by Rick Ybarra
A recent GAO report has shed light on our progress (or lack thereof) in delivering effective care and bending the cost curve. It is well worth the read, especially with an eye on what strategies can be implemented to address providing care with the aim (that’s the Triple Aim) of improving population health, increasing the public’s engagement and satisfaction with their health care, and cost-effective health care delivery!
Healthcare spending studies generally find that a small percentage of individuals account for the majority of health care expenditures, and Medicaid is no exception. The GAO report states that Medicaid expenditures for fiscal year 2013 totaled approximately $460 billion, covering about 72 million people, some of whom were also dual eligible (eligible for both Medicaid and Medicare).
What the GAO found
A small percentage of Medicaid-only enrollees (not eligible for Medicare) consistently accounted for a large percentage of total Medicaid expenditures. In each fiscal year from 2009 through 2011, the most expensive 5 percent of Medicaid-only enrollees accounted for almost half of the expenditures for all Medicaid-only enrollees. Other takeaways from the report include:
- The most expensive one percent of Medicaid-only enrollees in the nation accounted for about one-quarter of the total expenditures for Medicaid-only enrollees.
- The most expensive five percent accounted for almost half of the expenditures.
- The most expensive 25 percent accounted for more than three-quarters of the expenditures.
- In contrast, the least expensive 50 percent accounted for less than 8 percent of the expenditures.
What can we learn from this GAO report…and what we already know?
It is important to note that states vary widely in the distribution of their expenditures among service categories, so each state will need to do a further “drill down” analysis to determine utilization and costs. That said, this data reflects the continuous trend of a small percentage of persons with chronic (and often multiple) physical and mental/behavioral health conditions consistently accounting for the large percentage of total health care (and Medicaid) expenditures.
Since the report falls short of offering solutions, I’ll take this opportunity to offer mine.
The positive news is that a growing body of research and evidence shows that integrating, or systematically coordinating, physical and behavioral health care to treat the whole person can improve health outcomes. In addition, there are evidence-based approaches and models to effectively treat mental health conditions like depression. Because depression is a highly treatable but often under-recognized or under-diagnosed condition, health care programs and services should adopt an integrated health care approach to the delivery of care, to include the coordination of care across providers and components such as depression screening and evidence-based treatment. By screening for mental health conditions, effectively coordinating care, having psychiatric consultation available and providing stepped treatment with a focus on health outcomes, health care providers will have the opportunity to achieve positive health outcomes. Let’s take what is working with some of the payment reform pilots taking place in other states (Missouri, Oregon, Arkansas, and Colorado) to put that into action and evaluate the results.
State policy makers need to hold state leaders accountable for delivering effective health care, using evidenced-based approaches and controlling costs. State agency leaders should take bold action to pilot, implement and evaluate promising solutions to address this health care dilemma. State agency leadership should also work with contract providers to adopt IHC as a standard of care and identify common metrics to evaluate health outcomes, program effectiveness and cost savings.
These are complex state-level challenges, so it holds true that these challenges will require state-level solutions.
Perhaps the next GAO report will be more positive in demonstrating an improvement in the delivery of health care and less costs to the Medicaid system. We can surmise what the next report will reveal if we do not make policy, program and practice changes to how health care is delivered: poor health outcomes, ineffective care being delivered and significant costs to public programs. Follow the money….
The Hogg Foundation for Mental Health is excited to announce that for the entire month of May, videos by the Austin-based Mental Health Channel, a web-based network devoted exclusively to producing short documentaries/webisodes about mental health, will be featured in the Daily Special section of our Mental Health Daily news services. Their mission, as stated on their website, is simple: “engaging, enlightening, informative programming, commercial free, to help all viewers improve their mental health.” They went live last summer, and we were immediately impressed by their passion and commitment to quality storytelling. To get a taste, check out a video they produced last August titled, “Ride to Live,” about the 23-23 Combat Veterans Motorcycle Association.
“Mental Health Channel is a fresh face on the mental health news scene, and a very welcome one,” said Dr. Octavio N. Martinez, Jr., executive director of the Hogg Foundation and associate vice president for diversity and community engagement at The University of Texas at Austin. “We are looking forward to a mutually beneficial partnership and being inspired by their approach to informing and engaging the public on issues that we care about.”
To subscribe to our Mental Health Daily, visit this link. Happy viewing!
This past month the Hogg Foundation launched an RFP for a new grant program, “Trauma-Informed Approaches to Behavior in Schools.”
You can read the details of the program in the RFP but, for me, the easiest way to think about it is to consider one of the basic cycles that perpetuates the “school-to-prison pipeline.”
