Enhanced Role for Nursing in Milwaukee County's Redesigned Mental Health System

Few would dispute the idea that effective mental health care relies on the quality and accessibility of health care professionals, especially nurses. As stakeholders in Milwaukee County work to redesign the county’s mental health system, one of the crucial issues they face is how to build an effective and efficient mental health nursing workforce in light of anticipated changes under the new system.

The Nursing’s Voice project is a collaborative effort of local and national foundations, higher education institutions, and other interested parties to enhance the supply of mental health nurses in Milwaukee.  As part of the project, the Forum surveyed 120 mental health nurses and 34 employers to illuminate the state of the county’s current mental health workforce and to gather insights to inform the redesign planning process and the work of Nursing's Voice.  

Survey responses identified three broad categories of need that an effective redesign effort must address – the need for training and professional development of nurses, specifically in mental health care; the need for a larger mental health nursing workforce today and in the future; and the need for nurses and employers to clarify their respective expectations about what constitutes effective mental health nursing skills and practices. In the research brief that summarizes the survey findings, the Forum describes key policy implications:

• Because of a perceived need for nurses with an interest in mental health both now and in the future, incentives for increasing the mental health workforce might be necessary. The redesign process should also anticipate the need for more nurses. 
• Although employers are satisfied with the mental health nurse applicant pool, very few nurses are nationally certified or advanced practice nurses. This suggests that while schools of nursing provide a basic foundation of mental health training, planners should explore possible reasons for the apparent lack of deeper knowledge and discern how this deficit will affect future service provision.
• Employers envision a larger role for mental health nurses in outpatient/community settings. However, today most nurses work in inpatient settings. Planners should explicitly consider the optimal roles of nurses in community health settings.
• Turnover among mental health nurses is relatively low (less than 10%) with the greatest source of job satisfaction deriving from patient care. Sources of job dissatisfaction are related to pay and advancement. If nurses’ responsibilities become more administrative or policy-oriented under a redesigned system, the reduction in patient contact may cause nurse job satisfaction to suffer (and attrition to rise), particularly if wages do not change.
• Employers and nurses lack consensus about which skills are most important for patients’ recovery. This suggests either a lack of clear communication or differing expectations as to the job objectives. Employers and nurses should work toward greater clarity about these differences if the role of nurses is to change under a redesigned system.
• Employers and nurses find more common ground regarding their views of the specific skills that need strengthening. Planners should therefore focus future professional development resources in these areas.
• Both nurses and employers placed specific importance on the ability of nurses to understand the treatment needs of patients diagnosed with dual/co-occurring disorders in which mental illness coincides with substance abuse. As the county shifts its focus to dual/co-occurring disorder treatment, the need for improved training for nurses will be imperative. 

These findings could serve as guideposts to planners, employers, and nurses themselves as they navigate the uncharted territory of a redesigned mental health care system in Milwaukee County. In addition, Nursing’s Voice will play an active role over the next two years to bring the perspective of mental health nurses to both the redesign and implementation of the new system. To do this, the collaborative partnership will undertake three key activities: 1) conduct research and data collection, such as this survey, to document the current and future need for mental health nurses in the new system; 2) develop strategies to encourage nursing students to pursue a career in mental health service and to provide them with the essential skills to be successful; and 3) provide a platform for the voice of nurses so that the new mental health delivery system can make optimal use of their skills and ideas.

People Speak: Citizens concerned about health care costs and reform

The latest edition of the People Speak poll finds Milwaukee area citizens are concerned about health care costs in general, as well as the costs of the new health care reform law.

Of the 436 residents polled in early November, a majority (62%) agree with Wisconsin joining 25 other states in challenging the constitutionality of the federal health care reform law. Residents do not seem to base their support on uneasiness with the mandate that individuals be required to have at least minimum insurance coverage, however. In fact, 64% say they favor a requirement of this type. Support for the individual mandate drops to 42% when the question is rephrased to include a hypothetical tax increase to cover the costs for those who cannot afford insurance on their own, indicating concerns about the cost of the law may factor into support for the legal challenge.

