When the voices in his head become too overwhelming, Kevin Scott heads to the emergency room.
Scott, 54, said he wants regular therapy and medication for his depression and schizophrenia but has had trouble getting either. He said his primary care doctor urged him to seek help through the Los Angeles County Department of Mental Health, but the department just sent him back to his doctor.
“It’s passing the buck,” said Scott, who used to work as a security guard. “It’s the only way to put it. You get frustrated.”
For low-income Californians enrolled in the state’s Medi-Cal program, mental health care is divided. Managed care plans are responsible for covering people with mild to moderate conditions, while county mental health departments treat those with more serious illnesses.
This means that if people have a serious mental illness and then stabilize, they are expected to switch providers, which doesn’t make sense and is not common practice in other areas of medicine, said Bill Walker, Kern County’s director of mental health. “We don’t do that with diabetes or high blood pressure,” he said. “But we do it with psychiatric issues.”
The arbitrary division of labor between private managed care plans and county health departments can leave Medi-Cal beneficiaries like Scott stuck in the middle or bouncing back and forth between two disconnected systems. It also can drive up health care spending because patients often turn to high-cost emergency rooms when they aren’t getting the care they need elsewhere. The problem is that for many people, mental health conditions often are in flux.
“Their psychiatric issues on certain days could be severe and on other days could be moderate,” said Jennifer Kent, director of the state’s Department of Health Care Services, which runs the Medi-Cal program. “There is not a clear line.”
Historically, Medi-Cal’s mental health services were reserved for people with serious conditions, and under the California constitution, that responsibility falls to the counties. Then, in 2014, the state expanded the benefits to include those with mild to moderate conditions. Through Medi-Cal managed care health plans, beneficiaries could receive multiple services, including therapy, psychiatric consultation and medication management.
That same year, under the Affordable Care Act, California expanded Medi-Cal to single, childless adults and those earning slightly higher incomes than the previous rules allowed.
That gave many low-income residents with depression, anxiety and other mental health conditions a chance to get help, said Catherine Teare, an associate director of the California Health Care Foundation. “People have more access to services [than] before, and that’s a plus,” Teare said. (California Healthline is an editorially independent publication of the California Health Care Foundation.)
But the benefit didn’t guarantee collaboration between the plans and the counties, she noted. “There needs to be a lot more done to improve communication and data sharing across the gulf, so people can be managed well.”
Patients often have to navigate the separate systems on their own, which can lead to delays and disruption in care, said Mark Ghaly, a director with Los Angeles County’s Department of Health Services. And on top of mental illness, the Medi-Cal recipients also may be dealing with substance use disorders, homelessness or other problems, he said.
“This adds on another set of challenges,” Ghaly said. “Our systems shouldn’t create additional challenges.”
The new benefit can help people get services, but managing it “presumes that the definitions of mild or moderate or severe are neatly defined,” said Allison Hamblin, a vice president at the Center for Health Care Strategies. “The reality is that it is not that neat.”
Sotha Hok, a Medi-Cal patient who lives in Los Angeles, has bipolar disorder and post-traumatic stress disorder, and he just stopped using methamphetamines about four months ago. Hok, 34, said he went to a few clinics before getting therapy from Exodus Recovery.
He said he is glad to be receiving help for both his addiction and his mental health problems, but he wishes it had been easier to find and manage his care. “The system is kind of broken,” he said.
How managed care plans provide mental health services varies across the state. Some contract with vendors, while others work directly with psychiatrists, psychologists and counselors.
Inland Empire Health Plan manages its own mental health services for enrollees with mild to moderate conditions, said CEO Bradley Gilbert. And if someone has a serious mental illness, the plan links that person directly to a county provider. Strong relationships with county officials and mental health providers help guarantee a smooth transition, he said.
“We never just say to the member, ‘Call the county,’” Gilbert said. “We make sure there is a connection.”
Some counties are collaborating with health plans on other ways to improve care, especially for people who hover between moderate and severe mental illness. For example, they may place primary care doctors in county mental health clinics or mental health practitioners in primary care settings. “Then you completely close the loop,” Gilbert said.
Kent said solutions are limited at the state level because California’s constitution makes clear that counties are responsible for providing specialty mental health services to people with severe illness. Changing that would require a constitutional amendment, she said. But Kent said she is trying to ensure that counties and health plans have clear agreements that help remove barriers to care for patients.
“They are all Medi-Cal recipients,” she said. “It is my responsibility, our department’s responsibility and the counties’ responsibility to deliver those services regardless of who is paying for it.”