Mental Health in California: For Too Many, Care Not There MARCH 2018 Mental Health Introduction Mental health disorders are among the most common health conditions faced by Californians: Nearly 1 in 6 California CONTENTS adults experience a mental illness of some kind, and 1 in 24 have a serious mental illness that makes it difficult to carry out major life activities. One in 13 children has an emotional disturbance that limits participation in daily activities. Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Federal and state laws mandating parity in coverage of mental and physical illness, together with expansion under the ACA of both Medi-Cal eligibility and scope of mental health services, have made more services available to more Prevalence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Californians. Public and private actors have devoted significant resources to expand access to care, better integrate physical and mental health care, and reduce stigma. Despite these efforts, the incidence of some mental illnesses Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 continues to rise, many Californians still fail to receive treatment for their mental health needs, and many have poor overall health outcomes. Suicide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Using the most recent data available, Mental Health in California: For Too Many, Care Not There provides an overview of Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 mental health in California: disease prevalence, suicide rates, supply and use of treatment providers, and mental health in the correctional system. The report also highlights available data on quality of care and mental health care spending. California’s Public System. . . . . . . . . . . . . . . . 27 KEY FINDINGS INCLUDE: Medi-Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 • The prevalence of serious mental illness varied by income, with much higher rates of mental illness at lower income levels for both children and adults. Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 • Compared to the US, California had a lower rate of suicide, although it varied considerably within the state by gender, age, race/ethnicity, and region. Care Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . 43 • About two-thirds of adults with a mental illness and two-thirds of adolescents with major depressive episodes did not get treatment. Quality of Care. . . . . . . . . . . . . . . . . . . . . . . . . . 45 • Medi-Cal pays for a significant portion of mental health treatment in California. The number of adults receiving Criminal Justice System. . . . . . . . . . . . . . . . . . 48 specialty mental health services through Medi-Cal has increased by nearly 50% from 2012 to 2015, coinciding with expansion of Medi-Cal eligibility. Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 • The supply of acute psychiatric beds may have stabilized after a long period of decline. However, emergency department visits resulting in an inpatient psychiatric admission increased by 30% between 2010 and 2015. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 More robust community services might decrease emergency department use. • The incidence of mental illnesses in California’s jails and prisons is very high. In 2015, 38% of female prison inmates and 23% of the male prison population received mental health treatment while incarcerated. CALIFORNIA HEALTH CARE FOUNDATION 2 Mental Health Mental Health and Mental Disorders Defined Overview Mental health disorders encompass Any mental illness (AMI) is a categorization for adults 18 and older who currently have, or at any many diagnoses, including depression, time in the past year had, a diagnosable mental, behavioral, or emotional disorder, regardless of the level of impairment in carrying out major life activities. This category includes people whose anxiety, schizophrenia, attention mental illness causes serious, moderate, or mild functional impairment. deficit hyperactivity disorder, and Serious mental illness (SMI) is a categorization for adults 18 and older who currently have, or at post-traumatic stress disorder. These any time during the past year have had, a diagnosable mental, behavioral, or emotional disorder resulting in functional impairment that interferes with or limits major life activities. diagnoses may affect a person’s Serious emotional disturbance (SED) is a categorization for children 17 and under who currently thinking, mood, or behavior. Some have, or at any time during the past year have had, a mental, behavioral, or emotional disorder disorders are acute and short-lived. resulting in functional impairment that substantially limits functioning in family, school, or community activities. Others are persistent and can lead A major depressive episode (MDE) is a period of at least two weeks when a child or adult has to difficulty with functioning and experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of specified depression symptoms. Approximately 64% of adults and 70% of children with MDE disability. Psychotherapies, behavioral have functional limitations that meet the criteria for SMI or SED. management, and medications have been proven effective in promoting recovery from mental disorders. Sources: Behavioral Health Barometer: California, Volume 4, Substance Abuse and Mental Health Services Administration, 2017, www.samhsa.gov (PDF); 58 Fed. Reg. 96 (May 20, 1993): 29422; “12-Month Prevalence of Major Depressive Episode with Severe Impairment Among U.S. Adults (2015),” in “Mental Illness,” National Institute of Mental Health, www.nimh.nih.gov. CALIFORNIA HEALTH CARE FOUNDATION 3 Mental Health Incidence of Mental Illness Prevalence Adults and Children, California, 2014 In 2014, 1 in 24 adults in California PERCENTAGE OF POPULATION experienced a serious mental illness, 4.2% Adults with Serious Mental Illness 15.4% Adults with Any Mental Illness defined as difficulty in carrying out major life activities. About 1 in 6 adults experienced a mental, behavioral, or emotional disorder (any mental illness). One in 13 children in California had a serious emotional disturbance that could 7.6% Children with Serious Emotional Disturbance interfere with home, learning, or getting along with people. Children do not have an equivalent “any mental illness” designation. Notes: Serious emotional disturbance (SED) is a categorization for children age 17 and under. Serious mental illness (SMI) is a categorization for adults age 18 and older. See page 3 for full definitions. See page 54 for a description of the methodology used to develop these estimates. Source: Charles Holzer and Hoang Nguyen, “Estimation of Need for Mental Health Services,” accessed December 22, 2017, charlesholzer.com. CALIFORNIA HEALTH CARE FOUNDATION 4 Mental Health Adults with SMI and Children with SED, by Region Prevalence California, 2014 The rate of serious emotional PERCENTAGE OF POPULATION disturbance among children in Central 4.2% California regions varied from a high Coast 7.5% í Adults with SMI of 8.1% in San Joaquin Valley to a Greater 3.4% í Children with SED Bay Area 7.1% low of 7.1% in the Greater Bay Area. Inland 4.7% The prevalence of serious mental Empire 7.8% 4.3% illness among adults ranged from Los Angeles County 7.8% a high of 5.4% in the Northern and Northern 5.4% Sierra region to a low of 3.4% in the and Sierra 7.8% Orange 3.6% Greater Bay Area. County 7.3% Sacramento 4.4% Area 7.5% San Diego 4.3% Area 7.5% San Joaquin 5.3% Valley 8.1% CA AVERAGE: 4.2% 7.6% 0.000 1.375 2.750 4.125 5.500 6.875 8.250 9.625 11.000 Notes: Serious emotional disturbance (SED) is a categorization for children age 17 and under. Serious mental illness (SMI) is a categorization for adults age 18 and older. See page 3 for full definitions. See page 54 for a description of the methodology used to develop these estimates. See Appendix A for a map of counties included in each region. Source: Charles Holzer and Hoang Nguyen, “Estimation of Need for Mental Health Services,” accessed December 22, 2017, charlesholzer.com. CALIFORNIA HEALTH CARE FOUNDATION 5 Mental Health Children with SED, by Race/Ethnicity Prevalence California, 2014 Serious emotional disturbance in PERCENTAGE OF CHILD POPULATION California children varied slightly 9.0 by race/ethnicity: Latino, African CA AVERAGE: 7.6% American, Native American, and 7.2 7.9% 8.1% 8.1% Pacific Islander children experienced 7.6% 6.9% 7.0% 7.1% rates of SED close to 8%, while rates 5.4 for white, Asian, and multiracial children were about 7%. 3.6 1.8 0.0 White Asian Multiracial Pacific Native African Latino (non-Latino) Islander American American Notes: Serious emotional disturbance (SED) is a categorization for children age 17 and under. See page 3 for full definitions. See page 54 for a description of the methodology used to develop these estimates. Source: Charles Holzer and Hoang Nguyen, “Estimation of Need for Mental Health Services,” accessed December 22, 2017, charlesholzer.com. CALIFORNIA HEALTH CARE FOUNDATION 6 Mental Health Children with SED, by Income Prevalence California, 2014 Serious emotional disturbance is PERCENTAGE OF CHILD POPULATION more common in children from 10 lower-income families. One in 10 children below the poverty level 10.0% suffered from a serious emotional 8 CA AVERAGE: 7.6% disturbance. 8.0% 6 7.0% 6.0% 4 2 0 <100% FPL 100%–199% FPL 200%–299% FPL 300%+ FPL Notes: Serious emotional disturbance (SED) is a categorization for children age 17 and under. See page 3 for full definitions. FPL is federal poverty level; 100% of FPL was defined in 2014 as an annual income of $11,670 for an individual and $23,850 for a family of four. Excludes 2% of children for whom the level of income could not be determined. See page 54 for a description of the methodology used to develop these estimates. Sources: Charles Holzer and Hoang Nguyen, “Estimation of Need for Mental Health Services,” accessed December 22, 2017, charlesholzer.com; 79 Fed. Reg. 14 (January 22, 2014): 3593–94. CALIFORNIA HEALTH CARE FOUNDATION 7 Mental Health Adults with SMI, by Gender and Age Group Prevalence California, 2014 California women were more likely PERCENTAGE OF ADULT POPULATION than men to experience serious 6.5000 mental illness. Rates of serious mental 6.3% illness increased steadily by age group, 5.6875 5.8% from 2.0% (18 to 20) to a peak of 4.8750 5.1% 6.3% (35 to 44) and then declined 4.8% CA AVERAGE: 4.2% 4.0625 4.3% in older age groups to a low of 1.5% 3.2500 3.6% among those 65 and over. 2.4375 2.9% 1.6250 2.0% 1.5% 0.8125 0.0000 Female Male 18–20 21–24 25–34 35–44 45–54 55–64 65+ Gender Age Group Notes: Serious mental illness (SMI) is a categorization for adults age 18 and older. See page 3 for full definitions and page 54 for a description of the methodology used to develop these estimates. Source: Charles Holzer and Hoang Nguyen, “Estimation of Need for Mental Health Services,” accessed December 22, 2017, charlesholzer.com. CALIFORNIA HEALTH CARE FOUNDATION 8 Mental Health Adults with SMI, by Race/Ethnicity Prevalence California, 2014 Rates of serious mental illness in PERCENTAGE OF ADULT POPULATION California adults varied considerably 00000 among racial and ethnic groups. Native American, African American, 28571 7.0% and multiracial adults experienced 57143 5.6% 5.8% the highest rates, and Asians and Pacific Islanders had the lowest. 