KEY

Mental Health Services Dynamics and Dilemmas Example

Read the arrows on this page as "causes" or "links".
Neighborhood concerns to group homes for mentally ill Low number of group homes
Neighborhood concerns to group homes for mentally ill "causes" low number of group homes.
Commissioners' Dilemma
More clients eligible for more treatments
The different colors for the arrows ( ) aid tracing of
This map was developed by the Multnomah County Task Force on Mental Health. It Draft v.12 long causal connections. They do not have any other significance.
More diverse customers than the rest of the state
portrays the way public mental health services are delivered and the major factors that Please send comments Fragmented
This "Fragmented Administration" icon is used by the Task Force as a More seriously ill clients
and suggestions to: Up to $15.3 million
contribute to the problems faced by the different agencies and their customers. hornbob@earthlink.net. reminder of areas of mental health administration that could benefit from less Medicaid funds
Administration
greater administrative integration. Less money to serve them
available for mental
health
Huge reduction in services
1. Passed Oregon Health Plan (OHP) to increase health 5. OHP plan is to control costs, Fragmented 125
Oregon State Legislature care access by prioritization of treatments by cost- Federal Sector Fragmented system administration
$100
million $85
provide incentives to manage care by 100 million

$ millions
effectiveness. Legislature biannually approves the cut- Health Care Financing Administration (HCFA) Administration
distributing funds on a population (not 75
off line below which treatments are not covered. a per client/patient) basis Customer complaints accelerate
Medicaid is an entitlement Because Medicaid is 50
Fragmented
HCFA program so HCFA doesn't allow state to an insurance program Poor and incomplete data 25
FRAGMENTED DRUG AND ALCOHOL PROGRAM. implement priority plan by rejecting HCFA needs billing
2. Separated alcohol and drug abuse funding from COST CONTAINMENT FALTERS
requests to reduce the number of services data for cost control Increased administrative costs 1997 1998
Mental Health Administration
Medical and surgical costs can’t
mental health and redirected to medical/surgical to be covered. Not known until September 1999
Goal: To cover be contained as the Oregon Civil rights act
payers and providers. People suffering from Requires a new, uniform Accountability diffused
treatment of a Health Plan was intended to do. requires access
mental illness and alcohol and drug abuse cannot “encounter” data system for
full range of for minorities
be treated within any one system of care. all Medicaid services.
mental The HCFA was indecisive (1995-
It becomes more difficult to pay the 40 percent (An encounter is a one-time
disorders not 1998) on allowing managed care visit of a customer to a
3. Integrated mental health diagnoses and treatment federal matching requirement for expanded mental health agency.)
previously of Medicaid for Oregon.
into the priority list of Oregon Health Plan benefits. coverage from limited state resources
provided by Fragmented

24% increase in clients eligible for more benefits. Increased assets limits, residency requirements, Housing Sector
integrating them
in the health and premium co-payments to reduce costs by Administration

4. State requires counties to

care priority list. making fewer poor people eligible.
care for those at serious risk Oregon State Executive Sector Rentals to mentally
of harm to self or others. CHILDREN LEFT OUT ill require case Greater mental
New Fragmented HOUSING CAN'T BE USED
Mental health advocates and Counties also must pay for 6. Intensive treatment services for Request 1 : Waivers to implement OHP Priority Plan benefits. management Subsidized housing is deterioration
eligibles acute hospital care
providers, thinking more Administration
children (residential) left out of Request 2: Waivers to implement managed care available but unused due to
create
money would be available for managed care by Legislature, lack of mental health
competition Dammasch State
expanded services, pressed interrupting continuity of care. State Mental Health State Medicaid support services.
for resources Hospital closed
hard for inclusion in OHP. (1995) Agency (MHDDSD) Agency (OMAP)
State Mental Health and Developmental People can't be
Disability Services Division Requires “encounter” released from Customers don’t have
Attempted to integrate mental data system by payers. State Hospital Lack of affordable needed supportive services
The Medicaid Payment Sector health into full coverage healthcare Did not initially housing
Medicaid pays for about 78% of the $100 million (1998) total mental plans. Required competition for allocate the funds for

Issue Map® by MacroVU®, Inc. R. E. Horn, Information Designer.

POSH
health services in the County including OMAP fee-for-service. Medicaid contracts. setting up the data Low number of
State Mental Health Agency creates and contracts directly Portland
However Medicaid managed care is only about 29% of total mental system (low priority). group homes
with these payers: Stopped requiring Oregon State

Yolanda Montijo, Graphic Production. December 16, 1999.

