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Access To Mental Health Services In Frontier AmericaLetter to the Field No. 4by Dennis F. Mohatt, M.A., Table of Contents IntroductionWhile comprehensive healthcare reform at the federal level now appears unlikely, the
healthcare marketplace is nonetheless changing rapidly. The traditional American
healthcare system of independent providers being reimbursed by patients and indemnity
insurers on a fee-for-service basis is rapidly yielding to myriad new payment and delivery
systems, multi-provider networks, and innovative private and public efforts to manage the
care of beneficiaries. This shift toward what is most often called managed care has been a
clear trend in the marketplace for the past decade, and has currently shown a rapid
acceleration of pace (US Congress, Office of Technology Assessment [USC-OTA], 1995). The
trend is especially evident in the public sector, where 42 states have received approval
from the federal Health Care Financing Administration (HCFA) for various managed care
approaches to Medicaid (WAMI Rural Health Research Center [WAMI], 1994). The rural implications of this trend have not been empirically established, due to a
lack of rural-specific managed care experience and the rapid evolution of managed care
strategies. Rural issues that may impact the development of managed care have however,
been clearly illuminated in recent years. Limited access to and availability of
appropriate mental health care for rural residents are just two examples. These issues
take on new meaning and are even more dramatic in isolated "frontier" areas of
the United States. Murray (1990) testified at a regional field hearing on rural mental
health that "we are beyond needing to argue that there are rural human resource
shortages or that rural practice is unique and presents a special set of demands on
professionals; solutions to these problems need to be provided." This is particularly
true in our evolving efforts to reform the healthcare system through the imposition of
managed care strategies, and imposed funding growth ceilings for federal spending in
Medicare and Medicaid. Some are already concerned that managed care efforts, instead of providing for more
affordable and accessible services, will further limit already sparse mental health
services in rural frontier areas (T. Perkins, personal communication, 1995; J. Fowler,
personal communication, 1995; K. Quint, personal communication, 1995). While others
(Korczyk, 1994) believe managed care may actually be more effective than the current
system in enhancing health care access for rural populations, they also feel it will be
less effective in reducing the cost of care to rural populations. Korczyk believes rural
residents will probably have greater access to primary care under managed care, but will
need to utilize urban resources for more specialized care at a greater cost. Serrato and
Brown (1992) suggest, from their review of the Medicare system, that rural areas are
typically underserved and not a source of high cost. As a result, they believe, emphasis
can be placed upon increasing access in rural areas, rather than on controlling costs.
Clearly the need is critical to better understand the impact of such dramatic system
change on accessibility and availability of services in behavioral health systems serving
remote frontier populations. Aday and Anderson (1974) assert that "access may be defined as those dimensions
which describe the potential and actual entry of a given population group to the health
care delivery system." In reviewing existing literature, three spheres of access seem
to impact individuals seeking health and/or mental health services. The special issues of
rural frontier environments impact all three spheres. The first sphere is financial access
to care, how the care for an individual in need is funded. The second sphere is physical
access to care, not to be confused with availability, which relates to how a person
directly links with the caregiver. The third sphere is psychological access, which is the
actual acceptability of the caregiver, treatment setting, and modality of care to the
consumer. As access is explored in this paper, all three spheres will be examined.