85714 CA AVERAGE: 4.2% 5.0% 4.2% 14286 42857 2.4% 71429 1.7% 00000 Asian Pacific Islander White Latino Multiracial African Native (non-Latino) American American Notes: Serious mental illness (SMI) is a categorization for adults age 18 and older. See page 3 for full definitions. See page 54 for a description of the methodology used to develop these estimates. Source: Charles Holzer and Hoang Nguyen, “Estimation of Need for Mental Health Services,” accessed December 22, 2017, charlesholzer.com. CALIFORNIA HEALTH CARE FOUNDATION 9 Mental Health Adults with Serious Mental Illness, by Income Prevalence California, 2014 The prevalence of serious mental PERCENTAGE OF ADULT POPULATION illness was highest among the 10 poorest Californians, affecting close to 1 in 10 adults below 8 9.0% 100% of the federal poverty level. 6 6.3% CA AVERAGE: 4.2% 4 3.6% 2 1.9% 0 <100% FPL 100%–199% FPL 200%–299% FPL 300%+ FPL Notes: Serious mental illness (SMI) is a categorization for adults age 18 and older. See page 3 for full definitions. FPL is federal poverty level; 100% of FPL was defined in 2014 as an annual income of $11,670 for an individual and $23,850 for a family of four. Excludes 2% of adults for whom the level of income could not be determined. See page 54 for a description of the methodology used to develop these estimates. Source: Charles Holzer and Hoang Nguyen, “Estimation of Need for Mental Health Services,” accessed December 22, 2017, charlesholzer.com. CALIFORNIA HEALTH CARE FOUNDATION 10 Mental Health Reported Having an MDE in the Past Year Prevalence Adolescents, California vs. United States, 2011 to 2015 Depression, one of the most PERCENTAGE OF ADOLESCENTS í California í United States prevalent mental health disorders, HEALTHY PEOPLE 2020 BENCHMARK* has been steadily increasing among teens in California and the US. In 33333 12.3% 11.9% 11.5% 2014 –2015, one in eight teens 11.0% 10.5% reported experiencing a major 66667 9.9% 9.2% depressive episode (MDE) in the past 8.7% 7.5% year. Approximately 70% of teens 00000 who have MDE experience functional limitations that meet criteria for a 33333 serious emotional disturbance (not shown). 66667 00000 2011–2012 2012–2013 2013–2014 2014–2015 *Healthy People is a set of goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts, www.healthypeople.gov. Notes: Adolescents are age 12 to 17. MDE is major depressive episode. Respondents with unknown past-year MDE data were excluded. State estimates are based on a small area estimation procedure in which state-level National Survey on Drug Use and Health (NSDUH) data from two consecutive survey years are combined with local-area county and census block group / tract-level data from the state to provide more precise state estimates. Source: Behavioral Health Barometer: California, Volume 4, Substance Abuse and Mental Health Services Administration, 2017, www.samhsa.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 11 Mental Health Reported Having an MDE in the Past Year Prevalence Adults, California vs. United States, 2011 to 2015 Depression is one of the most PERCENTAGE OF ADULTS í California í United States common forms of mental illness. 8 HEALTHY PEOPLE 2020 BENCHMARK* From 2011 to 2015 roughly 6% of 7 California adults annually, or close to two million people, experienced a 6 6.4% 6.7% 6.6% 6.8% 6.3% 6.6% 6.6% 5.8% major depressive episode. Depression 5 5.9% is associated with higher risk of suicide and cardiovascular death. 4 3 2 1 0 2011–2012 2012–2013 2013–2014 2014–2015 *Healthy People is a set of goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts, www.healthypeople.gov. Notes: MDE is major depressive episode. See page 3 for full definitions. The National Survey on Drug Use and Health is a nationally representative survey of the civilian, noninstitutionalized population of the US, age 12 or older. Approximately 70,000 people are surveyed each year. Data from more than one year were combined to ensure statistically precise estimates. Sources: National Survey on Drug Use and Health Model-Based Prevalence Estimates (50 States and the District of Columbia), Substance Abuse and Mental Health Services Administration, 2009–2010 to 2014–2015; Jean-Pierre Lépine and Mike Briley, “The Increasing Burden of Depression,” Neuropsychiatric Disease and Treatment 7, Suppl. 1 (2011): 3–7, doi.org. CALIFORNIA HEALTH CARE FOUNDATION 12 Mental Health Adults with SMI and SUD and Children with SED and SUD Prevalence California, 2011 to 2015, Selected Years The rate at which people with PERCENTAGE USING COUNTY MENTAL HEALTH SERVICES mental health disorders experience a co-occurring alcohol or substance 33.1% 33.3% 34.4% í 2011 í 2013 use disorder was high compared to those with no mental health disorder í 2015 (not shown). For those using county mental health services in California, a third of adults with serious mental illness, and nearly 10% of children with serious emotional disturbance, had a co-occurring substance use 10.5% 9.2% 9.2% disorder. Adults with SMI and SUD Children with SED and SUD Notes: Serious emotional disturbance (SED) is a categorization for children age 17 and under. Serious mental illness (SMI) is a categorization for adults age 18 and older. See page 3 for full definitions. Substance use disorder (SUD) is a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by two or more diagnostic symptoms occurring in a 12-month period. County health services are provided for people with SED or SMI who have Medi-Cal or are uninsured, among others. Sources: California Mental Health National Outcome Measures (NOMS): SAMHSA Uniform Reporting System, 2011–2015, www.samhsa.gov; Sarra Hedden et al., Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration, 2015, www.samhsa.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 13 Mental Health Maternal Depressive Symptoms Prevalence Prenatal and/or Postpartum, California, 2013 In 2013, one in five California women MATERNAL DEPRESSIVE SYMPTOMS, who gave birth had either prenatal or PRENATAL OR POSTPARTUM, BY RACE African American postpartum depressive symptoms. 20.5% 27.6% Latina Rates of prenatal and postpartum 23.9% depressive symptoms varied by the Asian/Pacific Islander 15.9% mother’s race/ethnicity. In 2013, 14.9% White 15.3% AVERAGE about one in four African American 20.5% 12.8% and Latina mothers reported depressive symptoms. In contrast, about one in six Asian/Pacific Islander and white mothers reported these 7.2% symptoms. Prenatal or Postpartum Prenatal Postpartum Prenatal and Postpartum Notes: Data from population-based survey of California-resident women with a live birth in 2013. Data are weighted to represent all women with a live birth in California. Source: “Maternal Mental Health in California” (Presentation at Maternal, Child, and Adolescent Health Statewide Directors’ Meeting, October 7, 2015), cloudfront.net (PDF). CALIFORNIA HEALTH CARE FOUNDATION 14 Mental Health Treatment for Mental Illness Treatment Adults with AMI, California, 2011 to 2015 Slightly more than one-third of PERCENTAGE WHO . . . California adults with a mental illness reported receiving mental health treatment or counseling during the past year. This was lower than the national rate of 42.9% (not shown). Received Mental Health Adults may not be aware that they Services have a mental disorder, they may fear 37.2% the stigma of mental illness, or they may encounter barriers to treatment. Did Not Receive Mental Health Services 62.8% Notes: Estimates are annual averages based on combined 2011–2015 NSDUH data. Treatment estimates were based only on responses to items in the NSDUH Adult Mental Health Service Utilization module. Respondents with unknown treatment/counseling information were excluded. Estimates of any mental illness were based on self-report of symptoms indicative of any mental illness. Any mental illness (AMI) is a categorization for adults age 18 and older. See page 3 for full definitions. Sources: Behavioral Health Barometer: California, Volume 4, Substance Abuse and Mental Health Services Administration, 2017, www.samhsa.gov (PDF); Larry Goldman, Nancy Nielsen, and Hunter Champion, “Awareness, Diagnosis, and Treatment of Depression,” Journal of General Internal Medicine 14, no. 9 (September 1999): 569–80. CALIFORNIA HEALTH CARE FOUNDATION 15 Mental Health Unmet Need for Mental Health Treatment Treatment Adults with AMI, California, 2012 to 2014 Even among California adults with PERCENTAGE WHO SOUGHT TREATMENT AND . . . any mental illness who sought treatment, 17% reported that they did not get it. The national rate of Did Not Receive unmet need was higher (20%, Mental Health Treatment not shown). Common barriers to 17.2% accessing services include lack of health insurance, lack of available treatment providers or programs, and inability to pay for treatment. Received Mental Health Treatment 82.8% Notes: Estimates are a three-year average. Unmet need is defined as feeling a perceived need for mental health treatment/counseling that was not received. Any mental illness (AMI) is a categorization for adults age 18 and older. See page 3 for full definitions. Sources: “Mental Health in America – Access to Care Data,” www.mentalhealthamerica.net; “National Survey on Drug Use and Health (NSDUH),” Substance Abuse and Mental Health Services Administration, 2012–2014, www.datafiles.samhsa.gov. CALIFORNIA HEALTH CARE FOUNDATION 16 Mental Health Treatment for Major Depressive Episode Treatment Adults, California, 2011 to 2014 Nearly two-thirds of California adults PERCENTAGE REPORTING MDE IN THE PAST YEAR WHO . . . who report a major depressive episode receive treatment. This is lower than the Healthy People target of 75.9%.