Mental Health Association of Portland

Oregon counties aim for more dollars for community mental health care and Bexar County, Texas-modeled center

Posted by Jenny on 4th September 2014

Commissioner Judy Shiprack

Commissioner Judy Shiprack

An improving state budget combined with the new wellspring of Medicaid dollars for low-income healthcare has Multnomah County Commissioner Judy Shiprack and the Association of Oregon Counties feeling like the time is right to make considerable investments in community mental health that will reap great savings by reducing police and jail costs.

The Oregon counties are rolling out a lobbying campaign to improve services for people with severe mental illness, particularly those who burden the public safety system. With help of new state funding as well as new Medicaid dollars, they hope to save money now spent on jails and police time while improving the lives of their most vulnerable residents at the same time.

The Association of Oregon Counties is holding up Bexar County, Texas, as the model they’d like to emulate, and Multnomah County Commissioner Shiprack told The Lund Report that a team of people from public safety and mental health at Multnomah County traveled to San Antonio to see their work first-hand.

Bexar County runs a “Restoration Center” that provides transitional housing for people with severe mental illness and drug and alcohol addictions, along with acute in-patient treatment and support services as individuals recuperate.

“We’re going to be a reliable partner in getting something done,” Shiprack said. “We’re merging mental healthcare with the justice system.”

Andy Smith, the lobbyist for the Association of Oregon Community Mental Health Programs, said that the high level of services in San Antonio could serve as a goal for a large county like Multnomah and individual components of Bexar’s system could be adopted by even the smallest counties. Full rollout could take a decade, but they’re hoping to get going with a legislative concept that establishes a “Mental Health Justice Reinvestment Program.”

None of the ideas are exactly new — Multnomah County has the Crisis Assessment and Treatment Center and diversion programs have been available for years across the state to treat incidents related to mental health and addictions as a symptom of illness rather than a crime.

Smith said they would like to do some more work on the front-end, and more informally hook people on the streets who need help with treatment without waiting for the formal diversion after a petty crime has occurred.

“They literally intercept people and divert them from jail,” Smith said of Bexar County. “It’s an expensive program to create but it’s saved them money by preventing the cynical churning of people in and out of jail.”

Bexar County had the luxury of a wealthy philanthropist to establish the up-front costs, but Shiprack said that their operation has saved $50 million in reduced recidivism rates since 2009. The county would have paid for chronic offenders anyway, but the investment allowed Bexar to do so in a way that would help people with severe mental illness and addictions troubles lead healthier, happier, more productive lives.

As one of their top goals, Smith and Shiprack hit on a regular theme of the National Alliance of Mental Illness in Oregon — the lack of stable housing for people with mental illness. State money, along with pooling of mental health and public safety budgets, could be used to establish more housing units for people with a mental illness.

“The reality is we’re using our jails as a housing resource,” Smith said.

This problem is certainly more severe in Portland than in San Antonio given the West Coast’s housing shortage and extremely tight rental market. If healthy people with stable employment struggle to find affordable housing, the situation is much worse for people with few resources and a mental health or addiction issue, which of course only becomes more devastating without a safe place to sleep.

“We know that treatment works a lot better if the person’s not homeless,” Shiprack said, with a touch of irony.

Mental Health Investments

Gov. John Kitzhaber made significant investment in mental health with his 2013-15 budget, which the Legislature bolstered through the passage of a small cigarette tax, led by Senate President Peter Courtney, D-Salem. Smith said the governor, if re-elected, plans to increase this investment next year by $60 million on top of last biennium’s money. The counties would like to get some of that money for their programs to use as seed money; if they can see Bexar County-type results, the overall savings to public safety budgets should be able to keep them self-sustaining.

The Association of Oregon Counties’ legislative concept is written so that the Oregon Criminal Justice Commission would distribute the money to the counties, but to avoid a turf battle with the state, Smith said it would be rewritten so that the money is handled by the Addictions and Mental Health Division at the Oregon Health Authority, with the understanding that the money would be distributed more equally this time around, instead of forcing counties to bid against each other. “Some of our coastal counties didn’t get any crisis money,” he said. “Pretty much every county is going to need help.”

But the real game-changer is the Medicaid expansion. Instead of relying on a strained county or the whims of unreliable state budgets for mental health services, treatment programs will be able to use federal dollars from the coordinated care organizations now that the vast majority of the targeted clientele now qualify for the Oregon Health Plan.

Medicaid more than anything previously should keep a stable funding stream for treatment for people who cost the counties tremendous amounts of money in police and jail resources when what they really need is a few good therapists or medication.

“Counties are signing people up when they appear in our jails,” Shiprack said. “We take the opportunity to make sure people who need healthcare have access to healthcare.”