These concerns about the cost of reform may reflect respondents' personal situations. A majority (64%) say they are very or somewhat worried that they will not be able to pay their medical bills in the event of a serious illness in the future, although just 23% say that cost has prevented them from seeing a doctor for a medical problem in the past 12 months. Of these 101 respondents who have skipped a doctor visit in the past year due to cost, almost half (47%) report having employer-provided insurance.

Other findings:

• The 64% of respondents in favor of requiring all Americans to have at least minimum health insurance includes 80% of Democrats and 55% of Republicans.


• While 67% of respondents overall agree that states should be allowed to opt out of the federal health care reform law and devise their own health care coverage systems, 92% of Republicans and 42% of Democrats agree.


• Almost half (48%) of respondents favor guaranteeing health care for every American, even if it doesn't do much to control health care costs.


• On the whole, however, health care is not at the top of people's minds when asked to name the most important issue facing the Milwaukee region. Just 2% said "health" or "health care" is the top issue, while 47% said "jobs" or "unemployment" is most important.

The People Speak poll is a tracking poll conducted three times per year in partnership with the Center for Urban Initiatives and Research at the University of Milwaukee and The Business Journal Serving Greater Milwaukee. Full results of the November 2011 poll and all previous polls can be found at the People Speak website.

Managing local government health care costs: The ambiguous incentives of federal health care reform

Recent local government and school district budget deliberations have honed in on deep and often contentious modifications to health care benefits. Many have asked how far local governments will go in reducing benefits now that they have been given greater flexibility to pare down employee health care costs without having to collectively bargain with most unions. These questions likely will continue and become more dynamic with the phasing in of the federal health care reform law.

In 2014, federal law will require all individuals to have health insurance, with new government-subsidized health care exchanges offering an alternative option for small businesses and individuals who are not eligible for Medicare, Medicaid or affordable employer coverage. States can allow large employers to participate in these exchanges in 2017.

How large employers, both public and private, will react to the federal health care reform law is a big unknown. Besides taking advantage of lower cost plans provided through exchanges, some speculate that employers may also consider dropping coverage altogether.

The wild card is a “play or pay” penalty imposed on large employers for not providing affordable employee health care coverage. Large public and private employers who fail to do so will be subject to a $2,000 annual penalty beginning in 2014 for each of their employees, provided that any of their employees have a household income low enough to qualify for a federal subsidy to help pay for coverage within an exchange. Employers offering coverage that pays less than 60% of expenses would face similar penalties, but only for those employees eligible for the federal subsidy. This applies to even seasonal employees that work full-time hours in any given month, a population that currently does not get health coverage in most local governments.

With many local governments paying annual premiums of $20,000 or more for family plans, and picking up more than 80% of plan costs, a $2,000 penalty would be a bargain. Consequently, some argue that many local governments will drop or significantly reduce employer-based coverage.

A recent Urban Institute report challenges this perspective, arguing that for any large employer such a shift would wrongly ignore market realities and the dynamics of worker preferences. While the Institute's report notes that exchanges could better suit some lower-income individuals because of the subsidies for which they are eligible, employers still need to maintain an edge over competitors to retain and attract highly skilled and higher paid employees. Those individuals would not receive subsidies and their share of the exchange plan costs would be approximately 30%, as compared to the typical 15% in employer-based plans.

The report also argues that market competition will force employers who decide to drop health insurance to fully cover the lost benefit with increased wages. On top of that, the employer would still face the $2,000 penalty for each worker.

Do these considerations hold true for local government employers in particular? One factor that has been downplayed is that local governments and their competitors will likely be pressured to contemplate significant changes to employee compensation. Consequently, the market pressure to maintain health care benefits in order to remain competitive may be diminished as all employers continue to recalibrate compensation. Nevertheless, a key question is how local governments will balance the reality of restricted resources and the need to preserve critical public services with their equally compelling need to attract and retain quality workers.

Escalating health challenges for inner city Milwaukee

Two recent reports have raised concerns about healthcare access for low-income Milwaukeeans. First, The Business Journal Serving Greater Milwaukee reported on Aurora Health Care’s relocation of orthopedic and heart surgeons from its Sinai Medical Center, located just west of downtown, to a new hospital in Grafton. The transfers have caused some to fear further service reductions at Sinai, particularly in light of the decades-long trend of hospital closures in the City of Milwaukee. Days after the Business Journal article, the Center for Urban Population Health (CUPH) released a report revealing entrenched health disparities among Milwaukee residents based on socioeconomic status. With state budget cuts to Medicaid as an additional hurdle on the horizon, are the healthcare challenges facing low-income Milwaukeean’s about to get even worse?