Finally, availability of services appears to be impacted by the complex interactions of
the distribution of professionals and agencies, the comprehensiveness of a continuum of
services, and the choice of public and private service delivery systems. Current Access to Mental Health Care in Frontier and Rural AreasOver one-fourth of the population of the United States reside in non-metropolitan
areas, and nearly all states have distinct rural populations. These rural Americans
experience incidence and prevalence rates of mental illnesses and substance abuse which
are equal to or greater than their urban counterparts (Wagenfeld, Murray, Mohatt, &
DeBruyn, 1994). They also suffer from chronic shortages of mental health providers and
services which significantly impact the organization and delivery of behavioral
healthcare. Rural and frontier residents are less likely than their urban counterparts to
have access to inpatient mental health services. One study indicates that in isolated,
rural counties inpatient psychiatric services are almost nonexistent (Wagenfeld,
Goldsmith, Stiles, & Manderscheid, 1988). While the data does not look specifically at
inpatient resources in frontier areas, it appears evident that persons residing in these
isolated, low population areas will be least likely to find psychiatric inpatient
resources within their community hospitals. Over sixty percent of rural areas have been designated as federal Mental Health Professional Shortage Areas (USC-OTA, 1990), and many of these are frontier counties. The public mental health system is often the only provider in rural areas and primarily serve persons with serious mental illnesses (Wagenfeld et al., 1994). Frontier areas are often served only by itinerant providers or regionalized systems requiring considerable travel to access most services. As a result, isolated rural residents must travel for substantially longer distances to access a mental health provider, and are much more likely to see a mental health provider with less advanced training than their urban peers (Schurman, Kramer, & Mitchell, 1985; K. Quint, personal communication, 1995). Rural areas are also less likely to offer a full array of behavioral health services (T. Perkins, personal communication, 1995; J. Fowler, personal communication, 1995; K. Quint, personal communication, 1995). For example, while 95% of urban counties have psychiatric inpatient services, only 13% of rural counties have such services, and outpatient services are available in twice as many urban as rural hospitals (Wagenfeld et al., 1988). Frontier settings, with small and widely dispersed populations, often cannot support the economies of scale necessary to maintain specialty services. Additionally, supportive resources such as public transportation, housing, and vocational assistance, which are vital for promoting independence in persons with serious and persistent mental illnesses, are often limited or unavailable in rural areas (Wagenfeld et al., 1994). In sparsely populated frontier areas such as those found in the larger western states
(such as Nevada, Arizona, Utah, New Mexico), consumers may have to travel hundreds of
miles for mental health care (J. Fowler, personal communication, 1995; Quint, personal
communication, 1995). An example of distance as a barrier to treatment was given by a
physician's assistant, Mary, who sought care for depression precipitated by the tragic
death of her only child. Mary was working in an Indian Health Service (IHS) hospital on
the Rosebud Reservation in South Dakota. Her son was killed in a tragic car accident on
the way home from a basketball game. In the weeks following his death, Mary became
increasingly depressed and pondered suicide. Although a range of care was available in
Rosebud's IHS hospital, specialty mental health services were unavailable. As a federal
employee, Mary's health care was reimbursed through the Federal Employee Health Plan
(FEHP); however its nearest approved provider for mental health care was in Rapid City,
150 miles northwest of Rosebud. When Mary finally sought care, it required her to drive
over four hours twice weekly to receive outpatient care. While Mary had the resources and
transportation to seek this care, for many persons the time and travel required to access
care would prove an insurmountable barrier. Catchment areas can also complicate access to services for rural residents. These
service area designations for public mental health providers are often the artifacts or
remnants of the Community Mental Health Centers (CMHC) Act (U.S. Congress, 1963 as
amended). This act initially guided federal efforts to develop community based
comprehensive treatment options across the nation. Although the CMHC Act lapsed in the
early 1980s, replaced by the Mental Health Block Grant (OBRA 1981), many rural catchment
areas endure based upon the acceptable practices of the Act. As a result, the delivery
system for public mental health maintains its ties to county and state policy and revenue
streams, which serve as the conduit for public oversight and revenue. While useful for
public accountability for disbursement and revenue accounting, and implementation of
mental health public policy by the states, these catchment areas often have little if
anything to do with the reality of how persons seek services, which is more likely to
relate to their patterns of trade or commerce. An example of this was clearly illuminated by a consumer from the panhandle region of
Nebraska. The panhandle region is in northwest Nebraska, and is a typical western frontier
area. The consumer routinely travels 120 miles (one-way) to Cheyenne, Wyoming for
everything from groceries to healthcare. Cheyenne is the center of trade and commerce for
the region. However, since her son, who has a serious and persistent mental disorder and
receives public assistance due to this disability, receives his mental health care from
