Mind and Body

Changing the dynamics around public safety, mental health

New city initiative to expand behavioral health response capabilities at Providence Fire Department, during a time of increased demand for mental health interventions

Photo by Richard Asinof

Mayor Jorge Elorza signs a proclamation in honor of Mental Health Awareness Month at the fire station on Branch Avenue, in a ceremony following the announcement of a new public safety initiative to embed behavioral health clinicians from The Providence Center at 9-1-1 offices and as part of a mobile response team.

By Richard Asinof
Posted 5/23/22
The long-term failure by the state to increase low reimbursement rates for Medicaid providers appears to have reached a tipping point, threatening to upend the status quo around budget investments.
Will the R.I. General Assembly be willing to increase Medicaid rates in this year’s budget deliberations, moving against Gov. Dan McKee in an election year? How will the rise in COVID cases as well as the rise in “Long COVID” cases influence voters about how they choose candidates? How will the deliberations and allocations approved by the Opioid Settlement Advisory Council play out in regard to accountability of how the more than $100 million in legal settlement fees is spent? Will there be further investigations into the role that Optum is playing in managing behavior health care claims two of the state’s Managed Care Organizations?
The R.I. Office of the Health Insurance Commissioner completed its latest market conduct examinations, reviewing the performance of four major commercial health insurers operating in the state and their compliance with state law and regulation related to network adequacy and provider directories.
As a result, each of the four commercial health insurers was ordered to make financial investments in support of either perinatal or doula workforce communities. Blue Cross and Blue Shield of RI is “investing” $100,000, Neighborhood Health Plan of RI is “investing” $75,000, Tufts Health Plan is “investing” $100,000, and UnitedHealthcare is “investing” $275,000 – a total of $550,000 in such contributions.
“Market conduct examinations like thse play a significant role in OHIC’s ongoing efforts to protect consumers by holding insurers accountable,” said R.I. Health Insurance Commissioner Patrick Tigue.

PROVIDENCE – May is “Mental Health Awareness Month, and there was more than a wee bit of irony in how Gov. Dan McKee and his team put together a plan to celebrate a Mental Health Action Day with a Facebook Live convo on Friday morning, May 20.

The “Action Day” featured a bevy of key elected and appointed officials – including the interim director of R.I. EOHHS Ana Novais, the R.I. Commissioner of Education Angélica Infante-Green, and the director of R.I. BHDDH Richard Charest.

However, the Governor’s “Action Day” event left one community agency executive “just shaking my head” in anger and disbelief, who shared a flyer about the Governor’s “Action Day” in an email to ConvergenceRI.

The agency executive expressed bewilderment about how such a “public display of affection on social media” promoting “awareness” about mental health in Rhode Island could be promoted, given all the gaping holes in the safety net for vulnerable Rhode Island residents when it came to mental health, many of which were occurring on Gov. McKee’s watch.

Actions, not words
A week earlier, a different kind of ceremony in celebration of “Mental Health Awareness Month” took place, on Wednesday afternoon, May 11, when Providence Mayor Jorge Elorza signed a declaration at the Providence Fire Station on Branch Avenue, announcing that the city was partnering with The Providence Center, a division of Care New England, to implement the city’s behavioral health crisis response program by embedding two clinicians, one as part of a Providence Fire Department mobile response team, the other as part of the 9-1-1 response team.

“The city is committed to providing better services for people experiencing a mental health behavioral crisis, and this rings especially true as we recognize Mental Health Awareness Month,” Mayor Elorza said in a news release.

In a brief question-and-answer session following the proclamation signing, Mayor Elorza said that this new direction in public safety was prompted by an operations audit. It revealed that “the city did not have enough resources or training to deal with the behavioral health issues that were coming in,” according to Mayor Elorza.

The director of the city’s Health Communities Office, Laurie Moise Sears, promised that her office would gladly share the results and metrics of the new program, but suggested that reporters check back in with her in three months, when she felt that there would be numbers to share. She also pointed out that the program had retained a data manager specifically for the purpose of analyzing data.

[Editor''s Note: With the murder of 10 African-Americans in Buffalo, N.Y., in which the gunman specifically targeted his victims by race, invoking the "replacement theory" hyped by commentators such as Tucker Carlson on Fox News, there has been an increase in conversations around gun violence and its connection to behavioral health issues. Dr. Megan Ranney, an outspoken advocate for better gun control laws, sought to clarify the narrative that she said confused 'people with mental illness' versus 'people who hate.' "People with #mentalillness are at risk.. but primarily of killing themselves," Ranney tweeted. "People who HATE are more likely to kill others. Easy access to a firearm by people who hate is what allows horrible things to happen."]