* Did Not Receive Treatment for Depression 36.4% Received Treatment for Depression 63.6% Notes: MDE is major depressive episode, as determined by survey respondents’ self-report of symptoms indicative of this diagnosis. Respondents with unknown past-year MDE or *Healthy People is a set of goals and objectives treatment data were excluded. with 10-year targets designed to guide national Sources: National Survey on Drug Use and Health Model-Based Prevalence Estimates (50 States and the District of Columbia), Substance Abuse and Mental Health Services Administration, health promotion and disease prevention efforts, 2009–2010 to 2014–2015; Jean-Pierre Lépine and Mike Briley, “The Increasing Burden of Depression,” Neuropsychiatric Disease and Treatment 7, Suppl. 1 (2011): 3–7, doi.org. www.healthypeople.gov. CALIFORNIA HEALTH CARE FOUNDATION 17 Mental Health Treatment for Major Depressive Episode Treatment Adolescents, California, 2011 to 2015 A majority of adolescents with a PERCENTAGE REPORTING MDE IN THE PAST YEAR WHO . . . major depressive episode (MDE) did not receive treatment. On average, between 2011 and 2015, about one- third of California adolescents who Received reported experiencing symptoms of Treatment for Depression MDE during the past year received 32.1% treatment. This was lower than the national rate of 38.9% (not shown). Did Not Receive Treatment for Depression 67.9% Notes: Estimates are annual averages based on combined 2011–2015 NSDUH data. Adolescents are age 12 to 17. MDE is major depressive episode, as determined by survey respondents’ self-report of symptoms indicative of this diagnosis. Respondents with unknown past-year MDE or treatment data were excluded. Source: Behavioral Health Barometer: California, Volume 4, Substance Abuse and Mental Health Services Administration, 2017, www.samhsa.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 18 Mental Health Suicide Rate, Adults and Children Suicide California vs. United States, 2011 to 2014 California’s suicide rate remained 15 PER 100,000 POPULATION, AGE ADJUSTED í California í United States stable from 2011 to 2014 and HEALTHY PEOPLE 2020 BENCHMARK* was consistently lower than the national rate. Most people who 12 12.6 12.6 13.0 12.3 die by suicide have a mental or 10.2 emotional disorder, with 30% to 70% 9 10.4 10.0 10.2 10.5 experiencing depression or bipolar disorder.1 In addition, people with 6 substance use disorder are six times more likely to commit suicide than 3 those without.2 0 2011 2012 2013 2014 *Healthy People is a set of goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts, www.healthypeople.gov. Notes: Suicide is death from a self-inflicted injury. California data come from registered death certificates. National data are collected from death certificates filed in state registration offices. Statistical information is compiled in a national database through the Vital Statistics Cooperative Program of the Centers for Disease Control and Prevention’s National Center 1. aris Strom and Robert Strom, Adolescents in the Internet P for Health Statistics. Age, 2nd Edition: Teaching and Learning from Them Sources: Kenneth Kochanek, Sherry Murphy, and Jiaquan Xu, “Deaths: Final Data for 2011,” National Vital Statistics Reports 63, no. 3 (July 27, 2015), Centers for Disease Control and (Charlotte: Information Age, 2014). Prevention (CDC), www.cdc.gov (PDF); Sherry Murphy et al., “Deaths: Final Data for 2012,” National Vital Statistics Reports, 63, no. 9 (August 31, 2015), CDC, www.cdc.gov (PDF); Jiaquan Xu 2. atjana Dragisic et al., “Drug Addiction as Risk for Suicide T et al. “Deaths: Final Data for 2013,” National Vital Statistics Reports, 64, no. 2 (February 16, 2016), CDC, www.cdc.gov (PDF); Kenneth Kochanek et al., “Deaths: Final Data for 2014,” National Attempts,” Materia Sociomedica 27, no. 3 (June 2015): Vital Statistics Reports, 65, no. 4, (June 30, 2016), CDC, www.cdc.gov (PDF). 188–191. CALIFORNIA HEALTH CARE FOUNDATION 19 Mental Health Suicide Rate, by Region Suicide All Ages, California, 2011 to 2013 Of all California regions, the PER 100,000 POPULATION, 3 -YEAR AVERAGE Northern and Sierra region had 22.0 the highest suicide rate, at 21.1, 21.1 twice the state average of 10.4. 17.6 The Central Coast, Sacramento, and San Diego areas also had 13.2 higher-than-average rates, CA AVERAGE: 10.4 12.9 12.6 while Los Angeles County had 11.8 8.8 9.8 10.4 10.0 10.6 the lowest in the state, at 7.7. 7.7 4.4 0.0 Central Greater Inland Los Angeles Northern Orange Sacramento San Diego San Joaquin Coast Bay Area Empire County and Sierra County Area Area Valley Notes: Suicide is death from self-inflicted injury. Data come from registered death certificates. See Appendix A for a map of the counties included in each region. Sources: Author calculations based on CDPH Vital Statistics Death Statistical Master Files and Report P-3: State and County Population Projections by Race/Ethnicity, Detailed Age, and Gender, 2010–2060, Department of Finance, January 31, 2013, ucdavis.edu. Both reports prepared by California Department of Public Health, Safe and Active Communities Branch and generated from epicenter.cdph.ca.gov. Vital statistics report generated on March 2, 2016; population report generated on October 7, 2016. CALIFORNIA HEALTH CARE FOUNDATION 20 Mental Health Suicide Rate, by Age Group Suicide California, 2011 to 2013 Suicide rates for California adults age NUMBER OF SUICIDES PER 100,000 POPULATION 45 and over were much higher than 0.6 rates for younger age groups. For older 5–14 0.4 í 2011 adults, physical disease is strongly 0.6 í 2012 í 2013 associated with suicide. 7.8 15–24 7.4 8.1 11.1 25–44 10.8 10.9 16.7 45–64 16.1 16.0 16.7 65+ 16.2 16.8 0.0 4.5 9.0 Notes: Suicide is death from self-inflicted injury. Data come from registered death certificates. 13.5 18.0 Sources: Author calculations based on CDPH Vital Statistics Death Statistical Master Files and Report P-3: State and County Population Projections by Race/Ethnicity, Detailed Age, and Gender, 2010–2060, Department of Finance, January 31, 2013, ucdavis.edu. Both reports prepared by California Department of Public Health, Safe and Active Communities Branch and generated from epicenter.cdph.ca.gov. Vital statistics report generated on March 2, 2016; population report generated on October 7, 2016. CALIFORNIA HEALTH CARE FOUNDATION 21 Mental Health Suicide Rates, by Gender and Race/Ethnicity Suicide All Ages, California, 2011 to 2013 Suicide rates differed dramatically 20 PER 100,000 POPULATION, 3 -YEAR AVERAGE by gender and race. Men had rates three times those for women. Rates 18.4 for whites and Native Americans were 15 16.1 16.4 considerably higher than average suicide rates, while rates for other CA AVERAGE: 10.4 racial/ethnic groups were considerably 10 lower than average. 5 6.8 7.3 4.8 4.4 0 Female Male Latino Asian/ African Native White Pacific Islander American American Gender Race/Ethnicity Notes: Suicide is death from self-inflicted injury. Data come from registered death certificates. Information on the multiracial population was not included in suicide data. These data exclude other/unknown race/ethnicity. Sources: Author calculations based on CDPH Vital Statistics Death Statistical Master Files and Report P-3: State and County Population Projections by Race/Ethnicity, Detailed Age, and Gender, 2010–2060, Department of Finance, January 31, 2013, ucdavis.edu. Both reports prepared by California Department of Public Health, Safe and Active Communities Branch and generated from epicenter.cdph.ca.gov. Vital statistics report generated on March 3, 2016. CALIFORNIA HEALTH CARE FOUNDATION 22 Mental Health Suicide Attempts Among High School Students Suicide by Gender and Need for Treatment, California vs. United States, 2015 Among high school students, self- PERCENTAGE OF HIGH SCHOOL STUDENTS reported rates of attempted suicide in 12 í California í United States the prior year were over twice as high 11.9% HEALTHY PEOPLE 2020 BENCHMARK* for females as for males nationally 11.6% 10 and in California. Attempts resulting in an injury, poisoning, or overdose 8 8.6% that had to be treated by a doctor or 8.2% nurse were higher for males than for 6 females in California, but did not show 5.5% the same pattern nationally. 4 4.7% 3.7% 2.8% 2.8% 2 1.7% 1.9% 1.9% 1.0% 0 Female Male OVERALL Female Male OVERALL Attempted Suicide Attempted Suicide and Treated by Nurse or Doctor *Healthy People is a set of goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts, www.healthypeople.gov. Source: Laura Kann et al., “Table 27” and “Table 28,” in “Youth Risk Behavior Surveillance — United States, 2015,” MMWR Surveillance Summaries 65, no. 6 (June 10, 2016): 78–79, www.cdc.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 23 Mental Health All Health and Mental Health Expenditures Spending United States, 2009 to 2020 Spending on mental health in the 5000 IN BILLIONS United States is projected to grow $4,338 í Mental Health by over 60%, from $147 billion in $4,057 5.5% 4000 í Other Health $3,818 5.5% 2009 to $238 billion in 2020. All $3,605 5.6% $3,404 5.6% other health spending is projected $3,204 5.7% $3,028 5.8% to grow by close to 90% during the 3000 $2,793 5.9% $2,647 same time. Mental health’s share of $2,541 6.2% $2,330 $2,424 6.3% 6.4% 6.4% total health spending is expected to 6.3% 2000 decrease slightly from 6.3% in 2009 to 5.5% in 2020. 