Grading the States 2006: Wisconsin - Narrative

Wisconsin is nationally distinguished as the birthplace of both NAMI and Assertive Community Treatment (ACT), and known locally for its strong network of consumer advocates, but its mental healthcare system still has weaknesses, as well as strengths.

The system is county-based. Some advocates believe it is too decentralized, with the state not providing enough financial support - particularly to counties with underdeveloped systems. At the same time, the state has limited ability to control care locally and quality of services varies across the state.

The Bureau of Mental Health and Substance Abuse Services (BMHSAS) is located inside the Division of Disability and Elder Services, which itself is a subdivision of the Department of Health and Family Services. Finances for mental healthcare are primarily controlled elsewhere - by the Division of Healthcare Financing and by the individual counties. This structure leaves BMHSAS facing barriers to controlling mental health expenditures, along with a bureaucratic view that counties are the state's primary customers - rather than people with serious mental illnesses.

Nonetheless, the county-based system is effective at reducing demand for state hospital admissions. Every system requires balanced options. Broad community services in Wisconsin get credit for the fact that no significant waiting lists exist for state inpatient hospital care.

The vision shown by the state leadership has been mixed with disappointments. To his credit, Governor Jim Doyle recently vetoed legislation that would have increased co-pays on Medicaid prescriptions and placed artificial limits on the total number of prescriptions. On the other hand, the governor vetoed a requirement that the state's new SSI managed care programs report on progress and outcomes to the legislature - effectively eliminating oversight of changes, and an opportunity to spot design errors in pilot programs.

In reporting on ACT use, BMHAS states that its community support programs (CSPs) are the equivalent of ACT. This is not true - a disappointing misconception for the state in which ACT began.

• ACT inspired CSPs, but they are not equivalent. CSPs do not meet ACT national standards. ACT teams have no more than 8-10 clients per staff member; 75 percent or more of services are delivered outside program offices; and peer specialists are required. Wisconsin's CSP standards require only that 50 percent of services be delivered outside the office and the client ratio is 1:20. There are no requirements for peer specialists.
• Although CSPs are not the same as ACT, they do have some of the right ingredients and are well supported by the state. They deserve close study of their actual effectiveness. CSPs are present in all but 10 rural counties, and the state goal is to add programs in one county per year for the next three years. At last count there were approximately 80 certified CSPs, serving 5,500 persons with serious mental illness at a cost of about $10,000 per client.
• The state has created a new Medicaid benefit - Comprehensive Community Services (CCS) - designed to help consumers who don't require the intensity of CSP, but still need more assistance than general outpatient treatment provides. Unfortunately, the population served by CCS is poorly defined, with only vague definitions of the individuals to be served and no system-wide outcome measures. Advocates are concerned that these factors will cause the program to be simply eliminated, before it ever is adequately and uniformly implemented.

Overall, Wisconsin has a strong foundation built on community services. As the state continues to move forward, it is a model for the nation.

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