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For decades Texas and other states treated the mentally ill by giving them "asylum" in a hospital or institution. That changed in the 1960s, when the federal government began funding construction of community mental health centers.
Today 38 local agencies receive funding for indigent care each year from the Texas Department of Mental Health and Mental Retardation. Traditionally, local agencies, including the Mental Health and Mental Retardation Authority of Harris County, acted as both the "authority," charged with coordinating and overseeing the services, and the provider of services.
However, in 1997 state legislators told local agencies to expand the network of providers, increase consumer choice and implement other managed-care principles. To that end, state mental health officials last year launched a pilot program called Northstar in a seven-county area, including Dallas. State-funded services were put in the hands of two private companies.
Supporters say Northstar has proved to be more efficient in delivering services. Indeed, in its first year Northstar increased the number of patients by 21 percent. Northstar also managed to spend 96 percent of its allocation for new-generation medication, compared to 31 percent for MHMRA.
However, critics say Northstar suffers from the same problems associated with all managed-care programs: The amount and quality of services has decreased. Moreover, Northstar has proved to be an unreliable safety net; one of the companies, Magellan, dropped out of the program after the first year, citing inadequate state funding and rising drug costs.
Gerry McKimmey, director of community services for the Texas Department of Mental Health and Mental Retardation, says Northstar has inspired "a lot of passion" on both sides, but not enough solid data to determine whether it works. "It's just too new to have shown us one way or the other if it will have a lasting impact on improving service delivery."
With only so much money available each year, managed care of the mentally ill is inevitable, says Steven Schnee, executive director of MHMRA of Harris County. Schnee says MHMRA has separated its authority and provider roles by making agency clinics "behavioral health organizations." Schnee says the method allows the public mental health system to retain control over managed care of indigent patients.
"We believed we knew this population and we could come to the table with a commitment and bring the values we stand for so that we wouldn't lose the "care' in managed care," Schnee says. "We wouldn't just be managing resources, we would be there trying to use those resources the best way on behalf of our constituents."
But while Schnee's method looks good on paper, it ignores the chief benefit of managed care: choice. After all, MHMRA hasn't increased the number of providers but is simply sending patients to the agency's existing clinics. Joe Lovelace, a former president of the Texas chapter of the National Alliance for the Mentally Ill, says MHMRA is still "the fox guarding the henhouse."
"It's an issue of independent accountability," Lovelace argues. "It's a huge conflict of interest for a mental health authority to also be a provider. First off, there is nobody watching them."
State Representative Garnet Coleman, the legislature's strongest advocate for mental health care, says separating the oversight and provider roles of local agencies will be difficult. In many rural areas, the local MHMR agency is the only provider of psychiatric services, and in larger urban areas, the local agency already has an established network of clinics.
"What are you going to do, mothball those?" Coleman asks. "You have a public infrastructure, centers and facilities that are owned by the county. The minute you start spreading that money around" to private companies, "you risk losing the infrastructure that's already in place."
So what will public mental health care look like in the future? That's going to be discussed extensively in the upcoming legislative session, Coleman says. One possibility is providing financial incentives for local agencies that treat more people.
Ultimately, though, Coleman and others believe the mentally ill will continue to receive substandard public services as long as mental illness is so misunderstood. "Is it health care?" Coleman asks rhetorically. "Then why do we have two separate health care departments?"
The reason, of course, is that many people still view mental illness as some kind of character defect rather than a disease like any other. But according to a 1999 report by the U.S. surgeon general, 20 percent of the adult population has a mental disorder, from simple phobias to schizophrenia, in any given year. Not surprisingly, one of five patients who receives care from the Harris County Hospital District's community health centers also suffers from some form of mental illness.
"We don't stigmatize people with Alzheimer's disease. We know it's a brain disease, just like we know schizophrenia is a brain disease," says Kathryn Kotrla, chief of psychiatry at Ben Taub Hospital. "There's a mental health clinic over here, but if you get sick, you have to go over there. I don't know if that makes sense."
Lois Moore, chief administrator at the Harris County Psychiatric Center, agrees. Many mentally ill people have other medical problems; moreover, about half of the most basic mental health care -- prescription medication -- is provided by private primary-care physicians. "With the number of people we have with multiple diagnoses, it makes sense to look at a more collaborative or integrated system," Moore says.
There's no question the state-funded mental health system needs to evolve, much like it did in the 1960s, says Coleman. New and improved drugs have emerged so rapidly that the subsequent demand for assistance in finding jobs, housing and educational opportunities caught the state flat-footed.
"Mental health is in the dot-com age," says Coleman. "The system hasn't caught up with the science. We're still dealing with a system that is not used to putting people back to work."