Students who have experienced trauma at home are more likely to get in trouble at school. When schools respond to behavior problems with exclusionary and punitive discipline, it can exacerbate the feelings of anxiety, alienation, and disregulation that were often behind the problems in the first place, which can then lead to more behavior problems and more discipline. Students who are suspended or expelled from school, in turn, are more likely to end up in the juvenile justice system.
This cycle looks even more tragic when we consider a few additional facts: Poor students are more likely to experience trauma in the first place and are less likely to receive treatment if they do. African-American students, a disproportionate number of whom are poor, are on average more harshly disciplined than students from other groups. And students in special education are more likely to be more harshly disciplined.
What you have, then, is a system set up to take the students who are already confronting the most significant emotional, economic, and structural challenges to success and put more obstacles in their way.
What we’re hoping to do, in a small way, is to help interrupt and invert that system. Let’s help schools become a site where trauma is recognized and understood with compassion, and where the primary goals of disciplinary encounters are the building of resilience and the healing of trauma to promote better educational outcomes rather than the “fixing” of “bad behavior.”
This is not a new concern for us, or for me. The Hogg Foundation’s engagement with the mental health of children goes back 75 years to the birth of the foundation, and to the concerns of our founder and benefactor, Ima Hogg.
In the past decade, we have zeroed in, in particular, on the impact of untreated trauma in school children, particularly related to school discipline.
In 2005, for example, we conducted preliminary research and published a brief report titled School Discipline and Children with Serious Emotional Disturbances. The analysis of Public Education Information Management System (PEIMS) data showed racial and ethnic disparities in school discipline as well as disparities by special education status.
One of our policy grantees, Texans Care for Children, published a report in 2014 on the likely benefits to Texas school children if school districts were to replace exclusionary and punitive disciplinary models with the Positive Behavioral Supports and Interventions (PBIS) model.
Since 2011, I’ve taught a graduate seminar at the University of Texas at Austin on the school-to-prison pipeline and, more recently, mental health and social policy. A number of the papers written in those classes address the connections between trauma, childhood and adolescent development, and the school-to-prison pipeline.
The new grant program is also connected to a great deal of work that our parent division at the university, the Division of Diversity and Community Engagement, is doing to boost the odds that the growing number of children from underrepresented groups who are entering the Texas educational pipeline get both the opportunity to enroll in college and the chance to thrive there.
As you’ll see in the RFP, we’re not expecting schools to solve all of the problems of trauma, economic inequality, and discrimination on their own. These are massive, systemic, social wounds that will require the attention of people and groups at every level of society, over decades, if they’re ever to be healed.
What we are hoping, however, is that we can help schools achieve better educational outcomes by implementing evidence-based practices or promising emerging practices and transforming from a site where problems are often exacerbated into a site where trauma is seen and compassion rules.
It won’t be easy. Changing the culture and practices of any organization is hard work. But it’s doable, and it matters.
by Ike Evans
The Hogg Foundation does its part to combat damaging stereotypes, particularly those that affect persons with mental health conditions. Stereotypes and stigma go hand-in-hand. Not only are they antithetical to effective, person-centered treatment, but they pose an ongoing challenge to those in recovery, who must somehow forge a hopeful identity while navigating a world filled with preconceived ideas about who they are, what they can do, and how they can be. It’s no wonder that our Language Matters brochure is one of our most requested publications. The dual monster of stereotypes and stigma is a destructive force for the countless thousands with a stake in our mental health system, as well as a factor that complicates the best efforts of people to achieve meaningful recovery.
All of this makes stereotypes, and their psychologically debilitating effect on marginalized groups, a worthy topic for Into the Fold. Dr. Kevin Cokley, a member of the Hogg Foundation National Advisory Council and director of The Institute for Urban Policy Research & Analysis at the University of Texas at Austin, has recently authored a book, The Myth of Black Anti-intellectualism, in which he challenges commonly held beliefs about black attitudes toward academic achievement. In particular, he takes aim at the Acting White hypothesis — i.e. the notion that black youth discourage academic achievement among their peers by accusing such peers of “acting white,” and that this is uniquely to blame for lower levels of achievement among black students.
In the latest episode of the podcast, Dr. Cokley not only discusses the book but also breaks down stereotype threat, the observed phenomenon in which the pressure of disproving a stereotype about one’s social group can actually undermine that individual’s performance on standardized tests and other cognitive tasks. For younger African Americans whose self-concept is still taking shape, the implications are profound:
When I teach, for example, my Psychology of African American Experience class, and I have a section on education and I talk about stereotype threat, for many African American students there’s sort of like this “Ah-ha!” moment, like I’m naming something that they have felt for a long time, but they didn’t know there was a name for it, they didn’t know that there was research to describe what they were feeling.
