Iowa commission suggests mental health policy changes

The report comes around a year after an overhaul to the state's Mental Health and Disability Service (MHDS) regions, which centralized funding for the groups and jeopardized the service model of many in the process. Members of the Southeast Iowa Link (SEIL) region were among the most vocal opponents to that change.

"There have been extraordinary changes to the MHDS system over the last two years," the commission report said. "We urge all stakeholders to recognize what has been accomplished and renew their commitment … to ensure that our MHDS system has adequate and predictable resources to meet the challenges of transition and growth, and to achieve high quality and long-term stability."

Evaluation identifies gaps in psychiatric care

The report evaluated the work of mental health actors around the state, identifying several areas of achievement in the last two years.

The document said MHDS regions were performing above par, overall.

"The MHDS Regions continue to surpass expectations in the development of core and additional core," it said. "(Reforms) moved Crisis Services into the core service domain, and are now a requirement of the regional service array such as Mobile Response, 23-hour observation, Crisis Stabilization and Subacute Services."

Specifically, the document also highlighted expanding core services for children, and tiered psychiatric care reimbursement rates as areas of positive impact.

The report said some parts of the system, however, were underperforming, leaving gaps in Iowans' mental health care.

Behavioral health workforce shortages, red tape between Managed Care Organizations providing health care, and inconsistent treatment costs were among the problems identified.

Regional gaps in mental health care access are another pressing concern. Commission members said fractured provider networks made the problem worse.

"Siloed services related to brain injury (BI), intellectual disabilities/developmental disabilities (ID/DD) and addictions contributes heavily to this issue," the report said. "Most MHDS Regions do not fund BI services, and BI is not recognized as a multi-occurring condition with serious mental illness (SMI) or addiction services."

The resulting lack of intensive psychiatric hospital beds means individuals with more "complex care needs" are often pushed into non-specialized, less helpful facilities, according to the report.

"That shifts responsibility for acute care settings to the community hospital network, which currently lacks the ability to appropriately treat individuals with severe multiple complex needs," the report said. "The Legislature has sought to address this issue with … tiered reimbursement rates for inpatient psychiatric care, but it continues to be a concern."

Policy recommendations focus on workforce, children

The biannual report made a six-point list of policy recommendations for legislators, with items including regional flexibility, insurance rules and data infrastructure. Other points, however, prompted more detailed calls to action.

The commission said lawmakers needed to address a workforce shortage in mental health fields for professionals, paraprofessionals and direct support workers.

"The shortage of psychiatrists and other prescribers, and the barriers to accessing acute psychiatric care in our state are still readily apparent," the report said. "In addition, the ability to hire and retain therapy providers continues to be a significant workforce challenge."

The group recommended incentive programs, both to keep professionals trained in the Hawkeye State, and to attract them from elsewhere. Such an approach would combine with efforts to raise wages and benefits for the state's providers, another consideration encouraged by the group.

"Professionals indicate that effective incentives include loan forgiveness programs and opportunities for fellowships," the document said. "Such programs could be targeted to specific professionals and specialties that are most needed. Current loan forgiveness programs are restricted to areas that are designated as 'Health Professional Shortage Areas' and should be expanded."

The report also discouraged noncompete clauses for mental health care providers and agencies, which it said, "reduces available workforce and restricts access, especially in rural areas."

On another issue, officials said the state needed a more robust system for children with mental health and developmental disabilities.

The report said such a system would need to align with Family First legislation, and remain evidence-based.

"Early intervention and prevention are essential to reduce the incidence, prevalence, personal toll, and fiscal cost of mental illness, intellectual disabilities, and developmental disabilities," it said. "Actions by the Governor and the Legislature in creating a system of care for children with behavioral health needs was a first step in providing for the needs of children with disabilities in Iowa.

"Expansion to include the development and management of a system of care for children in other diagnostic groups by the MHDS Regions is paramount. In addition, the Legislature must ensure that the state continues adequate funding for this system."

Money still matters

As with most things, the availability and stability of funding were among the most frequently-discussed matters of the MHDS report.

The commission said lawmakers could expect the financial needs of the MHDS system to grow, recommending a 3.25% increase in funding, mostly to account for inflation.

Addressing monetary problems would require attention to a variety of issues at once, according to the report.

"The Commission recommended addressing Iowa's MHDS workforce shortage with a multi-pronged approach which include the evaluation of the sufficiency of all Medicaid fee schedules and increasing the maximum allowable fund balance for Iowa's MHDS Regions," it said. "The Commission also encouraged the Department to support fully funding the standing state appropriations for the regional mental health services."

Another point of contention: carryforward money. A law passed in 2021 would only allow regions to carry over 5% of their funds from one fiscal year to the next, starting in 2024. The commission said that was insufficient.

"We believe that good business practices require 45 days of operating capital, which equates to an 18% fund balance versus the 5% that is currently in Iowa Code," the report said. "Failure to make this change could negatively impact the ability to fund services and the salaries of those providing services."

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