the public sector, he must use a Nebraska provider. This requires regular trips of 90
miles (one-way) in the opposite direction and clearly outside the routine patterns of
trade/commerce for the family. Since the community where the mental health care is
available in Nebraska lacks the services and products routinely accessed in Cheyenne, the
family is forced to make extra trips, incur extra expenses, and often delay or postpone
care due to access barriers (e.g. weather, cost of travel, time). The consumer relays,
"...the solution to this issue for me would be to shop where I want for the services
that best suit me and my family." While the previous example relates to a more complex issue of interstate public policy
and cooperation, the same problem also arises within state boundaries. A family living in
a frontier county in northcentral Montana faces similar difficulties due to county
borders. Their child needed specialized treatment as a result of Serious Emotional
Disturbance (SED). Although the child attended school across the county-line in a small
town (pop. 3,500), only 25 miles from their ranch, the public mental health agency, which
they were required to utilize for care five days per week, was 60 miles in the opposite
direction. Since the provider catchment areas were organized via multi-county
designations, and received county funds, the family would have to seek the approval for
payment of services received outside the area. Rural areas also have disproportionate populations of uninsured and underinsured. As a
result of a large percentage of rural persons being employed in small business or
self-employed, they are more likely to be uninsured or have only "catastrophic"
insurance coverage, which lack behavioral health benefits. Only one-fourth of the rural
poor qualify for Medicaid, compared to 43% of the poor in urban areas (U.S. Senate, 1988).
The combination of professional shortage and limited array of services, coupled with a thin layer of third party payors, creates a fragile continuum of care for rural residents, especially those residing in remote frontier areas. These conditions have traditionally resulted in: 1) rural persons going without appropriate care; 2) rural persons accessing less than timely care, resulting in increased cost and duration of care; 3) rural persons being treated at higher (and more costly) levels of care; and 4) rural persons receiving care at a greater distance from their home and work, resulting in loss of community ties and difficulty in reintegration (Beeson & Mohatt, 1993). Effective health care systems, such as managed care strategies, must address each of these issues to ensure both cost containment and access to quality service in frontier areas. Collectively, these issues make up a "check-list" of potential challenges to the planning, implementation, management, delivery, and evaluation of mental healthcare in rural and frontier settings. These include:
Two Frontier Area ExamplesRural advocates and researchers stress the need to carefully develop our view of rural
America. Rural America is not homogenous. The frontier environment is equally diverse,
with Kewauna County, Michigan being vastly different from Apache County, Arizona. This
diversity has specific impact upon access and availability of services, and the strategies
shaped to address them. Apache County in northeastern Arizona stretches over 350 miles along the New
Mexico border north/south from the Utah border, and is the longest county in the United
States. Its more than 60,000 residents are widely dispersed across 11,211 square miles.
The geography includes high mountains, the fertile Little Colorado river valley, and high
desert. The nearest large metro areas are Flagstaff, Tucson, and Phoenix in Arizona, and
Albuquerque in New Mexico, each of which are many hours away by car. The area is not
served by commercial airlines or public transportation (except for limited specialized
transportation for senior citizens). The county population is predominately Native
American, with the northern one-third of the county dominated by the Navajo Nation. The
county is also home to a small Zuni reservation and a portion of the Whiteriver Apache
Reservation. The remaining quarter of the population is Caucasian or Hispanic. Reservation residents have access to mental health services operated by either the
tribes, Indian Health Service, or sometimes both, as well as community mental health
programs funded by other public and private sources off-reservation. The non-reservation
residents are primarily served by a community mental health program and a minimal number
of private providers who serve the area on an itinerant basis out of Phoenix. Any
inpatient psychiatric treatment must be accessed in a distant metro area. While patterns of trade and commerce in this area cross county, state, and tribal
boundaries, access to outpatient mental health care is primarily limited to defined
service areas. As a result, the issues relating to access to and availability of mental
health care are complicated and complex; involving multiple funding streams, policies and
procedures, governmental and agency boundaries/responsibilities, patterns of trade and
commerce, and last, real cultural diversity relating to mental healthcare and help-seeking
behavior. For example, it is not uncommon for a non-Indian residing on the reservation to
experience a mental health crisis requiring involuntary admission to the State Hospital in
Phoenix. Often they enter the mental health emergency services system through the
intervention of law enforcement. They are on the Reservation, a region larger than some
states, however outside the jurisdiction of either the Navajo Department of Public Safety
or Tribal Court System. Although the Tribal Police may be the initial point of contact,
they must call in either an Arizona state law enforcement officer or county deputy
sheriff, who will then transport the person (under emergency protective custody) to a