In addition to his scholarship, Dr. Cokley has also come into his own as a savvy commentator on popular culture, as attested by his recent articles in Huffington Post and American Prospect. I couldn’t resist snagging that Bill Cosby piece for Mental Health Daily!
Click the logo to reach the Into the Fold feed on iTunes. The latest is Episode 10. You can also listen to the audio here.
Many thanks to Dr. Cokley for agreeing to be interviewed, and we hope you like the episode. As always, thoughts and feedback are appreciated.
Carey S. Pulverman, a doctoral student in the Department of Psychology at The University of Texas at Austin, was selected to receive the 2015 Frances Fowler Wallace Memorial for Mental Health Dissertation Award by the Hogg Foundation. The award will go to support research expenses for her dissertation on the relationship between childhood sexual abuse, depression and post-traumatic stress disorder in women.
Frances Fowler Wallace, the award’s namesake, was married to John Forsythe Wallace, who served as a member of the Texas House of Representatives and the State Board of Control. She died July 18, 1972, in Austin at the age of 80. The Wallace Award provides partial support for doctoral students’ dissertation research on “the cause, treatment, cure, and prevention of mental disease, mental illness, and mental disorders,” as directed in her will. The award provides up to $1,500 for research-related expenses.
“As a community, we are just beginning to understand the mental health effects of trauma, and there is an urgent need for the kind of research Ms. Pulverman is doing,” said Dr. Octavio N. Martinez, Jr., executive director of the Hogg Foundation.
We spoke with Pulverman about her research.
- Tell us about yourself. At what point did you decide to pursue a career in mental health research, and what influenced that decision? I had always been interested in psychology because I think human behavior is fascinating, but in college I got a little scared off by the hard science aspects of the field. I majored in urban sociology, which was an adventure in itself, and then worked in that field for a couple of years before going back to school to get my Masters in psychology. Then I applied to doctoral programs in clinical psychology.
- Your dissertation is titled, “The Relationship Between Depression, Post-traumatic Stress Disorder, and Sexual Dysfunction Among Women with a History of Childhood Sexual Abuse.” What questions are you trying to answer with this work? This project will examine depression and PTSD as mediators of the relationship between a history of childhood sexual abuse and sexual dysfunction in adulthood. The exact relationship between depression and PTSD, which are very common after sexual abuse, and sexual problems, is not well understood. A better understanding of this relationship will help psychologists design better treatments for this constellation of related disorders.
- What led to your taking a professional interest in this particular topic? I have been interested in sexual assault prevention and education since I was a sophomore in high school, and now my research focuses on the impacts of sexual assault on women’s mental and sexual health. Sexual abuse is a horrific crime that usurps a person’s control over his or her physical integrity. Survivors often struggle with the negative effects of abuse for a lifetime, and I hope to have a career focused on bringing more attention to these problems and on developing new treatments for this under-served group of women.
- How do you think your research methods and approach will help you to answer the questions that you’re posing? My research methods involve a laboratory manipulation to increase sexual arousal, which is followed by an assessment of women’s appraisal or evaluation of their arousal. It is possible that sexual arousal leads to negative affect among women with a history of abuse, which might then lead to depression and PTSD. Avoiding sexual experiences may be one way to try to manage depression, but is also an approach that contributes to sexual problems. Study participants also complete self-report questionnaires on their mental and sexual health. I plan to use my data to examine the interplay between these many different mental and sexual health variables.
- Are there any suggested readings you can recommend for those who might be interested in learning more about this topic? Yes! For academic papers I recommend:
Rellini, A., & Meston, C. (2007). Sexual function and satisfaction in adults based on the definition of child sexual abuse. Journal of Sexual Medicine, 4(5), 1312-1321.
Meston, C. M., Rellini, A. H., & Heiman, J. R. (2006). Women’s history of sexual abuse, their sexuality, and sexual self-schemas. Journal of Consulting and Clinical Psychology,74(2), 229-236.
For women struggling with sexual difficulties I recommend these self-help books:
Maltz, Wendy. (2012). The Sexual Healing Journey: A Guide for Survivors of Sexual Abuse.Harper Collins: New York, NY.
Heiman, Julia & LoPiccolo, Joseph. (1988). Becoming Orgasmic. Prentice Hall Press: New York, NY.
