Maryland lawmakers seek to remake the state’s health delivery system

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Lawmakers returned to Annapolis last week determined to scrutinize Maryland’s health systems for solutions to structural issues the pandemic highlighted and exacerbated for the state’s most vulnerable residents.

Leaders in the House and Senate are crafting two comprehensive bills addressing the state’s public health and behavioral health systems with study commissions and proposals, including federally qualified clinics for mental illness and substance abuse treatment.

They will work with incoming health secretary Laura Herrera Scott, a physician and deputy health secretary under former governor Martin O’Malley, who inherits an agency with widespread vacancies and a workforce exhausted after three years on the front lines of the pandemic.

The state’s hospitals were at or near full capacity due to staffing shortages as the legislative session opened Wednesday, with patients presenting sicker than pre-pandemic levels and people suffering from mental health crises boarding in emergency departments awaiting beds, according to the Maryland Hospital Association. In the first year of the pandemic, the state had the worst average ED wait times in the nation, data from the Centers for Medicare & Medicaid Services shows.

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While lawmakers made piecemeal changes — expanding testing and vaccine access and requiring implicit bias training for health-care workers — throughout the pandemic, officials say the mounting challenges magnified by the coronavirus demand a comprehensive response.

They want to restore staffing levels to full capacity, fully fund programs proved to help patients and build community services to keep people out of hospitals and the criminal justice system. The bills, which could be introduced in the next week or two, call for a four-year behavioral health study and specific proposals as well as a two-year public health study, lawmakers said.

Joseline A. Peña-Melnyk (D-Prince George’s), chair of the House Health and Government Operations Committee, said the legislation will address structures but also social determinants of health, including financial instability, unreliable transportation, no access to education, and inadequate housing.

Research shows in addition to conditions in which people are born, grow, live, work and age, public health officials should consider the role that structural inequities, such as racism, classism and gender oppression play in health outcomes.

Del. Ariana B. Kelly (D-Montgomery) is spearheading the public health bill, which would create a commission to examine the state’s response to the pandemic and overdose deaths as well as racial and ethnic disparities in maternal mortality and birth outcomes.

The cost will be calculated when the bills are introduced. Lawmakers say the investment will be significant. They aim to draw on the state’s $2.5 billion surplus and $3 billion “rainy day” savings account, although Moore has cautioned that the state cannot afford the more than $2 billion in requests already made to the state government.

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“You either pay now or you pay later and how do you pay? You pay when people commit suicide, when families are not functioning, someone is miserable,” Peña-Melnyk said in an interview.

The pandemic highlighted and exacerbated the mental health crisis, leaving many without the resources to seek help even if the state had enough providers.

“If we don’t do it now, are we ever going to do it?” said Del. David Moon (D-Montgomery), who will shepherd the behavioral health bill in the house. “The need right now is so great and with the funds there at the moment it would be a real shame if we don’t put a down payment on part of this build out.”

In Maryland, 781,000 adults — or 19 times the population of Annapolis — have a mental health condition, according to data compiled by the state chapter of the National Alliance on Mental Illness. Almost 40 percent of Maryland adults reported symptoms of anxiety or depression, in February 2021 one year into the pandemic and about a third were unable to access counseling or therapy, NAMI says.

Behavioral health patients account for about one quarter of emergency room admission, but 70 percent of days spent by patients occupying emergency room beds as they wait treatment elsewhere, according to an analysis by the Maryland Institute for Emergency Medical Services Systems.

Moon said after eight years of trying to reform criminal justice from his place on the judiciary committee, it’s time to turn to the behavioral health system in hopes of keeping people out of court and jail.

The bill would create a commission to figure out where the system is failing patients, create a behavioral health and drug treatment system in all counties for people seeking help and how to train more providers, Moon said.

“That sounds simple but it’s remarkable how far we are from it,” he said.

Mental health advocates are pressing lawmakers to beef up community services through Certified Community Behavioral Health Clinics, federal and state funded clinics that provide outpatient mental health and substance abuse disorder treatment, case management and primary health screening.

Lori Doyle, director of public policy for the Community Behavioral Health Association of Maryland, said the goal is to get people outpatient therapy and services before their condition deteriorates to the point where they end up in a hospital emergency room or jail. Without accessible treatment, patients must rely on inadequate and expensive inpatient psychiatric hospitals, which were set up for long-term care — not a rotating load of patients who, once stabilized, do well with outpatient treatment.

“If you had diabetes, we wouldn’t say the best way to manage your diabetes is to go to the emergency department,” she said. “That’s never the approach we would advocate or think is good except for behavioral health.”

The Hogan administration last year missed a deadline for Maryland to pilot CCBHCs, despite a letter from most of the state’s congressional delegation.

Many states have had success with Certified Community Behavioral Health Clinics, Doyle said. In New York, monthly behavioral health emergency department costs dropped 26 percent; inpatient hospitalizations among adult clients Oklahoma psychiatric hospitals dropped 93 percent and in Missouri emergency department visits fell by 36 percent after three years, according to data compiled by the nonprofit National Council for Mental Wellbeing.

As it stands, most behavioral health clinics lose money because the reimbursement rate doesn’t cover the cost of services, making it difficult for even people with private insurance to locate services.

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That’s the case for Cornerstone Montgomery, a Certified Community Behavioral Health Clinic that sees 3,000 clients annually in Montgomery County and is preparing to add 500 more across St. Mary’s, Calvert and Charles counties, said CEO Cari Guthrie.

The center has access to some federal grant money as a result of the clinic designation and saw hospitalizations among its patients decline as services expanded, Guthrie said — down 59 percent in 2021 from a comparable three-month period in 2018.

“The results speak for themselves across the country,” she said, of the model lawmakers are considering.

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