Wyoming is reshaping the delivery of behavioral health services, and while most of the details remain to be finalized, it seems clear that fewer people will qualify for government-funded treatment. However, the result, proponents say, is that the state can prevent expensive and painful cycles of institutionalization and family separation by focusing scarce resources on those who need help most.
House Bill 38 community, passed during the 2021 legislature, requires the Wyoming Department of Health to reconsider the state-funded mental health and substance abuse system.
Wyoming pays for many mental health and substance abuse services provided through a network of community behavior centers. In recent years, the state has invested about $ 44 million a year in such programs, but demand for services consistently outpaced funding and supply. Then budgeters reduced mental health funding by $ 7.5 million annually – roughly 17%.
HB 38, the result of years of effort, was an attempt to get the maximum impact from this oversubscribed investment. One of the mechanisms to do this is through the establishment of priority treatment groups.
Now the Ministry of Health, lawmakers and other stakeholders are struggling to translate this new legal mandate and others into a functional policy.
A report will be submitted to the Joint Committee on Labor, Health and Social Affairs on September 1st. It should contain recommendations for the reuse of funds and the implementation of the changes required by the legislation. It will likely take years to complete.
During the second of three public sessions on Redesign Tuesday in Riverton, Health Department chief data analyst Franz Fuchs described the ongoing effort as “a big beast.
“We were very careful with this redesign and, in my opinion, proceeded very iteratively,” said Fuchs. “We’re taking small steps and going backwards, trying to solve a lot of the very delicate and really big problems we’re talking about.”
Rep. Lloyd Larsen (R-Lander), co-chair of the Special Committee on Mental Health and Substance Abuse and member of the Steering Committee for the Redesign, said in a May interview that there was consensus among stakeholders, lawmakers and officials that certain populations should be given priority for receiving state-paid benefits.
These categories include those coming out of prison with severe mental illness, those who would otherwise be admitted to the Evanston State Hospital, and families where a lack of intervention could result in a child being removed from the home .
The state has been operating on a generalized access model for years, whereby anyone, regardless of treatment required, was entitled to government-funded services if they were unable to pay – essentially a first-come-first-served model without prioritization based on circumstance or condition. Larsen said the legislation does so that certain people seeking help with mental health and substance abuse must find an alternative to government-funded treatment.
“It’s just a matter of good politics,” said Larsen. “Do we have an open door policy where everyone, no matter who they are, has mental health services paid for by the state? And the consensus was no, that is not the job of the state government. “
But not everyone agrees that setting prioritized categories is the right approach. Andi Summerville, executive director of the Wyoming Association of Mental Health and Substance Abuse Centers, is concerned that adding barriers to entry for those not in the priority categories will lead to escalating problems that earlier, lower-cost interventions would have avoided she said.
The legislation defines three levels of priority, with level 1 being the highest priority and level 3 being the lowest. Level one includes individuals working in the criminal justice system, adults with acute or severe mental illness, and families at risk. Category 2 clients – needy adults whose disorder affects their ability to function in society and who are not insured against drug abuse or treatment for mental illness – would have to earn a household income of less than 150% of the poverty line to be eligible for government funding. Clientele in the third category are needy, uninsured people whose income is below 150%, but who lack a disorder that impairs their function in society.
“At levels two and three, the financial cutoff level is 150% of the poverty line, and in general most counties are hitting 300% right now, so you’re essentially cutting universal access in half,” Summerville said. “In most places we don’t have an answer as to where these people should go.”
According to the federal poverty guidelines for 2021, those earning more than $ 19,320 will not be eligible for state assistance in grades two or three.
Sue Wilson (R-Cheyenne) MP, who is a member of the Steering Committee and chair of the House Labor, Health and Social Affairs Committee, said she doesn’t necessarily see the redesign as a reduction in the number of people who are entitled to services. Instead, it only brings the neediest to the top of the line.
“Right now there is a de facto prioritization that is first come, first served,” said Wilson. “My hope is that it just means that people with greater needs are given priority over people with lesser needs.”
The fact that the state needs to reshape the system so that some who are unable to pay public support are not eligible for public support is an indication of systemic flaws that lawmakers need to address in other areas, said MP Karlee Provenza (D-Laramie). .
“I think if we can honestly expand Medicaid it will help fund some of it,” Provenza said. “I think if we realize that we need to fund this and that it can save us money, we will be better off. I’m just worried about any model that people may have to turn away because they can’t pay. “
Four working groups of stakeholders and lawmakers are working to resolve the unanswered policy questions about eligibility, transitions, outcomes and payment. The process started in May, but much remains to be done before the September 1st report is due.
Health Department Fuchs said the eligibility discussion raised more questions than answers, but stressed that there was ample time to do the work required.
“We’re not trying to have the system implemented tomorrow or at the end of summer or even next year,” he said. “The system doesn’t need to be implemented right away, so we want to be really careful.”
Summerville, who is on each working group, said that answering the unanswered questions about eligibility, transitions, and results will take weeks, but that perhaps the biggest challenge remaining is redesigning the payment model.
The payments issue, Summerville said, is a chicken-and-egg scenario, and postponing that conversation to the end of summer has left uncertainty in making policy recommendations.
“It’s difficult to design a system if you don’t know how much the state is willing to pay,” she said.
The current system distributes government funding for mental health and substance abuse treatment and federal bloc grants to community mental health centers through a contractual process. The centers automatically deduct 30% as the base payment and then bill the remaining 70% monthly based on the service hours the centers make available to customers, with a maximum monthly amount based on the overall contract for two years.
The Payment Working Group tries to define how providers will be paid in the future and how much risk the providers will bear towards the state. A new model could consist of a mixture of:
Fee for service
Fundamental design of the subsidy payment
Determining how the payment works is complicated, Wilson said, and she now doesn’t have quick answers.
“Every payment structure has advantages and disadvantages,” said Wilson. “You not only have to consider what the incentives of certain structures are, but also how the remuneration structure or the incentive affects patient care.”
The final payment model will likely be a hybrid, Wilson said, and could be changed as experience teaches those involved what works and what doesn’t.
A meeting on August 17 will be the last time the working groups and the Steering Committee will meet before the report is presented to the Joint Committee on Labor, Health and Social Affairs. Fuchs said payment would be the focus of the August 17th meeting.
Work on reshaping the state’s approach to mental health and substance abuse services will continue long after the September 1 report is due, Wilson said. Because, like so many things that the Labor, Health and Social Affairs Committee deals with, the problem is never really solved.
“We are looking at the same issues: high health costs, aging, mental health, labor shortages,” she said. “They’re pretty much long-running, and that’s the way it is. We won’t stop thinking about it. “