Solving Minnesota’s Perpetual Mental Health Crisis
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Despite the work of countless government committees, mental health study groups, task forces, action groups and advocacy organizations over the past 25 years, mental health disorders in Minnesota continue to be prevalent and generally go untreated.
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Despite the work of countless government committees, mental health study groups, task forces, action groups and advocacy organizations over the past 25 years, mental health disorders in Minnesota continue to be prevalent and generally go untreated. This results in not only significant suffering and financial repercussions for these individuals and their families, but also in massive hidden costs within multiple State programs. In fact, mental health and/or chemical health disorders are primary contributors to runaway costs in the Corrections, Social Services, Special Education and Health Care systems. There is a reason why these problems have not been solved, and why they never will be solved under the present model of State management. With the appropriate paradigm shift and system redesign, Minnesota has the opportunity to create a system that results in significant clinical improvement and vastly improved cost savings.
Research indicates that approximately 20% of children and adults have mental health disorders, and at least 5% have severely impairing disorders. Yet only one third of adults and one fifth of children and adolescents receive treatment for these disorders. Of those who do receive treatment, the vast majority do not see mental health professionals; 70-80% of mental health treatment is provided by primary care physicians. These physicians are also providing medical treatment to patients who have unidentified mental health disorders, but, due to their limited training in the identification and treatment of these disorders, these patients often go unidentified and untreated. Also, research indicates serious problems in primary care physicians’ quality of treatment of disorders such as Major Depression.
Despite the fact that primary care physicians are providing the vast majority of mental health treatment in Minnesota, the Department of Human Services (which has no connection to or oversight of primary care physicians’ treatment) is designated as the Mental Health department in the state. As DHS is mandated to assure services for the most severely psychiatrically disturbed Minnesotans, it tends to work under a “high threshold” social services model (e.g., “you have to be this disabled in order to receive services”).
Public health principles, on the other hand, encourage a “low threshold” model that encourages early intervention and prevention principles.
The term “mental health” is confusing to the general public and to policy makers, as it encompasses numerous issues (culture, family, life satisfaction, etc.) not directly related to mental illness. Also, there is little public awareness that mental health disorders such as Depression have comparable, or even superior treatment results than many “medical” disorders. In fact, the term “mental illness” is a misnomer, because the major psychiatric disorders affecting Minnesotans (Depression, Bipolar Disorder, Schizophrenia, Panic Disorder, Obsessive Compulsive Disorder, Attention Deficit Hyperactivity Disorder, etc. etc.) are biologically based and not due to “mental” causes. They are, in fact, medical disorders. If Tuberculosis and Meningitis, rather than mental health disorders and chemical health disorders, were the leading causes of high costs and poor outcomes in multiple public systems, it would be obvious that a public health approach would be necessary, with a primary focus on early intervention, identification, diagnosis and treatment.
There are countless examples of the hidden costs and system failures surrounding these disorders. For example, Minnesota has one of the highest rates of children returning to foster care after failed attempts to re-unify them with their families. A brief analysis indicates that a typical scenario involves a single mother who is chemically dependent who, because of neglect, has her children removed from her care. Although research indicates that 70% of chemically dependent women have co-existing mental health disorders, and that integrated, dual-diagnosis treatment is the only treatment that is likely to be successful, Minnesota has very few such programs, and had not been successful in braiding chemical health and mental health funding streams. Thus, hundreds of millions of dollars were wasted due to the lack of public health principles of screening and the lack of funded effective treatment programs. These costs are “hidden” and are not recognized in Social Services budgets. And, even worse, is the family disruption and disintegration that takes place as a result of this systemic failure.
The Special Education system has massive cost overruns for students in the Emotional/Behavioral (EBD) Disorder category, and research indicates that these students tend to have poor outcomes (despite expensive educational interventions) because their mental health disorders generally go untreated. School districts are reluctant to identify these disorders and recommend mental health evaluations because they are potentially the “payer of last resort”.
The medical system incurs massive costs due to mental health and chemical health disorders. For example, a patient who has diabetes and depression costs twice as much to treat as one who only has diabetes. If a chemical health disorder is also present, the cost is four times as much.