secure facility (i.e. jail or hospital emergency room) for emergency mental health
evaluation and, if appropriate, the filing of a petition for involuntary treatment with
the Superior Court. This would likely occur in the county-seat, St. Johns, which may be
anywhere from 1 to 3 hours from the person's residence on the Reservation. Following their discharge from an involuntary hospitalization, it would be highly
unlikely for them to receive aftercare services from the off-reservation mental health
program due to the vast travel distances involved. The Indian Health Service and Navajo
Nation operate mental health programs on the Reservation, however the non-Indian
Reservation resident cannot access care from these systems. Kewauna County in Michigan is at the very tip of the long finger-like Upper
Peninsula reaching out into Lake Superior. An area which is now dependent upon the trade
generated by tourism, it formerly was a center of mining and timber industry. It is one of
the few frontier counties east of the Mississippi, sharing primarily its low population
density with its western frontier peers. The residents of the county do not face the
diversity of jurisdictions or complexity of service delivery responsibilities as those in
Apache County. Instead residents face simple isolation, compounded by winters where snowfall can
exceed 250 inches. The nearest outpatient mental health services are available primarily
through the community mental health provider, an official multi-county authority. The bulk
of the continuum of care is located in Houghton, at least an hour long drive away. The
nearest inpatient psychiatric services are in Marquette, MI, requiring at least a three
hour drive. The population is simply too small and dispersed to support a full array of
community-based services in a cost-effective manner. However, unlike many western frontier
areas, a full continuum of services is available within an hour's drive and in a location
which is a part of resident's routine pattern of trade/commerce. These two counties, one in the southwest and the other in the northcentral U.S., are
representative of the ends of the "frontier spectrum", and between them rests
frontier America. Accessibility and availability to mental health services are strongly
associated with the specifics of the particular place, its culture, and myriad other
factors. Although the county in Michigan's Upper Peninsula is as isolated as many frontier
places, the fact that Michigan ranks second in per capita expenditures for public mental
health (National Association for State Mental Health Program Directors, 1995) makes it
much more likely for these frontier residents to have access to a full array of services
in relatively close proximity. In Nebraska, which ranks forty-ninth, frontier resident's
access and availability is impacted by both isolation and public policy.
- Jeffrey Human, former Director, Federal Office of Rural Health Policy Medicaid and the Emergence of Managed CareCurrently more than 33 million Americans receive their health insurance through
Medicaid. The cost of Medicaid has increased over 400% since 1980 and it absorbs an
average of 16% of state budgets (WAMI, 1994). Congressional efforts to balance the
national budget have seen the emergence of managed care as a strategy (along with spending
ceilings) for controlling the cost of Medicaid. Frontier and rural areas are likely to be
disproportionately impacted by such strategies, since they have proportionately greater
populations of Medicaid and Medicare beneficiaries. The need to control cost is obvious,
and managed care is being embraced as the vehicle to drive cost containment. While the
motive for the move to managed care is clearly cost containment, it is unclear how this
marketplace shift will impact rural and frontier behavioral healthcare where the
challenges are more closely related to access and availability than cost containment. Regardless of the changes which evolve, the focus in rural areas remains trying to
address the same underlying problem always faced in relation to health care: how to keep
local, financially accessible, good-quality care available to rural populations less able
to pay and less efficient for providers to serve (because of low population density) than
their urban counterparts. When not considered in the move to managed care through the
waiver process, the rural issues previously discussed can pose serious barriers to
consumer access. For example, a current 1915b waiver for a Medicaid managed care program for mental
health and substance abuse in a western state contains standards for pre-treatment
assessment and supervision of care that may create significant barriers to consumer access
to treatment. These standards, which are part of the waiver, require a pre-treatment
assessment of all recipients prior to the provision of outpatient care (i.e.,
psychotherapy, day treatment) by a psychosocial intake-diagnostic process. These new
standards require the mental status portion (inclusive of the diagnosis) to be completed
by either a physician or licensed doctoral level psychologist. Furthermore, the standard
requires monthly supervision by a physician or psychologist of all cases where treatment
is provided by other mental health providers (e.g., social workers, counselors,
psychiatric nurses) including a verbal discussion/case presentation. The supervising
professional is also required to have face-to-face contact with the consumer at six-month
intervals. Obviously the intent of such standards, albeit influenced by the political
process, is to ensure quality of care. However, considering that much of the west is rural
and has serious shortages of health and mental health professionals (especially physicians
and doctoral level psychologists), these standards could seriously impede consumer access
to treatment resources currently available primarily via mid-level practitioners.
