Grading the States 2006: Missouri - Narrative
Missouri is a state in which the legislature has pounded the public mental healthcare system with budget cuts. At some point, cuts mean more than trimming fat or saving money; instead, they become harms, cutting muscle and bone, translating into needless suffering and early deaths.
Missouri already has passed that point.
In 2005, the state cut Medicaid eligibility to 85 percent of the poverty line. Approximately 100,000 people with disabilities lost coverage, about a third of them persons with serious mental illnesses. More cuts are expected.
The Department of Mental Health (DMH) is trying to navigate through the storm, even while leading the nation in some areas.
The state confronts shortages in housing, acute care beds, and community alternatives to hospital care. Solving these problems requires money. The key tosolutions is unquestionably held by the state legislature.
In 2004, the legislature passed mental health insurance parity, an important step which demonstrated some understanding that unless middle class taxpayers have access to care, costs to the public system will increase, as families spend down assets. But greater recognition by the legislature of cost-shifting relationships is still needed. When mental health services are reduced or eliminated, emergency room visits and hospitalizations increase, and in some cases, greater costs are imposed on the criminal justice system.
Missouri's mental health care system is centralized. In a significantly rural state, centralization can lead to complexity. Missouri counties have the option of funding and delivering mental health services on their own, but only St. Louis and 13 of the state's 114 counties actually do. In the face of state budget cuts, this structure contributes to fragmentation, putting rural areas at a disadvantage.
The state uses an approach called "Procovery," a model that other states can learn from. Procovery focuses not on a return to conditions before the onset of serious mental illness, nor static maintenance, but rather on moving people forward in their lives to the highest possible level. It is pragmatic, holistic, and to some degree spiritual in its outlook.
Missouri also leads the nation in oversight of clinical prescription practices, through a voluntary program for doctors conducted by a collaboration between the Missouri Mental Health Medicaid Pharmacy Partnership (MHMPP) and a private company called Comprehensive NeuroSciences (CNS). The program has reduced hospitalizations and unnecessary poly-pharmacy, and saved the state approximately $8 million in 2004. Equally important, MHMPP is grounded in sound clinical practice, rather than indiscriminate, restrictive formulary approaches. The federal Center for Medicaid and Medicare Services (CMSS) has identified MHMPP as a national model and the American Psychiatric Association (APA) and the Disease Management Association (DMA) gave it their Gold Award for innovation in 2005.
Other states, such as Massachusetts, have their own versions of MHMPP, but the "Show Me" state is the one that has delivered results. It is a national best practice model.
Work is a key to recovery for many consumers. DMH reports that it works with the state's Division of Vocational Rehabilitation to provide vocational services to approximately 18,500 persons. Its first plan was established in 1999 and has been continually revised, reflecting a proactive commitment.
Decriminalization of mental illness is another area of progress. In Kansas City and St. Louis, advocates see police Crisis Intervention Teams (CIT) and jail diversion programs working effectively - but ultimately, their success depends on the availability of community services.
DMH has initiated a disease management approach to mental illness which includes treatment for physical disorders - such as heart disease and diabetes - which often are interrelated.
The state has studied its suicide prevention effort and is tracking data.
Death is one harsh, but real, outcome for some consumers. The state needs to continue to study mortality among its service recipients, particularly in light of the cuts in Medicaid and services. Improving mortality data is consistent with DMH's record to date of confronting hard issues honestly, learning from them, and responding creatively. Transparency and accountability are essential to preserve the state's "show me" reputation.
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