health costs. Remaining 71% is for extended care and fee-for-service. existing data Hospital is full
Private Managed Care ACTUARIAL RATES NOT ADJUSTED
Regence and Family Care contract with state, and Ceres system before Used questionable assumptions in setting Dramatically reduced
The state created mental health "carve-outs" (1997). Carve-outs are new system managed care rates for mental health benefits. Neighborhood
Behavioral Healthcare System (affiliate of Magellan Behavioral state hospital population
new entities, Mental Health Organizations (MHOs), that receive and operational. Did not provide "risk adjustments" as was concerns to group
Health) operates the "carve-out" for them. increases demand for
distribute capitation payments to providers and report data to the state. done for physical healthcare for increased homes for mentally ill
group homes
Capitation refers to payments based on the number of people who fall into the Public Managed Care severity of illness among urban poor.
Federal categories of poverty and those who are newly eligible. CAAPCare (County Behavioral Health Division, Department of (Risk adjustments are differential rates of
Carving out refers to the separation of mental health from physical health payers. payment for seriousness of diagnoses.)
Community and Family Services)
Increased Administrative Overhead Cost Some other providers (e.g. residential facilities) also receive direct Lack of bilingual staff
(Difficult to allocate to cost centers.) Medicaid payments from the state.
County (CAAPCare) 12% (up fr om 3%)
Non-Profit Community-Based Provider Agencies
Insurance Carrier (Regence) 5% (new cost) Public Agency Provides MINORITIES NOT SERVED Increase in severity of problems
Ceres Behaviorial Healthcare 12% (new cost) 75% of Managed Mental Health Care
Accessible services for The Case Worker Sector Can’t provide
Networks of provider agencies 3 - 8% (some new cost) Mostly work for non-profit agencies
minorities do not yet exist needed Some agencies are not
Non-Profit community agencies est. 10-18% (increased cost) Ceres and data not collected. supportive
Approx. 26% To be efficient adequately handling
Before Direct Services Est. 1998 data CAAPCare Affects all sectors. services transition to managed care.
cut in payments must cut staff
Overhead Increased errors
during 1997-98. Data recording must be
After Direct Services
Overhead increased significantly
Must amalgamate Decreased number
clinics into fewer sites Case workers Layoffs and
of visits and
have to fill out reductions in
decreased time for
more paperwork services
each customer visit.
in less time
Multnomah County Sector Need to upgrade Case workers can’t keep
data system for up with service demand R. E. Horn
County Data System DATA NOT AVAILABLE
publicly managed Case workers are Visiting Scholar
Sector Required data not reported
health care Case load increase paid less than Stanford University
to state on a timely basis. 2819 Jackson St. #101
Poor accountability. from 35 to 100 per teachers - $25,000 MAJOR SERVICE DECREASE
Department of Community and Staffing deficiencies case worker Major decrease in access to
San Francisco CA 94115
per year (415) 775-7377
Family Services, Behavioral prevent mental health mental health services. hornbob@earthlink.net
Health Division (BHD) data system from being Experienced case workers URL: www.stanford.edu/~rhorn
Most programmers are fixed (at present) Dilemma of fragmented leave in droves (From 15% Poor continuity
Up to $15.3 million decrease (in transition busy fixing the Y2K and antiquated state data to 40% in one year) of care
to Oregon Health Plan). problem system Public
contracting is
Fragmented
Family, Child & Adolescent
There are more clients who appear to have Many new inexperienced
too slow and case workers Customer Sector
more serious problems than expected when Administration

the rates were set (based on anecdotal Scarcity of complex

Rapid growth Adult Customer Sector Schools lack Impact of cultural diversity on
information). software
of high tech access to service delivery not understood
programmers Increased salaries Turnover in
“Silicon Forest” Uncompleted Customers complain community End of 5-year partnership program
because of scarcity data
IMPACT OTHER DEPARTMENTS around Portland contract for and seek other treatment funding in 1998 from Robert Wood
(nationally and management Law Enforcement Sector
Increased overhead costs lead to encounter sources of help resources Johnson Foundation
locally) of positions
less money for actual delivery of data system
programmers Officers are often the first treatment
services. These combined No continuity of
factors decrease ability to meet providers, sorting out appropriate
response to domestic violence, alcohol
Fragmented Return to children's services
the increasing demand for Caretaker FAMILIES DON'T
and drug abuse, as well as mental fragmented
services and broadly impact Major life families not GET SERVICES Increased
illness, and sometimes spending supported Emotionally
Administration
program delivery
other County Departments. crisis juvenile crime
County Aging and several hours with customers, calming disabled children
County Jail Lack of Increased long-
Fragmented
BHD can't control mental health system Disabilities Services people down and trying to find a place 25-35% and families lack
(Corrections employment support services term residential
because state directly funds some Department for them. increase in
County Health) training and or treatment they care Juvenile court
Administration
services and because of fragmentation Mentally ill people number of
Health Increased demands on aging and Deliver customers placement support need. often must place
of alcohol and drug system. go to primary care mental health Increased foster
Dept. disabilities services. (often repeat customers) emotionally
clinics for help and customers Customer care
This diverts county resources that could Increased mentally ill inmates to treatment location disturbed children
medication. 16% Clients discharged from intensive co-payments
go to shore up deteriorating outpatient from 1500 to 3000 in 2 years. in detention
increase in two years. services with no outpatient follow-up. required
and case-management services. Inmates lose Oregon Health
Plan coverage. Poor communication among all
TRIAGE CENTER OFTEN FULL sectors, especially with the
County contracts for 3 secure Pressure on traditional
Mentally ill inmates often Crisis Triage Center.
beds in Crisis Triage Center services for women STREET NEEDS UNMET The Street Sector
and children for acute released to street. Difficult to Increased homeless street
(Providence Hospital) to relieve Housing, case management, and
primary care and get casework, treatment, and population in which service (The vast uncounted)
pressure on acute care. But social support services inadequate. Increased enforcement of petty Alcohol and neighborhood drug
disease control. medications from mental needs for many are unmet.
these beds are often full, so 24-hour hotline for disabled Victims of crime arrests to protect customers dealer provides pharmaceutical
police have to find other health providers. 2,700 individuals seek shelter Fewer drop-in
clients overwhelmed by mental street predators and public (anecdotal evidence) relief. Approx. 80% of homeless
hospitals. There are complaints every night in Portland. At Centers
health crisis calls. have alcohol/drug problems.
about customer treatment. leasst 30% of homeless
people are mentally ill.