PROVIDENCE – A year ago this week, ConvergenceRI published a detailed analysis of the four reports under the rubric of the Truven Health Analytics study on behavioral and mental health in Rhode Island. The reports had been submitted to the state on Sept. 15, 2015.

Taken as a whole, the Truven studies provided the kind of evidence-based analysis in the cost, supply, demand and infrastructure of the state’s behavioral and mental heath systems of care, replacing a plethora of anecdotal stories that had tended to drive policy in the past.

The reporting in ConvergenceRI had examined the findings from the Truven reports in a comprehensive fashion. [See link below to ConvergenceRI story, “Looking for a sanity clause in Rhode Island.”]

Some things have changed on the landscape, but, for the most part, much has remained the same: there are new revelations about the way Big Pharma marketed prescription pain meds such as OxyContin; there is new federal legislation, the Comprehensive Addiction and Recovery Act, but no money invested by Congress to support its programs; despite the best of intentions and policy interventions, the epidemic of overdose deaths keeps spiraling higher, driven by fentanyl, both here in Rhode Island and across the U.S.; and the tragedies involved in mental health continue to take a high personal toll, such as when a 28-year-old man involved with the mental health recovery community, according to his obituary, committed suicide last week by throwing himself off the roof of the Providence Place Mall.

What are the odds that the moderator in the first Presidential debate in 2016 will pose a question about behavioral health and mental health in America?

It is worth revisiting what ConvergenceRI reported a year ago, invoking the wisdom of Billie Holiday – Them that’s got shall have, them that’s not shall lose. So the Bible says, and it still is news…

MUCH OF WHAT the studies found did not paint a pretty picture; the studies did, however, attempt to frame the issues with recommendations on how Rhode Island might move forward. These included discussion about moving toward population health and a coordinated, continuum approach to care. But, for whatever reasons, health equity and health disparities, and potential solutions to address social determinants of health did not emerge as prominent elements in the strategy.

The need to refocus and redirect resources to prevention and early intervention, instead of reaction and treatment, was also identified. The studies also spoke about the “glue” needed to bring together a comprehensive, coordinated approach. However, they did not address the apparent elephant in the room: the consolidation of behavioral health services within the larger framework of competing hospital systems, and how that has affected the interoperability of services and, in turn, undercut outlying community mental health services.

ConvergenceRI continued: Four fact-based, evidence-based studies now exist that detail Rhode Island’s behavioral health conundrum. The unanswered question is this: whether there is the political will to invest the necessary resources to change the state’s trajectory. If nothing else, the state’s political leadership cannot now claim the onset of political dementia. It remains to be seen if they can cross the big river denial.

Further, ConvergenceRI then shared the details about cost findings: There’s much to chew on in what these studies found and quantified:

• In total costs, Rhode Island spends more on direct and indirect behavioral health than most other states, some $853 million on behavioral health treatment in 2013.

• At the same time, public financing for behavioral health care for adults and adolescents dropped by about 10 percent between 2007 and 2014, from $110 million to $97 million.

• State funding for substance abuse services dropped from about $15.5 million to $5 million between 2007 and 2014, despite the fact that Rhode Island adults die more frequently from narcotics overdose than adults in other New England states.

• The greatest cost drivers behind the reasons why Rhode Island spends more in total behavioral health care services are the costs of inpatient hospital care and prescription medications.

• In 2013, prescriptions accounted for 43 percent of the spending by Rhode Island providers for mental health treatment but just 13 percent for substance abuse treatment; at the same time, inpatient hospitals accounted for 18 percent of mental health treatment spending and 16 percent of substance abuse treatment.

• Adults in Rhode Island had the highest rate of psychiatric general hospital admissions among New England states and nationally.

• Medicaid was the single largest payer for behavioral health treatment in Rhode Island. In 2013, Medicaid financed $270 million in treatment spending, an amount equal to 33 percent of all mental health treatment and 19 percent of all treatment for substance use disorders. The Truven studies found that spending per enrollee was highest for adults between the ages of 25-64, with the vast majority being spent on mental health treatments.

• In 2013, the three largest private health insurers of Rhode Island residents (Blue Cross & Blue Shield of Rhode Island, United Healthcare, Tufts Health Plan) paid $150.7 million for behavioral health treatment – $130.3 million for mental health conditions, and $20.3 million for substance use disorders. This spending amounted to 17 percent of all mental health spending and 20 percent of all spending on substance use disorders. Of all treatment spending by Rhode Island’s private insurers, 9 percent was for mental health conditions and 1 percent for substance use disorders.

Similar to Medicaid, the vast majority of spending was for mental health treatment. The highest spending per enrollee was for adolescents aged 12-17.