Bill Murray, the chief operating officer for Portland-area CCO FamilyCare, said that his organization is part of a countywide task force that was working closely to develop solutions at the nexus of public safety and mental health. Beth Sorensen, the spokeswoman for Portland’s other, larger CCO, Health Share, said her organization hadn’t seen the counties’ legislative concept but noted the expansion allowed them to serve 70,000 people who had been previously uninsured.

“Health Share works with our health plan partners to ensure that a full array of mental health and addiction treatment options are available for our members. Our focus is on providing services to people in community settings so they don’t have to seek in-patient treatment,” Sorensen said.

DOJ Settlement

Lingering in the background, at least in Multnomah County and the city of Portland, is a court settlement ordered by federal district Judge Michael Simon last week between the U.S. Department of Justice and the Portland Police Bureau, which requires the city to create a crisis-intervention team and expand its mobile crisis units from a single vehicle to one vehicle per precinct.

The agreement follows an investigation by U.S. Attorney General Eric Holder into police misconduct from years of violent encounters between police and people with mental disorders, including the tragic death of James Chasse, Jr., in 2006.

Ending police misconduct and improving community mental health are two discrete problems, but they too often cross, particularly when mental health disorders go untreated and police officers end up dealing with situations that they are untrained. The new behavior health unit, led by Portland Police Lt. Cliff Bacigalupi, is designed to provide “first responders” with the skills to recognize and handle people in the midst of a mental health crisis.

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Fifteen years after Olmstead decision, many with disabilities still live in restrictive environments

Posted by Jenny on 29th June 2014

OSH interior hallBrent Kaderli has a wheelchair-accessible van waiting in the driveway, a hospital bed in a spare bedroom and an electric lift that’s left unused. If the 30-year-old quadriplegic had his way, he’d be living here, in his father’s house, with help from aides. Instead, he is in an institution, hoping each day for a place that feels more like a home.

Fifteen years after a landmark Supreme Court ruling that the disabled should be given the choice to live outside nursing homes, mental hospitals and other institutions, its legacies are dueling. Progress has been made in every state to keep more aged and disabled people in their homes and communities, but only half of Medicaid spending goes to such care, with the services routinely denied by a system that favors institutions even though they’re typically more expensive to taxpayers.

Kaderli said Medicaid approved him for only three hours of at-home daily care, but he’d need at least six to get by while his father is at work. So he lives in a nursing home in Pasadena, Texas.

“It sucks and it’s sad and it’s depressing,” said Kaderli, who was paralyzed in a 2006 car crash and had his legs amputated after the wreck. “I wish I was somewhere else every day.”

In the June 22, 1999, decision in Olmstead v. L.C., the justices ruled that unnecessarily segregating people with disabilities in institutions amounts to discrimination under the Americans with Disabilities Act if they can be cared for in more home-like settings. Advocates for the mentally ill, older people and the physically disabled regularly cite the ruling, but it has limitations. It says individuals should be “reasonably accommodated,” specifically noting “the resources available to the state,” caveats that have made it difficult to assess compliance and that have fueled widely different outcomes around the country.

Nationally, the share of Medicaid long-term care spending that went to home and community services was 28 percent at the time of the ruling, according to a Department of Health and Human Services report. By 2012, the latest year for which data were tallied, the figure had risen to 50 percent, according to the Centers for Medicare and Medicaid Services. Every state has increased its allocation to non-institutional services, but the allocations range from 78.3 percent of Medicaid spending in Oregon down to 27.4 percent in Mississippi and New Jersey.

The ruling offers no guidance on the allotment of funds. Many advocates argue that states could allow all individuals to be treated at home or in community-based settings such as group homes. The industry says there will always be some people who require or prefer institutional care.

“States determine where they are going to put their resources, and in some states and some communities they continue to make the decision to support a higher number of individuals in facilities,” said Sharon Lewis, a special adviser on disabilities to Health Secretary Sylvia Mathews Burwell. “We at the federal level can encourage and incentivize and support, but ultimately Medicaid expenditure decisions are a state decision.”

Institutional care remains the default in Medicaid, and getting beyond it is cumbersome. Waivers must be obtained for alternative care, such as in-home services, and some states have lengthy waitlists. Nationally, more than half a million people were on waiting lists in 2010 for Medicaid-provided home and community care waivers, according to a report from the Kaiser Family Foundation, a nonprofit that analyzes health policy issues.

“The way people are treated in modern society, in our society, to me is still shocking,” said Sue Jamieson of the Atlanta Legal Aid Society, the lead attorney on behalf of the two plaintiffs in the 1999 case, who sued then-commissioner of the Georgia Department of Human Resources Tommy Olmstead. “We still treat people in so many ways as less than human.”

Medicaid is the leading payer of long-term care, spending $140 billion on it in 2012. To make non-institutional services a right across states rather than an option for eligible Medicaid recipients, legislators would have to approve a change in federal law.

