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Saturday, August 17, 2013
Mental Health: Can Reform Solve Hawaii’s Homeless, Prison and Unfunded Liability Problems?
By Andrew Walden @ 10:02 PM :: 17608 Views :: Health Care, Homelessness, Justice Reinvestment

by Andrew Walden

The Hawaii Community Health Needs Assessment (CHNA) released July 3, 2013 shows that mental health emergencies are the leading cause of hospital admissions in Hawaii.  The failure of the mental health system is front and center in Hawaii’s homelessness problem, in Hawaii’s near-highest-in-the-nation teen suicide rate, and in the rate of incarceration.    

It is difficult to imagine any other issue where humanitarian and budgetary interests so clearly align in favor of reform.  The failure of Hawaii’s mental health system increases the cost of health insurance and burdens Hawaii’s hospitals with repeat emergency room users. Solutions to the mental health crisis would shore up the financial sustainability of medical care, reduce crime, reduce drug abuse, and by reducing the cost of medical care, reduce the State’s multi-billion dollar unfunded liabilities backlog.

The CHNA findings do not include figures from the Hawaii State Hospital – meaning that the true scope of Hawaii’s mental health problem is underestimated.  Hawaii and Rhode Island are apparently the first two states to complete the CHNA, which is required under the Affordable Care Act (ACA) also known as Obamacare.  All 50 states are required to produce CHNA reports over the next three years.

Pointing to Hawaii’s 5,180 mental health admissions in 2011, the CHNA report warns of the special challenge created by ACA/Obamacare incentives.  In a scheme similar to No Child Left Behind, doctors and hospitals whose patient populations do not meet ACA benchmarks will see their Medicare/Medicaid remuneration cut.  The question is how will the medical profession respond.  The ACA incentivizes providers to wipe inconvenient or recalcitrant cases off the patient roster in order to boost overall performance and claim financial rewards or avoid penalties.  Mental Health patients can be some of the most recalcitrant of all.

In an August 17, 2013 Star-Advertiser column, Dr Ira Zunin writes

Never before has the risk been so fully shifted to the providers for patients who live at the fringe of society. Inappropriate emergency visits and hospital readmissions will now need to be tackled head-on. A great deal of this work will involve finding sustainable solutions for the mentally ill, particularly those with the dual diagnosis of substance abuse.

Hawaii health reform leaders have warned that reimbursement cuts will drive mental health professionals and other medical providers into retirement.  The remaining providers may consciously or unconsciously restrict their availability to the most needy patients.  One way to avoid this would be to eliminate the penalties for underperforming patient populations and a separate set of penalties for those who do not adopt electronic health records.  The State can and should nullify the federal penalties by granting a countervailing payment from State funds.  The rewards would stay in place to provide positive incentives.  The lack of penalties would pay for itself many times over just from the savings in reduced emergency room admissions.

The CHNA report explains:

“Special consideration for mental health, a chronic condition that significantly influences overall health, is critical for achieving population health goals…. While Hawaii has relatively good health insurance coverage, some essential health needs remain inaccessible to many, including full spectrum mental health services….Unmet mental health…needs are recurring themes supported by data and key informant interviews.” – pg 5-6

“Many specialized services, and some primary services, such as mental health services, are not available on each island, requiring costly air transportation to receive care or not receiving the needed care.” – pg24

Research by University of Chicago Law Professor Bernard E Harcourt, correlates late 1960s de-institutionalization with rising crime rates and rising prison populations.  Dr Zunin describes Harcourt's findings:

According to Bernard Harcourt, until the 1960s, hospitalized mental health patients outnumbered prison inmates in the United States by approximately 5-to-1. Today it is the inverse. The shift occurred in the 1960s, when the Kennedy administration shifted a great deal of the responsibility to care for the mentally ill to the community but the promised community resources never fully materialized. I recall my father, as a young psychiatrist, giving lectures about the problem. Later, he served at the Napa State Hospital, and as a medical student I spent some time with him seeing patients. Those few who were deemed sick enough to remain there for the long term were unspeakably, unimaginably ill.

Hawaii is no different. The vast majority of mentally ill patients referred to inpatient mental health facilities are discharged within days, regardless of their severity, if they are not considered an active danger to self or others. As a primary care physician in Hawaii for more than 20 years, I have referred many patients to these facilities and been amazed at how quickly they are again discharged, often without a solid plan for follow-up despite severe, ongoing mental illness and inability to care for themselves.

I recall one patient who I referred to an inpatient facility on Oahu. He was discharged two days later and made a suicide attempt the following week. Only after the suicide attempt did I receive a call from the psychiatrist saying that he had been discharged. It was too late....

The State's implementation of Obamacare combined with the State's huge unfunded liabilities for the medical care of State employees and retirees create major political and economic pressure for cost-saving medical solutions. Hawaii’s burgeoning and imported population of mentally ill homeless is in turn creating major problems for the tourism industry upon which the State depends.

In Hawaii the moral case has been made for pressuring the homeless to accept shelter.  Likewise the moral case for re-institutionalization can and should be part of these economics-driven discussions.

The Treatment Advocacy Center describes itself as “a national nonprofit organization dedicated to eliminating barriers to the timely and effective treatment of severe mental illnesses….  The American Psychiatric Association awarded TAC its 2006 presidential commendation for ‘sustained extraordinary advocacy on behalf of the most vulnerable mentally ill patients who lack the insight to seek and continue effective care and benefit from assisted outpatient treatment.’”

Interviewed by Hawai’i Free Press, Michelle Farquhar Esq. of Treatment Advocacy Center points to reforms enacted in Act 221 of 2013:

Hawaii passed legislation earlier this year to make it easier to use “involuntary outpatient treatment.”  This law allows a person suffering with severe mental illness to get treatment in the community.  Involuntary Outpatient Treatment, or Assisted Outpatient Treatment as it is called in some states, decreases incidence of homelessness, repeat psychiatric hospitalizations, incarceration, violence and crime, and improves treatment compliance for people who have a history of not taking their medication.

Our emergency departments, jails, and streets are filled with people suffering from severe mental illness.  We expect that, if implemented, Hawaii’s involuntary outpatient treatment law will help ease this suffering.

Hawaii has taken the positive step of adopting legislation that can provide help to its most vulnerable citizens.  The Treatment Advocacy Center is hopeful that Hawaii fully implements the IOT program to maximize its benefits to all Hawaiians.

Honolulu is pursuing ‘Housing First’ for the chronic homeless.  If implemented, Act 221 of 2013 can bring about ‘Treatment First’ for the mentally ill.




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