-Ira Moscovice & Jon Christianson, Health Care Reform: Issues for Rural Areas Provider and System IntegrationThe development of horizontally or vertically integrated provider networks has become a
well established industry response to managed care across the country. It has been
frequently adopted in rural and underserved areas as a popular mechanism for rural
provider response to both access and availability issues. The objective of managed care is
clear: the achievement of cost containment via utilization management. Management of
utilization can best be achieved through systematic protocols for access, level, and
duration of care, which are directly related to the measurement of outcomes. Clearly the
predominant system of public behavioral health care in the United States does not operate
in such an environment. Instead, persons traditionally served by the public system often
go without appropriate care; access care later than desirable resulting in increased cost
and duration of care; are often treated at higher (and more costly) levels of care; and
receive care which is not integrated with their physical healthcare. Integrated networks
seek to achieve the objectives of managed care through collaboration among providers. So what exactly is an integrated network? Conrad and Dowling (1990) define it as
"...an arrangement whereby a health care organization (or closely related group of
organizations) offers a broad range of patient care and support services operated in a
functionally unified manner." When organizations agree to form a network to provide
services, the concept of autonomy for those individual organizations diminishes. Figure 1 outlines the progression from autonomy to integration
which occurs through the formation of a provider network (Rosenberg, 1994). All provider
organizations consist of four functional levels, which are represented in Figure 1:
In most public mental health organizations this translates into:
Developmental Aspects of Network FormationThe process depicted in Figure 1 is indicative of a
developmental process which occurs over time as providers move from independent and
autonomous operation to collaboration. Each stage of development requires ever increasing
interdependence, and the cornerstone of such interdependence is trust. As with any group,
such trust is dependent upon the partners' capacity to adopt a shared vision for mission
and values, and their ability to resolve internal and external conflict. Furthermore, in
establishing a network it is far more important to address issues of "process"
rather than structure. How it works, how it is integrated, and how it communicates is more
important initially than its size, shape, function, and structure (Rappaport, 1977).
Unless such process issues are examined, accepted, and implemented any structural
integration is doomed to failure. For some frontier areas, the establishment of integrated service networks could provide
a solution for enhancing access and availability. However the very culture of
frontier/rural society demands a developmental process sensitive to their desire for local
control and flexibility. In addition, networking in rural and frontier areas is not
without its own special problems. The limited number of providers and basic rural/frontier
demographics mean that if local providers form an integrated service network, the result
may be a monopoly (McKay, 1995), raising serious anti-trust issues. A discussion of two
possible types of integration, vertical and horizontal, for frontier areas follows. Vertical IntegrationVertical integration approaches to managed care seek to network a group of rural
healthcare providers, at various levels of primary care and behavioral health, to form an
integrated service network (Casey, Wellever, & Moscovice, 1994). They seek to develop,
via cooperation, a coordinated, consumer focused, seamless continuum of care designed to
improve access and availability through efficiencies gained by the elimination of
redundant services or systems. A model rural, vertically integrated system is the Laurel Health System in northeastern
Pennsylvania. Laurel was founded in 1989 with the merger of five not-for-profit
organizations: 1) Laurel Management Services, 2) Laurel Realty, 3) Soldiers and Sailors
Memorial Hospital (SSMH), 4) Soldiers and Sailors Memorial Volunteers, and 5) North Penn
Comprehensive Health Services (North Penn). This network spans the human service gamut
inclusive of primary care, nursing homes, senior housing, ambulance service, and hospital.
