Oklahoma's Mental Health System Relying On 'Triage' Approach

By Clifton Adcock, Oklahoma Watch

Every year, thousands of Oklahomans with mental-health or addiction problems call or show up at state-funded treatment centers and get little or no care.

The message is: Until you get sicker, you will get minimal help from the state.

That's because Oklahoma's mental-health system relies on a “triage” approach that limits most subsidized treatment to the seriously ill.

The result is that many people are going without early intervention and then are seeing their troubles grow worse, mental-health officials and providers say. Those Oklahomans will often need more extensive and costly care later and may end up in prison or jail.

State officials say they face a dilemma. While the number of mentally ill people needing state-paid care has climbed, state funding for core treatment services has dropped. If the state spreads its money around more to increase preventive services, the most severely ill will receive less intensive treatment. That includes people with illnesses such as schizophrenia and bipolar disorder.

“We have to serve those most in need because we have limited resources, so that's how we have to prioritize,” said Terri White, commissioner of the Oklahoma Department of Mental Health and Substance Abuse Services. “What that means is you go without until you get sick enough – which is a horrible way to do health care.”

White's department pays for mental health and substance abuse services for the indigent, uninsured and underinsured. The services are offered primarily through dozens of nonprofit treatment centers around the state. When patients call or arrive with problems that don't rise to a certain level, the state often will not pay for the care. The Department of Mental Health stopped counting people who are turned away several years ago, saying it was a bureaucratic burden.

“There's a lot of what we call walking wounded out there. They're still functioning but they're hurting. They have mild anxiety or mild depression or marital issues or work-related issues. Those people are falling through the cracks,” said Verna Foust, CEO of Red Rock Behavioral Health Services in Oklahoma City.

Those with untreated mental illness may lose their job or family or suffer other consequences. As their lives deteriorate, their mental illness deepens. Treatment in later stages will cost taxpayers more. Many of the mentally ill are eventually incarcerated and have worse health outcomes, White said.

“Unless we get an investment of resources, we don't have a choice (but to prioritize cases),” White said.

The Sickness Hurdle

Under state guidelines, all people can receive state-paid emergency mental-health services regardless of income.

In non-emergency cases, though, people age 18 or older who lack mental-health insurance must meet certain criteria before the state will pay for treatment.

Their annual household income must be no more than 200 percent of the federal poverty level, or $20,090 for a family of three. Their condition also must fall into the two highest levels of “illness severity,” based on the diagnosed illness and degree of functional impairment. The levels range from one to four, with one being the most severe.

The state requires the same income levels for substance-abuse treatment and accepts those in the top three priority levels, including pregnant women and injecting drug users.

Qualified patients must get their services from state-designated community mental health centers or substance abuse centers contracted by the state.

Often there is not enough money or resources to serve people beyond the top priority levels, said Janet Cizek, CEO and managing partner for the Center for Therapeutic Interventions in Tulsa, which offers drug treatment.

“We're seeing the worst of the worst,” Cizek said. “We have to turn people away all the time. You either have to get into a crisis where you're using (drugs) so much you're about to die or you start committing crimes.”

She estimates that for every 75 people who seek treatment for substance abuse at her facility, about 20 don't fall into the top three priority levels for treatment and are turned away.

Community mental health centers will often put non-qualifying individuals on a waiting list, refer them to other organizations or provide limited services, said Carrie Slatton-Hodges, deputy commissioner of treatment and recovery for the state mental health department. Providers often use donations and grants to provide treatment to clients with less serious issues.

“What you see happen probably more is they will try to serve everyone who comes through the door. They just can't offer as wide array of services,” Slatton-Hodges said.

Between 2012 and 2014, the amount of uncompensated care provided by Department of Mental Health contractors rose from around $7 million to more than $7.5 million, according to department figures.

Even organizations that accept non-qualifying clients referred by other providers said it is hard to keep up with demand.

Catholic Charities in Oklahoma City once accepted counseling referrals for non-qualifying clients, but five years ago the charity tightened its criteria because its small staff was overwhelmed, said Monica Palmer, senior director for clinical services.

“When you get less folks being served by community mental health centers or longer waiting lists, then they tend to come to churches and nonprofits for help,” Palmer said.

On the Front Lines

To Clark Grothe, chief operating officer for NorthCare, a community mental health center in central Oklahoma, the situation resembles the opening to the television show “M.A.S.H.”

“That's really what our mental health system is right now – a triage system where we welcome anyone who walks through our door,” Grothe said. “Unfortunately, the resources are such that we can really only give immediate services to those in the highest risk situations.”

Grothe said NorthCare tries to serve everyone who seeks treatment, but a lack of resources often requires the center to place those with lower-priority problems on a waiting list. Waits can be more than six weeks.

“Then the person moves on and doesn't get the help they need and the symptoms will likely exacerbate,” Grothe said.

At Red Rock, people who fall outside the top two priority levels come in regularly but are referred to other organizations, Foust said.

“We're never able to do the preventative type stuff so people don't get sick,” Foust said.

Community mental health centers used to provide services to anyone seeking treatment if their household income was at or below 200 percent of the poverty level, said Slatton-Hodges, of the mental health department. Then, about 13 years ago, the department began using priority levels.

“It was to the point where pended services (uncompensated care) were in the millions of dollars,” Slatton-Hodges said. “They were trying to honor their contract – seeing anyone in their region who come to them for mental health needs. But they truly couldn't continue to do that.”

More in Need, Less Money

In fiscal 2009, a total of 69,939 people were served by the state Department of Mental Health system, excluding those who received Medicaid services. By 2013, that number had grown to 79,150, according to department data.

During that period and since, the department's budget for core services has dropped. In fiscal 2009, about $210 million was available for core services, compared with $181 million in 2015, according to the department.

The department's total budget has risen in recent years. But the increases went to specialty programs, such as drug and mental health courts that divert people from prison, or the state share of behavioral health Medicaid, which the department manages.

The state mental health department got a $2 million increase for fiscal 2016, but that money will not fund core services, said department spokesman Jeff Dismukes.

Britta Ostermeyer, chair of psychiatry for the University of Oklahoma College of Medicine, said the system's current focus is not only a product of years of underfunding, but of apathy as well.

“We have to make a point in society that we believe the treatment of psychiatric disorders is important to the person, to the family as a unit, but also to the community, to the state and to the country,” Ostermeyer said. “Because if we don't treat mental illness appropriately, we're going to pay for the consequences anyway.”

Several providers criticized Oklahoma's decision in 2012 not to expand its Medicaid program under the Affordable Care Act.

About 80 percent of people served by the state mental health system would be eligible for Medicaid if it had been expanded, Slatton-Hodges said.

Cizek, who runs the Tulsa drug center, said the injection of federal funds would ease the strain on the system and help more people.

“There's a huge gap of people out there, from 250,000 to 300,000, who could access Medicaid federal dollars, but can't because our state didn't expand Medicaid,” Cizek said. As a result, “I think the state is in a world of hurt.”

Oklahoma Watch is a nonprofit, nonpartisan journalism organization that produces in-depth and investigative content on a range of public-policy issues facing the state. For more Oklahoma Watch content, go to www.oklahomawatch.org.