About 4,000 Medicaid clients with severe mental illnesses will no longer get mental health services through the state under changes set to start taking effect this summer, but instead will get treatment from their health insurers — a switch that some worry will leave clients with reduced or no mental health care.

The switchover comes as advocates are increasingly warning that the safety net for the state's most severely mentally ill is being decimated by state cuts to mental health services — a crisis they say could have public health and safety implications if people aren't getting treated.

The state counters that cuts are being made in an informed way, and that clients are still getting the services they need.

In fact, they say this switchover isn't a cut at all, but a measure meant to provide easier access to care and streamline services.

Advocates, however, say there are continuing concerns about whether health insurers who cover the clients will be able to provide the help adults with severe mental illnesses need, and they question whether the insurers will have stricter caps or cover some services at all, such as housing or day treatment at "clubhouses," where the mentally ill go for a host of services.

"Will Medicaid reimburse for clubhouse? What level of case management will they reimburse for? What about ancillary services?" asked Marya Grambs, executive director of Mental Health America of Hawai'i. "There's grave concern" about care.

Providers and community health centers are also raising questions, in part because they're unsure how services they offer would be paid for.

"We're not sure how it's going to work," said Adrianna O'Donnell, of the Waikiki Health Center. "We're worried."

NO COST SAVINGS

The state says the change will not save money, since it will be funneling money to health insurers to pay for clients' behavioral health care.

"It really doesn't result in any cost savings," said Michelle Hill, the deputy director of the state Health Department, which provides services to about 15,700 severely mentally ill people through its Adult Mental Health Division.

At a legislative briefing on Wednesday, she said that the concerns voiced by advocates are being looked at to ensure services aren't cut and clients are transitioned smoothly.

She also said it's early in the process, so details are still being worked out.

Yesterday, in a separate legislative briefing on the changes, some lawmakers called on the state to reconsider the movement of the AMHD clients, saying the switch could leave the mentally ill vulnerable to cuts in services or even create confusion that would have some people losing care.

"This population of folks is a little different than the other ones you've worked with before," state Sen. Rosalyn Baker, D-5th (W. Maui, S. Maui), said at the legislative briefing yesterday. "It could create suicide, it could create a whole lot of other irreversible outcomes" if some of the AMHD clients to be switched miss treatments.

SUMMERTIME SWITCH

The change is set to go into effect July 1 for about 1,700 Quest clients who get AMHD services. Some 2,300 Quest Expanded Access clients will be moved later, though a firm date has not been set.

The switch is happening at a time of mounting uncertainty for Quest — the state's version of Medicaid that provides health care to 245,000 low-income people. The Department of Human Services recently warned health insurance companies they may delay as much as $300 million in payments to Quest insurers for April, May and June because of a shortfall.

Some providers say they don't know how they'll continue care with the delay.

One-third of the funding for Quest comes from state dollars, while the rest is covered by the federal government. The state pays out about $100 million a month in state and federal dollars to five insurers under Quest or Quest Expanded Access.

The number of AMHD clients has ballooned over the past decade, largely in response to a federal lawsuit over the delivery of mental health services in the state.

Health Department officials acknowledge they are making moves to temper that growth, given the economic climate. DOH has called that growth "unsustainable."

The movement of the adult Quest and Quest Expanded Access clients from AMHD services to mental health treatment provided by their health insurer will leave the division with about 11,700 clients.

Patti Bazin, Department of Human Services health care services branch administrator, said the state is working with health insurers to determine how they'll contract with providers to offer some key services, such as case management and psychiatric treatment.

She said she understands why people are raising concerns, but stressed that the change isn't meant to cut services.

"We're not having any decrease in services," she told lawmakers yesterday. "We're not looking at this as an opportunity to save money. We really believe that our clients receive better services when ... these services aren't carved out."

She said with Quest clients going to AMHD for services, which have been offered through state-run or state-contracted programs, "we're finding there's been difficulty coordinating services over the years."