Tuesday, February 10, 2009

Hogan's Heroes

NYS Commissioner Michael Hogan initials his transformation of the mental health system

This is about our local Niskayuna product, the present NY State Commissioner of Mental Health Michael Hogan, PhD, who came to the job two years ago flying in on his coat tails as director of mental health in Ohio (henceforth considered progressive) and as chair of the prestigious President's New Freedom Commission on Mental Health in 2002-03.

Let's see how the commish is doing these days now that he's put his transformation spin on the NY mental health system to the joint legislative committees in Albany. It comes at a bad time--just when the state's economy has accelerated its nosedive.

Former NY State Governor Eliot Spitzer paid a big bill for this star player just as George Steinbrenner was handing out money to the top Yankee prospects that winter and spring. Hogan was quickly confirmed by the Legislature in March 2007.

Hogan soon made an impact in the crusty Office of Mental Health in Albany. As some of us remember, he brought fresh views about mental health—he was open to change, smart, a listener, a doer. He started to appear around the state at regional forums to gauge what his constituents wanted —mental health consumers and their parents, professionals and business people whom he was calling “stakeholders” and some of whom we called “the grassroots.”

He endeared himself to us when we learned he had a family member with mental illness himself, and he grew up in Alplaus and went to Niskayuna High School. From there he went to Cornell and Brockport State U and then Syracuse U for his doctorate. While he served as Connecticut and Ohio commissioner he won distinguished awards from NAMI and the state Governor's Association, he authored untold papers and articles and finally came to his appointment as head of the New Freedom Commission in Washington.

He's a modern Renaissance man, you might say, capable of seeing the big picture in a world of high technology and master planning, while showing that empathy so important in dealing with something as fleshy and uncompromising as mental illness

The commissioner really believes that recovery from severe mental illnesses like schizophrenia and bipolar disorder is possible, that lives can be restored. Rehabilitation is the key and people can get well faster through combinations of short term intensive treatment and self-help and peer-led supports after a relapse. He's still for doctors and medicine but he'd shift the focus of care over to the patients and more choice of treatment if he could.

From the First Plan Onward

When he arrived in Albany in January 2007, Hogan brought with him a comprehensive state mental health plan he developed for Ohio. One wouldn't have to look far to find the similarities between it and the updated NY State plans issued since his takeover. Hogan is a progressive decentralist who wants to make mental health services local, close to home, more productive and less expensive and he's now going front with these views.

His ideas are revealed most recently in his testimony to the joint legislative committees in Albany last month. Here are what you might call “Hogan's Heroes” in the recent go-around with the legislative members, an exposition of what's needed to transform the system of mental health care in New York State into something much better:

He speaks of “good care,” exemplified by what enables people to “live, learn, work and participate fully in one's community.” To do this he would change the funding streams to include more than “medically necessary” services, include job services under Medicaid and self help and peer support under insurance; and broaden the safety net of services for both the seriously and less seriously ill.

He'd expand Medicaid coverage to include a home and community waiver so adults with mental illness can get services in the home that keeps them out of a hospital. He'd put supportive and rehabilitative services under Medicaid and make Medicaid rules more consonant with the other programs.

He wants to reform mental health care by restructuring mental health clinics. He'd remove regulatory barriers to clinic expansion and change the “COPS” supplemental rate (once an incentive to get clinics to enrich services).. Workers there have long griped about poor pay and it's led to high job turnover. While his proposal is to increase clinic rates it would be offset by less funding for continuing treatment programs, not Hogan favorites.

He'd go from there to a future reimbursement policy that “requires health payers to pay for discreet services, rather than the current OMH approach that involves the same payment approach for a doctor's visit as one to a therapist, and the same payment for a complex evaluation session as for a routine visit.” This is called Ambulatory Patient Groups or APGs and it's the new wave although it sounds like old fashioned common sense.

Hogan asks reform of psychiatric inpatient care, too. He told the legislators that “access to acute inpatient care is hard to achieve. Problems in finding housing while someone is awaiting discharge is a leading cause of long stays. Access problems mean that many psychiatric patients are stuck in crowded emergency rooms.” But he doesn't offer anything solid to tackle these issues.

Psychiatric emergency room care is especially costly and ineffective, he continued. “A few individuals overuse the ER and acute inpatient treatment because their ongoing treatment is not adequate.” He said he would look to alternative care to untangle this.

There are more items among “Hogan's heroes”, but we'll just cite two more examples. Hogan claims the state OMH hospitals, like CDPC, are becoming more productive, admitting more patients--and that may mean shorter stays, for better or worse. And the hospitals are finding useful ways for the campuses to supplement community services.

To halt the fragmentation of care in community mental health he said he'd work more closely with other agencies. “This problem is prominent for individuals who have multiple long term or chronic illnesses, including people with serious mental illness, he said. Their health has been compromised by their illness, smoking, obesity and poor lifestyle.

He also wants to expand housing through “joint development of mixed use housing” and would support converting some group homes to permanent supportive apartments, projects high on the agendas of non-profit housing providers.

Trouble ahead

But like the housing proposals, where's the money to pay for this? Projects planned to combine community residence-supported apartment models are frozen. Trouble is, these are tough times. When you change the existing order you create waves. People don't like to be laid off, others suffer when programs are cut, hospitals don't want to receive less money, nursing homes need money, too, and you can't throw the whole system out of balance by holding onto the state hospital system and knocking out basic community services like continuing treatment, in my opinion.

When we were promised 1,000 supported apartments and millions of dollars in new construction for congregate housing early last year it's a shame to find the building projects are on hold. There's no evidence of any new mental health housing in Schenectady. It's not the commissioner's fault but surely the housing is more important than talking about agency coordination and data collection, more studies and more monitoring.

Neither is it Hogan's fault that the state OMH hospital system, the biggest in the nation with 4,000 beds in 17 adult hospitals, plus six childrens' hospitals and three forensic facilities, monopolizes the state mental health budget. He can't close a single building—only the legislature can do this, and it simply crimps resources that might be used for community mental health.

And Medicaid is a bigger problem than even he lays out. Health Department runs Medicaid, which pays most of the bills for mental health and has unbelievably bad rules that don't fit the circumstances the consumers and workers find themselves in. The contracts don't allow for growth and change that are needed.

He also has to face growing disgruntlement about ineffective mental health programs, sometimes voiced in the legislature. No matter what is tried, the lawmakers say, there isn't a payoff, there isn't any sure way of curing someone's sickness or relieving his aberrant behavior or getting him back to work. With every part of state government expected to take a hit over the budget, the governor and the legislature are ready to slash the roughly $3.5 billion state mental health budget, too.

While we wish the commissioner well, it looks like his “heroes” are in trouble. (Roy Neville)

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