By Matt Birchenough and Alissa Gulin
Special to Capital News Service
COLLEGE PARK, Md. – As Maryland health officials and advocates debate the need to shift more mentally ill patients from institutional to community-based care, the state is being challenged by an explosion of patients in need of treatment, officials say.
The number of adults receiving mental health services from the state Mental Hygiene Administration ballooned from about 56,000 is 2008 to more than 93,000 in 2011, according to the state’s operating budget for fiscal year 2013.
This jump was largely fueled by a rise in the number of people enrolled in Medicaid, due to more people meeting financial requirements during the recession, according to Brian Hepburn, executive director of the Mental Hygiene Administration. Medicaid, a joint federal-state program, provides health care insurance to the low-income.
The number of Medicaid recipients receiving community mental health services climbed from 108,896 adults and children in 2010 to 132,600 in 2011, the budget shows.
The sluggish economy impacted those on mental health care doubly hard, said Dan Martin, director of public policy for the Mental Health Association of Maryland. Personal financial struggles led more people to seek services, he said, at the same time fewer of those services were available.
“If you’re laid off from your job or your house is underwater, if you’re having difficulty with money issues and the recession, that can lead to some kind of depression or some other kind of mental condition,” Martin said.
The recession hurt the government, too.
“That same money issue — it’s the same thing that leads to the state having to cut back on funding for things like mental health treatment,” Martin said.
Although funding for the Mental Hygiene Administration increased from $683 million in 2010 to $746 million in 2011 and was expected to increase to more than $800 million for 2013, according to the state budgets, that number still does not approach the nearly $900 million budgeted in 2008, when there were about 30,000 fewer people receiving mental health services.
“There’s been some tough decisions we’ve had to make going on three, four years — if not more — because of budgets being so tight at the state level,” said Crista Taylor, director of adult services at Baltimore Mental Health Systems, a nonprofit agency established by the city to oversee treatment facilities for the mentally ill. “Part of the reason for this is that the Medicaid population is going up. … It’s an entitlement, so the state has to cover that.”
The increase in Medicaid benefits comes amid a national movement to shift much of the mentally ill and developmentally disabled populations out of state-run institutions into community programs. That movement began in the 1950s, with the development of more effective medication, gained momentum in the 1960s, with support from President Kennedy, and saw a rapid acceleration after a 1999 Supreme Court decision. Olmstead vs. L.C. ruled that mentally and physically disabled people should be treated in the least restrictive setting possible. (See timeline.)
In 1991, there were 12 state-run facilities for the mentally ill in Maryland, serving more than 8,600 adults and children. That number had shrunk to about 5,300 in 11 state psychiatric institutions by 2000, a year after the Supreme Court’s Olmstead decision.
Currently, the state operates only seven psychiatric facilities for children and adults, serving an estimated 2,600 inpatients and 1,000 residential patients this year.
View Institutions in Maryland for the Mentally and Developmentally Disabled in a larger map
Most of these decreases were due to the closings of entire hospitals — Crownsville Hospital Center in Anne Arundel County in 2004, the Regional Institute for Children and Adolescents-Southern Maryland in Cheltenham in 2008, the Walter P. Carter Center in Baltimore in 2009 and the Upper Shore Community Mental Health Center in Chestertown in 2010. (See map.)
Other facilities, however, simply downsized rather than shutting their doors entirely. Springfield Hospital Center in Sykesville, for instance, treated 2,550 patients in 1991 but had dropped to only 1,046 by 2000.
But in addition to favoring this movement for ideological reasons, public health officials in many states, including Maryland, have tapped deinstitutionalization as a method of budget reduction in recent years.
“The original reason was basically [providing] compassionate care and trying to address the needs of people with mental illness in the same way that physical illness is addressed,” Hepburn said. “Over the years, [there’s been] a recognition that it’s cheaper to take care of people in the community rather than in institutional care.”
The average cost of a state hospital bed is $180,000 a year as opposed to less than $50,000 a year for comprehensive community care, according to Herb Cromwell, executive director of the Community Behavioral Health Association of Maryland, a professional organization for the state’s community mental health providers.
Despite the financial savings, Hepburn said he does not believe further deinstitutionalization will occur in Maryland in the near future.
“I wouldn’t predict a significant decrease in capacity or closures in the next 10 years,” Hepburn said. “As the science improves and as we do a better job of providing the care that’s needed for individuals with severe mental illness so that everybody’s able to be taken care of in the community, then we may see a decrease.”
However, advocates believe that further deinstitutionalization can and should be taking place.
Even a person with a prison background “can get to a point where they’re OK to live in a community, and I know that’s very controversial, but that’s the case,” said Emily Hoffman, a recovery employment counselor for the mental health advocacy group On Our Own of Maryland.
The top questions individuals ask when she meets them is why they aren’t included in their discharge planning and when they will be discharged, said Sarah Rhine, an attorney with the Maryland Disability Law Center, a protection and advocacy organization for individuals in institutions. “Those people are frustrated and would like to leave,” she said.
Hepburn, while acknowledging that some patients might be kept in psychiatric hospitals longer than necessary, said complying with the Olmstead ruling is not always so cut and dry.
“Is it possible that people are staying longer than they should? Of course,” he said. “[The court] feels very strongly about the people that are there, and there aren’t good alternatives for them in the community. And so their goal is to try to protect the individual and protect the community, and so they would argue that the individual is only kept in as long as they need to be kept in.”
Whether or not deinstitutionalization continues, Cromwell said it isn’t the only factor affecting the availability of funds for community services.
“It’s not just a matter of diverting the money out of the institutions into the community; it’s really more the basic budget process is not adequately supporting community services,” Cromwell said.
The real issue, he said, is the wasteful spending that occurs throughout the entire health care system. For example, overuse of emergency rooms for those with behavioral health issues leads to significant levels of unnecessary spending, he said.
Taylor said there are other ways to save costs other than reducing services. One way to make the system more efficient is to streamline the delivery of services, she said, such as merging the Alcohol and Drug Abuse Administration with the Mental Hygiene Administration.
Many providers favor this idea because so many patients have substance abuse problems in addition to mental illness, Taylor said.
“How many clients come with just schizophrenia?” she asked. “But you have two administrative bodies, two separate sets of regulations, two sets of billing rules,” she said. “So you can save money by merging those two agencies … and treating those people by what they really are, by all the symptoms they’re presenting with.”
In fiscal year 2007, 14,000 adults in the public mental health system had co-occurring diagnoses of substance dependency and mental illness, but by 2010, there were more than 17,000 adults in this category.
Hepburn said that although funds for certain services and positions have been lacking, such as for child psychiatrists, he said he didn’t think the public mental system has been totally inundated.
“So far, we’ve been able to keep up with it, but the question would be how many more years of increases [in patients] can we sustain?” he said. “At some point, the demand is going to overwhelm the supply. We’re just not there yet, but we could be there next year or the year after.”