Low Vitamin D and Your Mental Health

Vitamin D has received a lot of attention lately from medical researchers because of its wide range of effects upon the body and the mind. As a primary care physician working in the Idaho Rocky Mountains, a large number of my patients live in canyons and gulches that run throughout the mountains, where they receive little direct sunlight. The result is that most patients I see are low to very low to very very low in Vitamin D. Thus, it was with great interest when I came across an article in that reviewed the role of vitamin D and the mental health in older adults.

We have known for decades that vitamin D is a steroid hormone that is vital to your health. Like all vitamins, it is a compound that cannot be made in the body, so we need to either consume it in our diet or be exposed to enough sunlight, or we will get very sick. Historically, the role of vitamin D has been recognized to be essential to maintaining healthy bones, but more recent research indicates that it also works throughout the body and throughout the brain. One of the primary interests currently is how vitamin D affects our personality and our overall mental health. The possible link between low levels of vitamin D and psychiatric disorders has generated significant interest from the mental health community because of the far reaching implications of vitamin D deficiency.

Several mental illnesses have been associated with vitamin D deficiency according to a recent review article in Current Psychiatry Reports, including depression, bipolar disorder, and schizophrenia. Low vitamin D levels also have been associated with an early or more rapid decline in our memory and ability to think as we age. Given these apparent widespread effects of vitamin D, the authors suggest that older adults should supplement their diet with vitamin D.

Our basic personality also appears to be associated with the levels of vitamin D that we have in our blood. A recent research trial reported in Psychopharmacology concluded that vitamin D may influence personality traits, and act to promote an outgoing personality and open behavior. A tongue in cheek article even suggested that in fantasy literature, where good consistently triumphs over evil, that the evil characters consume less vitamin D in their diet and get less sunlight compared to the good characters. Certainly in regards to the inhabitants of Middle Earth in JRR Tolkien’s novel The Hobbitt, the researchers found the virtuous characters had higher “vitamin D scores.”

So after reading the medical literature, I have to wonder, are low vitamin D levels a problem? Or should we just tolerate all of these diseases, and not worry about it? Although the research isn’t conclusive, there’s strong evidence that low vitamin D levels are common, and that this deficiency results in sub-optimal health. Now we just we need to figure out whether supplementation will help prevent or cure these wide ranging health problems.

Mental Health Care Coverage in Minnesota – Supplementing Federal Healthcare Reform

In 2007, the governor of Minnesota proposed a mental health initiative and the legislature passed it. One of the more important components of the initiative was legislation amending Minnesota’s two programs for the uninsured – General Assistance Medical Care and Minnesota Care – to add to the comprehensive mental health and addictions benefit.

Who Is Covered?

General Assistance Medical Care covers those with income at or below 75% of the federal poverty level who meet one or more of additional criteria known as General Assistance Medical Care qualifiers. Qualifiers include waiting or appealing disability determination by Social Security Administration or state medical review team; or being in a homeless or live in shelter, hotel, or other place of public accommodation.

Minnesota Care covers children and pregnant women, parents, and caretakers up to 275% of the federal poverty level, except that parents and caretakers gross income cannot exceed $50,000. Single adults without children increased to 200% of federal poverty level by January 1, 2008 and will rise to 215% of federal poverty level by January 1, 2009.

What Services Are Covered?

For Minnesota Care, there are limits of $10,000 on inpatient care for any condition (physical, mental health, or addictions) for parents over 175% of federal poverty level and childless adults. For General Assistance Medical Care, inpatient benefits are fully covered. Both programs cover chemical dependency outpatient services. An intensive array of outpatient and residential mental health services are available.

What Is The Cost?