Meanwhile, back at the ranch…
The behavioral health and mental health care system in Rhode Island appears to be lurching from crisis intervention to crisis intervention.

Two days before the Governor's  “Action Day,” Hasbro Children’s Hospital, a division of Lifespan, announced that it had reached a peak level of overcrowding in its emergency room, including many young patients awaiting access to inpatient beds for treatment mental health conditions – because there were simply no places for them to go.

The trauma of overcrowded ERs spilled over into the news headlines. News reporters from major media outlets – including the Boston Globe, the Providence Journal, and WPRI – interviewed doctors and experts, who in turn gave their dutiful explanations about the causes why this trauma was occurring, pointing to the usual suspects: there were “ongoing staffing shortages plaguing hospitals,” and there were the pressures of “increased isolation, increased pressures” stemming from COVID-19.

The overcrowded ERs, with kids being warehoused, should have surprised no one. A month earlier, on April 19, a coalition of pediatricians and psychiatrists had declared that a state of emergency existed in Rhode Island for child and adolescent mental health.

• “This worsening crisis in child and adolescent mental health is inextricably tied to stress brought on by COVID-19 and the ongoing struggle for racial justice and represents an acceleration of trends observed prior to 2020,” the declaration read, as reported by WPRI.

In an interview last week with ConvergenceRI to mark the release of the 2022 Rhode Island KIDS COUNT Factbook, Elizabeth Burke Bryant, the executive director of Rhode Island KIDS COUNT, had talked at length about the growing increase in the numbers of children with mental health issues in Rhode Island.

“I think that there has been a real increase in children with mental health issues,” Burke Bryant said. “It was a system that wasn’t what it needed to be before the pandemic.”

Burke Bryant continued: “And the pandemic has really exacerbated the number of children and youth with behavioral health issues. We know that there was a doubling of the calls to Kids’ Link RI hotline in the past two years. That is a huge jump, from a little over 4,000 to a little over 9,000 calls per year, and that is the latest data that we have in terms of being able to really compare, between March of 2020 and March 2022.”

The increase in demand for mental health and behavioral services, Burke Bryant said, was a data fact being highlighted in this year’s Factbook, “Because mental health is such an important [focus] for our children and their families. There is a need for a seamless, comprehensive mental health/behavioral health system of care for children and youth. We need to really work urgently to be sure that the mental health needs of our children and youth are met.”

Further, Burke Bryant argued, “We also need to a focus on prevention and early intervention of mental health issues, so that they can get the treatments that they need in their home and community before it escalates to be an emergency requiring hospitalization.”

Youth wants to know
Beyond identifying the symptoms and documenting the long waits in emergency rooms, the bigger question is: Why was this shortfall in services occurring? The answer, it turns out, was no big secret, but, for some reason, it keeps getting conveniently left out of the news coverage and the political reporting.

The cause of the escalating crisis in mental health and behavioral health services is the long-term failure by the state of Rhode Island – by the past two Governors, by the R.I. General Assembly, and by the R.I. Medicaid office – to raise the low reimbursement rates for Medicaid providers, many of which have not been increased in more than a decade or longer.

The health care workforce crisis, the breakdown of community-based services for behavioral and mental health conditions in the face of escalating demand, and the dysfunction of hospital emergency rooms being turning into warehouses for mental health and behavioral health patients can all be directly linked to the failure to increase Medicaid reimbursement rates.

[Editor’s Note: For months, ConvergenceRI has been reporting on the Medicaid reimbursement rate problems. See link below to ConvergenceRI story, “Waist deep in the Big Muddy.”]

And, for months, community advocates, testifying at numerous State House hearings, have provided heartfelt testimony, pinpointing the problem as low Medicaid rates. The question is: Why has it been so hard to translate such concerns into action?

At the State House last week, a bipartisan coalition of advocates looking to change that equation testified in favor of new legislation, S 2311, to enable the R.I. General Assembly to establish rate-setting for Medicaid. Every Senator, in a remarkable display of unity, has co-sponsored the legislation. The legislation would take effect in the FY 2024 budget, leaving what will happen in the current FY2023 budget “hazy” at best.

[Editor’s Note: What seemed to escape media attention, for the most part, was the testimony presented by R.I. EOHHS opposing the rate-setting legislation during finance committee hearings. The agency had put forth the argument that such rate-setting by the R.I. General Assembly would prove to be an unworkable task, because of all the different potential billing codes involved, which the agency claimed amounted to more than 7,000 such codes – a whopper of a red herring of inaccurate information.]

