State audit finds gap in mental health spending

JEFFERSON CITY, Mo. -- Missouri spends 39 percent more for individualized care for the mentally and developmentally disabled than for group homes, according to a new study.

The study, ordered by state Auditor Claire McCaskill, is the first effort to evaluate expenditures on the disabled and to determine if they are getting the care they should by law.

The Department of Mental Health spent more than $160 million in fiscal year 2000 for staff to care for clients. Of that, $67 million was spent for 2,500 clients to live in group homes, while more than $93 million was spent for another 2,500 clients live in individualized living facilities, or 39 percent more.

The difference, the study says, has resulted in more than $4.8 million a year in additional costs which could be avoided by closer supervision by the department's Division of Mental Retardation. This estimate is based on $3 million in excess costs to operate individualized facilities.

Between fiscal years 1998 and 2001, the average cost for a client residing in individualized living facilities increased 34 percent, from $33,200 to $44,500. The average cost of a group home increased the same percentage, from $24,700 to $31,200. Further analysis shows that the projected fiscal year 2001 costs for 273 of the clients residing in individualized living facilities exceeded the average of $44,500 and will exceed $75,000 each at year's end. Forty-two of these clients' costs will exceed $100,000.

These costs do not include room and board, only payments for staff to care for the clients' daily needs.

Federal and state regulations allow clients to choose the type of facility they want to live in under the Medicaid waiver program. The inspection team report states that this choice needs to be balanced with ensuring all Medicaid waiver services are cost-effective. But state mental health officials have not established procedures to ensure this, the study says.

The reports says that saving on costs should be a factor in placing clients because mental health officials acknowledge there is no material difference in the type of care needed for 178 clients in state-operated facilities and the care for nearly 5,000 clients being served in contractor-operated facilities.

Many without nurses

Apart from money, the study also found that more than two-thirds of the contractors operating non-institutional facilities for the state do not have a registered nurse on staff to support care as required by law. But the disabilities division's standard contract with operators of group homes and individualized facilities does not require that a registered nurse be employed.

A health-care survey conducted a year ago by mental health agency employees found many of the clients suffer from major medical problems, such as frequent, uncontrolled seizures. State statutes say nursing tasks required for the treatment of several of these conditions must be performed with the oversight of a registered nurse.