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That wasn't the vision for NPC held by David Clark, a consumer of MHMRA and former president of the Houston Area Mental Health Advocates. A slight, sandy-haired man, Clark was a vocal supporter of NPC and actively lobbied county commissioners in MHMRA's behalf. "Dr. Schnee encouraged me to appear with other advocates at commissioners court in '94 and '95," Clarks recalls, "carrying signs in some cases."
At best, Clark believes he was misled by Schnee; at worst, he feels used. Since NPC opened, Clark has been increasingly critical of Schnee's leadership at MHMRA, and he isn't shy about publicly challenging the agency's chief administrator. At a public forum last month to discuss the agency's budget, Clark grilled Schnee on rumors that MHMRA had shifted funds from outpatient services to cover costs at NPC. Schnee denied the charge and, once again, reminded Clark that the state failed to allocate enough money for NPC's operations.
That's not the point, says George Santos, director of privately owned West Oaks Hospital. A member of the county's Mental Health Needs Council, Santos argues that MHMRA doesn't need to operate its own psychiatric beds. One reason is the availability of beds at Harris County Psychiatric Center. HCPC is licensed for 250 beds, at least 50 of which are set aside for paying customers. MHMRA pays the psychiatric center $18 million a year to operate 143 beds for indigent and uninsured patients. On any given day, HCPC has 50 to 60 empty psychiatric beds. In Santos's view, MHMRA should have given HCPC the money to open some of those.
That argument makes sense if you consider that about 15 percent of NPC's $10 million budget goes toward operating the acute-care facility. That same $1.5 million would buy a dozen additional beds at HCPC, which is an accredited, fully staffed hospital with lower per-patient costs. Moreover, NPC lost more than $1 million its first year. This year the center needs to generate almost $3 million in revenue to cover expenses. That means NPC's 16 beds are "targeted" for insured patients, Dawson says.
Santos says this is akin to heaping insult upon injury. For years MHMRA refused to authorize the transfer of indigent patients from private hospitals to HCPC. That drove up the costs at private hospitals and, along with managed care practices, led several of them to shut down. More than 500 private psychiatric beds have closed in the last few years, Santos says. Those that remain are now competing with the public mental health system.
"MHMRA built the case that they needed this new hospital, so they built this really nice place at a cost of $5 million," Santos says. "Now they say they don't have enough money for anything, so they're in a situation where they're after earning some money. And the indigent, the people who truly need it, are at the bottom of the list because this publicly funded institution has to compete with the private sector."
MHMRA's policy of bedding down only insured patients at its new facility and sending the indigent to underfunded HCPC has created a bottleneck at Ben Taub Hospital. Sue Luna, coordinator of psychiatric services for the Harris County Hospital District, says MHMRA used to reserve ten beds a day at HCPC for Ben Taub's indigent patients who need hospitalization. Now, she's lucky if MHMRA sets aside more than a few beds each day.
"This is what is hurting us," Luna says. "We're seeing the same number of patients, but we can't move them out fast enough if they are indigent. We have a letter from Dr. Schnee saying the funding is not there. The part I have to live with is that there are empty beds, and I can't move our patients out."
The increased demand for hospital beds and emergency care is directly linked to cutbacks in services that help mentally ill people remain stable, says Lois Moore, HCPC's executive director. Moore says Harris County needs a long-range plan that puts less emphasis on medication and acute care and more on early intervention and aftercare support.
"I think until we have that," Moore says, "we will have a system where we spend a large amount of our resources on the same patients."
Depending on who's talking, Steve Schnee is either a spin artist who deftly shapes an issue to fit his particular needs, a near-saint who works 12 to 14 hours a day for the citizens of Harris County, an able administrator hamstrung by a tightfisted legislature, or a well-intentioned but ultimately ineffective bureaucrat.
A psychologist, Schnee was superintendent of San Antonio State Hospital before taking over MHMRA of Harris County in September 1992. Earlier in his career, he was executive director of the Central Counties MHMR Center in Bell County. Until the mid-'90s, Schnee was president of the Texas Mental Retardation Institute, a nonprofit that owned Cresthaven Nursing Center, a 96-bed "intermediate care facility" for the mentally retarded in Austin.
Schnee was still an executive over Cresthaven in May 1994 when the Texas Department of Health sent a team of inspectors to the nursing center, whose day-to-day operations were managed by a for-profit company.
The inspectors found appalling conditions: empty oxygen tanks and a shortage of emergency life-saving equipment; patients with bedsores so deep their tendons were exposed; patients sitting and, in some cases, sleeping in their own excrement, surrounded by swarming gnats. An executive with Nursefinders, which provided extra staff to help Cresthaven correct its problems, described the facility as "something out of a horror movie."
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