Grading the States 2006: Rhode Island - Narrative
Even in the face of a "dismal economic climate," there are many thoughtful practices and efforts happening today in Rhode Island. Rhode Island's system of care is the least like the Presidential Freedom Commission's "shambles" or a "patchwork" relic in the nation - there are points of accountability and access in eight clearly delineated catchment areas.
The state leads the nation in the development and deployment of Assertive Community Treatment (ACT) service, with 15 teams for a very small state. ACT is a Rhode Island Medicaid benefit, which is also a national model for improved access. The system is remarkably easy to understand, and the state's decision to combine its Medicaid division with the service delivery components may continue to reduce fragmentation, in one of the already least fragmented states.
The system is so easy to follow that the state can convey at a high level basic information to consumers and family members who call or use the internet. The state got a perfect curved score (top 20 percent of states) on our consumer family test drive, easily outpacing most other neighboring New England states. Rhode Island is doing something well in terms of streamlining its system and the way the state can explain it to the average person. Rhode Island is taking advantage of its history and manageable size to advance the field.
Money problems are never far from ruining the perfect day at the famed beaches here, however. The state 2004 block grant notes the following:
- "…The state budget is still under severe constraint and the public mental health operating system is still under acute pressure."
- "The system is still confronted with extremely high demand, driven in part by the almost complete unraveling of the private psychiatric healthcare system; many mental health providers will simply not accept private insurance, arguing that it costs more than they are reimbursed."
- The federal block grant cut of 6.8 percent was "the largest in the nation (Washington State was second at 3.4 percent)."
The state has some noteworthy structural advantages - it is physically tiny and has a little over a million inhabitants, with minimal rural population. Size may help, but Rhode Island has much better evidence-based practices (EBPs) penetration than small New Hampshire, where the EBPs were developed, at Dartmouth. Rhode Island has reasonably good supported employment as well as ACT.
States need to look at their problems, gather information, and create responses. Rhode Island noted that much of the bed pressure they feel (and it is substantial) was driven by an uninsured population of young people with mental illness and substance abuse disorders. By figuring out who they were treating, the mental health providers were able to develop a program that reduced admissions in this population by devoting targeted outpatient resources to them. This is crucial, as Rhode Island runs without a free-standing state hospital - they are down to 104 continuing care beds.
A major concern in the state is the near-abandonment of the private sector, which naturally increases public demands. Reimbursement rates are low for practitioners taking insurance, so they are refusing to take it. This makes private mental healthcare increasingly a concern for the relatively well-off, and makes the concept of insurance parity a mockery. Cardiologists take insurance in Rhode Island. The link between depression and the heart fascinates researchers but does not move insurance panels here.
Recently, the Chief of Psychiatry at Eleanor Slater Hospital resigned in protest of the inappropriate placement of a sex offender who had completed his prison sentence. This raises serious questions about how the state is choosing to use its scarce mental health resources.
Mostly due to recent Hispanic immigration, Providence was recently named New England's second-largest city. Despite this growth, the cultural responsiveness and budget numbers to support programs for Hispanics in Rhode Island have not fared well in the past few years.
Federal cuts, state money woes, and providers opting out of the insurance market make for a complex blend of concerns here. Additional challenges for the Ocean state include the longest-running acting commissioner, at 18 months, and the complex dynamic of the large number of uninsured Rhode Islanders. The now-open pharmacy formulary must be preserved or - the state is at risk of losing its good score for access to the best medications.
In addition to the disappearing workforce on the private side, hospital beds and alternatives to hospitals are a problem in a state that has decided to lean so heavily on the private sector. This is a real test of leadership. Rhode Island's history suggests it will deliver and will openly show how they did it. Advocates will be watching.
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