The Corrections system is overrun with individuals who have mental health and chemical health disorders. Many of these individuals would not be in this system if their disorders had been identified and treated early in their course.
Adding to these problems is the fact that mental health services have been “carved out” of many insurance plans, with separate oversight from their “behavioral health” departments. These departments have their own budgetary goals, and are not rewarded if an increase in mental health service costs results in a significant decrease in overall health care costs for the insurance company. The creation of separate “behavioral health” billing codes resulted in a situation that was identified in the Minnesota Psychiatric Association’s report on psychiatrist access indicating that psychiatrists were paid up to 40% less than primary care physicians for providing psychiatric services!
Thus, in Minnesota, there is no oversight of the vast majority of mental health services that are being provided, and no effective inter-system coordination process that addresses mental health disorders as the common thread between systems.
The solution is to switch from a 19th century “social services model” to a 21st century “public health model” of mental health, by creating a free-standing Department of Mental Health and Chemical Health as has been done in other states, or to transfer the oversight of mental health disorders from the Department of Human Services to the Department of Health. If the latter approach is done, the Department of Health would need a significant increase in infrastructure and expertise to accomplish this task.
In fact, the Citizen’s League’s January 2001 report, “Meeting Every Child’s Mental Health Needs: A Public Priority”, that was prepared at the request of the Minnesota Department of Health and the Department of Human Services recommended that “In order to ensure that every child's mental health needs are appropriately identified and met, Minnesota must take a public health approach to childhood mental illness”, and, “Within state government, the resources and authority for children's mental health should largely be shifted to the Department of Health (MDH)”. (The same principles identified in their Children’s Mental Health study also apply to Adult Mental Health). Their recommendation to shift oversight was rejected, and Minnesota has had business as usual.
If mental health issues are to be effectively addressed in Minnesota, a major paradigm shift is necessary. A restructured Department or Division of Mental Health and Chemical Health would address these disorders as other health disorders are addressed, with a focus on epidemiology, data collection and analysis, education of health care providers, cost analysis among public systems, overcoming barriers to system integration, promotion of effective screening procedures, and working with Minnesota DHS to restructure reimbursement rates in order to encourage inter-system collaboration.
In this time of fiscal crisis, it is all the more important to address unnecessary costs. And no costs are more unnecessary than those arising from unmet mental health needs that lead to failed interventions in multiple public systems. Restructuring mental health oversight in Minnesota will be a major step in improving the lives of countless Minnesotans and in meeting the demands of fiscal responsibility.
Research indicates that approximately 20% of children and adults have mental health disorders, and at least 5% have severely impairing disorders. Yet only one third of adults and one fifth of children and adolescents receive treatment for these disorders. Of those who do receive treatment, the vast majority do not see mental health professionals; 70-80% of mental health treatment is provided by primary care physicians. These physicians are also providing medical treatment to patients who have unidentified mental health disorders, but, due to their limited training in the identification and treatment of these disorders, these patients often go unidentified and untreated. Also, research indicates serious problems in primary care physicians’ quality of treatment of disorders such as Major Depression.
Despite the fact that primary care physicians are providing the vast majority of mental health treatment in Minnesota, the Department of Human Services (which has no connection to or oversight of primary care physicians’ treatment) is designated as the Mental Health department in the state. As DHS is mandated to assure services for the most severely psychiatrically disturbed Minnesotans, it tends to work under a “high threshold” social services model (e.g., “you have to be this disabled in order to receive services”).
Public health principles, on the other hand, encourage a “low threshold” model that encourages early intervention and prevention principles.
The term “mental health” is confusing to the general public and to policy makers, as it encompasses numerous issues (culture, family, life satisfaction, etc.) not directly related to mental illness. Also, there is little public awareness that mental health disorders such as Depression have comparable, or even superior treatment results than many “medical” disorders. In fact, the term “mental illness” is a misnomer, because the major psychiatric disorders affecting Minnesotans (Depression, Bipolar Disorder, Schizophrenia, Panic Disorder, Obsessive Compulsive Disorder, Attention Deficit Hyperactivity Disorder, etc. etc.) are biologically based and not due to “mental” causes. They are, in fact, medical disorders. If Tuberculosis and Meningitis, rather than mental health disorders and chemical health disorders, were the leading causes of high costs and poor outcomes in multiple public systems, it would be obvious that a public health approach would be necessary, with a primary focus on early intervention, identification, diagnosis and treatment.
