Alaska’s mental health crisis: ideas and possible solutions

I read with interest ADN’s recent review of Alaska’s mental health system. Having been involved in the financial and operational management of medical facilities in Alaska for 32 years, I have a few thoughts to add.

Mental Health America, founded in 1909, is the nation’s leading community-based nonprofit addressing the needs of those living with mental illness and promoting the overall mental health of all Americans. It ranks Alaska 47th out of the 50 states and Washington, D.C., in delivery of mental health services. Alaska has both a higher prevalence of mental illness and lower rates of access to care.

Russian author Fyodor Dostoevsky said, “The degree of civilization in a society can be judged by entering its prisons.” I would add to that its mental facilities. Alaska Psychiatric Institute (API) has failed. The starting point to review and correct mismanagement at API is the findings of the independent investigation of API issued last September. That report addressed safety, low employee morale, staff shortages and a lack of behavioral health resources in Alaska. Progress has been made:

• API received $3.1 million in fiscal 2019 for 20 new psychiatric nurse positions with competitive salary increases beginning Sept. 16, including psychiatric nurses salary increasing by two pay ranges. 
• API has implemented changes dealing in problems with scheduling. 
• The Department of Health and Social Services has hired Joint Commission Resources to review and improve the hospital’s seclusion and restraint policies. 
• DHSS submitted an application for an 1115 Behavioral Health Medicaid Waiver Demonstration. If approved, it would bring new ranges of treatment services across the state and funding.

This is a good start, but the most crying needs at API are:

• The lack of an intensive care/admitting unit.
• Lack of consequences for assaultive patients.
• Discharge coordination of outpatient services.
• Reopening the closed beds and the addition of 22 more desperately needed beds.    

The bright spot in this dour tale is the aggressive stance in investment policies of the Alaska Mental Health Trust, which will utilize its trust lands for resource development and will provide greater funding for dedication to those in need of mental help. With more than a million acres of land and assets, the fund in fiscal 2017 brought in more than $11 million for the trust. With assets of more than $680 million, the trust should be producing substantial new income to provide API for its expanded role.

Another bright spot is the potential to swap lands for income-producing oil land in ANWR, NPR-A and on state land. The land and its riches are Alaskans’ out to three miles offshore, and royalties on oil developed in that area goes to the state. If land were swapped, Alaska acre for Alaska acre, the balance sheet of the trust could become several billion dollars, which could effectively wipe out mental health as a scourge in Alaska. This land swap could also solve problems for the University of Alaska, which also enjoys ownership of trust lands as a land-grant college.

It is little wonder that a cycle of discharge to street, shelters or a cab, without case management and support services in place, leads to and adds to the cycle of homelessness, crime and jail, then back to the revolving door of API. We must break this circle through our providers’ assurance that case management/aftercare are in place for each patient.

Hospitals provide referral services and should screen out those not appropriate due to drug or medical issues. API serves the mentally ill and should not be treated as a drug detox center.

Federal money is also available to API. Additional treatment for those in need is available with waivers from Medicare and Medicaid. Each source must be diligently pursued. Federal officials can help with Section 1115 Medicaid demonstration waivers, providing states an avenue to test new approaches in Medicaid that differ from federal program rules. Waivers can provide states considerable flexibility in how they operate their programs.

Pulling the pieces and players together is a huge challenge but immensely doable. In the future, we may need to look at privatizing or utilizing for-profit mental health companies for the management of API. API and its clients can survive and prosper by working with each segment of the overall solution.

The key is to start now.

David Morgan has more than 32 years of financial and operational management experience in tribal health care organizations, Community Health Center and Hospitals in Alaska. He served as a member and Chairman of the Municipality of Anchorage Health and Human Services Commission for six years and a member of Alaska Health Care Commission for five years.

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