POSTED ON AUGUST 7, 2013:
The Seven Percent Solution
Why mental health is changing in Oklahoma
Sharing his future meant meeting with some scorn.
"He said. 'You're going into psychiatry?' I said, 'Yeah.'" recalled Dr. Gerard Clancy.
The talk was with a cardiologist whose lab Clancy had been working in as a young research fellow sponsored by the American Heart Association.
"He said, 'What a waste,'" Clancy recollected. "I remembered that."
Motivation, for sure, as the mild-mannered Clancy, now president of the University of Oklahoma-Tulsa, described it: "My attitude was, 'I'll show you.'"
But the talk also exemplified the separation between mind and body in the attitudes of many doctors.
"We've had deep institutional divides, where mental health and medical care have been separated," Clancy said.
With health care reform, that may change soon for Oklahomans. One out of every 12 people categorized as low-income and without insurance have a "serious mental illness," according to government estimates emphasized in the recently-released Leavitt report. If expanded to include those with "serious psychological distress," the numbers rise to one in five.
The Leavitt report provides recommendations for what Gov. Mary Fallin has described as "an Oklahoma plan" to help low-income Oklahomans without insurance -- though many groups, including the National Alliance on Mental Illness, have urged states to accept Medicaid expansion. For NAMI, Medicaid expansion is a way to provide health care coverage for those with mental health needs, with the advocacy organization citing a need to help those who otherwise end up needing care in an emergency room or possibly a jail.
Such emergency care is costly, and if Oklahoma chooses to forego Medicaid expansion, the Leavitt report advises paying greater attention to behavioral health concerns -- detailing the financial reasons for doing so.
"Recent research shows that for those with chronic conditions, health care costs are as much as 75 percent higher for individuals with mental illness and two to three times higher for individuals with co-occurring substance abuse disorders," the report states.
Along with providing some sort of subsidized health insurance, the Leavitt report also recommends the state take more steps to coordinate care. The report pushes for more use of a health home model to help Oklahoma "achieve higher levels of integrated physical and behavioral health care."
Clancy said he's "a strong believer" in that model, which involves a patient having a team of doctors, nurses and -- if the Leavitt report's recommendations are followed -- mental and behavioral health professionals all working together in a coordinated way to help the patient.
"The watchword for care coordination for me is helping people get to the right clinician at the right time," Clancy said. "For most people, navigating the system is incredibly complex."
From her own experience, Attonia Sarch said private insurance doesn't necessarily solve everything when seeking mental health treatment.
"The co-pays, the deductibles are really high," said Sarch, a board member of the Tulsa chapter of NAMI.
Affordability is a factor, but so, too, are the limited outlets for treatment.
Then there's the "stigma" still associated with mental illness, Sarch said.
"I have a mood disorder, and an anxiety disorder and a personality disorder," she said -- acknowledging the hesitation she still feels before sharing the information, even as she works with NAMI to educate others about the realities of mental illness.
"The biggest obstacle to getting mental health treatment is actually stigma. It's individuals who don't feel comfortable asking for help," Sarch said.
But despite the complexity in helping others, "the easier it is for people to access care, the more likely they will," Sarch said.
She singled out a need for more licensed professional counselors.
"I would like to see one in every doctor's office," Sarch said, supporting the idea of greater integration of mental health and medical services.
Clancy, who treats patients at the OU Wayman Tisdale Specialty Health Clinic in North Tulsa, said affordability concerns affect patients and doctors.
"I can tell you, from lots of experience with patients -- both mental illness and medical issues -- bills and the financial burden of accessing health care are a huge concern and a huge decision point whether people will decide to seek treatment or not," he said.
Those concerns influence what doctors recommend to patients, he said.
"When I have an uninsured individual coming to me, I design a treatment plan they can afford. It's not always the best treatment plan, but it's one they can afford," Clancy said.
Doctors treating a patient with insurance have "a much better set of options," he said.
One solution that might be pondered by state legislators involves expanding some form of Insure Oklahoma, an existing program offering partially-subsidized health coverage to lower-income residents.
"Anything is good right now as far as making progress, is where I am," Clancy said. "And if people can get more comfortable with a more robust Insure Oklahoma program, then maybe people get more comfortable with Medicaid expansion after that."