In Minnesota, the Medicaid Temporary Assistance for Needy Families population, General Assistance Medical Care and Minnesota Care are enrolled in comprehensive nonprofit health plans that are responsible to deliver and are at risk for the entire health benefit, including behavioral health. Adding mental health rehabilitative services (including adult rehabilitative mental health services individual and group rehabilitation services, assertive community treatment, intensive residential treatment and mobile and residential crisis services) to Minnesota Care was projected to cost $3.40 per person per month. For General Assistance Medical Care, which includes a homeless population, the cost was $7.01 per person per month. The additional targeted case management service was projected to cost $2.22 per person per month for Minnesota Care and $7.66 for General Assistance Medical Care.

The legislature appropriated a total of $1 million in additional state dollars in fiscal year 2008 and $ 3.5 million in fiscal year 2009 to add the adult rehabilitative services and case management in Minnesota Care. State funds previously targeted for case management were moved from the counties to the state in an amount of $4.4 million in fiscal year 2009.

What Led To Comprehensive Coverage?

The state collected data on the residents served by Minnesota Care, General Assistance Medical Care, and Medicaid managed care plans serving non-disabled populations, and discovered that an increasing number of individuals with serious mental illnesses were in these plans. Several insurance reforms – similar to those included in the national healthcare reform bill – modified the private market, including guaranteed issue in small and large group plans, broader rate bands, parity for mental health and chemical dependency services, medical loss ratios, high risk insurance pool, and others. A lawsuit by the attorney general called attention to health plan denials of payment for court-ordered treatment, for example for civil commitment or out of home placement for adolescents.

Health plans settled with an agreement that behavioral and mental health benefits would be covered by a health plan if the court based its decision on a diagnostic evaluation and plan of care developed by a qualified professional. In addition to the court-ordered services provision, the state contracts and capitation with prepaid health programs (Minnesota Care and General Assistance Medical Care) were amended to align risk and responsibility for services in institutions for mental illnesses, 180 days of nursing home or home health, and court-ordered treatment. There were also highly successful experiments reducing costs and improving outcomes for commercial and non-disabled Medicaid clients who were offered a more intensive community based mental health service that improved coordination with and linkages to behavioral healthcare, primary care, and other needed services.

These demonstrations produced a positive return on investment – $0.38/person/month – and gave the health plans tools to manage the increased risk that resulted from several insurance reforms, including parity, a statutory definition of medical necessity, and the court-ordered treatment provision.

The state supported comprehensive coverage because it sought to provide mental health and addiction services in Minnesota as part of mainstream healthcare. Minnesota’s mental health agency and other stakeholders desired to move mental illness from its historical treatment as a social disease requiring social services to an illness like any other. They wanted to foster earlier interventions and avoid shifting enrollees among different programs in order to access specific services. Operationalizing this change required rethinking medical necessity determinations, provider credentialing, contracting, procedure codes and other processes common to private insurance plans.

How Did It Get Through The Political Process?

Three factors significantly contributed to the political viability of a benefit expansion in the Minnesota Care and General Assistance Medical Care programs:

>> The governor of Minnesota and the administration provided strong leadership. The provisions to expand the mental health benefits in these plans were part of the governor’s mental health initiative, set forth in advance of the 2007 legislative session.

>> An extremely strong coalition of stakeholders formed a mental health action group. This group is co-chaired by a representative from the department of human services and included representation from the private insurance industry and organized and knowledgeable advocacy and provider communities.

>> There was strong support in the legislature for the expansion of benefits in Minnesota Care and General Assistance Medical Care, including from a member of the finance committee in the house, who has a son with schizophrenia. The creation of a mental health division in the health and human services policy committee also helped move the policy discussion forward.

Why Does This Approach to Healthcare Reform Work?

A recent survey of community behavioral health organizations found that on average, 42% of reimbursement for services came from private insurers. While this represents the average, the survey found that there was quite a range in reimbursement sources. For community behavioral health organizations that specialize in services such as Assertive Community Treatment or case management, Medicaid is the predominant reimbursement source, either through fee-for-service or managed care.

Reimbursement from private insurance and Medicaid managed care is uniformly better than Medicaid fee-for-service. In addition to higher rates, the private insurers and Medicaid managed care organizations have been willing to offer special contracts for packages of services for crisis care and hospital discharge plus aftercare.