.3 million.

What happened was that state health officials coped with the cuts, amounting to $25 million in 2009, by reducing the categories that could be served by the state.

Post-traumatic stress disorder and major depression were eliminated, said Marya Grambs, executive director of the nonprofit Mental Health America of Hawaii, leaving only psychosis diagnoses to be treated through state programs. Not all military veterans get PTSD treatment through the military, Grambs said, adding that the disorder afflicts civilian patients as well.

Further, the eligibility has been tightened for Medicaid, meaning that fewer low-income people qualify for that program. And many of them end up at the ER door.

All of this must be revisited. Despite short-term strategies for balancing the budget, necessary in the crisis of the recession years, problems persist and have to be dealt with. And where illness is concerned, it is generally more effective and cheaper to deal with them at the front end.

The larger problem will require changes to the Medicaid program, called QUEST in Hawaii, to make it less burdensome for participating physicians. In the case of mental-health services, psychiatrists are finding it harder to get paid and facing more difficult rules for issuing prescriptions, with the result that more of them are waving off Medicaid patients.

Only about a third of the state’s 180 psychiatrists accept Medicaid patients, whose financial need often drives them to seek help when they’re sickest, adding to the unreimbursed expenses of hospitals. In the past, these have ended up back on the state taxpayers’ tab, through special appropriations to boost reimbursements, and they have inflated premium costs for other health insurance subscribers.

But the most unconscionable element in all of this, said Grambs, is the suffering that could be reduced with a more rational way of addressing mental illness. She cited the Obama administration’s recent pledge to raise awareness and dispel some of the stigma wrongly attached to the mentally ill.

Destigmatizing the disease will be key to developing better state policies on mental health. And it’s clear from the numbers that there’s a lot of room for improvement.