1000 0 2009 2010P 2011P 2012P 2013P 2014P 2015P 2016P 2017P 2018P 2019P 2020P Notes: Projections (shown with P) of treatment expenditures for mental health compared to the Centers for Medicare & Medicaid Services National Health Expenditure Accounts (NHEA). Spending includes clinical treatment and rehabilitative services and medications and excludes both peer support services for which there is no cost and activities to prevent mental illness. Projections incorporate expansion of coverage through the Affordable Care Act, implementation of the provisions of mental health parity regulations, and expectations about the expiration of patents for certain psychotropic medications. Source: “Table A.1,” in Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020, Substance Abuse and Mental Health Services Administration, 2014: A-2, store.samhsa.gov. CALIFORNIA HEALTH CARE FOUNDATION 24 Mental Health Mental Health Expenditures, by Service Category Spending United States, 1986, 2009, 2014, and 2020 The delivery of mental health services evolved between 1986 5% 7% 8% 8% ■ Insurance Administration and 2009, resulting in significant 8% ■ Prescription Drugs changes in expenditures for mental ■ Other Outpatient 14% 28% 28% 26% and Residential health treatment. As a percentage ■ Physicians and Other Professionals of total expenditures, hospital and 17% ■ Freestanding nursing facility expenditures declined Nursing Facilities 17% 18% 19% ■ Hospital while the share of expenditures for 15% prescription drugs and outpatient 16% 17% 18% care increased. During this time, 6% 6% 6% many new and expensive psychiatric 42% medications with fewer side effects 26% 23% 23% resulted in more widespread use. 1986 2009 2014P 2020P Notes: Projections (shown with P) of treatment expenditures for mental health include clinical treatment and rehabilitative services and medications and exclude peer support services and activities to prevent mental illness. Other outpatient and residential includes other personal, residential, and public health plus freestanding home health services. Sources: “Table A.7,” in National Expenditures for Mental Health Services and Substance Abuse Treatment: 1986–2009, Substance Abuse and Mental Health Services Administration (SAMHSA), 2013: 66, store.samhsa.gov; “Table A.3,” in Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020, SAMHSA, 2014: A-5, store.samhsa.gov. CALIFORNIA HEALTH CARE FOUNDATION 25 Mental Health All Health vs. Mental Health Expenditures Spending by Payer, United States, 2015 Total US mental health expenditures PERCENTAGE OF TOTAL PROJECTED SPENDING in 2015 are projected to be $186 billion, or 6% of total health care All Health Mental Health expenditures. Medicaid and other public programs are projected to pay Other Public Other for slightly more than half (53%) 12% Public of mental health expenditures, 21% Private 29% but only one-third of overall Private Medicaid Total: 38% Total: health expenditures. 22% $3 trillion $186 billion 3% Medicaid Medicare Medicare 32% 15% 23% 4% Other Private Other Private Notes: Other public includes other federal, state, and local payers. May not sum to 100% due to rounding. Spending includes clinical treatment and rehabilitative services and medications and excludes both peer support services for which there is no cost and activities to prevent mental illness. Projections incorporate expansion of coverage through the Affordable Care Act, implementation of the provisions of mental health parity regulations, and expectations about the expiration of patents for certain psychotropic medications. Source: “Table A.7,” in Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020, Substance Abuse and Mental Health Services Administration, 2014: A-12 and A-13, store.samhsa.gov. CALIFORNIA HEALTH CARE FOUNDATION 26 Mental Health California’s Public Mental Health Delivery System California’s Public System California has a complex public mental A Complex Delivery System California counties are responsible for both Medi-Cal specialty mental health services and for safety-net (non-Medi-Cal) health care system. Most services are community mental health services. While counties have historically provided most Medi-Cal mental health services in the delivered through county systems state through county mental health plans, and some are available on a fee-for-service basis, other services (typically for people with less serious mental health conditions) have become available through Medi-Cal managed care health plans that operate separately from other since California expanded the scope of mental health benefits available to Medi-Cal beneficiaries in 2014. Coordination among these different delivery systems is a work in progress. safety-net health care services, and Funding are funded through a number of The most significant sources of funding for public mental health care in California include: dedicated revenue streams. • Federal Medicaid funds • State sales tax and vehicle license fees distributed to counties (realignment* funds) • The state’s Mental Health Services Act (MHSA), which imposes a 1% surtax on personal income over $1 million (see page 28) Available Data Comprehensive data to permit a full accounting of service use, outcomes, and spending across California’s public mental health system is not available. The most complete and timely statewide data is for county Medi-Cal specialty mental health services and these data are presented in the “Medi-Cal” section that follows. *Realignment is the transfer of administrative and financial control from the state to counties. California underwent two major mental health system realignments: in 1991 and in 2011. Notes: For more information on the organization and financing of public mental health services in California, see Sarah Arnquist and Peter Harbage, A Complex Case: Public Mental Health Delivery and Financing in California, CHCF, July 2013, www.chcf.org; Kim Lewis and Abbi Coursolle, Mental Health Services in Medi-Cal, National Health Law Program, January 12, 2017, www.healthlaw.org. Source: Welfare and Institutions Code sections 5600–5623.5. CALIFORNIA HEALTH CARE FOUNDATION 27 Mental Health California’s Public Mental Health System California’s Public System Financing Trends, FY 2008 to FY 2018 Funding of California’s county-based IN BILLIONS mental health system more than $7 doubled and the federal share of Other Medicaid mental health services $6 2011 Behavioral Health almost tripled, from FY 2008 to Realignment Subaccount $5 FY 2017. Mental Health Services Mental Health Services Act (MHSA) Act (MHSA) funds are projected $4 Redirected MHSA to approach $1.3 billion in fiscal year 2018. $3 State General Funds 1991 Mental Health $2 Realignment Account Federal Financial Participation $1 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017E FY 2018P Notes: These figures encompass revenues received, estimated (E), or projected (P) to be received by counties in support of the Medi-Cal and safety-net mental health services they provide. Other public mental health services, such as forensic services in state hospitals and mental health services and medications provided by Medi-Cal managed care plans and Medi-Cal fee-for-service, are not included. Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. See Appendix D for definitions. Source: Financial Report, Mental Health Services Oversight and Accountability Commission, January 26, 2017, www.mhsoac.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 28 Mental Health Use of Medi-Cal Specialty Mental Health Services Medi-Cal Adults and Children, California, FY 2012 to FY 2015 In 2012, similar numbers of children UNDUPLICATED NUMBER OF SERVICE USERS and adults used Medi-Cal specialty 603,534 mental health services. By 2015, 557,191 ■ Adults both groups had grown, but the 336,619 ■ Children 477,567 293,282 number of adults grew considerably 456,520 faster (48% growth from 2012 to 230,815 2015), compared to 17% for children. 227,705 Expansion of Medi-Cal eligibility to additional adults in 2014, and the transition of children with Healthy 263,909 266,915 Families coverage into Medi-Cal in 228,815 246,752 2013, contributed to this growth. FY 2012 FY 2013 FY 2014 FY 2015 Notes: Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. Specialty mental health services are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consist of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. Children are age 0–20; adults are age 21 and older. Source: Statewide Aggregate Specialty Mental Health Services Performance Dashboard, California Department of Healthcare Services, 2016, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 29 Mental Health Use of Medi-Cal Specialty Mental Health Services Medi-Cal Adults, by Demographic, California, FY 2015 Slightly more women than men PERCENTAGE OF ADULT (21+) SERVICE USERS WHO ARE… used Medi-Cal specialty mental Gender health services. Few adults over age 65 used services, while adults age 21 to 44 and those 45 to 64 were Male equally likely to use services. African 47% Female 53% Americans and Native Americans were overrepresented among service users Age Race/Ethnicity in comparison to their percentage of 65+ the adult population (not shown), 6% Other Native American (1%) 15% while Latinos and Asian/Pacific Asian/Pacific Islander 8% White 37% Islanders were underrepresented. 21 to 44 45 to 64 48% African 46% American 16% Latino 22% Notes: Specialty mental health services are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consist of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. Segments may not sum to 100% due to rounding. Source: Statewide Aggregate Specialty Mental Health Services Performance Dashboard, California Department of Healthcare Services, 2016, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 30 Mental Health Use of Medi-Cal Specialty Mental Health Services Medi-Cal Children/Adolescents, by Demographic, California, FY 2015 A higher percentage of male than PERCENTAGE OF CHILD/ADOLESCENT (0–20) SERVICE USERS WHO ARE… female children and adolescents used Gender Medi-Cal specialty mental health services. Those age 6 to 17 constituted 76% of child and adolescent service Female users. African American children Male 45% 55% represented 11% of users but 5% of the population (not shown). Age Race/Ethnicity In contrast, Asian/Pacific Islander Other children were 3% of mental health 18 to 20 0 to 5 Native American (1%) 12% 12% 9% Asian/Pacific Islander (3%) service users, but 11% of the child African American 11% population (not shown). Latino 6 to 11 51% 12 to 17 34% 42% White 25% Notes: Specialty mental health services are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consists of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. Source: Statewide Aggregate Specialty Mental Health Services Performance Dashboard, California Department of Healthcare Services, 2016, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 31 Mental Health Medi-Cal Specialty MH Service Users and Approved Claims Medi-Cal Adults, by Medi-Cal Member Type, FY 2015 In January 2014, the Affordable Care 393,450 $1.7 billion Act raised adult income limits for Medi-Cal eligibility. From July 2014 ■ Medi-Cal Expansion Members 126,856 $491 million ■ Other Medi-Cal Members through June 2015, 127,000 Medi-Cal expansion clients used $491 million in Medi-Cal specialty mental health services. This group of 266,594 $1.3 billion new beneficiaries represented a third of all adult users of services. Adults Using Services Approved Claim Amounts Notes: Under the ACA expansion, individuals age 18 and older can apply for Medi-Cal. Specialty mental health services defines adults as individuals who are 21 or older. As such, ACA expansion clients and non-ACA adults currently receiving SMHS cannot be directly compared. MH is mental health. Specialty mental health services are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consist of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. Based on approved claims received through June 30, 2016. Includes both Short-Doyle and fee-for-service claims. Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. Segments may not sum to total due to rounding. Source: Medi-Cal Specialty Mental Health Services, November Estimate, Policy Change Supplement for Fiscal Years 2016–17 and 2017–18, Department of Health Care Services: 22–23, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 32 Mental Health Use of Medi-Cal Specialty Mental Health Services Medi-Cal by Age Group and Service Category, California, FY 2015 Of those people receiving county PERCENTAGE OF UNDUPLICATED ENROLLEES specialty mental health services, Mental Health Therapy 72% similar percentages of adults used 93% mental health therapy as used Medication Support medication, while children were 66% 30% much more likely to use therapy Targeted Case Management than a psychotropic medication. 39% Approximately 40% of children 37% í Adults Crisis Intervention Services í Children and adults used targeted case 14% management for assistance in 8% accessing community services. Crisis Stabilization Services 14% Smaller percentages of adults 4% and children used inpatient and Hospital Inpatient crisis services. 12% 6% Notes: Specialty mental health services are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consist of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. Mental health therapy includes therapy and other service activities; hospital inpatient includes psychiatric health facility and administrative days, managed care and fee-for-service psychiatric inpatient hospital days. If Medi-Cal enrollees used more than one type of hospital care, they will be counted twice. Children are age 0 through 20; adults are age 21 and older. Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. Source: Statewide Aggregate Specialty Mental Health Services Performance Dashboard, California Department of Healthcare Services, 2016, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 33 Mental Health Medi-Cal Specialty Mental Health Services Expenditures Medi-Cal Adults and Children, California, FY 2012 to FY 2015 Average expenditures per Medi-Cal APPROVED CLAIMS PER SERVICE USER specialty mental health service user í FY 2012 í FY 2013 í FY 2014 í FY 2015 were at least 33% higher for children 7000 than for adults. Expenditures for 6125 adults grew at a faster rate (22%) $6,347 $6,368 $6,417 5250 $5,903 than expenditures for children (9%) between fiscal years 2012 and 2015. 4375 $4,600 $4,826 $4,342 3500 $3,963 2625 1750 875 0 Adults Children Notes: Specialty mental health services are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consist of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. Children are age 0–20; adults are age 21 and older. Approved claims for specialty mental health as of August 3, 2016. Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. Source: Statewide Aggregate Specialty Mental Health Services Performance Dashboard, California Department of Healthcare Services, 2016, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 34 Mental Health Diseases Treated, Most Costly 5% of Medi-Cal Enrollees Medi-Cal All Ages, California, 2011 Mental health disorders are associated PERCENTAGE OF ENROLLEES TREATED FOR . . . with high costs in the Medi-Cal program, which provided $26 billion Any Mental Health in health care services in 2011. 59% Among the 5% of the 7.9 million Medi-Cal service users with the 15.0% highest total costs of care in 2011, Hypertension more than twice as many were 27% treated for mental illness as for hypertension or diabetes. Diabetes 21% 0.000000 9.166667 18.333333 27.500000 36.666667 45.833333 55.000000 Notes: Includes Medi-Cal members participating in fee-for-service, managed care, or both. Excludes Medi-Cal members also enrolled in Medicare. The condition categories used are based on the Clinical Classification Software (CCS) for the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and were originally developed as a part of the Healthcare Cost and Utilization Project under the Agency for Healthcare Research and Quality. Source: Understanding Medi-Cal’s High-Cost Populations, Department of Health Care Services, June 2015, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 35 Mental Health Medi-Cal Spending on Diabetes, by Service Category Medi-Cal With and Without SMI or AD, California, 2011 Diabetes is one of the most common PER MEMBER PER MONTH SPENDING chronic conditions in the adult $3,743 Medi-Cal population. Total costs ■ Mental Health and Other Specialty of care for members with diabetes $815 ■ Prescriptions $3,101 ■ Other Medical Care and no behavioral health condition $549 averaged $1,459 per month. $774 Average monthly costs for those $752 with a co-occurring SMI were more CA AVERAGE: $1,899 $2,154 than double that amount, and more $1,459 $1,800 $188 than two and a half times higher if $266 an alcohol or drug problem was $1,005 also present. Diabetes Diabetes Diabetes with SMI with SMI and AD Notes: Fee-for-service expenditures for adults with Medi-Cal coverage only. SMI is serious mental illness. AD is alcohol and drug treatment. Mental health and other specialty includes mental health, in-home support services, dental, home- and community-based services for developmental disabilities, and other. Other medical care includes outpatient services, hospital inpatient services, and nursing facility and emergency medical transportation. Source: Understanding Medi-Cal’s High-Cost Populations, Department of Health Care Services, June 2015, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 36 Mental Health Acute Psychiatric Inpatient Beds Facilities California, 1995 to 2014 California has acute psychiatric beds in general acute and specialized í Total (in thousands) Per 100,000 Population psychiatric hospitals that provide 9.6 short-term care for people who 8.5 experience a psychiatric crisis and 8.2 8.2 8.0 7.7 7.6 7.5 require 24-hour care. Acute psychiatric 7.4 7.2 6.9 beds per 100,000 population 6.6 6.5 6.6 6.6 6.6 6.6 6.6 6.3 6.5 29.5 decreased 42% from 1995 through 2014. During this time, 44 facilities either eliminated inpatient psychiatric 17.0 care or closed completely. California would need an additional 1,158 beds to reach the national average of 20 beds per 100,000 population. 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Notes: Acute psychiatric inpatient beds excludes beds in California state hospitals. It includes beds in psychiatric units in general acute care hospitals (including city and county hospitals), acute psychiatric hospitals, and psychiatric health facilities. These beds are licensed to provide one of the following types of psychiatric service: adult, child/adolescent, geriatric- psychiatry, psychiatric intensive care, or chemical dependency. Bed counts for 2009 and 2010 differ from those reported in an earlier CHA report. Source: California’s Acute Psychiatric Bed Loss, California Hospital Association, October 25, 2016. CALIFORNIA HEALTH CARE FOUNDATION 37 Mental Health Adult and Child/Adolescent Acute Psychiatric Inpatient Beds Facilities by California County, 2015 There was significant geographic variation in the availability of acute Del Norte Siskiyou Modoc í Adult Beds Available psychiatric inpatient beds in California: Shasta Trinity Lassen í Child/Adolescent Beds Available Humboldt (in addition to adult beds) 25 counties had no adult acute Tehama Plumas Glenn Butte Sierra psychiatric beds, and 46 counties Mendocino Lake Colusa Yuba Nevada Placer had no psychiatric beds for children, Sutter Yolo El Dorado Sonoma Napa Sacra- Amador mento Alpine in 2015. When inpatient facilities are Solano Calaveras Marin San San Francisco Contra Costa Joaquin Tuolumne Mono far from where people live, it is more Alameda Stanislaus Mariposa San Mateo Santa Clara Merced difficult for families to participate in Madera Santa Cruz San Benito Fresno Inyo treatment and for facilities to plan Tulare Monterey Kings post-discharge care. San Luis Obispo Kern San Bernardino Santa Barbara Ventura Los Angeles Orange Riverside San Diego Imperial Notes: Acute psychiatric inpatient beds excludes beds in California state hospitals. It includes psychiatric units in general acute care hospitals (including city and county hospitals), beds in acute psychiatric hospitals, and beds in psychiatric health facilities. Source: California’s Acute Psychiatric Bed Loss, California Hospital Association, October 25, 2016. CALIFORNIA HEALTH CARE FOUNDATION 38 Mental Health Psychiatric Inpatient Beds Facilities by Type, California, 2014 Inpatient psychiatric care provides Acute Care NUMBER OF BEDS stabilization for mental health crises Acute Psychiatric that can make patients dangerous to 6,104 themselves or to others. Acute care State Hospital, Acute facilities provided 70% of beds for 1,998 acute psychiatric care in California. Psychiatric Health Facility (PHF) 484 State hospitals also offered both acute care and intermediate care Intermediate and Long-Term Care beds that were used primarily to State Hospital Intermediate treat incarcerated patients with 4,578 Special Treatment Program (SNF) mental illness. 