Since 1977, nine hospitals have closed in Milwaukee, including the 1995 closing of the county-owned John Doyne Hospital, which had long served as a safety net for the uninsured. Initially, these losses were tied to the city’s population decline, but the most recent closings – Northwest General in 2000 and St. Michael’s in 2006 – occurred despite a stabilization of the city’s population during the past decade. Another major factor that has been linked to hospital closings in the city is a dramatic increase in poverty, which has resulted in higher rates of publicly insured and uninsured residents.

Despite the fact that Sinai has operated at a loss nearly every year over the past decade, Aurora Health Care maintains it is committed to downtown Milwaukee. But with the state’s proposed $500 million in Medicaid cuts over the next two years, private hospitals may be faced with further cuts in Medicaid reimbursement and/or an increase of uninsured patients. The details of the state’s Medicaid budget have not been announced yet, but the BadgerCare Plus Core plan for childless adults had already instituted a waiting list long before budget debates began.

Milwaukee’s healthcare safety net for the uninsured has gone through several changes over the past 20 years. The county’s John Doyne Hospital served the uninsured free of charge until it was closed by county officials in 1995. To partially replace Doyne Hospital, Milwaukee County created the General Assistance Medical Program (GAMP), which provided health coverage for low-income, childless adults – the portion of Milwaukee County’s low-income population that didn’t qualify for Medicaid at the time. When the State of Wisconsin expanded BadgerCare in 2009 to cover childless adults, the GAMP program was eliminated. Consequently, if BadgerCare eligibility is now restricted in response to the state’s Medicaid funding gap, there will be no public safety net program to provide backup.

Milwaukee’s four federally qualified health centers (FQHCs), which provide primary care services to patients regardless of their ability to pay, fill an important role in serving the city’s uninsured. All four centers are expanding their operations and together may be positioned to take on additional patients in the near future. In addition, the downtown AIDS Resource Center of Wisconsin (ARCW) clinic is working to become a fifth primary care FQHC, which would allow it to serve many more patients. These are encouraging signs, but capacity constraints remain a concern at the FQHCs and continue to be a focus of the health system leaders who comprise the Milwaukee Health Care Partnership.

As the local impacts of the state’s Medicaid budget are revealed, there may be even greater strains on the regional healthcare system. A key question is whether Milwaukee policymakers and healthcare leaders will be able to respond as quickly and effectively as the demand for services may warrant.

A new strategic direction for mental health care in Milwaukee County

A recent series of articles in the Milwaukee Journal Sentinel on safety issues at Milwaukee County's Mental Health Complex is the latest to raise questions about the level and quality of mental health care in our community. Unfortunately, while these exposes have ranked high in shock value, they have yet to produce the comprehensive redesign of the public and private mental health systems that many feel is needed.

A report released today may provide the impetus for such change. The report - authored by Massachusetts-based Human Services Research Institute - culminates a two-year project initiated by the Milwaukee Health Care Partnership (a collaboration headed by the five major health systems in Milwaukee County), the Medical Society of Milwaukee County, and the Milwaukee County Behavioral Health Division. The project’s objective was to bring in national expertise to examine gaps in the existing adult mental health care delivery system and devise ways to transform that system into one that more closely mirrors national best practices. The Public Policy Forum has served as local facilitator for the project.

Readers of the report should be forewarned - in many respects, this is a technical document that contains dozens of pages of data findings and analysis and lots of references to mental health policies and practices that may not be familiar to the average citizen.

But that also may be its strength. Indeed, by suggesting a new strategic direction based on data and facts, it is hoped that this report can de-politicize and de-sensationalize a set of complex issues and challenges that must be confronted for the sake of the overall health of our community and the fiscal health of Milwaukee County government.

