Tuesday, April 15, 2008

Interesting Conversation Today

I had a conversation today with people involved in mental health services in Boise County--such as those services are. What they told me seems inconceivable--unless the objective of Idaho's Department of Health & Welfare Department is to demonstrate the truth of the statement, "Never underestimate the power of stupid people in large groups."

I was told that the rules that Health & Welfare has for Medicaid reimbursement (since states actually administer the Medicaid program) require that mental health counseling must be done in a permanent facility, with at least two counselors, supervised by at least one psychiatrist, also in that facility.

I can somewhat see the point of having a psychiatrist providing supervision for mental health counselors. These rules might make sense in a county of several hundred thousand people. In a county with 7200 people, spread over several hundred square miles, this effectively prohibits Medicaid providing any mental health services in our county--and most others. The density just isn't high enough.

So what happens to patients who are having mental health problems and who are covered by Medicaid (people with very low incomes)? I suspect that they don't get services until they reach the point where they end up hospitalized in Boise. By that point, what was mild depression might have escalated to a suicide attempt--and schizophrenia or bipolar disorder has escalated from something just starting, to something full blown. Before the people I was talking to reached that point, I was suggesting what they want--someone "riding circuit" from town to town on a regular basis. It wouldn't conform to H&W's rules, but it would allow serious problems to be identified before they reach a crisis point.

I'm guessing that there is some legitimate motivation for these rules, and someone either is too stupid to see that they don't make sense in rural Idaho, or too inflexible to work around it. Even if the goal was to save money by preventing poor people in rural Idaho from getting mental health care (and that would mean that there are monsters at work in our state government), I am very skeptical that this even saves any money. A couple weeks in a mental hospital in Boise is going to run well above $10,000. You can pay for a lot of hours of a psychiatrist, psychologist, or counselor for that kind of money--and perhaps short-circuit at least some of those hospitalizations. The money might be coming out of a different budget--but the taxpayers still end up paying it.

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