Section 5: Causes of Gaps
This section outlines the perceived causes of the identified gaps in Wisconsin's mental health and substance use services system, as expressed in the interviews, focus groups, survey participants.
Gaps can stem from numerous factors like the lack of integrated systems, including regulation and insurance issues, workforce challenges, and stigma around mental health and substance use disorder.
Lack of integrated systems
A fragmented system of service provision, requiring minimal collaboration, creates confusion, duplication, and treatment gaps. State government shares mental health and substance use services responsibilities with counties and Tribal nations. While local control has benefits, respondents believe the drawbacks, such as inconsistent access to services, outweigh them. Many survey participants discussed regionalization of services instead of Tribal nation or county specific services as a systems change to address lack of integrated systems.
Medicaid issues or policies named as creating gaps in treatment
| Key issue | Impact |
|---|---|
| Medicaid only covers withdrawal management in hospital settings (for example, alcohol withdrawal) but not in community-based settings (for example, opioid withdrawal). Opioid withdrawal does not meet hospital-level care requirements under Medicaid because opioid withdrawal is not typically life-threatening. This leads to a lack of accessible support for opioid users. | Missed opportunities for engaging treatment and connecting individuals in need with appropriate treatment during moments of high need. |
| Residential care is a powerful modality for supporting consumers to focus on treatment and recovery. Medicaid benefits cover treatment costs while in residential care, but not the costs of housing the consumer. | Missed opportunities for engaging treatment and connecting individuals in need with appropriate treatment during moments of high need. |
| In many parts of the state, public transportation does not exist, and medical transport is unreliable. However, mobile providers are a powerful tool for eliminating transportation, stigma, and confidentiality barriers. | Many clients cannot afford transportation costs to get to treatment. At the same time, providers cannot afford to cover the transportation costs, so the service is not provided. |
Providers, administrators, and families point to the challenges of the “benefits cliff," the phenomenon wherein services become unavailable for people with incomes at or near set income guidelines. For example, some people stabilize to the point of having employment and private insurance, but don’t make enough money to cover the co-pays under that private insurance. They no longer qualify for Medicaid but can’t afford to pursue treatment through private insurance. With disrupted treatment, consumers often decompensate to the point where they can no longer maintain employment, then return to Medicaid to stabilize. Then, if they achieve a certain level of stability, they often “graduate” from the treatment they were dependent upon for stability. Respondents expressed a strong sentiment that insurance dictates treatment options, not doctors, contributing to the instability of patient welfare, and increasing demand for acute services.
In discussions about gaps in the mental health and substance use services system, people interviewed spoke of the tension between public and private systems. Private and public insurance have different scopes of coverage, so they often do not effectively coordinate, resulting in gaps in options for services. For example, it may be unnecessary and cost-prohibitive for every county to provide the full continuum of services its residents might need, given how infrequent the needs are for more intensive care and the sparse populations in some counties. To manage this need, several counties rely upon a regional hospital system to provide inpatient beds and medication management needs. Some of the people interviewed believe existing private hospitals are scaling down or unable to assist with complex admissions due to costs. This can lead to the public system needing to serve people who fall through the cracks, thus increasing the strain on limited county resources.
Over 58% of survey respondents indicated an absence of care coordination across programs.
Public and private insurance offer coverage for different services, creating gaps for people with either source. For example, the public system offers services such as Comprehensive Community Services and Community Support Programs. Private insurance does not cover these services, which can create barriers in accessing this treatment.
Workforce
Workforce shortages are the result of burdensome licensing processes, low reimbursement rates, combined with geographic and cultural challenges. Key workforce shortages lead to long waitlists, especially for non-English speakers and members of communities that face disparities.
Participants gave specific examples of challenges including the credentialing process, which they described as burdensome and uncompensated, with lengthy processing periods before a provider can start getting reimbursed. Additionally, providers report feeling micromanaged, undercompensated, and unappreciated, which contributes to burnout and disincentivizes the pursuit of substance use disorder specializations.
A strong theme that persists throughout the survey and interviews is the frustration surrounding the separation of mental health and substance use funding streams and services, combined with the general under preparedness of the workforce to serve people with substance use disorder.
Stigma and norms
Participants conveyed they feel certain cultural norms contribute to gaps in the system.
Some participants cited that seeking help from government agencies causes concerns unrelated to mental health and substance use needs, such as immigration enforcement. Assumptions substance use disorder is a moral failing rather than a health condition limits the spread of lifesaving resources and investment in prevention. Stigma and norms were also described as apparent from providers too, specifically, that some do not understand the background of clients who seek care in both the mental service and substance use disorder services array.
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