Some of the report's recommendations may be controversial, and some may require new fiscal resources (though the report emphasizes re-directing existing dollars, as opposed to finding new ones). Implementing those recommendations will not be easy, and will require teamwork and cooperation from several levels of government, law enforcement, consumers, advocates, community-based organizations, and private sector payers and providers. Yet, the diversity of the stakeholders group that has brought the project this far certainly provides hope.

The media release accompanying the report - which provides additional details about the project's history and the stakeholders that have guided it - can be accessed here. The executive summary and full report can be accessed here and here.

All politics and all health care reform is local

Here at the Forum we try to keep our work current, focusing on topical issues of importance. Health care reform is obviously one such issue. Yet the Forum's mission is to inform local policy debates, not national ones. So it was not immediately apparent what role we might have to play in the conversation about health care reform.

An article in last month's Governing Magazine made it more clear--local policy decisions can have big impacts on health care costs and on the health care system itself. The Governing article was actually about state budget decisions; it seems many states are cutting their support for poison control centers, which some studies have shown save big money in emergency treatment costs.

The author of the article (none other than Don Kettl, namesake of the Kettl Commission on state-local partnerships) notes that "most of the political and budgetary pressures we face are pulling policymakers away" from investment in system efficiencies and preventative medicine, and are instead resulting in "strategies that might save a few dollars now but drive up health costs in the long run."

As we digest the proposed 2010 City and County budgets, we should keep in mind that there may be long-term ramifications of budget cuts that will reverberate beyond Milwaukee. The proposed budget for the city's Health Department, for example, includes an 8% reduction in expenditures and an 11% reduction in staff compared to the 2009 adopted budget. Cuts in state and federal revenues result in a county budget that calls for a 9% reduction in expenditures in adult community mental health services and a 7% cut in expenditures for AODA services (drug and alcohol treatment) compared to 2009--leaving holes that are difficult to fill with local revenues.

These cuts may in fact reflect new efficiencies and may not negatively affect services or outcomes. Or, they may be penny-wise and pound-foolish from a taxpayer's point of view, saving money today that will create a debt later. Citizens need to be aware of the potential for either outcome and judge proposed budgets accordingly. The Forum will try to help; look for our detailed city and county budget analyses in mid-October.

Questions we need to ask after the Coggs Center incident

In the wake of Monday's unfortunate events at the County's Marcia P. Coggs Human Services Center - in which a huge crowd seeking emergency food stamp benefits became dangerous and unruly - it was inevitable that we would see those from both the right and the left using the situation to buttress their longstanding beliefs. As a former county health and human services director, I would like to offer my own observations:

• This incident should serve as a wake-up call to state and county elected officials regarding the dysfunctional nature of the state-county relationship when it comes to human services. The two entities are supposed to be partners, but seldom act that way. In this case, the state gave the county little notice before announcing the new benefit, despite knowing full well that the county can't adequately handle its existing food stamp caseload, let alone a surge of thousands of new applications. In the rush to announce the availability of the benefit, did the state genuinely try to coordinate, to jointly plan, or to say "hey, can we give you a hand?"

• Citizens and policymakers need to be aware that each and every day, hundreds of desperate people face significant challenges signing up for benefits at the Coggs Center. For years, Milwaukee County has experienced big problems in serving the tens of thousands of residents seeking eligibility determination for food stamps, Medicaid and child care. As a result, benefits regularly are delayed for those who are eligible, and the challenges involved in obtaining them often jeopardize both health and employability. Both the state and the county have known and admitted this, but neither accepts accountability; instead, the state blames the county for not administering the programs effectively, while the county blames the state for grossly underfunding a mandated service. Meanwhile, the problem never gets fixed.

• It is certainly legitimate to question why the emergency benefit was made available by the federal government and/or the state to anyone who met income and residency criteria, regardless of ability to prove hardship due to flood damage. The answer likely lies in the desire to err on the side of quickly getting food assistance into the hands of those who truly needed it, as opposed to preventing fraud. Nevertheless, despite the probable good intentions of those making this decision, it is unfortunate that the impression left with the public is that all food stamp benefits are similarly easy to obtain by those who may not be eligible, and that further anecdotal ammunition has been provided to those who argue that safety net programs are wasteful and unnecessary.