The continuum of care is focused in Laurel's two major service anchors, SSMH and North
Penn. The merger linked a primary and tertiary health care system serving a balanced
public/private payor mix, with a community health and mental health system which was
heavily government subsidized (six federally qualified rural health centers and the
community mental health program). To accomplish the merger, both major organizations were
forced to, and succeeded in, overcoming a history of rivalry dating back to 1972. Today, Laurel is moving forward in its partnership. In its move toward managed care,
Laurel has turned its planning focus toward the development of a health maintenance or
preferred provider organization (HMO/PPO) option for the local insurance marketplace.
Laurel is seen as a model integrated rural health delivery system, successful in its
mission to provide the community a seamless system of care inclusive of both traditional
health and mental health services. Horizontal IntegrationThe horizontally integrated network brings "same type" providers together to
achieve the advantages of economies of scale, and to position organizations to eliminate
administrative duplication. Access is enhanced through the redirection of resources
formally utilized in redundant, primarily administrative, functions. A recent example of such a horizontal integration is the 1994 formation of Northpointe
Behavioral Healthcare Systems in Michigan's sparsely populated Upper Peninsula. It was
formed as a proactive response to the evolving managed care environment in public sector
mental health. Northpointe was established through the consolidation of two community
mental health programs serving three rural counties. The consolidation allowed the CMHCs
to centralize executive administration, management information, fiscal management, and
human resources for the new entity which employs more than 300 people and serves more than
3,500 consumers annually. Neither CMHC alone would have possessed the capital to effectively build the management
and information infrastructure necessary for a managed care operation. The efficiencies
gained through the consolidation have allowed Northpointe to invest its combined capital
in managed care readiness efforts. The new entity employs centralized intake and
utilization review, coupled with an evolving clinical outcome and consumer satisfaction
assessment system. Northpointe utilized a portion of Michigan law, known as the Urban
Cooperation Act, which allows elements of local government to consolidate to more
effectively meet public needs (previously used primarily to form airport and solid waste
authorities). This act allows Northpointe to establish for-profit and not-for-profit
subsidiaries, and provides the participating county governments legal separation from
Northpointe related risk. ConclusionRural areas present a unique environment for the creation of state-of-the-art
behavioral health care systems, such as managed care. The managed care movement seeks to
contain costs through effective and efficient clinical management, however, it is unclear
how such a system will impact and address the problems of serious underservice in rural
frontier America. While health care in urban settings is characterized by competition,
health care in remote rural areas will likely take on aspects of cooperation due to a
limited number of providers. The formation of both vertically and horizontally integrated
networks has become a common response to managed care in rural health care settings. Despite some existing cooperation, integration, which rests upon an ability for
collaboration and cooperation, faces many challenges in the rural environment. Historic
relationships between providers may often exclude collaboration. Geographic realities of
many frontier regions, where the population is widely dispersed and the service continuum
extremely limited, may mean they simply do not have the resource base to effectively meet
the demands of a managed care approach. Finally, integration poses risks to provider
autonomy. Through collaboration the partners must agree to share authority,
accountability, risk, as well as benefit or loss. In a managed care environment, it is
essential to ensure beneficiaries are linked with both the most appropriate level of care
and provider of care. For an integrated network to succeed, the partners must be capable
of addressing myriad issues arising out of such shared responsibility for utilization and
outcome. As with any group process, the key to success as a cohesive group will be the
member's ability to resolve conflict. The bottom-line has remained constant for decades; Rural and frontier populations are underserved by the health care system in general, and the mental health system in particular. Accessibility and availability are impacted directly by the costs associated with providing a comprehensive continuum of quality care to dispersed population areas. Additionally, the disparity between rural and urban populations in relation to rates of insurance, high-risk populations, and infrastructure makes the enhancement of access and availability especially challenging. Finally, the ability to effectively address access and availability is a complex process which must involve the entire health care system and community. ReferencesAday, L., & Anderson, R. (1974). A framework for the study of access
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