Sylvia Waring, 45, of Philadelphia, entered a nursing home in 2011. She has multiple sclerosis and uses a wheelchair, and her care costs Medicaid $355 daily. She is suing for services in her own apartment, where lawyer Stephen Gold believes costs would be cut by half or more.

“It doesn’t make much sense to me: They’re always talking about money, money, money,” said Waring, a former cafeteria worker. “It feels like I’m being prosecuted because I was sick. I just need a little bit of help.”

Medicaid paid an average of $225 per person per day in 2012 for those receiving institutional care, according to CMS figures. Among those receiving waivers for home and community care, the average cost was $125 daily. Home care is generally cheaper because most people don’t require round-the-clock care, but some worry that making more non-institutional services available will prompt a flood of people to seek them and increase costs.

“Everyone knows the state will save a fortune by providing home and community services,” said Gold, who has represented individuals around the country trying to get out of nursing homes. “The problem is a political one. By and large, this is a business, and disabled people are cash cows.”

After her release from a psychiatric hospital, Olmstead plaintiff Lois Curtis slowly gained back her ability to complete basic tasks — cooking, picking out clothes, shopping. Today, Jamieson said, her former client lives in her own apartment and goes to a studio each day to work on her art. She even made a trip to the Oval Office and presented one of her paintings to President Barack Obama.

The other plaintiff, Elaine Wilson, died in 2005. She said being released from a mental hospital was like being free again.

“I felt like I was in a box that I would never get out of,” she said in 1999. “I feel like a real person again.”

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Private study finds lower Medicaid costs for residents of Bud Clark Commons

Posted by CoffeeX3 on 10th April 2014

From the Oregonian, April 10, 2014

Monthly health care costs for Medicaid recipients who live at the Bud Clark Commons in Portland plummeted 55 percent after moving into the alcohol-and-drug-tolerant public housing project, according to a new study.

But those savings were inflated by 9 percentage points because two high-needs residents apparently died almost immediately after moving in.

Home Forward, the housing authority that operates the commons, funded the $50,000 study. The report touts its findings as an indication that supportive housing had a “profound and ongoing impact on health care costs” for the people who live there.

READ – Integrated Housing & Health; a Health-Focused Evaluation of The Apartments at Bud Clark Commons (PDF)

The study found across-the-board cost reductions for people who moved into the 130-unit studio apartment project, said Bill Wright, associate director for research of the group that conducted the study.

But Wright cautioned there is not a cause-and-effect relationship between living in the commons and lower health care costs.

“Moving in was associated with a reduction,” he said. “That doesn’t mean it’s a direct cause.”

Read the rest of this article here.

READ – Health care study explores the impact of housing on health care use, costs and outcomes, press release from Health Share Oregon


Report Conclusions

COST SAVINGS

Residents with Medicaid coverage saw significant reductions in medical costs after moving into BCC: the average resident saw a reduction of over $13,000 in annual claims, an amount greater than the estimated $11,600 it costs annually to house a resident at BCC.

Importantly, this reduction in claims was maintained into and beyond the second year of residency, suggesting that supportive housing had a profound and ongoing impact on health care costs for those living at BCC. We examined historical, pre-BCC claims data for residents to determine whether some reduction in costs might have been expected in this population even in the absence of housing.

We did not find evidence of a natural “regression to the mean” in costs for the population BCC serves; indeed, their health care costs steadily rose for the 2.5 years prior to moving into BCC, peaked just prior to move-in, and then immediately fell to a much lower level after move-in. In the absence of a formal experimental “control group” to compare out-comes, this represents the best available evidence that cost reductions are likely attributable to the acquisition of housing and would not have been expected to happen in its absence.

SHIFTS IN UTILIZATION

We examined utilization data in order to understand the mechanism by which costs were reduced. We found evidence that residents maintained connections to outpatient behavioral health, primary care, and pharmacy after moving in, but saw significant declines in inpatient and ED utilization. This suggests that cost savings among the BCC residents came from efficiently managing health care in appropriate settings, helping to reduce acute health crises and avoid more expensive types of utilization.

We also examined self-reported utilization data in order to determine if similar patterns held true for non-Medicaid residents. We found patterns in the self-report data that matched those in the claims: continued engagement in outpatient care accompanied by a reduction in acute events.

Hospitals absorb significant uncompensated care costs for such events. Given these costs, the “true” savings associated with housing at BCC are likely considerably higher than our Medicaid-only estimate.

ACCESS, HEALTH, & TRAUMA

Residents saw significant declines in unmet health care needs, and significant improvements in self-reported physical and mental health, after moving into BCC. There was also a significant increase in overall happiness.