• The estimated indirect costs of untreated mental illness from the R.I. Executive Office of Health and Human Services numbers and R.I. Department of Corrections numbers is calculated to be a total of about $276 million, which represents 12.8 percent of the total Department of Corrections budget and 3.15 percent of the total Rhode Island enacted budget for the year 2015.

As ConvergenceRI reported, the Truven studies attempted to document the causes behind the fact that Rhode Island was being overwhelmed by the high demand for behavioral and mental health services:

THE FIRST OF THE TRUVEN REPORTS found that Rhode Island faced a series of unique challenges [many of which have been documented by advocacy groups such as Rhode Island Kids Count when it comes to the health and well-being of children].

The study noted that a variety of factors – including biological attributes, individual competencies, family resources, school quality, and community-level characteristics – can increase or decrease the risk that a person will develop a mental or substance use disorder.

• Children in Rhode Island faced greater economic, social, and familial risks for the development of mental health and substance use disorders than children in other New England states and the nation.

• Unemployment among parents in Rhode Island is higher than in other New England states, more children live in single parent households, and one in five children in Rhode Island is poor.

“These socio-economic challenges help explain why children and adolescents in Rhode Island experienced higher rates of adverse childhood events and subsequent behavioral health conditions such as ADHD, major depression, and illicit drug use than children and adolescents in other New England states and nationally,” the study said.

Further, the study continued, such “higher risk factors are expressed in adulthood as higher prevalence rates of disease.” Adults in Rhode Island have higher rates of drug abuse and dependence and serious psychological distress than other New England states and the national averages.

ConvergenceRI’s reporting continued, detailing some of the studies’ other specific findings:

• Children and adolescents aged 5-17 years in Rhode Island had higher rates of attention deficit hyperactivity disorder, and adolescents had higher rates of illicit drug use and marijuana use than the national average.

• Adults aged 18–44 years in Rhode Island had more general hospital admissions for mental health issues than similarly aged adults in other New England states and nationally.

• Rates of drug and alcohol use in Rhode Island often were higher than the national average, and adult residents had higher age-adjusted death rates from narcotics and hallucinogens than the national average.

• Many adults in Rhode Island were more likely to report unmet need for treatment of mental and substance use disorders than residents in the other comparison states.

• Compared with national and other New England state rates, Rhode Island had the highest rate of hospital admissions for mental health issues among individuals aged 18–44 years.

Translated, Rhode Island has, in the current political vernacular, a huge, huge problem. Many of the problems begin in childhood but become full-blown by adulthood, tied to a lack of preventive services and an increase in adverse childhood events, correlated with conditions related to the fact that some 20 percent of Rhode Island’s children live in poverty.

What took so long?
Amazingly, a full year later after the Truven reports were made public, the study served as the starting point for the Rhode Island Business Group on Health annual health care summit, held on Sept. 23, under the heading: “Curbing the Costs of Behavioral Health.”

RIBGH, which functions as the trade group for the commercial insurance industry sector in Rhode Island, had attempted to frame the discussion largely within the parameters of its members own self-interest:

• What impact do behavioral health services have on employer’s health insurance premiums?

• What actions can businesses take or support to improve the value of behavioral health services in the state of Rhode Island?

Translated, the conference, despite its lineup of knowledgeable speakers and expert panelists, appeared to be geared toward finding an answer and developing a plan of action to address the high cost equation of care.

The first hour of the five-hour session began with an overview of what the Truven studies had contained. [Yes, as much as some of the speakers challenged the paradigm of the 50-minute hour as defining what gets reimbursed and what doesn’t in behavioral health care, the tendency at such gatherings is to have experts talk and talk and talk and talk at the audience as the best way to impart knowledge.]

Some of the expert panelists later admitted that they had never read the report because it was too long. [If you read the beginning of this story, you would have a better understanding of what was contained in the Truven reports than what was actually presented at the RIBGH conference by Corinna Roy, acting deputy director at the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.]

Dissembling the truth
One of the most telling moments came from a question from the audience, after Roy’s presentation, directed at Rebecca Boss, the acting director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, asking for the context of current substance abuse epidemic, given that much of the material in the Truven studies may now be dated, since it had been based upon data from 2013.

“We have plateaued,” Boss said, claiming that the interventions undertaken by the Raimondo administration had proven effective in halting the epidemic. At the table where ConvergenceRI was sitting, that statement was greeted with mutterings, a shaking of heads, including one person who said out loud: “Bullshit.”

The questioner from the audience persisted, asking Boss: when was that plateau reached?

“In 2015,” Boss replied. [More shaking of heads and disbelief at the table.]

No one stood up and contradicted Boss, challenging her statement, saying that she was simply not telling the truth, that the idea that Rhode Island had somehow reached a plateau in 2015 in its drug epidemic was a kind of magical, deluded thinking.

