Public Policy Forum Blog

Milwaukee County outpatient capacity challenges linked both to supply and coordination

As Milwaukee County has accelerated its efforts to downsize its Mental Health Complex and move to a community-based system of care, there has been considerable debate about whether savings produced from bed closures have been sufficiently re-directed into the community, and whether the County ultimately can and should get out of the inpatient business entirely.  In fact, the Forum analyzed both of those issues in analyses on inpatient capacity analysis released last September and the fiscal impacts of the mental health redesign process this past March.

But is creation of a robust community-based service model dependent entirely on resources, or are there other critical factors at play? And who should lead the effort to ensure that those seeking clinical behavioral health services in the community have access to the services they need?    

The Forum tackles those questions in a report released this morning.  This is the third report issued jointly by the Forum and two nationally-recognized behavioral health research organizations – the Human Services Research Institute and the Technical Assistance Collaborative.  We also teamed up on a comprehensive mental health redesign report released in October 2010 and the inpatient bed capacity analysis referenced above.  

Our research finds that Milwaukee County is challenged by issues of fragmentation among outpatient providers, lack of communication between providers and hospital discharge specialists, a shortage of psychiatrists, and insufficient Medicaid reimbursement rates that are negatively impacting provider supply.

In fact, in trying to determine whether the overall unmet need would best be reduced by a simple increase in the supply of providers – or by alleviating inefficiencies and barriers to access among the array of providers currently in place – we conclude that both are significant factors and both need to be addressed.

For example, a notable feature of Milwaukee County's outpatient "system" is the large number of providers that serve very small numbers of consumers, and the handful of large organizations that serve a preponderance of low-income individuals.  On the one hand, this poses a challenge to integration and continuity of care.  On the positive side, however, these low-volume providers may represent untapped potential for capacity expansion, particularly if stakeholders could get a better handle on identifying and communicating where there may be excess capacity.

Another key finding is that despite a huge increase in Medicaid enrollment in 2014 caused by the State's implementation of the Affordable Care Act, utilization of behavioral health outpatient services by Medicaid recipients remained about the same.  This phenomenon may result from the low reimbursement rates for Medicaid relative to other payment sources, which create a disincentive for providers to  accept more Medicaid clients.  Another possibility is that providers’ ability to expand capacity is constrained by workforce shortages, as widely reported by stakeholders.

The report issues a series of recommendations to address both system fragmentation and provider shortages, including the following:

  • Having the County's Behavioral Health Division (BHD) – which plans to outsource its remaining inpatient and emergency care – expand its role in coordinating outpatient services by identifying capacity among existing outpatient providers, communicating available capacity to discharge specialists from area hospitals, and coordinating increased use of health information technology.
  • Formalizing and enhancing the role of Federally Qualified Health Centers in integrating behavioral health care with comprehensive patient-centered medical homes for low-income individuals.
  • Expanding use of telepsychiatry – which has been found to be effective in treating individuals with a variety of mental health conditions – to increase access to psychiatric care.
  • Increasing Medicaid rates for behavioral health outpatient services and engaging Medicaid managed care organizations in addressing gaps in outpatient care.
  • Addressing the fragmentation and discontinuity of behavioral health services by establishing comprehensive and well‑integrated data systems that will provide for overall monitoring of system performance and identification of opportunities for improvement. 

The report concludes that BHD, on the basis of its defined mission and statutory authority, may be in the best position to define the vision and the goals for this effort and to lead the monitoring of its progress.  However, success ultimately will be determined not only by how well BHD performs in this role, but also by how well the State, private health systems, and the diverse array of other stakeholders in the community work with BHD and together.

The full report can be accessed here and our media release here.

Rob Henken