CODY — At a time when most states are struggling to cope with gaping budget deficits, Wyoming legislators earlier this month completed their 2011 session with a $1 billion surplus.
That’s in stark contrast to other states where spending cuts mean everything from lower salaries and benefits for public workers to cuts in essential services, including mental health care. A study released last week by the National Alliance on Mental Illness found that more than a dozen states have cut mental health spending by more than 10 percent over the last three years.
Wyoming faced across-the-board state budget cuts of roughly 10 percent in 2009. But that reduction followed years of booming growth, and a major increase in mental health spending that began in 2007, and which caregivers credit with vastly improving mental health care in the state.
Yet despite the strong current fiscal outlook and overall increased spending and focus on mental health care in recent years, providers and patient advocates say Wyoming continues to face formidable challenges in serving the state’s residents, especially those in crisis who require acute care and patients living in remote, rural areas.
Most residents seeking mental health care in Wyoming are likely at some point to pass through one of the state’s community behavioral health providers. Most counties have a single provider — typically operating as a private, nonprofit facility — which contracts with the state to provide services.
Designated providers must apply to the state for contracts, and are required to charge on a sliding scale based on a client’s ability to pay. They are expected to serve as many clients as possible.
Providers say they are happy about the additional $19.8 million in new funding since 2007 that has been appropriated for mental health and substance abuse treatment across the state. But some say the state’s mental health care system had long been drastically underfunded, and it still requires additional revenues to bring patient care standards to appropriate levels.
“It’s fairly unique and it works,” said Alice Russler, executive director of Yellowstone Behavioral Health Center, of the state’s system of contracting with community providers. “If it could be funded at a good level, it would work very well.”
With 16 clinical staff members, Yellowstone Behavioral Health served about 1,200 clients last year in Park County. In fiscal year 2009-10, YBH took a 7.1 percent cut following statewide spending reductions that affected all community providers.
That could have meant the loss of one or two clinicians, but Russler and her staff decided not to cut personnel, which would have translated to a loss of services to between 50-100 patients for the year.
Instead, they cut general operating costs, including travel and professional development for staff certification.
Russler said the waiting list in Park County is short for children and families, but can run from two weeks to more than a month for adults.
“Economic times are hard and it’s creating stress for a lot of people, and we’ve seen that in our own clients who are accessing services,” Russler said.
Many new clients are experiencing problems coping with the loss of a house or a job, she said, and are people who might not otherwise seek mental health counseling during stable economic conditions.
The rising needs of those patients comes at a time when charitable donations and foundation funding is down.
State contracts for mental health services make up just over 60 percent of the center’s total revenues, Russler said.
Private donations, grants, medicaid, insurance payments and patient payments make up the rest of the operating budget for her facility and others like it in counties around the state.
“Only about two percent of our revenue comes as cash from client payments,” she said.
“If we have another budget cut to that contract, there’s nothing left to cut, so we will have to cut services. There were centers around the state who did cut back in programs,” she said.
Russler said the overall bump in funding since 2007 has helped greatly, but more money is still needed.
“We have had vast, significant improvements in terms of funding infused into the system,” she said. “But all that money brought us up to the level where we should have been years ago. We were way underfunded.”
Absorbing losses
“Last year, about 69 percent of our funding came through state contracts. The rest was client fees, insurance, city/county funding and medicaid,” said David Birney, executive director of Peak Wellness Center, the state’s largest community behavioral health care provider.
Peak Wellness serves clients in Cheyenne, the state’s largest city, as well as in smaller rural communities in southeastern Wyoming.
Last year, Medicaid accounted for about 18 percent of Peak Wellness revenues.
“Last year, overall, we lost about $800,000 out of our budget, which was about $17 million,” Birney said. “We were able to absorb those cuts relatively well.”
The center cut back on case management and skills training to kids, and saw some clients less often.
But compared to 2007, when Birney’s total budget was $14 million, even last year’s cuts left Peak Wellness better off than it had been before the Legislature made mental health funding a priority, he said.
“Our waiting lists are in very good shape,” he said, with most patients able to see a counselor the same day they make first contact.
“The mental health system and the people of this state have been extremely fortunate that the Legislature has been so attuned to these needs,” Birney said.
In March 2005, the Legislature created a new Select Committee on Mental Health and Substance Abuse Services to address what many saw as substandard mental health care and funding in Wyoming.
“I had seen constituents and clients over the years just not get the treatment they needed,” said Colin Simpson, a former state representative who was instrumental in creating the select committee and in securing additional funding for enhanced and new mental health services.