In fact, by the R.I. Department of Health’s own numbers, the number of overdose deaths so far in 2016 were increasing, a direct result of the increase of fentanyl in the illicit drug supply, with 150 confirmed deaths by the end of July, putting Rhode Island on the trajectory to reach 300 confirmed deaths in 2016, a 14 percent increase over the 258 confirmed deaths in 2015. [See link to ConvergenceRI story, “Fentanyl appears to be driving OD deaths toward record numbers in 2016,” below.]

ConvergenceRI wondered: How would a clinical social worker, psychologist or psychiatrist describe and diagnose that kind of dissembling of reality?

If there had been an advocate from the recovery community invited to participate as an “expert” on the panel, would Boss’s remarks have gone unchallenged?

Rebel music
A number of speakers did rebel, if that’s the right word, challenging the audience of business folks to change the emphasis away from cost equations and instead focus on access and prevention.

But, for the most part, each tended to describe the world as filtered through their own lens of their job and their biases.

Here is a brief synopsis:

Gary Sasse, the moderator of the panel, often talked about the problem through the filter of his self-declared Republican politics and his belief in the need to tweak the Affordable Care Act.

Al Charbonneau, the executive director of RIBGH, sought to keep the focus on developing an action plan, listing four to five items as the take-away at the end of the summit.

Kathryn Power, the Region 1 administrator of SAMHSA, provided an hour’s history lesson with passion, declaring her hope that the bifurcation of mind and body in health care might finally be over in the U.S.

Power asked the audience to recognize that the behavioral and mental health system of care was one of “our own making,” the manifestation of a long history of neglect, one that we needed to own.

She argued for a system of prevention, targeting pediatric youth as the primary target. She reordered what she thought the priorities should be: access, quality, innovation, and then cost.

[One reason, she said, why plans to develop a single-payer program had failed in Vermont was that its population of 450,000 was too small to make it work; taken together, the six New England states had population of 15 million, which might make a single-payer system workable. Not necessarily a popular topic for commercial health insurers attending, for sure.]

Judith Hoffman, executive director of Coastline EAP, spoke about the stigma as a major barrier, and she argued that investing in more frequency and better access to outpatient services gets you better outcomes as well as lowering costs.

Richard Leclerc, the president and CEO of Gateway Healthcare, who is about to retire, talked about how commercial insurers in the private sector were being subsidized by the public sector. Leclerc described the consequences of what happened when the state cut $2 million in funding for community mental health centers which, because of another $2 million in federal matching funds, resulted in a total of $4 million in cuts, making it difficult it not impossible to provide services to clients beyond those clinicians who were reimbursable. He decried the philosophy of some in government that “all cuts to human services are good.”

Dr. Lawrence Price, president of Butler Hospital, attempted to reframe the question of costs in terms of the return on investment in outcomes. He cited a WHO study on behavioral health that calculated $310 billion in savings in improved health and $399 billion in higher productivity. He also attempted to reframe the question about access as not being about having too few or too many hospital beds, but rather, on access to prevention services before a crisis occurred. Price also said that there was a need to invest in research, pointing to AIDS, and the important role that AIDS activists played in demanding those investments. Unfortunately, he continued, there was not yet a similar push by the community to push for better research into emotional disorders.

Dale Klatzker, president of The Providence Center, pointed out that access to clinicians was a major problem, driven in part by lower reimbursement rates in Rhode Island, compared to colleagues in Massachusetts. Klatzker also pointed to an innovative approach that The Providence Center had developed with Blue Cross & Blue Shield of Rhode Island that had managed to shave some $700 a month in health care costs. While he applauded the R.I. General Assembly’s efforts to endorse telemedicine, Klatzker wondered why the implementation had to wait until January of 2018. “We’re not talking about somebody else,” he said, urging that businesses acknowledge the need to deal with the whole person.

Rally for Recovery
In stark contrast to the RIBGH event, what a different scene it was at Roger Williams National Memorial on Saturday, Sept. 17, where a large, energetic crowd had gathered to celebrate at the annual Rally4Recovery.

The difference in the two events was emblematic of how the approaches to behavioral and mental health are much like two rivers that keep traveling closer and closer to each other but never quite seem to converge. The customer – the patient, the person in recovery, and the survivor – does not ever seem to be invited to join the discussion by policy experts. Why is that?

Yes, everyone stood up at the RIBGH when Dale Klatzker of The Providence Center, asked them to stand up if they knew someone who had experience a mental or behavioral health problem, either themselves, someone in their family, or a colleague at work.

And, yes, the issue of stigma was addressed at both events.

But, perhaps the most important difference were the number that was generated at the Rally4Recovery that calculated the total number of days for people now in recovery in Rhode Island.

