Many States Hoard Medicaid Data, Shun Collaboration

Only a handful of states release for public consumption all data on the growing amount of mental health spending and services provided through their Medicaid programs, according to one of the first systematic surveys of all state programs.

The survey of state Medicaid agencies, undertaken by the Substance Abuse and Mental Health Services Administration (SAMHSA) and released last November, is among the first to examine differences in how these agencies administer mental health services.

The report comes as federal health officials have begun to propose broad cost-cutting measures for Medicaid—some of which could be implemented administratively, without congressional approval. The report's findings about state Medicaid agencies' approaches to mental health care could have an impact on those federal cost-cutting moves, according to mental health advocates.

The survey report is based on hour-long telephone interviews with state Medicaid directors or their designees conducted over a seven-month period in all 50 states and the District of Columbia.

Among the many organizational differences that the survey identified across state Medicaid agencies, the one that mental health advocates were particularly concerned with is the finding that only eight states publicly release all reports on the extent and costs of their mental health programs under Medicaid.

“One issue that has concerned us is the lack of data on where the money is being spent and who is being treated,” said Mary Giliberti, director of public policy and advocacy at the National Alliance on Mental Illness (NAMI), in an interview with Psychiatric News. “NAMI wants more transparency.”

Such information is needed not only by program administrators to make good policy decisions, she said, but also by other stakeholders—such as researchers, advocates, and the public—who help form those policies.

The survey reported that seven of the 48 states that generate reports on the extent and costs of their mental health programs under Medicaid restrict them to internal use. However, 22 states have a mix of publicly available and internal-only reports. Among the 29 states in which some or all of the mental health service reports are available only internally, there are 26 in which the Medicaid agency shares the report with other state agencies.

Slightly more than half of the states reported that their Medicaid and mental health agencies frequently collaborate on external meetings, public reports, or presentations to the legislature. Nine other states reported that the agencies collaborate “somewhat regularly” on such information releases.

The findings on state Medicaid administration of mental health benefits are increasingly important because the state agencies have taken on a growing role over the last 30 years in funding, managing, and monitoring public mental health services in the states.

Medicaid's share of total national mental health spending—both public and private—rose from 16 percent in 1986 to 26 percent in 2003, according to a study published in the August 1, 2007, issue of Psychiatric Services. Non-Medicaid state mental health spending dropped from 27 percent of total national mental health spending in 1991 to 23 percent in 2001, according to the SAMHSA report. Medicaid's share of total state mental health spending is projected to rise from more than half to as much as two-thirds by 2017.

“The shift toward greater Medicaid funding of mental health services,” the authors stated in the report's executive summary,“ has resulted in part from the movement of mental health services from institutional settings, where Medicaid funding is limited, to community settings, where it is more readily available.” The change also reflects efforts by states to obtain federal Medicaid funding for services that previously were funded entirely by state or local governments.

William Emmet, director of the Campaign for Mental Health Reform—to which APA belongs—said in an interview with Psychiatric News that the survey highlights the mixed blessing that comes with the states' increased reliance on federal funding for their mental health services. The federal approach creates some uniform standards to which all of the programs must adhere, but those standards stem from a system that was not designed for mental health care.

The report “points out the need for state mental health and other state health officials to work closely together because many of them understand the need for mental health services that may not be understood by CMS [the Centers for Medicare and Medicaid Services],” Emmet said.

The survey report comes as CMS officials have begun broad cost-cutting reviews and issuing new regulations to control rising costs in Medicare and Medicaid. Mental health advocates said the survey results can inform CMS about the different approaches the states have taken in their provision of mental health care.

Another survey finding was that while state Medicaid agencies retain ultimate authority over all aspects of their programs, some states have delegated responsibility for some activities to other state agencies or to private contractors.

“As a result of this flexibility, the administration of Medicaid mental health services varies considerably across states,” according to the report.

Among those differences are whether state Medicaid and mental health agencies are within the same umbrella agency. They are united in 28 states—usually under health and human services—and separate in 22 states and the District of Columbia.

Medicaid and mental health agency collaboration tends to be highest in states where both agencies are in the same umbrella agency and lowest where they are in separate agencies and where the mental health agency has authority to set some Medicaid rates, according to the report.

Selby Jacobs, M.D., chair of APA's Committee on Public Funding for Psychiatric Services, told Psychiatric News that state Medicaid and mental health agencies should communicate and collaborate, but decision-making authority is a key issue.

“Having both Medicaid and [mental health] agencies under an umbrella agency seems to have advantages for integration of the two,” he said.

The authors' attempt to pull together information from each state to find commonalities and differences among these state government entities was a difficult task but an important achievement for mental health advocates, according to Anita Everett, M.D., section director of Community and General Psychiatry at Johns Hopkins School of Medicine.

“A community psychiatrist or psychiatrist advocate could take this document and learn a great deal about the functioning of these critical government agencies within her or his own state by pulling information from the charts in this report,” said Everett, who has studied mental health policy at the federal and state level.

“Administration of Mental Health Services by Medicaid Agencies” is posted at<http://mentalhealth.samhsa.gov/publications/allpubs/SMA07-4301/>.▪