Trauma histories were very common among BCC residents; even after moving in many residents still face traumatic events in their lives. Understanding the link between trauma survivorship and health care utilization/costs will be a key component of caring effectively for this population.

CHALLENGES

Our interviews with residents also revealed some challenges of the supportive housing model. Some residents told us that getting clean and sober was actually more difficult than they expected in an environment where others are still actively using. Others mentioned feeling unsafe or threatened by others living in the building, which sometimes hampered their involvement in social activities or use of other services. New strategies to overcome these challenges will help residents fully engage in the BCC model.

IMPLICATIONS FOR REFORM

These results suggest that health care reformers would be well served to think carefully about the relationship between housing and health, particularly in vulnerable populations such as those served by BCC. Among those in our study, getting into stable housing resulted in a significant reduction in total health care costs; these savings were greater than the estimated annual cost of housing someone at BCC, do not appear likely to have reflected natural regression to the mean, and were maintained over time. Housing also im- proved self reported health outcomes. In this acutely ill and vulnerable population, supportive housing was effectively a health care intervention, and it appears to have worked.

Additional research can help replicate and substantiate these findings. For now, however, these results suggest that Oregon’s commitment toward a broader view of health care — one that thinks beyond service delivery and encompasses the social determinants of health — may have real potential to help bend the cost curve. Policy and funding pathways to support and expand such models should be strongly considered as part of Oregon’s ongoing transformation effort.

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Increased Medicaid coverage expected to overwhelm mental health services

Posted by Jenny on 19th February 2014

mental-health1TDN.com, Feb. 17, 2014

As millions of Americans gain health coverage through the Affordable Care Act’s Medicaid expansion, experts say their higher rates of mental health and substance abuse disorders will be difficult to treat due to a lack of counselors and behavioral therapists who accept Medicaid patients.

In the District of Columbia and the 25 states where the expansion is under way, nearly 1.2 million uninsured adults newly eligible for coverage will have substance abuse problems, according to federal estimates, and more than 1.2 million are projected to have some sort of mental illness. An estimated 550,000 of those will have serious mental disorders that impair their everyday functioning.

As these patients seek treatment for any number of problems, a shortage of caregivers — from physicians to dentists — will pose a major challenge for Medicaid, the federal-state health program for poor people and those with disabilities. The lack of providers may be most acute in the area of mental health services.

The Medicaid expansion extends coverage to adults who earn up to 138 percent of the federal poverty level. Those with behavioral problems will be treated at community mental health agencies and health centers that serve low-income patients. This new expansion population will strain the limited resources of these facilities, many of which already have staff shortages and waiting lists for behavioral treatment.

Further complicating the problem: Most mental health therapists in private practice won’t treat Medicaid patients because of the program’s low reimbursement rates.

And now that the health care law has made mental health treatment a mandatory, or “essential,” benefit for millions of people with private coverage, the demand for therapists and counselors will increase, making it even harder for Medicaid’s community-based providers to recruit and retain behavioral health professionals.

“As more people are insured, more people are also going to be seeking services,” said Rusty Selix, the executive director of the California Council of Community Mental Health Agencies. “Our biggest concern is more competition for a limited number of professionals and the cost pressures that’s going to create. We’re going to have to pay more to retain people. It’s supply and demand.”

Already, the demand far outstrips the supply.

Americans live in federally designated mental-health-professional shortage areas, where there’s only one psychiatrist for at least every 30,000 residents. That’s compared with only 59.4 million who live in primary-medical-health-professional shortage areas and 46.7 million who reside in dental-health-professional shortage areas.

Fifty-five percent of U.S. counties — all of them rural — have no psychiatrists, psychologists or social workers, according to the U.S. Department of Health and Human Services.

Filling the needed positions nationally would take 1,846 psychiatrists and 5,931 other professionals, federal estimates show.

“That’s a critical problem. And the Medicaid expansion will make that even worse,” said Susan Mandel, the CEO of Pacific Clinics, the largest community mental health agency in Southern California.

Joel Miller, the executive director and CEO of the American Mental Health Counselors Association, said he was expecting to see “pretty significant increases” of 20 to 25 percent in the numbers of psychologists, mental health counselors, social workers, and marriage and family therapists over the next five years, based on student enrollment trends.

“I’m very much an optimist,” he said. “But sure, if you look at the current capacity, there are holes. There are gaps in inner cities and in rural areas.”

Most of the expansion enrollees will be single, childless adults, a group that Medicaid traditionally has declined to cover. Among this group, military veterans, the homeless and former jail inmates are expected to have higher rates of mental illness.

For many, the Medicaid expansion will provide their first opportunity for health coverage as adults. After living for years with untreated or undiagnosed disorders, their pent-up demand for care might trigger a run on Medicaid services.