• In the wake of Hurricane Katrina, planning was initiated on the state and local level for emergency situations in which thousands of uprooted and otherwise desperate people would need to seek and obtain critical food and health care benefits. Does this incident tell us we are not prepared for a true natural disaster in this essential area of emergency response? Should we be questioning whether we would have similar challenges providing mental health, drug/alcohol and disabilities services in a true emergency?

Perhaps the worst outcome of this week's Coggs Center incident would be its casual dismissal. Instead, this incident must be viewed as a potential symptom of a much larger problem - an overwhelmed social services infrastructure in Milwaukee County that is badly in need of apolitical attention from both state and county policymakers.

The Orwellian world of public opinion

Advocacy groups, no matter what they advocate, often provide survey research that isn't very useful. That rule of thumb is evident in a recent report that Wisconsinites overwhelmingly oppose universal health insurance. This may be the case, but the finding that City of Milwaukee residents are opposed 86% to 8% sent me to seek the source of the survey.

According to the web site of the sponsoring organization, the Wisconsin Policy Research Institute, this was the question posed to survey respondents:

Do you think the best way to reform health care in Wisconsin is by replacing the current private health insurance system with a new universal health insurance system that is run by the Wisconsin state government? ~ or ~ Do you think the best way to reform the current private health care system is to cut costs and provide more choices by increasing competition among private insurance companies and by requiring health care providers to publicly release their actual costs?

Let’s count some of the ways the question begs respondents to choose the second option:

1. Cut costs – The question presumes the second idea would cut costs whereas a universal health insurance system wouldn’t. That’s an opinion.
2. Choices -- Everybody likes choice; that’s why abortion advocates call themselves pro-choice, that’s why the school voucher program is called school choice, and that’s why the survey designers used the word in their preferred response.
3. Competition – It’s the American way. Wouldn’t there be competition in a universal plan? Maybe yes, maybe no, but survey researchers usually let the respondents be the ones offering the opinions.
4. Accountability (“requiring health care providers to publicly release their actual costs") -- Would there be accountability under a universal plan? Maybe there would, maybe not, but if you want my opinion, let me offer it.

To appreciate the bias, imagine the findings with different wording:

Do you think the best way to reform health care in Wisconsin is by replacing the current private health insurance system with a new universal health insurance system that would cut costs, provide more choices, increase competition and hold health care providers accountable? – or -- Do you think the best way to reform the current private health care system is to trust private insurance companies and health care providers to reform themselves?

Neither wording provides true insight into public attitudes, which raises a question: If surveys like this aren’t useful, why do them? If the intent is to mislead policymakers about the views of the electorate, that’s anti-democratic.

So why should we care if an organization wants to spend money on useless surveys? Well, we all pay a price for propaganda posing as research if it sways policymakers. One example: Milwaukee’s school choice program (for which Wisconsinites have spent more than $600 million since the late 1980s) began with public opinion research designed to create the impression that people wanted it. At the time, maybe people did want it. Maybe not. We'll never know.

Healthy Wisconsin Plan

If State Senate Democrats were looking to spark further debate about health care in Wisconsin, then their proposal and passage of the Healthy Wisconsin Plan, which is estimated to cost $15.2 billion in its first year, has accomplished that goal. However, mixed reactions to the plan from elected officials and the business community may show the need for more debate and discussion than occurred in the two days between release of the full plan and the Senate’s final vote. A previous Public Policy Forum post notes that budgets are often used by Wisconsin legislators to create substantive policy change. Such changes are rarely given their own public hearings and the quality and extent of the debate surrounding the issues suffers.

A study sponsored by the AARP and conducted by the Lewin Group projects the possible costs for government and employers. The study projects that health care costs for all employers will decrease under the Healthy Wisconsin Plan, regardless of whether they currently contribute to insurance for their workers. This decrease is seen for all employers because the Lewin Group assumes that wages will go down to compensate for the increased payroll tax under the Healthy Wisconsin Plan. There is some debate as to whether the plan will attract businesses to Wisconsin or drive existing businesses away.