The kids are not alright
Meanwhile, with the state apparently awash in budget surpluses, legislative leaders and the Governor keep hinting at the potential to create tax rebates as one way to share the largesse of state and federal funds during this budget season of abundance.

As WPRI’s Ted Nesi reported in his “Nesi’s Notes” from May 21, “[Gov.] McKee is expected to try and address those [economic] concerns soon when he announces a plan to use part of the state’s huge $878 million surplus to lower taxes. [True, an economist would say cutting taxes is only going to fuel inflation further – but that doesn’t mean it won’t popular with voters.] Speaker Shekarchi has called a closed caucus of House Democrats for Wednesday [May 25] to discuss the budget.”

Translated, money talks, and Medicaid recipients walk – at least when it comes to making state budget investments.

Rep. Teresa Tanzi, in a tweet put out on Friday, May 20, provided an insightful look into how the state budget numbers may have been misrepresented by the state’s legislative leaders.

She tweeted: “It means we used significant amounts of federal $$ to supplant general fund $$ and massively underinvested in key programs like mental health services & paying providers who rely upon state rate setting. We’re pretty notorious for both of these things.”

Rep. Tanzi then referenced a settlement reached last week involving the Rhode Island Parent Information Network and the Community Provider Network of Rhode Island, the U.S. Department of Justice, and R.I. EOHHS, over the failure by the state to meet its obligations to provide services and support for thousands of children with disabilities.

The settlement, which occurred far under the radar screen of most Rhode Island news media, addressed the state budget failures to invest in services for disabled children.

The two agencies, in a joint news release about the settlement, said: “The state has a nearly $900 million surplus and over $1 billion in federal aid to tackle this problem. Now is the time to make long-needed investments that will allow providers to recruit and retain high-quality staff to meet our children’s needs.”

Rep. Tanzi tweeted: “RI was just forced by a court decree to increase our pay to ID/DD providers and actually account for their needs in our annual caseload estimating conference. We literally never accounted for their needs when building our budget and still wouldn’t be had we not been sued.”

Further, Rep. Tanzi continued: “RI still imposes crushing caseloads on DCYF staff. Their workload is still not concretely considered in our caseload estimating conference & therefore not in our state budget. No wonder we cannot fill these positions, we fail the workers & the children we are tasked with serving.”

Peeling back the veneer
As the number of cases of COVID continues to rise in Rhode Island, so, too, does the protective veneer around Gov. McKee and his policies appears to be unraveling, with overt criticism from former state workers directed at Gov. McKee.

In a series of tweets last week, Julian Drix, a former employee at the R.I. Department of Health, publicly criticized Gov. McKee. “Rhode Islanders should know that @GovDanMcKee is incompetent. #WaitAndSeeMcKee is sleepwalking yet another COVID surge, having learned nothing from his past mistakes.”

Drix continued his criticisms of Gov. McKee, saying that the Governor “treats health department staff like extensions of his campaign. He’d have community vaccination events set up as self-promotions. He’d pass out home test kits like candy at municipal events with his Trump Democrat Mayor friends Polisena and Lombardi.”

In an interview with Amanda Milkovits of The Boston Globe, Drix, who had served as the acting co-director of the Health Equity Institute at the R.I. Department of Health, elaborated on his criticisms of Gov. McKee. Such criticism, Drix told Milkovits, were widely held, “not just [at the R.I. Department of Health], but across the government and community organizations. …It’s the worse-kept secret in the state, but so few [will] say it publicly.”

In particular, when it came to the COVID response, Drix claimed that the Governor was largely uninvolved. When Gov. McKee did become involved, according to Drix, “He’d undercut and critique, he is slashing budgets, he doesn’t want to hear about it and is really difficult to engage with.”

Nursing homes raise alarm
The long-term failure by the state to increase Medicaid reimbursements is also predicted to take its toll on the future of skilled nursing facilities in Rhode Island.

The Rhode Island Health Care Association [RIHCA] issued a news release last week citing a national report, which said: “87 percent of the state’s nursing homes were at financial risk of closure. John Gage, president of RIHCA, blamed the situation on “the chronic underfunding by R.I. Medicaid of a quarter of a billion dollars over the past decade,” and an historic workforce shortage, with a loss of more than 21 percent of nursing home workers in the last two years.

The report predicted that by 2027, there would not be a enough nursing home beds in Rhode Island to serve those in need.

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