“I think we’re going to see a pretty good uptick, an increase, right off the bat,” Miller said. “Based on what we’ve looked at in states that have increased coverage for people who were uninsured with a behavioral health condition, we expect there’ll be a pretty significant increase right from the get-go.”

When Oregon’s Medicaid program began accepting childless adults in 1994, for example, the new enrollees logged three times as many mental health and substance abuse treatment visits as the program’s low-income parents.

At Yakima Neighborhood Health Services, a community mental health agency in Yakima, Wash., 40 to 50 percent of the several hundred homeless Medicaid-expansion clients who’ve enrolled since October have had some sort of mental illness, said Rhonda Hauff, the agency’s chief operating officer.

The most common problems are depression, anxiety and post-traumatic stress disorders, along with more serious problems such as bipolar disorder and schizophrenia, Hauff said, adding that a fourth full-time behavioral specialist was needed.

Medicaid providers are likely to face similar pressure in Minnesota, where an estimated 30 percent of uninsured, expansion-eligible adults suffer from some form of mental illness and 19 percent have serious mental illnesses, according to federal estimates.

In Delaware, Ohio, West Virginia and Vermont, roughly 1 in 4 uninsured expansion-eligible adults have mental illnesses, federal data shows. Those states — along with Iowa, Rhode Island, Kentucky and Oregon — have double-digit rates of serious mental illness among that group.

“When the new enrollees get coverage, there’s a real opportunity to engage them in treatment, but there needs to be capacity in the system to do so. And that, I would say, is one of the challenges,” said Allison Hamblin, the vice president for strategic planning at the Center for Health Care Strategies, a nonprofit resource center.

Finding psychiatrists is one of the toughest problems faced by Mandel, of Pacific Clinics. The number of practicing psychiatrists in the U.S. declined by 2 percent from 2000 to 2010, according to the Association of American Medical Colleges, even as the population increased by nearly 10 percent. Retirements by an aging workforce are a big part of the problem. Nearly 57 percent of U.S. psychiatrists are 55 or older, the group reported in 2012.

Recruiting younger ones is hard, Mandel said, because most newly trained psychiatrists don’t want to relocate.

“When people go to medical school and go into their residency, they tend to put down roots in that community,” she said. “They marry. They have kids. So if you don’t have a medical school with a department of psychiatry in your neighborhood, it’s very hard to recruit people.”

Not everyone, however, is fretting about the situation. Matt Salo, the executive director of the National Association of Medicaid Directors, said the new expansion patients weren’t likely to arrive en masse but probably would seek treatment gradually, making them easier to accommodate.

“And we really don’t know who’s going to come in,” Salo said. “It’s hard to quantify people who haven’t shown up yet.”

The real problem may not be a lack of providers but a lack of funding, said Jennifer Mathis, the director of programs at the Bazelon Center for Mental Health Law, a national nonprofit advocacy group in Washington. From 2009 to 2012, states cut a collective $4.4 billion from their mental health budgets, according to the National Association of State Mental Health Program Directors.

Since the federal government will pay all the medical costs for Medicaid-expansion patients in 2014, 2015 and 2016, states have an incentive to offer greater mental health benefits, Mathis said.

“It remains to be seen whether there’s an actual shortage of providers,” she added. “I don’t think we have data to suggest one way or the other, really.”

In California, Selix said his organization was working to loosen licensing regulations for counselors so a broader segment of people could be hired.

“There’s a lot of people that have valuable experience but they don’t have mental health licenses, and we want to be able to use them for services as much as possible,” Selix said.

As an example, he cited “peer support” counseling, led by instructors who are recovering from their own mental health struggles.

“Using people who have been through that to help others navigate through it reduces the amount of licensed clinician time we need,” Selix said. “Plus it’s less expensive, so we’re trying to expand that.”

Efforts nationwide to place counselors, social workers and others with behavioral health credentials in clinics and other safety-net facilities will help provide greater access to counseling in primary care settings.

In Kentucky, where more than 14 percent of uninsured expansion-eligible adults are estimated to have substance abuse problems, the new Medicaid benefit presents their best hope for recovery — if the providers are available.

“We know that there’s a significant number of people that need substance abuse services who’ve not had a way before to pay for it,” said Tony Zipple, the CEO of Seven Counties Services Inc., which treats mentally ill Medicaid patients in the Louisville area. “Whether that becomes a problem for us depends on how many people come in, for what services and over what period of time.

“I may eat my words and we may be surprised tomorrow, but I really do think this will happen in an incremental enough way that we’ll be able to handle it reasonably well. But only time will tell.”

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Iowa Senator makes Oregon Medicaid prescriber data available

Posted by Jenny on 17th June 2013

By Jenny Westberg, June 17, 2013

ZyprexaWho are the state’s top prescription writers for widely abused drugs like Oxycontin and Xanax?