Now the Republican controlled Assembly will develop its own version of the budget bill. The Assembly Republicans have publicly stated that they will take the universal health plan out of the Assembly version of the budget. While Senate Democrats did not leave much time for examination and debate of their Healthy Wisconsin Plan, the Assembly has the opportunity to take time to sincerely discuss the plan before deleting it from the budget. As we noted after our Viewpoint Luncheon in May, the debate surrounding health care reform must include not only policy, but also health care outcomes and practices. A more balanced debate would include these factors along with the cost considerations that have been the focus thus far.

Reforming health care data, policy, and practice

At the Forum's Viewpoint Luncheon May 9, we had a panel of speakers representing the various health care reform plans now being batted about in Madison, as well as a speaker representing a more market-based view. All of the panelists agreed that costs (as well as access) are a problem and they all agreed that better information on cost and quality would benefit patients/consumers. But their opinions varied as to which policies would provide the best solutions, and even as to whether enacted legislation should be the default remedy.


What was missing from the conversation was the influence of practice: Can changes in how doctors practice lower costs? We've all heard by now about the experiment by Kaiser Permanente that found simple changes in hand-washing protocol resulted in fewer infections in patients. A post on the Wall Street Journal's health blog last week highlighted how a Utah health system dramatically reduced the number of babies needing costly newborn intensive care by postponing elective inductions of labor until 39 weeks gestation or later. And there's a relatively new book out by Maggie Mahar that controversially argues new and better medical equipment results in doctors eager to use new technology ordering tests merely because they can. From a Washington Monthly review of the book:

...[M]edicine is particularly vulnerable to perversions of Say’s Law, which states that supply creates its own demand. Diving into the data, Mahar relates Dartmouth researcher Jack Wennberg’s findings that the amount of care a patient receives is scarily dependent on where he lives. The more specialists, hospitals, and doctors you’ve got access to, the more surgeries, medicines, and treatments you’re likely to undergo. Worse, there’s no evidence that the outcomes differ between the two groups, and plenty of evidence that they don’t. Indeed, for those receiving the most intense care, the outcomes are worse—a predictable finding, considering the risk of complications, physician error, and infections.

The most effective changes in practice result from data analysis. Thus, transparency of data not only benefits us as consumers when we "shop" for care, but also as patients when a clinic, hospital, or health care system notices an unhealthy data trend and makes changes. But, no matter how transparent the data, savings will not occur unless the health care provider is willing to change its practices even if revenues could decrease in the long-run from healthier patients. That's were policy comes in. As health care becomes more profit driven, policies that provide incentives for cost-saving changes in practice may be needed.


The Milwaukee Journal Sentinel's Sunday Crossroads section May 20 included a roundtable discussion of health care experts. Two of these experts explicitly mentioned provider practices as an area in which improvement is needed, and the others made mention of better efficiency among providers. But efficiency is not the same concept. The doctors in Utah that were scheduling elective inductions probably believed they were being efficient by attempting to manage deliveries in a more predictable manner. Meanwhile, none of the doctors saw the deleterious and costly effects of the early inductions within their own patient groups; it was not until the administrators of the system put the data all together that the doctors became convinced their practices should change. And every hospital that operates its own array of high tech diagnostic equipment likely does so in the name of efficiency--and from the vantage point of a patient impatient for results, it is efficient. But it is costly, as well.

We are remiss when debating health care reform if we don't include policy, data transparency, and practice in our talking points. All three ingredients are necessary for reform to be made.

Radical Surgery: PPF Viewpoint Luncheon

The Forum's next Viewpoint Luncheon May 9, 11:45 am, Pfister Hotel:

Radical Surgery--Wisconsin’s search for access to lower-cost health care

A panel of experts will sort out various ideas and recent plans for improving health care access and costs for Wisconsin residents.

Panelists include Kevin Hayden, secretary, Wisconsin Department of Health & Family Services; Jon Richards, assistant minority Assembly leader; David Newby, president, Wisconsin AFL-CIO; and Dianne Kiehl, executive director, Business Health Care Group of Southeastern Wisconsin.

Moderated by Paul Nannis, vice president of government & community relations, Aurora Health Care.

Sponsored by Foley and Lardner, LLP and United Healthcare.

For more information and to reserve your place visit http://publicpolicyforum.org/events.php.