There are countless examples of the hidden costs and system failures surrounding these disorders. For example, Minnesota has one of the highest rates of children returning to foster care after failed attempts to re-unify them with their families. A brief analysis indicates that a typical scenario involves a single mother who is chemically dependent who, because of neglect, has her children removed from her care. Although research indicates that 70% of chemically dependent women have co-existing mental health disorders, and that integrated, dual-diagnosis treatment is the only treatment that is likely to be successful, Minnesota has very few such programs, and had not been successful in braiding chemical health and mental health funding streams. Thus, hundreds of millions of dollars were wasted due to the lack of public health principles of screening and the lack of funded effective treatment programs. These costs are “hidden” and are not recognized in Social Services budgets. And, even worse, is the family disruption and disintegration that takes place as a result of this systemic failure.
The Special Education system has massive cost overruns for students in the Emotional/Behavioral (EBD) Disorder category, and research indicates that these students tend to have poor outcomes (despite expensive educational interventions) because their mental health disorders generally go untreated. School districts are reluctant to identify these disorders and recommend mental health evaluations because they are potentially the “payer of last resort”.
The medical system incurs massive costs due to mental health and chemical health disorders. For example, a patient who has diabetes and depression costs twice as much to treat as one who only has diabetes. If a chemical health disorder is also present, the cost is four times as much.
The Corrections system is overrun with individuals who have mental health and chemical health disorders. Many of these individuals would not be in this system if their disorders had been identified and treated early in their course.
Adding to these problems is the fact that mental health services have been “carved out” of many insurance plans, with separate oversight from their “behavioral health” departments. These departments have their own budgetary goals, and are not rewarded if an increase in mental health service costs results in a significant decrease in overall health care costs for the insurance company. The creation of separate “behavioral health” billing codes resulted in a situation that was identified in the Minnesota Psychiatric Association’s report on psychiatrist access indicating that psychiatrists were paid up to 40% less than primary care physicians for providing psychiatric services!
Thus, in Minnesota, there is no oversight of the vast majority of mental health services that are being provided, and no effective inter-system coordination process that addresses mental health disorders as the common thread between systems.
The solution is to switch from a 19th century “social services model” to a 21st century “public health model” of mental health, by creating a free-standing Department of Mental Health and Chemical Health as has been done in other states, or to transfer the oversight of mental health disorders from the Department of Human Services to the Department of Health. If the latter approach is done, the Department of Health would need a significant increase in infrastructure and expertise to accomplish this task.
In fact, the Citizen’s League’s January 2001 report, “Meeting Every Child’s Mental Health Needs: A Public Priority”, that was prepared at the request of the Minnesota Department of Health and the Department of Human Services recommended that “In order to ensure that every child's mental health needs are appropriately identified and met, Minnesota must take a public health approach to childhood mental illness”, and, “Within state government, the resources and authority for children's mental health should largely be shifted to the Department of Health (MDH)”. (The same principles identified in their Children’s Mental Health study also apply to Adult Mental Health). Their recommendation to shift oversight was rejected, and Minnesota has had business as usual.
If mental health issues are to be effectively addressed in Minnesota, a major paradigm shift is necessary. A restructured Department or Division of Mental Health and Chemical Health would address these disorders as other health disorders are addressed, with a focus on epidemiology, data collection and analysis, education of health care providers, cost analysis among public systems, overcoming barriers to system integration, promotion of effective screening procedures, and working with Minnesota DHS to restructure reimbursement rates in order to encourage inter-system collaboration.
In this time of fiscal crisis, it is all the more important to address unnecessary costs. And no costs are more unnecessary than those arising from unmet mental health needs that lead to failed interventions in multiple public systems. Restructuring mental health oversight in Minnesota will be a major step in improving the lives of countless Minnesotans and in meeting the demands of fiscal responsibility.