How much does Oregon’s Medicaid  program pay for expensive mental health drugs like Seroquel and Zyprexa?

The data obtained by Sen. Charles Grassley (R-Iowa) may not provide every answer about Oregon clinicians’ prescribing practices, but it does shine a light on previously obscured information.

Grassley, who is ranking member of the Senate Committee on Finance, wrote to Bruce Goldberg, director of the Oregon Division of Medical Assistance Programs, in 2010 and 2012, expressing concern about heavy prescribing by a subset of providers and the possibility of waste and fraud.  In particular, Grassley asked about certain high-priced and often overprescribed antipsychotics, as well as common drugs of abuse that can wind up on the black market or lead to addiction and even death.

In response, Goldberg produced listings of the top 10 Medicaid prescribers of specified drugs, for 2008, 2009, 2010 and 2011.

The information covers the following second-generation “atypical” antipsychotics:

  • Abilify
  • Geodon
  • Seroquel
  • Zyprexa
  • Risperdal

and these frequent drugs of abuse:

  • OxyContin
  • Roxicodone
  • Xanax

The top 10 prescribers for each form of each drug (brand name, generic, long-acting, etc.) were identified with their 10-digit NPI numbers, along with total number of prescriptions and total cost to Medicaid for every entry.

As a service to journalists, researchers, and others interested, the Mental Health Association of Portland went through the raw data, found names for the NPI numbers, added up the numbers for different forms of the same drug, and matched data for the same provider appearing in different places.  We have entered it all on a spreadsheet on Google Drive, with several reports to show the data various ways (reports are on separate sheets you can see by clicking the tabs at the bottom of the spreadsheet).

It is important to remember that this is very specific information that applies only to the top 10 prescribers for each drug, and only for prescriptions billed to Medicaid.  For example, you might see a provider with totals for two drugs.  This does not necessarily mean they didn’t prescribe Drug #3.  But for the third drug, the provider wasn’t in the top 10.  Likewise, if a provider does not appear on the lists, it does not necessarily mean they are prescribing more conservatively; it could be that this provider does not take Medicaid patients.

Also, keep in mind that the antipsychotics have been coming off patent the past few years, so prescriptions could stay high while total dollar amounts dipped.

Finally, we did not include the data from 2008 in our spreadsheet.  During that year, many prescriptions had no NPI number. Another identifier was being used – but not always, and when there was no identifier, pharmacies recorded “999999.”  Since the 2008 data would not be comparable, we only worked with 2009-11. 

From the data alone, it is impossible to draw conclusions; a high-volume prescriber may be overprescribing — or busy.  We hope others will take these numbers and provide some context, so all of us can benefit from this store of information.

Read or download the Oregon prescriber data spreadsheet:  https://docs.google.com/spreadsheet/ccc?key=0Arv37LTwMHQHdFJJdUVyUWlzcEJsdVJ6bU5sWENLSnc&usp=sharing

 Correspondence and Raw Data (PDFs)

Letter from Sen. Grassley to Oregon DHS chief Bruce Goldberg 2010
Bruce Goldberg responds to Sen. Grassley 2010
Bruce Goldberg responds to Sen. Grassley 2010 with additional info
Letter from Sen. Grassley to Bruce Goldberg, asking for update 2012
Bruce Goldberg responds to Sen. Grassley 2012
DHS – Oregon Top Prescribers List 2008-2009
DHS – Oregon Top Prescribers 2010
DHS – Oregon Top Prescribers 2011

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Marianne Udow-Phillips on Oregon Medicaid study: Mental health is health, too

Posted by Jenny on 12th May 2013

By Marianne Udow-Phillips, Bridge Magazine, on MLive Media Group, May 12, 2013

girl-happyRecent reports about a Medicaid experiment in Oregon reveal a major disconnect we have in the health care world: we make a historic — and unwarranted — distinction between “physical health” and “mental health.” Worse, that distinction actually interferes with both our investment in mental health treatment and patients’ willingness to seek treatment.

The Oregon Medicaid study is about the impact that Medicaid coverage has had on a group of low-income individuals who obtained health insurance coverage for the first time several years ago. Researchers have been studying Oregon because of a unique set of circumstances that resulted in some uninsured adults being randomly selected to receive access to Medicaid, while others were not. That circumstance enabled a randomized controlled trial to be done in the “real world” — a rarity in health services research.

The experiment’s initial set of results, which relied on self-reports by the participants, were released last year. In the first year of the study, those with Medicaid coverage reported better health than those who were in the control group. In the most recent report, which includes second-year findings, researchers used actual health measures for cholesterol, high blood pressure, diabetes, and depression. This second set of data resulted in a more nuanced and complicated conclusion than the first-year report.