2,178 Mental Health Rehabilitation Centers* 1,369 *List from DHCS Licensing and Certification, www.dhcs.ca.gov (PDF). Years are not listed on this source. Notes: Acute psychiatric includes general acute care hospital psychiatric units and acute psychiatric hospitals. State hospitals offer acute care and intermediate care, primarily for forensic patients. Special treatment programs are beds in skilled nursing facilities, licensed by the Department of Public Health to provide intermediate and long-term inpatient care. Mental health rehabilitation centers are licensed by the Department of Health Care Services (DHCS) and provide intermediate and long-term care. Sources: 2014 Pivot Table, Office of Statewide Health Planning and Development (OSHPD), www.oshpd.ca.gov; Automated Licensing Information and Report Tracking System (ALIRTS) for listing of open Skilled Nursing Facilities with Special Treatment Programs, OSHPD, accessed October 10, 2016; any additional SNFs in Facilities and Programs Defined as Institutions for Mental Disease (IMDs): 2014, Department of Health Care Services, September 17, 2014, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 39 Mental Health ED Discharges to Inpatient Psychiatric Facilities Facilities California, 2010 to 2015 People experiencing mental health ED VISITS WITH DISPOSITION TO PSYCHIATRIC CARE crises frequently go to hospital í Total (in thousands) Per 10,000 Population emergency departments for help. Many people can be stabilized by the 92.9 95.9 emergency department or by referral 82.3 85.2 for outpatient care. However, an 76.9 increasing number of emergency visits 69.8 resulted in discharges to inpatient psychiatric care. Recent studies have 24.5 suggested more timely access to 18.7 outpatient treatment and specialized psychiatric crisis services could reduce the need for inpatient care.1,2 1. arry Baraff, Nicole Janowicz, and Joan Asarnow, “Survey L of California Emergency Departments About Practices 2010 2011 2012 2013 2014 2015 for Management of Suicidal Patients and Resources Available for Their Care,” Annals of Emergency Medicine 48, no. 4 (2006): 452–8. Notes: ED is emergency department. Disposition to psychiatric care includes discharges or transfers to a psychiatric hospital or distinct psychiatric unit of a hospital, including those that 2. idhya Alakeson, Nalini Pande, and Michael Ludwig, V are a planned inpatient readmission. “A Plan to Reduce Emergency Room ‘Boarding’ of Source: Author calculations based on Emergency Department Outpatient and Inpatient Data Pivot Profile, Office of Statewide Health Planning and Development, 2010–2014, Psychiatric Patients,” Health Affairs 29, no. 9 (2010): www.oshpd.ca.gov and Report P-1: State Population Projections (2010–2060): Total Population by County, Department of Finance, www.dof.ca.gov. 1637– 42. CALIFORNIA HEALTH CARE FOUNDATION 40 Mental Health Hospital Length of Stay / Discharges Facilities Acute Medical vs. Acute Psychiatric, California, 2006, 2010, and 2014 Acute psychiatric hospital stays are far less frequent than acute medical Average Length of Stay Hospital Discharges (in days) per 1,000 Population stays. Between 2006 and 2014, acute medical care discharges per 8.6 101.4 98.6 population decreased by 8.3%, while í 2006 7.7 7.6 93.0 í 2010 acute psychiatric discharge rates rose í 2014 by a similar rate. Average lengths of stay for acute psychiatric care were considerably longer than average 4.3 4.2 4.2 stays for acute medical care, but shortened between 2006 and 2010. 5.3 5.5 5.8 Acute Medical Care Acute Psychiatric Care Acute Medical Care Acute Psychiatric Care Notes: Includes discharges from general acute hospitals, acute psychiatric facilities, and psychiatric health facilities (PHFs). Discharges from chemical dependency recovery care, physical rehabilitation care, and skilled nursing / intermediate care are not shown. PHFs were designed as a cost-effective way to deliver acute psychiatric inpatient care. They do not have to meet the same facility regulations as hospitals, and provide medical care through arrangements with other providers. Sources: “Type of Care by County of Residence,” in “Hospital Inpatient Discharge Rates — County Frequencies,” Office of Statewide Health Planning and Development, 2006, 2010, and 2014, www.oshpd.ca.gov; population estimates from American Community Survey, US Census Bureau, 2006, 2010, and 2014, www.census.gov. CALIFORNIA HEALTH CARE FOUNDATION 41 Mental Health Hospital Discharges, by Payer Facilities Acute Medical vs. Acute Psychiatric, California, 2010 and 2014 In 2010, Medi-Cal paid for 26% of PERCENTAGE OF DISCHARGES California medical and psychiatric — 1.0% — 1.1% — 0.9% 2.2% 1.9% — 2.0% 5.2% ■ Other discharges. In 2014, Medi-Cal’s share 3.6% — 1.6% 3.0% — 0.2% 6.0% 2.8% ■ Other Government / 5.9% 3.2% Indigent increased to 31% of medical and 37% 26.4% 30.8% 7.1% ■ County Indigent of psychiatric discharges. The increase ■ Self-Pay ■ Medi-Cal was offset by decreased shares of 37.1% 26.8% ■ Medicare self-pay and county indigent ■ Private programs. Medicare paid for 33% of 32.3% 32.5% medical discharges but only 23% of 24.2% 22.6% psychiatric discharges in 2014. 32.9% 30.6% 28.0% 28.1% 2010 2014 2010 2014 Acute Medical Care Acute Psychiatric Care Notes: Includes discharges from general acute hospitals, acute psychiatric facilities, and psychiatric health facilities (PHFs). Discharges from chemical dependency recovery care, physical rehabilitation care, and skilled nursing/intermediate care are not shown. Other includes worker’s compensation and other payers. Source: “Expected Payer by County of Residence and Type of Care,” in “Hospital Inpatient Discharge Reports — County Frequencies,” Office of Statewide Health Planning and Development, 2010 and 2014, www.oshpd.ca.gov. CALIFORNIA HEALTH CARE FOUNDATION 42 Mental Health Mental Health Professions Care Providers California, 2016 California had about 75,000 licensed behavioral health professionals in Marriage and Family Therapists 2016. Marriage and family therapists 31,349 comprised the greatest share, almost Licensed Clinical Social Workers double the number of licensed 18,974 psychologists. This workforce does not Psychologists reflect the racial and ethnic diversity 16,683 of the state, and many professionals, Psychiatrists particularly psychiatrists and 5,806 psychologists, will reach retirement Counselors age within the next decade 1,207 (not shown). Psychiatric Nurses 306 Note: For more information on current and projected behavioral health workforce needs, see Janet Coffman et al., California’s Current and Future Behavioral Health Workforce, Healthforce Center at UCSF, February 2018, healthforce.ucsf.edu/BHWorkforce. Source: UCSF analysis of Department of Consumer Affairs, Professional Licensee Masterfile, June 2016. CALIFORNIA HEALTH CARE FOUNDATION 43 Mental Health Licensed Mental Health Professionals, by Region Care Providers California, 2016 The per population rates of PER 100,000 POPULATION ■ LOWER THAN STATE AVERAGE behavioral health professionals varied LICENSED MARRIAGE considerably by region in California. CLINICAL SOCIAL AND FAMILY PSYCHIATRIC REGION COUNSELORS WORKERS THERAPISTS NURSES PSYCHIATRISTS PSYCHOLOGISTS The Greater Bay Area’s rates were 38% Central Coast 3.6 45 120 0.9 15 45 to 67% greater than the state average Greater Bay Area 4.6 66 118 1.3 25 71 for the professions shown, while Inland Empire 1.9 26 41 0.3 8 16 the Inland Empire and San Joaquin Los Angeles County 2.4 56 80 0.9 15 46 Valley regions had rates that were Northern and Sierra 3.3 46 86 0.9 9 23 39% to 88% lower than average. Orange County 3.7 42 82 0.5 10 39 The Northern and Sierra region had Sacramento Area 3.7 57 76 0.3 15 35 rates of psychiatry and psychology San Diego Area 3.8 48 71 1.1 16 52 professionals that were at least 40% San Joaquin Valley 1.4 25 35 0.1 7 16 lower than average. State Average 3.1 48 80 0.8 15 43 Notes: Psychiatrists includes those who designate psychiatry as their primary specialty. County is determined by location of psychiatrist’s primary practice. County of psychologists is the county of personal residence. County of licensed clinical social workers and licensed marriage and family therapists is determined by each licensee’s chosen address of record. See Appendix A for map of counties included in each region. Sources: UCSF analysis of Department of Consumer Affairs, Professional Licensee Masterfile, June 2016; Healthforce Center at UCSF; “Annual Estimates of the Resident Population April 1, 2010 to July 1, 2016,” US Census Bureau, factfinder.census.gov. CALIFORNIA HEALTH CARE FOUNDATION 44 Mental Health Medication Treatment for Selected MH Conditions Quality of Care HMO and PPO Plans, California vs. United States, 2015 Nearly two-thirds of California adults í California í United States PERCENTAGE WHOSE TREATMENT MET STANDARD OF CARE prescribed antidepressant medication Adults Prescribed Antidepressant Med Children Prescribed ADHD Med met standards for effective initiation of treatment, but less than half met 67% 67% 64% 65% standards for continuing treatment. Less than half of California children 53% 50% 49% 51% prescribed medication for attention 47% 46% 45% 46% 43% 44% deficit hyperactivity disorder in 39% 39% California HMOs and PPOs met standards for effective initiation and continuation phase treatment. Initiation Continuation Initiation Continuation Initiation Continuation Initiation Continuation HMO PPO HMO PPO Notes: A widely accepted standard for effective medication management of adults who initiate treatment with an antidepressant medication calls for them to remain on the medication for six months. An accepted measure of the appropriateness of continued care for children (age 6 to 12) prescribed attention deficit hyperactivity disorder (ADHD) medication and remain on it for at least 210 days is to have at least two practitioner visits between the second month and the ninth month on the medication. California scores are the average of the state’s largest HMOs and six of the largest California PPOs. Nationwide results were calculated giving equal weight to reporting plans throughout the country regardless of its number of enrollees. HMO is health maintenance organization; PPO is preferred provider organization. Read more: “Strategies and Tactics in the Treatment of Depression: Continuation-Phase Treatment,” Armenian Medical Network, March 6, 2006, www.health.am. Sources: Office of the Patient Advocate, accessed June 13, 2017, HMO data (reportcard.opa.ca.gov) and PPO data (reportcard.opa.ca.gov). CALIFORNIA HEALTH CARE FOUNDATION 45 Mental Health Follow-Up After Hospitalization for Mental Illness Quality of Care Commercial HMO and PPO Plans, California vs. United States, 2015 Prompt follow-up with an outpatient PERCENTAGE RECEIVING A VISIT AFTER DISCHARGE í California í United States mental health provider after discharge from a psychiatric hospitalization helps maintain continuity of care and 83% prevent rehospitalization. California 72% 73% 68% 69% commercial HMOs exceeded their national counterparts on outpatient 56% appointments within 7 and 30 days 50% 49% of discharge. HMO PPO HMO PPO Within 7 Days Within 30 Days Notes: Includes HMO and PPO members age six and older. HMO is health maintenance organization; PPO is preferred provider organization. California HMO scores are the average of the state’s largest HMO. California PPO scores are the average across six of the largest California PPOs. The nationwide results are from PPO health plans located throughout the US and were calculated giving equal weight to each plan’s score regardless of its enrollment. Sources: Office of the Patient Advocate, accessed June 13, 2017, HMO data (reportcard.opa.ca.gov) and PPO data (reportcard.opa.ca.gov). CALIFORNIA HEALTH CARE FOUNDATION 46 Mental Health Follow-Up After Hospitalization Quality of Care Adults and Children Using Medi-Cal SMHS, California, FY 2015 Adults using Medi-Cal specialty PERCENTAGE OF PSYCHIATRIC INPATIENT HOSPITAL DISCHARGES RECEIVING OUTPATIENT SERVICES mental health services are substantially less likely than children í Within 7 Days í Within 30 Days to get a timely follow-up visit. 