Grading the States 2006: Maryland - Narrative
Maryland is an underachiever.
The state has a lot going for it, but can do better. There also are warning signs of a downward slide.
Maryland has the 4th highest per capita income in the nation and in 2002 ranked 7th in per capita spending on state-directed mental health services. The National Institute of Mental Health in Rockville and Johns Hopkins University in Baltimore are centers for cutting-edge research on serious mental illness. As the recipient of a federal Transformation State Incentive Grant (TSIG), the state is well-positioned for innovation and progress. Yet for all these advantages, the primary question seems to be whether or not the state will waste its opportunities.
In 2006, Maryland has a $1 billion budget surplus. Like Virginia, its regional neighbor and rival, Maryland should be considering renewed investment in the mental healthcare system as part of a plan for the future.
Responsibility for public mental health services rests with the archaically named Mental Hygiene Administration (MHA), housed within the state's Department of Health and Mental Hygiene. At the local level, 20 Core Service Agencies (CSAs), which are public or private agencies, are responsible for planning, managing, and monitoring services.
Beginning in 1999, as Maryland's system tried to meet a growing need for services, MHA outpaced its appropriations. As a result, the state mandated that the agency pull back spending through a series of painful cost-containment measures, in order to be in line with the budget by the end of FY 2005. MHA succeeded in bringing its budget under control, but through the paradoxical strategy of shrinking supply at a time when it faced increasing need.
It's time to reconsider.
During the past few years, the state hospital system has gone through significant changes. In 2003, the state legislature called for consolidation of inpatient care among three large state hospitals, leading to the closure of Crownsville Hospital Center and redistribution of $12 million in funds - half going to mental health services and half being applied to the state budget deficit. Despite MHA's commendable management of the closure process, the result has been high occupancy rates and pressure on new admissions.
To complicate matters, Medicaid currently covers acute care in private hospitals for individuals in crisis, under what is known as an "IMD waiver." The waiver expires in 2007, and there is significant concern that the result will be even greater pressure on the state hospitals to pick up the slack.
Two private psychiatric hospitals - Chestnut Lodge and Taylor Manor - also recently have closed. Meanwhile, lack of funds for additional residential rehabilitation program (RRP) beds, commonly used for recently discharged patients, has impeded moving patients from hospitals into community settings.
The net result is that people with serious mental illnesses crowd emergency rooms across the state. In response, MHA has shown leadership by creating a Centralized Admission and Referral Center (CARC) to assist emergency rooms in finding placements in state hospitals for individuals without insurance. Although CARC is a positive step, advocates still report waits of up to three days for acute care beds.
Capacity also depends on skilled workers, and Maryland here has a significant problem. During FY 2002-2005, budget cuts eliminated almost 500 positions in state hospitals and residential treatment centers, and another 15 positions within the MHA headquarters were lost. To its credit, MHA identifies its workforce as an "acknowledged weakness." Furthermore, no system exists to review and monitor provider quality, and no comprehensive assessment and strategic plan exist to address it.
The convening of the national Annapolis Coalition on the Behavioral Health Workforce in Annapolis in May 2004 provided a powerful and ironic counterpoint to Maryland's failure to demonstrate leadership on workforce issues.
Community housing for consumers is a major need. The cost of living in the Baltimore and Washington, D.C. suburbs is higher than the national average. Individuals with serious mental illnesses often live in poverty. But Maryland also is rural. Basic access to services, including transportation, is a problem in many areas. Vast disparities exist across the state.
On the positive side, MHA has been innovative in creating the state's TAMAR Project (Trauma, Addictions, Mental Health, and Recovery) for the treatment in detention centers of female consumers with histories of substance abuse, mental illness, or trauma; the program also helps their children. TAMAR has dramatically reduced recidivism rates among this population, and it serves as a national model.
Recent legislation has helped decriminalize mental illness by suspending, rather than terminating, Medicaid benefits for individuals incarcerated for less than a year.
Maryland's community-based system is moving aggressively towards broad implementation of evidence-based practices. In particular, MHA has invested insupported employment programs, including evaluation and collaboration with the Department of Vocational Rehabilitation Services. SAMHSA grants and a partnership with the University of Maryland have helped MHA accelerate the process - although access to services is still lacking.
MHA also is moving to convert some of the state's existing mobile treatment programs to ACT teams, a needed change.
There are reasons to be hopeful about progress in mental healthcare in Maryland, but much depends on whether policymakers are willing to invest surplus dollars smartly in the system. The 2006 state elections may be an appropriate time for serious dialogue about the state's direction in helping people with serious mental illnesses. Consumers, families, and taxpayers deserve better than the status quo.
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