Specifically, the researchers found no impact in the two years with regard to cholesterol and high blood pressure; an increase in diagnosis and treatment of diabetes but no impact on blood sugar levels; a significant reduction in depression; and a significant improvement in financial stability for those with Medicaid coverage compared to the control group.

Because these findings were released while many states are still considering whether or not to expand Medicaid, the Oregon story was reported across multiple media outlets. Headlines ranged from the fairly neutral (New York Times: “Medicaid Access Increases Use of Care, Study Finds”) to the more judgmental (Forbes Magazine: “Oregon Study: Medicaid ‘Had No Significant Effect’ On Health Outcomes vs. Being Uninsured”). Some commentators have said that the study and resulting headlines were almost like a Rorschach test about what one believes about the Affordable Care Act and the Medicaid expansion. But, even articles and publications that are generally favorable to the Medicaid expansion often reported that the study showed that the Oregon experiment had no impact on health.

These headlines are stunning in several ways. First of all, they generalize a few measures over a relatively short period of time to a sweeping conclusion about health insurance. But, beyond that, they seem to entirely discount the improvements in mental health as a “health outcome.”

Mental Health is ‘Health,’ too

In the Oregon Medicaid experiment, the rate of depression dropped by more than 9 percentage points and the relative improvement compared to the control group was 30 percent. Why is it that we don’t identify the significantly lower rates of depression as a significant health outcome?

For years, we have had research on the causes of depression and other mental health conditions. While the causes are likely multifactorial, including a combination of genetics, environment, biology and psychology, the National Institute of Mental Health describes “depressive illness” as a “disorder of the brain” —not a personal weakness.

More than 10 years ago, visionaries at the University of Michigan, under the leadership of Dr. John Greden, established the country’s first Depression Center. Dr. Greden reasoned that until we treat depression like we do cancer — as a disease that requires focused, team-based research and collaboration — we will not make the kind of progress in understanding this disease that we need to. Today there is a National Network of Depression Centers that includes 21 of the nation’s top academic institutions.

It is disappointing to realize that 10 years of this kind of work has not erased the distinction between “physical” and “mental” health. If we had, the headlines about the Oregon experiment would have been something like this, “Medicaid coverage shown to have significantly improve health relative to being uninsured.”  We should only be so lucky to find a health impact as large as this in other areas of the Oregon health experiment.

Marianne Udow-Phillips is director of the Center for Healthcare Research & Transformation and a former director of the Michigan Department of Human Services.

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‘Oregon experiment’ shows Medicaid expansion improves mental and financial – but not physical – health

Posted by Jenny on 1st May 2013

News release, Harvard School of Public Health, May 1, 2013

120504_health_care_overhaulNew findings from the Oregon Health Insurance Experiment show that Medicaid coverage had no detectable effect on the prevalence of diabetes, high cholesterol, or high blood pressure, but substantially reduced depression, nearly eliminated catastrophic out-of-pocket expenditures, and increased the diagnosis of diabetes and the use of diabetes medication among low-income adults. The Oregon Health Insurance Experiment is the first use of a randomized controlled study design to evaluate the impact of covering the uninsured with Medicaid and provides important evidence for policy makers as the U.S. undertakes Medicaid expansion in 2014.

The study, led by Katherine Baicker, professor of health economics at Harvard School of Public Health and Amy Finkelstein, Ford professor of economics at MIT, appears in the May 2 issue of the New England Journal of Medicine.

“This study represents a rare opportunity to evaluate the costs and benefits of expanding public insurance using the gold standard of scientific evidence—the randomized controlled trial. Without a randomized evaluation, it’s difficult to disentangle the effects of Medicaid from confounding factors like income and health needs that also affect outcomes,” said Baicker, co-principal investigator of the study.

In 2008, Oregon held a lottery to give additional low-income, uninsured residents access to its Medicaid program; about 90,000 individuals signed up for the lottery for the 10,000 available openings. Approximately two years after the lottery, the researchers conducted more than 12,000 in-person interviews and health examinations of lottery participants in the Portland, Oregon metropolitan area, and compared outcomes between those randomly selected in the lottery and those not selected in order to determine the impact of Medicaid.

Some of the key findings:

Physical health

  • Medicaid had no significant effect on measures of hypertension or high cholesterol, or on the rates of diagnosis or use of medication for these conditions.
  • Medicaid increased the probability of being diagnosed with diabetes after the lottery by 3.8 percentage points (compared to the 1.1% of the control group who were diagnosed with diabetes) and increased the use of diabetes medication by 5.4 percentage points (compared to the 6.4% of the control group who used diabetes medication), but had no effect on glycated hemoglobin (a measure of diabetic blood sugar control).

Mental health

  • Medicaid reduced rates of depression by 9 percentage points (compared to the 30% of the control group screening positive for depression) and increased self-reported mental health.