“I knew we could do a better job providing services to people, and I was convinced that the regional system of care was a great way to try and figure out how to deliver services to people within a cost-effective system,” said Simpson, who resigned as House speaker at the end of 2010 after an unsuccessful bid for governor, and is working as an attorney in Cody.
“We weren’t serving people in communities where they needed service, and the service we provided was often very late getting in, or a revolving door. We also had people in our county jails that were concrete holes,” he said, adding that treatment in many jails and hospitals was inadequate.
The adult psychiatric ward at the state hospital was full then, and the facility had lost five psychiatrists in the last three years. Some people sat in the hospital for 10 days with no treatment, Simpson said.
Working with his fellow legislators, staff members from the Wyoming Department of Health and others in the state’s mental health care community, Simpson and the state’s nonpartisan Legislative Service Office launched a comprehensive effort to study Wyoming’s mental health care system, with a goal of developing a regional system of care.
Long-distance care
Too many patients had to travel long distances to get care, and access to resources, when available, was unnecessarily complicated.
The LSO study showed that local care works better and costs less than sending patients to the state hospital, Simpson said.
But despite the increased funding and greater adoption of telemedicine by counselors and caregivers, many in Wyoming still must travel long distances for care, particularly when in crisis.
For Russler’s Park County patients, the closest psychiatric beds are in Lander or Casper, meaning a drive of three or four hours for visiting family members.
As part of a pilot program resulting from increased state mental health funding in 2007, Cloud Peak Counseling Center in Worland just opened the first six crisis beds that northwestern Wyoming’s Bighorn Basin has ever had. But even those beds can mean a two-hour drive for some Park County residents.
“Our choices are limited in Wyoming,” Russler said. “We still have the problem here of no local psychiatric beds for those individuals who are really high-risk.”
For a Lovell resident, commitment to the Wyoming State Hospital in Evanston can mean a seven-hour trip, while a 90-minute drive to a hospital in Billings, Mont. requires a voluntary commitment, because it is outside the state’s jurisdiction.
The Wyoming State Hospital in Evanston is located in the far southwest corner of the state, making it a long drive for family members in distant communities who want to visit patients.
The long drives apply not just to patients, but to caregivers, too.
Russler’s travel schedule shows how the state’s rural nature affects patients, doctors and other mental health care providers.
She has a home in Powell and works 25 miles away in Cody. Her husband, Mark Russler, is executive director of Cloud Peak Counseling Center, in neighboring Washakie County. He works in Worland and has a house 26 miles away in tiny Ten Sleep, a ranching community of 300.
During the week, the Russlers live in separate homes, 120 miles apart. They alternate each weekend, with one traveling to see the other.
“We joke about this with people, but it’s not just a matter of how we provide services, but also how we live,” Alice Russler said.
Birney, the Peak Wellness director in Cheyenne, said that even in the state’s largest city, recruiting a specialist like a child psychiatrist can be “extremely challenging.”
“The pool is very limited. It’s not simply a matter of it being expensive, there just aren’t that many people out there, and only a subset of those people are wanting to come to Wyoming,” he said of qualified psychiatric professionals.
Birney said it’s not uncommon to have to choose a psychiatrist from a pool of eight or fewer total applicants.
Community mental health centers often find themselves competing to recruit staff members during an oil or natural gas boom, which spikes wages for the relatively few qualified workers in small communities.
The recent pace of new oil exploration in southeastern Wyoming has Birney worried.
“If salaries in this area do go up, we will clearly start losing people to other jobs that might be available, which is a real concern for us,” he said.
The state’s sparse population poses other challenges.
Wyoming has never had a mental health parity law governing insurance providers, and its health insurance market is very limited, making for little competition or incentive for insurance companies to fund mental health care at levels comparable to physical ailments, or at similar levels to other states.
The federal Mental Health Parity Act, which became fully implemented last year, requires insurance plans to cover mental illnesses to the same degree as physical illness, but the law does not apply to health plans covering fewer than 50 employees, leaving many Wyoming small business workers outside that provision.
Birney and Russler both said they were unsure what federal health care reform would mean for mental health providers in Wyoming, but that they didn’t expect big changes in the near future.
The Legislature approved a $1 million expansion of a pilot health insurance program that provides limited coverage for residents who can’t afford health care at market rates. That program could accommodate up to 200 applicants.
Contact Ruffin Prevost at 307-213-9321 or ruffin@wyofile.com.