A large segment of Insure Oklahoma involves helping lower-income employees and the owners of small businesses. While the state also has an "individual plan," it's mainly geared for people who are eligible for unemployment benefits -- or disabled.
"There are several mental illnesses, that the nature of the illness pushes you toward poverty," Clancy said. He wondered aloud: "Do we have a strong enough Insure Oklahoma program in place for those people that really can't work?"
He described his concerns about the uninsured population needing mental health treatment.
"To get to that level of disability is a long fall in functionality and impairments. Do we want to do that to people? Do we want to make them fall far to the point that they become disabled by their illness? Or do we want to treat them upfront early, so they don't suffer for years before they end up on disability?" Clancy asked.
Michael Brose, executive director of the Mental Association in Tulsa, said the organization often helps people with a disability.
"Medicaid has limitations, but it does work as a very basic sort of low-platform basic insurance for our absolutely most vulnerable population," Brose said.
However, "most people don't want to be on disability," Brose said. The working poor are "getting left out" of having coverage, he said.
For Sarch, even at times when she's had no insurance, finding treatment has been possible in Oklahoma, she said.
"There have been huge improvements that have been made over the years to help people with no insurance," Sarch said.
Clancy described a program begun about nine years ago to aid those most needing help, known as Integrated Multidisciplinary Program of Assertive Community Treatment, or Psychiatry IMPACT, for short.
This program helps several dozen Tulsans "with the most impairment levels," Clancy said.
On average, they had spent 60 days in the hospital yearly before enrollment. Clancy said the program has reduced that number to about four hospitalization days yearly.
The program "provides daily care for these individuals while they're living in the community," he said. Along with OU, the Department of Family and Children's services is among the organizations offering mental health treatment in Tulsa to those without insurance.
To help those dealing with a psychological event like divorce or losing a job, the Mental Health Association in Tulsa offers help through what it calls its Bright Sky program.
People taking part "work, they pay their taxes, but they don't make enough to be able to hire a private therapist," Brose said. Individuals are asked to pay $5 per visit with mental health professionals who donate their time.
"We were hoping that healthcare reform might come to Oklahoma and basically put that program out of business, because that program is still very limited and it only reaches a fraction of people who need that," Brose said.
Another group that needs more help can be found among Tulsa's homeless population, Brose said. These people, if they could fill out the paperwork, might qualify for Medicaid currently, but "sometimes they're so sick on the streets and very chronically homeless," he said. Treatment for this population often comes in the form of hospital stays, with no one around able to pay for the care received, Brose said.
He said if this population could find a "health home," then "then they could start to access a primary care doctor and have primary care." Compensation for a primary care doctor would be one result, with the health homes able to "then lessen the load on our emergency rooms," Brose said.
Brose criticized state leaders for not going along with Medicaid expansion.
"In my opinion, at the end of the day, it's political considerations and aspirations for higher office that are driving them to agree to this and say we're saying no," Brose said. He added: "Our tax dollars are going to subsidize health care in other states, and we're going to get no benefit for it."
In a January report, the National Association of State Mental Health Program Directors noted that, over the last 20 years, "improvements in behavioral health care under the Medicaid expansion have not been a prominent part of the discussions and debates about health care reform." The group offered a reason why: "Probably because spending on behavioral health is under 7 percent of all health spending."
But Clancy, also dean of the OU School of Community Medicine, said he's seen "just a dramatic change in the 13 years I've been here in the state as far as recognition of the need to take mental illness seriously."
He spoke just days after the start of classes at the medical school, which now begins with aspiring nurses and social workers joining their peers wanting to be doctors "to let them know from the start, from now on you're working as a team," Clancy said.
A team model to treat patients could be expanded even more to help with mental illness or substance abuse problems, he said, to create "a more robust" medical home integrating mental health and substance abuse services onto that team so "it's fully integrated into the primary care treatment plan."
"It totally makes sense to me. It totally makes sense that you are also covering those things rather that putting them 'over here.' If they're prevalent, and they are very prevalent, why not at least start working with it at the primary care level," Clancy said.
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