Financial hardship

  • Medicaid virtually eliminated out-of-pocket catastrophic medical expenditures (defined as out-of-pocket medical expenditures in excess of 30% of household income) and reduced other measures of financial strain.

Utilization and access

  • Medicaid increased health care use, including use of physician services, prescription drugs, and preventive care.

“The study highlights the important financial protections that Medicaid provides, as well as the substantial improvements in mental health, but does not provide evidence that Medicaid coverage translates to measurable improvements in physical health in the first two years,” said Finkelstein, co-principal investigator of the study.

The current study is part of an ongoing research program gathering a wide array of data sources to examine many different effects of Medicaid, and represents a collaboration between non-profit and academic researchers and state policy makers. A previous study looking at data collected about a year after the lottery found that Medicaid substantially increased health care use, increased self-reported health, and reduced financial strain. More information can be found at http://www.nber.org/oregon.

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Senate President Courtney calls for ‘game-changing’ funding increase for children’s mental health

Posted by Jenny on 9th March 2013

By Christopher David Gray, The Lund Report, March 5, 2013

childrenA pathway has appeared to the game-changing funding levels that Senate President Peter Courtney signaled for community mental health — at least for children – when the increased funding made a list of priorities when the co-chairs released their two-year spending plan Monday morning.

Courtney’s proposal called for a funding increase of $331 million for community mental health, including $46 million for children and adolescents — $28 million more than what Gov. John Kitzhaber had earmarked.

“We’re gonna get there or we’re gonna get close,” said Courtney’s spokesman Robin Maxey after the press conference.

Part of that increased money would be included in the $4.3 billion dedicated to human services, while the rest would be part of the $275 million in new taxes by eliminating some unspecified corporate and individual tax write-offs.

“We should treat our tax expenditures and deductions the same way as we see our regular expenditures,” said Sen. Richard Devlin, D-Tualatin.

The co-chairman’s budget projects $75 million from these new resources for children’s mental health and other healthcare priorities such as the tobacco prevention program, the Farm to School program, the Oregon Health & Science University Rural Scholars Program, mandated physical health education and an increase in payments to home care workers.

The details for the budget still must be worked out through the various Ways & Means subcommittees and could definitely change, according to Devlin.

That budget also keeps the funding levels consistent with the governor’s budget for coordinated care organizations and the state mental hospital. The proposal also presumes the Medicaid expansion will take place, giving Oregon Health Plan coverage to 250,000 newcomers next year however those dollars will come from federal coffers, not the state’s general fund.

Devlin and fellow co-chairman Rep. Peter Buckley, D-Ashland, called for a $16.6 billion discretionary budget over the next two years, which assumes $705 million in savings to the Pubic Employee Retirement Savings — which is more modest than the $865 million in the governor’s budget.

“It’s trying to thread a needle in the dark,” Devlin said. “We need to find a path that is both fair and proposals that will have both short-term and long-term savings. … Higher levels that don’t hold up in court don’t do anyone any good.”

The budget also assumes the savings projected by Kitzhaber from prison reform.

Education funding would be $6.55 billion over the next two years, an increase from Kitzhaber’s $6.15 billion and local districts would realize $50 million less in savings from PERS reforms than the governor proposed. Meanwhile, the human services budget would bump up by 9 percent.

The minority Republicans also presented their own budget proposal, one that would hold revenues at current levels while promising $1.8 billion in PERS savings, despite the tricky legality of scaling back public employees’ promised pensions.

Republicans including Rep. Dennis Richardson of Central Point and Sen. Doug Whitsett of Klamath Falls said they were shut out of the budget discussions brought forward by the majority Democrats, unlike last session, when the House was split between the two parties.

“I think it’s unfortunate that the Republicans have chosen to politicize the co-chairs’ budget,” said House Speaker Tina Kotek, D-Portland.

The Republicans matched the Democratic co-chairmen’s numbers on education funding but sought to hold the line to roughly 2 percent annual increases for human services, roughly the current rate of inflation.

Richardson argued that the number of people seeking social services should decline as the economy recovers. “The caseloads should be decreasing,” he said.

He pointed out that human services represented 21 percent of the budget in 2005-07, yet absorbed 26 percent of the general fund last biennium because of the 2008 economic collapse. At the same time, the percentage of discretionary funds spent on education has declined from 44 percent to 38 percent.

“We’re placing the expansion of social programs on the backs of our children,” Richardson said.

Rep. Mark Johnson, R-Hood River, said the Republicans would be hard pressed to support any tax increases as Oregon’s unemployment rate clung to 8.3 percent.

But while tax increases require a bipartisan three-fifths majority vote, allowing tax expenditures already scheduled to lapse to actually expire does not require a similar majority.

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