In approximately 10 to 12 years, West Virginia's mental health system has deteriorated. By 1994 the state had reduced its psychiatric inpatient population by 96% over the course of four decades. The number of state inpatient facilities had dropped to two, and all state facilities for individuals with developmental disabilities had closed.
Community services, however, were left without adequate resources because of a shift in funding from state money for community programs to Medicaid funding, which was followed by federal Medicaid determinations that “safety net” services were ineligible for reimbursement and subsequently disallowed.
Even though the closure of state facilities and the emphasis on care in the community provided millions of dollars in savings to the state, these savings never were shifted to the community to support necessary programs to account for people who moved to West Virginia, thereby increasing service demand.
In this poor funding climate, most of the community behavioral health centers have not been able to provide cost-of-living increases to their staffs in the past five years—for some, it has been ten years. For their most important, hands-on staff, community behavioral health centers are competing with state facilities, nursing homes, and even fast-food restaurants and gas stations. It is almost impossible to retain trained staff and experienced workers for consistent programs.
A compounding factor has been the managed care system that Medicaid contracted with for behavioral health review as part of its negotiations with federal Medicaid officials to resolve the safety net disallowance problem. The role of the managed care company is to review the utilization of the main behavioral health Medicaid services provided by Medicaid providers and prior authorize those major services. The added costs of the extensive assessments and paperwork that the managed care company requires, along with the delay and reduced services that accompany its prior-authorization process, have resulted in a reduction of $31 million for the three cornerstone components of community-based behavioral health programs (the Medicaid Clinic, Rehab, and Targeted Case Management Options) over the past three years. Community programs thus are left with:
no replacement for state funds originally taken away in anticipation of Medicaid funding;
loss of Medicaid funding for essential safety net services;
years without any increase in Medicaid reimbursement for the services it does fund; and
additional costs and service reductions because of managed care.
As a result of these pressures, the commitment rates at the remaining inpatient state facilities have increased drastically, and they often are “overbedded” (The two inpatient facilities are JCAHO accredited for a set number of beds, but they are taking in more patients than their accreditation allows them to have filled because they don't have adequate staffing, programs, etc., to meet accreditation standards for the additional patients). The state has been forced to use private hospitals’ psychiatric beds for committed patients, which is more costly. Re-admission rates also have increased significantly. In addition, the number of homeless people with mental illness served by Medicaid increased more than 300% between FY 2001/2002 and FY 2003/2004. People with substance abuse issues have been committed to psychiatric facilities instead of being treated in community programs. And the former director of the state's regional jails was quoted as saying, “The state's prisons and jails have become the new mental institutions for thousands of West Virginians.”
As the dire situation became more obvious and more problems arose, a reporter for the Charleston Gazette, Scott Finn, wrote a series of articles called “Brother's Keeper: West Virginia's Mental Health Crisis,” for which he received a national journalism award. This series brought a lot of attention to the crumbling community service system and pointed out the repercussions. Finn also highlighted remedies that communities were piloting, as well as the need for additional funding or legislation.
As more people learned about the plight of people with mental illness, movement toward system transformation started in the state capital. In December 2005, the West Virginia Behavioral Health Care Providers Association presented a report about problems in the system to the joint House and Senate Legislative Oversight Commission on Health and Human Resources Accountability. House of Delegates member Barbara “Bobbie” Hatfield, with long-standing interest in behavioral health issues had attended training provided by the National Alliance on Mental Illness about the need for development of a state plan for behavioral health expenditures. In addition, this year the governor and secretary of the Department of Health and Human Resources, both facing their second year in office, expressed their support for behavioral health and community programs.
All of these factors came together in one relatively positive session of the legislature this year:
Medicaid received supplemental funding to finish this fiscal year and enough of an increase for the coming year to avoid funding reductions for behavioral healthcare, although no major reimbursement increases are expected.
The governor requested—and the legislature approved—$15 million to address the issue of overbedding and use of private psychiatric beds.
The state allocated $3 million to community behavioral health centers to hire community care coordinators to keep people from being admitted or re-admitted to the two state inpatient psychiatric facilities.