The total as of Monday, Sept. 26, was 757,932 days, or 2,076 years, according to David Martins, the executive director of RI CARES. Yes, it was a number being self-reported, but it still represented a powerful visualization of how recovery works.

Another big point of differentiation: Narcan training and free Narcan kits were provided at the Rally4Recovery. imagine if all the participants at the RIBGH forum had been trained in Narcan use and been given a free Narcan kit?

What’s still missing from the conversation?
One of the missing pieces in the discussion around behavioral and mental health care in Rhode Island, similar to the way that the development of Neighborhood Health Stations in Central Falls and Scituate are challenging the assumptions of the health care delivery system, is an effort to develop a community-based approach to behavioral health and mental health care based upon what the community needs are – not just what the provider needs are.

Dr. Michael Fine, one of the proponents of Neighborhood Health Stations, has been one of the leaders in developing the strategy, known as the Central Falls Substance Use Disorder Treatment and Prevention Plan, proposed by the Central Falls Substance Use Disorder Task Force.

The collaborative strategy lays out in detail the scope of the problem, defined within the Central Falls community, an inventory of resources, and finding and recommendations for prevention, harm reduction options and treatment.

Among the recommendations included in the draft plan are:

• A citywide public relations efforts involving all schools, city agencies, emergency medical services, police officers, churches and social organizations aimed at discouraging substance abuse.

• Building a data dashboard that is updated monthly to report on the following occurrences in Central Falls: overdose deaths, medical marijuana authorizations, drug related arrests, and all incidents of drug/alcohol related suspensions or discipline in the schools. The plan seeks to request better data from the R.I. Department of Health about yearly and year-to-date drug overdose deaths, Narcan use in Central Falls, and overdoses in Central Falls.

• A robust community discussion convened by the Mayor and the City Council about the open hours, open days, and density of alcohol retail stores and on-premises outlets. The City Council should consider reducing hours and open days by city ordinance if surrounding communities adopt similar ordinances.

• The City Council should consider prohibiting legal marijuana sales in Central Falls by city ordinance.

• Narcan should be provided to all school nurses, teachers and any businesses where there has been an overdose in the past, as well as to all parks and recreation staff.

• Central Falls should work with partners to create a single place for needle exchange that is open extended hours. In addition, the city should consider working with partners to develop a one-stop recovery center, as a strategy for providing effective treatment on demand and harm reduction at the same time.

• The Central Falls Office on Health should begin contact tracing at all residences where there has been an overdose, using a team that includes a community health worker, EMS personnel, and a peer recovery coach from Anchor Recovery.

• The city should advocate for the development of a sobering center at Memorial Hospital and the potential to collaborate with The Providence Center to enable residents of Central Falls to use The Welcome Center at Emmanuel House.

• Once a sobering center is located or opened, the Central Falls police, in collaboration with Anchor Recovery, should develop protocols on how to move intoxicated persons to the sobering center.

• Central Falls should work with partners to develop treatment options, including for medication assisted treatment and inpatient alcohol treatment, and ensure that those services are provided in a linguistically diverse and culturally appropriate manner, so that Central Falls residents are treated in their own community and in their own language, as appropriate.

Taking a different tack
ConvergenceRI asked Fine to describe what he saw as the differences in the Central Falls approach.

“The strategy uses a number of approaches,” he told ConvergenceRI. “First, it attempts to prevent addiction by getting the whole community involved in getting people to think critically about their substance use and by educating everyone – kids, parents, police, teachers, business people and the religious community – about substance use disorder, so that everyone can become thoughtful about substance use, and so that everyone recognizes the disorder as a disease and can urge people with the disorder to get treatment.”

Second, Fine continued: “It takes a community approach to recovery and makes both treatment and recovery support a community process, so that we have both in Central Falls, hidden in plain sight.”

Finally, Fine explained: “We are taking a robust community approach to harm reduction, integrating needle exchange into the recovery process, so that people who are injecting drugs become part of the recovery community, so the can access recovery support when they are ready – and making sure there is widespread access to Narcan.”

Other approaches focus on treatment, Fine said, which is very important. “But, [in our strategy], we’ve made prevention, treatment, and harm reduction a community responsibility, so people struggling with addiction get the best support.”

Editor's Note: Because of the way that the R.I. Department of Health manages its overdose death database, only confirmed deaths are shown, which means that the actual numbers of deaths are often completed two, three and four months later. The most recent number of overdose deaths for January 2016 through June 2016 was 161, 11 more than the 150 figure released at the beginning of September.

That would potentially put Rhode Island on a trajectory to exceed the 2015 confirmed death toll of 258 by more than 20 percent. It punches a big hole in the claim by Rebecca Boss, the interim director of BHDDH, that the substance abuse epidemic in Rhode Island has reached a plateau.