Kerner, Ian. (2004). She Comes First. Harper Collins, New York, NY.
by Ike Evans
On the Hogg Foundation website, there are currently six policy briefs that were each authored by a graduate student at The University of Texas at Austin. What else do they have in common? All of the students were either Hogg Foundation graduate research assistants or recently completed an interdisciplinary graduate seminar, “Mental Health and Social Policy,” taught by the foundation’s own Dr. Lynda Frost, director of planning and programs. Though the briefs do not reflect official positions of the foundation, we are happy to share them in hopes that they will further inform policy discussions, decision making, and smart action on complex issues in mental health policy in Texas.
Over the coming weeks, we will be featuring Q&A interviews with the graduate students in this blog space. This first interview is with Margo Johnson, a master of social work candidate in the School of Social Work at UT Austin. She opens up about her work in the area of unaccompanied immigrant children and their mental health needs.
Tell us about yourself. At what point did you decide to pursue a MSSW, and what influenced that decision? I am a native of Tucson, Arizona. I transplanted to Texas in 2011 to work at an emergency homeless shelter for immigrants and refugees called Casa Marianella. I had spent several years prior researching and working in different countries in Latin America, and decided to explore how I might be able to support the needs of immigrants living in the United States. I decided to pursue a MSSW at UT Austin as a result of my work at the shelter. I realized that through a graduate education in social work I could build the necessary clinical skills, leadership capacity, and networks to continue a career challenging the deeper issues facing vulnerable populations.
Your brief is titled, Responding to the Unmet Trauma and Mental Health Needs of Unaccompanied Immigrant Children in Texas. What questions are you trying to answer with this work? What led to your taking a professional interest in this particular topic? I decided to write this brief because I saw a need for the conversation in Texas. I noticed that the trauma and mental health needs of these children were being lost in the larger rhetoric of border security, often accompanied by strong anti-immigrant sentiments. I wanted to bring together the literature on the experience of forced child migration with what we know about childhood trauma and resilience. I was also driven to write the brief due to the time sensitive nature of the topic and projections for unaccompanied child migration to continue in the future. I believe that it is imperative that we proactively create systems that can support the mental health and trauma needs of the newest members of our country.
Are you interested in engaging in the policy process (local, state, federal) in other ways in addition to your academic work? Are there people or organizations you consider champions your issues? I am interested in bringing rigorous research and stories of human experience into the policy process to root legislative work in the real needs of our communities. Related to the specific issue of the mental health and trauma needs of unaccompanied immigrant children, I believe that any organization that works with children or mental health should consider how to build support systems for this specific population. The Immigrants Services Network of Austin is an example of a collaborative network that I have worked with to share these findings and champion the issue.
Are there any resources that you can recommend for those who might wish to learn more about the topic? Literature on the experiences and needs of unaccompanied immigrant children is still being written. The United Nations and Conference of Catholic Bishops have both produced well-researched reports on the most recent trends. The National Child Traumatic Stress Network is another resource for information of the impacts of childhood trauma and evidence-based interventions.
How do you plan on using what you learned while authoring your brief in your future work? What are those future aspirations? I want to continue to engage in cross-sector conversations about how to meet immigrant needs in Austin and Texas. I will be completing graduate school in the next few months and re-entering the professional sphere, hopefully in an emerging leadership role in the non-profit, public, or socially conscious for-profit sectors. I am particularly interested in bringing both participatory research frameworks and social enterprise principles into my work with immigrants and other vulnerable populations.
Our friend and colleague Stacie Bables passed away on Sunday, April 5th, after a long fight with ovarian cancer. Stacie, who joined the foundation in 2006 as assistant director of finance and operations, always called us her “Hogg family,” and the feeling was entirely mutual.
She was a loving, intelligent, funny, forceful, phenomenal woman, and it was a gift for us to have the time with her that we did. We’ll miss her.
Funeral services will be held at Mount Sinai Missionary Baptist Church in Austin, at 11 a.m. on Saturday, April 11. There will also be a reception with food after the service. Here’s a link to directions: http://www.themount.net/?page_id=60. Dr. Lynda Frost, director of planning and programs, will say a few words on behalf of the Hogg Foundation.
Along with her work for Hogg, her family, friendships, and faith were important to her. She served on the advisory council of Mount Sinai Christian Academy, along with numerous other volunteer and community service activities.
Here is her obituary in the Waco Tribune. Here’s a 2010 staff profile that gives an idea of what made her special. We were delighted that she was able to grace us with her presence one more time, at her birthday celebration on March 27. It was like old times.
For those who would like to do something on a personal level, Stacie’s family is requesting that donations be made in memory of Stacie to the Mount Sinai Christian Academy (http://www.ms-ca.org/web110/default.asp) or to the American Cancer Society (https://donate.cancer.org/index).
We’ll miss you, Stacie.