Mental Health Care Choice: The community feedback period for this idea began on 1/17/2019 and ended on 3/18/2019. *STATUS UPDATE*

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Keeping your doctor / keeping your care team. Mental health consumers in the County Behavioral Health system must comply with the Short-Doyle Act from 1957. Over the past 62 years, healthcare has changed quite significantly. In current time, compliance with Short-Doyle means avoiding employment that provides health insurance, avoiding employment that makes $48,000 or more annually, and feeling like a worthless drag on society with restricted freedom. Based upon these requirements, the financial consequences include the necessity to obtain food stamps, SSI/SSDI, Housing Assistance, Transportation Assistance, etc. Freedom doesn’t need to be restricted in this way.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
It is assumed that Orange County and its residents prefer having more freedoms over having less freedoms. It is assumed that Orange County and its residents want to see people experiencing mental illness perform to the best of their ability, unrestricted by public policy that forces unnecessary choices to underperform.

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
It is assumed that Orange County is compliant with Short-Doyle. To the best of my knowledge, OC doesn’t publish vital development statistics for people experiencing mental illness. Therefore it is difficult to measure how Short-Doyle, in present form, may be restricting economic activity. As for the rest of the United States, the Federalist system provides choice over 104+ medical jurisdictions that each have their own policies and procedures. Summarizing 104+ medical jurisdictions is beyond the scope of this form.

 What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Asking for more freedom in a mental health setting isn’t innovative. Typically this is done through a lawsuit such as Souder v Brennan. Giving consumers the ability to ask for policy change in a pro-active/constructive manner is innovative. Allowing consumers to tailor their mental health system in ways that encourage economic development/achievement is innovative.

What is the project idea? Please describe how this project will operate.
The project idea is to provide consumers who want to keep their care team with waivers from Short-Doyle requirements on a case by case basis. The additional upside of this is that Orange County can collect data with an intend to treat analysis. Consumers “lost to follow up” would possibly be reduced. This can encourage Orange County to share its mental health outcomes in publications, journals and abstracts.

Additional Information:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1577700/

https://www.dhcs.ca.gov/services/mh/Pages/MH-Medi-CalMentalHealthPolicy(MCMHP)Background.aspx

 

 

January 3, 2019

3 comments

Thank you for your submission.

This idea seems to be a system wide change that is primarily outside of the scope of Innovation projects since the requirements are set by the state. Any changes could take much longer than the 5 years allowed by Innovation funding. Given this limited time frame, what would be the learning objectives for this effort and how would the success of this effort be measured?

The social contract between people experiencing mental illness and the rest of society, including government, hasn’t been well articulated. The vital development statistics for decision making are missing. Proposals for waivers from regulation are the natural response in such a risky and unknown environment.

In urban California, the annual income required to afford market based housing is approximately $62,000 (https://www.nbclosangeles.com/news/local/Over-30-Dollars-a-Hour-is-Needed-to-Afford-Decent-Rent-in-California-485861801.html https://www.ocregister.com/2016/10/21/salary-needed-to-rent-a-studio-apartment-in-orange-county-is-much-higher-than-you-think-report-says/ ). Such an income disqualifies an individual from Short-Doyle, assuming the individual wants to have health insurance coverage/access for non-psychiatric medical care. It is estimated that 200,000 people live with serious mental illness in Orange County. There are not 200,000 units of low-income housing for people with mental illness in Orange County. Thus an economic incentive exists to increase income, placing mental health coverage/access at risk.

The Orange County Behavioral Health system is the closest entity to a Patient Centered Medical Home (https://pcmh.ahrq.gov/page/defining-pcmh) for someone experiencing severe mental illness in Orange County. The organizational skill and monetary cost required to maintain equivalent services in the market based behavioral health system is expected to be quite high. Which is better – living independently with shelter or having mental healthcare?

The success rate of transitioning from Short-Doyle/SNAP/Medicaid to market based economic activity isn’t published or isn’t easily found. The mean length of time one stays in market based economic activity after transitioning off Short-Doyle/SNAP/Medicaid is also not published or not easily found. The hard outcomes (i.e. morbidity/mortality or relocation) after moving into market based economic activity after being on Short-Doyle isn’t published or isn’t easily found.

Transitioning from low income to $62,000+ annually is risky and the likelihood of relapse is unknown or not easily found. Having the freedom to keep Short-Doyle coverage/access while taking on this personal risk provides a sense of security and reduces the number of major life changes (i.e. change in housing, change in job, change in health plan, change in doctor) involved in this transition. The number of people that would take advantage of a waiver is expected to be quite low, but is an unknown.

Case by case waivers are not a system wide change, but instead a way to study the economic impact and behavioral health outcomes of Short-Doyle in its present form. The anticipated implementation of this project would be to fund Short-Doyle services from a different monetary account to keep the system as-is. For Orange County, a consumer granted a waiver would see no difference in experience – keeping their doctor and care team – but the back end funding would come out of a different funding source. Think of it as adding an additional funding source that duplicates Short-Doyle services, but is not restricted by income/insurance criteria like Short-Doyle. This choice would only be open to consumers who are on Short-Doyle at the start of the innovation project, consumers previously dropped from Short-Doyle because of violating income/insurance requirements or consumers who are newly diagnosed with mental illness and enter the Short-Doyle system during the course of the innovation project. It is acknowledged that those who are newly diagnosed will have a short window of opportunity to take advantage of a project such as this and the timing of their first diagnosis greatly impacts their ability to participate in the project.

To summarize learning objectives:
1) What percentage of consumers could obtain greater income, but don’t because of Short-Doyle / Medi-Cal requirements?
2) What is the mean time a person granted a waiver can keep greater income?
3) What is the hard outcome of a person that takes the risk of obtaining a greater income (i.e. morbidity, mortality, relocation)? Alternatively, what is the outcome at 3-5 years?
4) What trends in income/employment are observed in consumers granted waivers and how is this related to mental health outcomes?

The County Of Orange can hire outside contractors to come up with a more comprehensive list of learning objectives from such a project.

Achieving success is measured by the ability to publish the learning objectives in a peer-reviewed academic journal or share the information with an equivalent standard of rigor.

This project can achieve the goals of:
1) Introduce a mental health practice or approach that is new to the overall mental health system, including, but not limited to, prevention and early intervention
2) Make a change to an existing practice in the field of mental health, including, but not limited to, application to a different population;
3) Possibly increasing the quality of services, including possible better outcomes
4) Promote inter-agency/public-private collaboration
5) Increase access to services

Innovations Team

Thank you for your idea submission. Upon review and discussion, it was determined that this idea is outside of the scope of an Innovation Project. The Innovation team is unable to continue exploring this idea under the MHSA Innovation component as proposed.

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