75% Close to 60% of child psychiatric discharges and 40% of adults 58% psychiatric discharges accessed 57% outpatient services within seven days. One-quarter of child discharges 40% and 43% of adult discharges had not accessed outpatient services within a month. Adults Children Notes: SMHS is specialty mental health services. SMHS are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consists of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. Excludes data on beneficiaries that received follow-up services from a non-Medi-Cal community-based program or in jail or prison. Children are age 0 to 20, and adults are age 21 and older. Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. Source: Statewide Aggregate Specialty Mental Health Services Performance Dashboard, California Department of Healthcare Services, 2016, www.dhcs.ca.gov (PDF). CALIFORNIA HEALTH CARE FOUNDATION 47 Mental Health Mental Health Among Jail Inmates Criminal Justice System California, 2016 On the last day of 2016, over PERCENTAGE OF AVERAGE DAILY JAIL POPULATION, BY TYPE OF SERVICE 17,000 inmates, representing Active Mental Health Cases 23% of the average daily population of reporting California jails, were 23% identified as having a mental health issue. Twenty percent of inmates were Inmates Receiving Psychiatric Medication using psychotropic medications, while 6% were in beds for people 20% with mental health conditions. Inmates Assigned to Mental Health Beds 6% 0 4 8 12 16 20 Notes: Active mental health cases are inmates identified as having a psychological disorder and who are actively in need of and receiving mental health services. The number of mental health cases and the number of inmates getting other mental health services are counted on December 31, and so represent a point-in-time count. Average daily jail population is the monthly average excluding people on holding status. Only jails that reported all indicators are included in the calculations. Excludes the following jails that did not report any of the measures: Marin, Mono, San Joaquin, and Sutter. Source: “Jail Profile Survey,” Board of State and Community Corrections, accessed December 18, 2017, www.bscc.ca.gov. CALIFORNIA HEALTH CARE FOUNDATION 48 Mental Health Prison Inmates’ Use of Mental Health Services, by Gender Criminal Justice System California, January 2013 to January 2015 From January 2013 to January 2015, PERCENTAGE OF FEMALE AND MALE INMATE POPULATIONS a growing share of California’s female and male prison populations received í 2013 í 2014 clinical case management services 38% í 2015 35% 36% in general prison settings. A smaller percentage of female and male inmates received enhanced 22% 23% outpatient treatment in a dedicated 19% unit for prisoners with mental illness. 2% 2% 3% 2% 2% 3% Clinical Case Enhanced Outpatient Clinical Case Enhanced Outpatient Management Services Services Management Services Services Female Male Notes: Clinical case management services are provided by a clinician who assists the inmate to access prison services, provides individual and group treatment, and monitors and tracks how the inmate is progressing. Enhanced outpatient services are housed in a dedicated unit structured to manage serious mental illness with functional problems. These services often help transition an inmate from a hospital or crisis program. Male inmates includes those in the general population, and excludes those in high-security and reception facilities. Source: By special request COMPSTAT DAI Statistical Report - 13 Month for Females and for General Population - Males, Department of Corrections and Rehabilitation, received May 12, 2016. CALIFORNIA HEALTH CARE FOUNDATION 49 Mental Health State Hospital Patients, by Type Criminal Justice System California, FY 1996 to FY 2014 California’s state-operated hospitals NUMBER OF PATIENTS admit people who have been 7,000 committed for involuntary treatment 6,086 by civil courts because they are a 5,971 6,000 danger to themselves or to others, 5,767 and people committed to hospital care 5,000 by criminal courts (forensic patients). 4,000 In the mid-1990s, similar numbers 3,661 Total Patients of people were committed by civil Forensic Patients 3,000 2,425 Civil Patients and criminal courts. Since then, commitments from criminal courts 2,000 have increased to account for over 1,000 95% of all commitments. 204 FY 1996 FY 1998 FY 2000 FY 2002 FY 2004 FY 2006 FY 2008 FY 2010 FY 2012 FY 2014 Notes: Data are a count of patients admitted to California state hospitals during fiscal years (FY) 1996–2014. Forensic patients are those sent to the Department of State Hospitals (DSH) through the criminal court system, who have been committed or have been accused of committing a crime linked to their mental illness. Civil patients are involuntarily committed to DSH from civil courts because they are a danger to themselves or others. Source: Department of State Hospitals Forensic vs. Civil Commitment Population, California Health and Human Services Open Data Portal, chhs.data.ca.gov. CALIFORNIA HEALTH CARE FOUNDATION 50 Mental Health Involuntary Detention, by Category and Region Criminal Justice System California, FY 2014 DETENTIONS PER 10,000 POPULATION Courts can order involuntary inpatient Central 33.6 hospital treatment for people in 20.7 Coast 11.2 í 72-Hour Evaluation/Treatment Adults mental health crises who are a danger Greater 47.6 Bay Area 24.3 í 72-Hour Evaluation/Treatment to themselves or others, but do not 15.7 Children 29.1 í 14-Day Intensive Treatment Inland 26.7 agree to treatment. California regions Empire 14.3 Los Angeles 72.7 used this option very differently, 35.9 County 35.9 with Los Angeles County and the Northern 13.1 0 Sacramento region using it at high and Sierra 4.2 Orange 27.3 rates, while Northern and Sierra, 11.2 County 8.9 63.1 Orange County, and San Joaquin Sacramento 53.3 Area 16.5 Valley using it at the lowest rates. San Diego 50.6 30.7 Area 6.8 San Joaquin 45.5 6.7 Valley 16.0 0 CA AVERAGE: 18.9 25.5 49.3 60 70 80 Notes: If a person becomes a danger to self, a danger to others, or gravely disabled due to a mental disorder, a court may order that person to undergo up to 72 hours of evaluation and treatment in an inpatient psychiatric unit. If the person remains dangerous at the end of 72 hours, an additional 14 days of intensive inpatient psychiatric treatment may be ordered by the court. Population was an average of 2013 and 2014 projections to correspond to DHCS methodology and the reporting year, which included both 2013 and 2014. Fiscal year (FY) refers to July 1 of previous year through June 30 of stated year. Sources: Author calculations based on California Involuntary Detentions Data Report, Fiscal Year (FY) 2013–14, Department of Health Care Services, and “Report P-3: State and County Total Population Projections by Race/Ethnicity and Detailed Age 2010 through 2060 (as of July 1),” in P-3: State and County Projections Dataset, Department of Finance, www.crf.ucdavis.edu. CALIFORNIA HEALTH CARE FOUNDATION 51 Mental Health Counties Implementing Laura’s Law (as of June 30, 2017) Criminal Justice System Del “Laura’s Law” established the option Norte Siskiyou Modoc for California counties to adopt Trinity Shasta Lassen assisted outpatient treatment (AOT). Humboldt Tehama Plumas AOT provides court-ordered treatment Butte Mendocino Glenn Sierra in the community for people with Nevada Colusa Sutter Yuba Placer Lake Yolo El Dorado severe untreated mental illness and Sonoma Alpine Napa Sacra- mento Amador Marin Solano San Calaveras a history of violence or repeated Contra Tuolumne Mono Costa Joaquin San Francisco Alameda Stanislaus Mariposa hospitalization. It has been used San Mateo Santa Merced as an alternative to court-ordered Clara Madera Santa Cruz Fresno San Inyo Benito Tulare hospitalization and as a bridge to Monterey Kings maintain psychiatric stability after San Luis Obispo Kern discharge from hospitalization. San Bernardino Santa Barbara Ventura Los Angeles Orange Riverside San Diego Imperial Sources: Mental Illness Policy Org, “County by County Information,” accessed on October 11, 2016, mentalillnesspolicy.org. Further detail obtained from various newspaper sources. CALIFORNIA HEALTH CARE FOUNDATION 52 Mental Health Methodology for Estimates of Prevalence of SED and SMI Prevalence estimates for serious mental illness and serious An additional adjustment was made to account for population emotional disturbance were developed by Dr. Charles Holzer size as estimated by the California Department of Finance. using a sociodemographic risk model. Serious mental illness ABOUT THIS SERIES Dr. Holzer’s estimates of serious emotional disturbance (SED) (SMI) is defined as a composite variable including diagnosis The California Health Care Almanac is an online in children are based on studies commissioned by Substance of a mental disorder excluding schizophrenia/psychosis and clearinghouse for data and analysis examining Abuse and Mental Health Services’ Center for Mental Health at least 120 days of impairment in the past year. When days the state’s health care system. It focuses on issues Services and published in the Federal Register. The Center for of impairment are not available, a score of 7 on the Sheehan of quality, affordability, insurance coverage and Mental Health Services’ definition of SED is “persons from birth Scale, which measures the extent to which a mental disorder the uninsured, and the financial health of the up to age 18, who currently or at any time during the past interferes with home management (like cleaning, shopping, system with the goal of supporting thoughtful year have had a diagnosable mental, behavioral, or emotional and taking care of the house); a person’s ability to work, form planning and effective decisionmaking. Learn disorder of sufficient duration to meet diagnostic criteria or maintain close relationships with other people, and/or have specified within DSM-IVR that resulted in functional impairment more at www.chcf.org/almanac. a social life; or by the number of days that activities are limited which substantially interferes with or limits the child’s role due to the disorder, is used. or functioning in family, school, or community activities. . . . AU T H O R The National Institute of Mental Health’s Collaborative Functional impairment is defined as ‘difficulties that substantially Wendy Holt, MPP, Principal Psychiatric Epidemiology Surveys (CPES) are the basis for interfere with or limit a child or adolescent from achieving or DMA Health Strategies estimating risk of serious mental illness. CPES combines three maintaining one or more developmentally appropriate social, nationally representative surveys: behavioral, cognitive, communicative, or adaptive skill.’’’ •• National Comorbidity Survey Replication (NCS-R) Dr. Holzer’s estimates are based on estimated rates of SED •• National Survey of American Life (NSAL) prevalence for children in families above and below the •• National Latino and Asian American Study (NLAAS) federal poverty level applied to the poverty and nonpoverty populations in each county using the 2015 ACS adjusted to the CPES provides data on the distributions, correlates, and risk population estimates of the California Department of Finance, F O R M O R E I N F O R M AT I O N factors of mental disorders among the general population, with excluding children living in institutional or group living settings. special emphasis on minority groups. Analyses of these data sets California Health Care Foundation results in estimates of the risk of mental disorder associated with Dr. Holzer’s estimates were used by the former California 1438 Webster Street, Suite 400 seven demographic characteristics: race, ethnicity, age, marital Department of Mental Health to allocate Mental Health Oakland, CA 94612 status, education, residential status, and poverty. Resulting risk Services Act revenue based on prevalence and by the California 510.238.1040 factors are applied to the demographic characteristics of each Department of Health Care Services in its California Mental www.chcf.org California county using American Community Survey (ACS) 2015. Health and Substance Use Needs Assessment Final Report. CALIFORNIA HEALTH CARE FOUNDATION 53 Appendix A: California Counties Included in Regions REGION COUNTIES Central Coast Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, Ventura NORTHERN Greater Bay Area Alameda, Contra Costa, Marin, Napa, San Francisco, AND SIERRA San Mateo, Santa Clara, Solano, Sonoma Inland Empire Riverside, San Bernardino Los Angeles County Los Angeles SACRAMENTO Northern and Sierra Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, AREA Humboldt, Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yuba Orange County Orange Sacramento Area El Dorado, Placer, Sacramento, Yolo GREATER BAY AREA San Diego Area Imperial, San Diego San Joaquin Valley Fresno, Kern, Kings, Madera, Merced, San Joaquin, NORTHERN Stanislaus, Tulare AND SIERRA CENTRAL COAST SAN JOAQUIN VALLEY INLAND EMPIRE LOS ANGELES COUNTY ORANGE COUNTY SAN DIEGO AREA CALIFORNIA HEALTH CARE FOUNDATION 54 Appendix B: Continuum of Mental Health Care, California 24-HOUR SERVICES OUTPATIENT MENTAL HEALTH COMMUNITY SERVICES ACUTE INPATIENT CARE INPATIENT CARE TYPE OF PROVIDER / LEVEL OF CARE SERVICES INTERMEDIATE/INTENSIVE HOSPITAL/NONHOSPITAL INTERMEDIATE/LONG-TERM RESIDENTIAL Therapists and Psychiatrists in Independent and 4 Group Practice Mental Health Clinics 4 4 Community Mental Health Centers 4 4 4 Specialized Community Providers 4 4 4 (e.g., Assertive Community Treatment) Psychiatric Units in General Hospitals 4 4 Acute Psychiatric Hospitals 4 4 Psychiatric Health Facilities 4 Nursing Home Specialized Treatment Programs 4 Mental Health Rehabilitation Centers 4 4 State Hospitals 4 4 Source: Welfare and Institutions Code sections 5670–5676.5; California Community Care Facilities Act (Health & Saf. Code, div. 2, chap. 3, § 1500 et seq); and Business and Professions Code chapters 5, 6, 13, 14. CALIFORNIA HEALTH CARE FOUNDATION 55 Appendix C: Credentials, Qualifications, and Customary Practices of Mental Health Practitioners, by Profession CREDENTIALS, QUALIFICATIONS, PSYCHOTROPIC PSYCHOLOGICAL TREATMENT CASE REHABILITATION AND CUSTOMARY PRACTICE MEDICATIONS TESTING PLANNING THERAPY MANAGEMENT AND SUPPORT Physicians MD/DO with general licensure as physician 4 4 and surgeon Psychiatrists MD/DO with a specialty in psychiatry, 4 4 4 some with a second specialty in child and adolescent psychiatry Psychiatric Clinical Nurse Advanced practice nurses, with a master’s or 4 4 4 Specialists (CNS) doctoral degree, who specialize in psychiatry Nurses RNs and LVNs with and without specialty 4 4 4 4 psychiatric training, plus licensed psychiatric technicians administer/ monitor only Psychologists Clinical psychologists licensed at the doctoral 4 4 4 level, perhaps specializing in psychological or neuropsychological assessment, including diagnostic test administration, assessment, and treatment recommendations Licensed Independent Master’s level clinicians licensed by the state 4 4 4 4 Clinical Social Workers LICSWs and LMFTs are eligible for (LICSW), Mental Health reimbursement under Medi-Cal and Counselors (LMHC), and Medicare as independent practitioners Marriage and Family outside of a clinic. Therapists (MFT) Occupational Therapists Licensed OT 4 4 4 (OT) Unlicensed Mental Health Mental health workers with high school, 4 4 4 Workers Qualified Under associate’s, or bachelor’s degrees providing the California Medi-Cal (under supervision) care management, Rehabilitant Option rehabilitation, behavior management, mentoring, milieu support, respite, and other supportive roles CALIFORNIA HEALTH CARE FOUNDATION 56 Appendix D: County-Based Public Mental Health System, Financing Detail, FY 2008 to FY 2018 (in millions) FEDERAL FINANCIAL 1991 STATE REDIRECTED 2011 BH OTHER PARTICIPATION 1 REALIGNMENT 2 GENERAL FUNDS 3 MHSA 4 MHSA 4 SUBACCOUNT 5 REVENUE 6 TOTAL FY 2008 $1,266.4 $1,211.5 $738.5 $1,488.2 n/a n/a $368.4 $5,073.0 FY 2009 $1,404.6 $1,072.4 $701.0 $1,117.0 n/a n/a $287.6 $4,582.6 FY 2010 $1,619.2 $1,023.0 $518.0 $1,347.0 n/a n/a $241.6 $4,748.8 FY 2011 $1,799.9 $1,023.0 $619.4 $1,165.1 n/a n/a $193.1 $4,800.5 FY 2012 $1,562.5 $1,097.6 $0.0 $1,029.9 $861.2 n/a $192.5 $4,743.8 FY 2013 $1,465.0 $1,124.0 $0.1 $1,589.0 $0.0 $1,131.0 $207.4 $5,516.4 FY 2014 $1,624.0 $1,185.0 $0.0 $1,235.0 $0.0 $1,129.0 $207.4 $5,522.9 FY 2015 $1,743.0 $1,216.7 $142.5 $1,730.0 $0.0 $1,193.0 $212.2 $6,094.9 FY 2016 $2,227.6 $1,256.1 $0.0 $1,418.8 $0.0 $1,230.3 $213.1 $6,395.9 Estimated FY 2017 $2,252.9 $1,285.5 $0.0 $1,340.0 $0.0 $1,303.4 $219.2 $6,401.0 Projected FY 2018 $2,252.9 $1,330.5 $0.0 $1,340.0 $0.0 $1,396.6 $220.2 $6,540.2 Change FY 2008 to FY 2018 77.9% 9.8% n/a –10.0% n/a n/a –40.2% 28.9% Notes: These figures encompass revenues received or projected to be received by counties in support of the Medicaid and safety-net mental health services they provide. Other public mental health services, such as forensic services in state hospitals and mental health services and medications provided by Medicaid health plans and Medi-Cal fee-for-service, are not included. 1. ederal Financial Participation (FFP) is the federal reimbursement that counties receive for providing specialty mental health treatment to Medi-Cal and Healthy Families Program beneficiaries. The amount of federal reimbursement received by counties F is based on a percentage established for California called the Federal Medical Assistance Percentage (FMAP). Managed care and Early and Periodic Screening Diagnosis Treatment (EPSDT) share of 2011 Behavioral Health Subaccount only. 2. 1991 realignment is the shift of funding and responsibility from the state to the counties to provide mental health services, social services, and public health, primarily to individuals who are a danger to themselves and/or others or who are unable to provide for their immediate needs. Three revenue sources fund realignment: 1/2 cent of state sales tax and a portion of state vehicle license fees and vehicle fee collections. Realignment is the primary funding source for community-based mental health services, state hospital services for civil commitments, and institutions for mental disease, which provide long-term care services. 3. The State General Fund includes revenues from personal income tax, sales and use tax, corporation tax, and other revenue and transfers. Prior to the governor’s FY 2012 Budget Proposal and Realignment II, these funds primarily supported specialty mental health benefits of entitlement programs including Medi-Cal managed care, EPSDT, and Mental Health Services to Special Education Pupils (AB 3632). 4. The MHSA (Proposition 63) is funded by a 1% tax on personal income in excess of $1 million. The primary obligations of the MHSA are for counties to expand recovery-based mental health services; to provide prevention, early intervention services, and innovative programs; and to educate, train, and retain mental health professionals. 5. 011 realignment, initiated in 2011, gives counties the funding responsibility for Medicaid EPSDT and mental health managed care. It is funded by 1.0625% of the sales tax. In FY 2011–12, MHSA funded realigned mental health services. 2 6. ther revenue is from county property taxes, patient fees and insurance, the Substance Abuse and Mental Health Services Mental Health Block Grant, other grants, etc. The primary obligation of counties is to fund mental health services sufficiently to O meet maintenance-of-effort requirements to qualify to receive realignment funds. Sources: Financial Report, Mental Health Services Oversight and Accountability Commission, January 26, 2017, mhsoac.ca.gov. CALIFORNIA HEALTH CARE FOUNDATION 57