a history of behavioral health policy in america
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A History of Behavioral Health Policy in America. “Policy” Webster's Dictionary 1966. “Prudence or wisdom in the management of public affairs” - PowerPoint PPT PresentationTRANSCRIPT
A History ofBehavioral Health Policy in America
“Policy” Webster's Dictionary 1966
“Prudence or wisdom in the management of public affairs”
“A definite course or method of action and selected from among alternatives and in the light of given conditions to guide and determine present and future decisions”
“Policy” Thomas Fuller 1608-1661
“Policy consists in serving God in such a manner as not to offend the devil”
Policy According to Broadway
“Money makes the world go round.”Song Line from musical Cabaret
“I'm just a girl who cain't say no,I'm in a terrible fix” Song Line from musical Oklahoma
1700’s
Family’s, Poor Houses, Jails
1840’s
First wave of Public Hospital Development
1880’s
Second Wave of State Hospital Development Shifts Cost and Responsibility to State Level
1920 & 1930’s
Departure of SyphiliticsDeparture of Epileptics
Post World War II
MI Begin to Depart to Community
1950’s
Arrival of Effective Antipsychotics and Antidepressants
State Hospitals Develop Outpatient Medication Clinics
Arrival of Child Guidance Movement
1960’s
Medicaid/Medicare Shift Many Costs to Fed
Persons with Dementia (and many MI) Depart to Nursing Homes
Growth of General and Private Acute Inpatient
Growth of OutpatientCMHC Movement and Federal Grants
1970’sIMD Exclusion Exemptions
- ICF MR created and MR/DD population Departs- Persons under 21 y.o.
Commitment Limited to Dangerousness
Harsher Drug Laws Increase number of MI in Jail and Prisons
First Presidential Report on Mental Health
1980’sIMD Exclusion Exemption for facilities of less
than 16 beds
Fed Block Grants CMHC Funds to States
States Retarget CMHC’s to SMI
TEFRA Stimulates Private Sector Inpatient Growth
States Take Advantage of DSH to Shift Costs to Fed
1990’s
Medicaid Waivers Allow States to Increase Federal Share of Funding
Behavioral Managed Care Causes Loss of Private Sector Inpatient
2956
1757 1762
3877
270 216 118 113 128 128 106 65 112 140 143 143
2341
1946
1725 1754 1841 1808 18631760 1828
1662
1320 1383 1323 1337 1356 1311 1295 1276 1253 12391089
4888
3447
3161 32193325
3225 3223 3148 3150 3144 3060
0200400600800
1000120014001600180020002200240026002800300032003400360038004000420044004600480050005200
1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 Current
Federal Private DMH All Beds
2000
Second Presidential Commission on Mental Health
2000 Up to 2008
Bed capacity fairly stable Stigma much reduced Increased Medication Usage Increased MH prescribing by PCPs Emergence of EBP Integration of BH and Medical Care
Overall
Treatments get continually better
Financing and Administration has become ridiculously complex
Community Focus and Locus Increases
“Better But Not Well”Richard Frank, PhD
Improvements in Care to MI due to: Disabled income and housing
supports Newer medications easier to
prescribe correctly Many more persons with SMI treated
by PCPs with medication
2008 through 2010Suddenly A New Environment
2008 - MH and SA Parity Act 2009 – Economic Crisis 2009 – HIT Act 2010 – Health Care Reform
Public Sector Mission
To Care for Persons whose behavior is so dangerous or socially unacceptable that their communities cannot tolerate their presence and no other entity can or will work with
Public Sector Goals
Treatment and Recovery Public Safety
Public Sector Admission Criteria
The facility or program is the least inappropriate currently available.
Missouri DMH Serves - 36% of persons in Missouri with
SMI5% of persons with a non-SMI
psychiatric need
Try to serve as many as possible with limited resources
Breadth vs. Depth
Everyone’s Choices
Give the best to a few
Give minimally adequate to many
Give something to everyone
Politically Viable Choices
Winners: Medication Access, Kid Services
Losers: Provider Rate Increases, Rehab Programs,
Psychotherapy, Dental Services
Our ChoicesMaximize Minimize
Case Management Therapy/CounselingMedication Services InpatientMedicaid Uninsured
AmbivalentHousingEmploymentCrisis
Mo National Per Capita Rank 2007 – Psych Bed Resources
All Inpatient 20th
State Hospital 14th Forensic Beds 8th Residential Services 31st
DMH Beds by Category
Type 2007 2010 PercentAcute adult 279 86 7.1 %Acute child 48 28 2.3%Intermediate 25 62 5.1%MIDD 20 20 1.6%LTC (88% forensic) 918 893 73.4%SVP 133 128 10.5%
Totals 1423 1217 -14.5%
States with No DMH Adult Acute Beds
Arizona PennsylvaniaFlorida OregonHawaii MarylandIndiana MichiganDistrict of Columbia