Steve Chesser waited until after his children had gone to school that September 1 morning. Then he beat his wife, Maria, very carefully -- he knew how to do it so that nothing would show -- tied her up with duct tape, held a gun to her head and said he would kill her if she didn't agree to stay with him.
Then Steve put the gun in Maria's hands and told her to shoot him. "He said, "Shoot me. Kill me. I can't be in this misery anymore,' " says Betty Chesser, Steve's mother. She sits in the front room of her modest home in Pasadena, recounting the last days in the life of her troubled son who was determined to hold on to a failing 14-year marriage.
Maria refused to pull the trigger, and the anger of the moment subsided. She fled the home and eventually moved into a women's shelter with her three daughters. Steve told his mother what he had done and realized he needed urgent help, Betty says.
She called the Mental Health Mental Retardation Authority of Harris County and was told to take Steve to the NeuroPsychiatric Center, MHMRA's crisis center at the old Ben Taub Hospital. According to his mother, Steve spent five hours at NPC on September 3. But while he apparently made no secret of his dangerous state of mind, Steve was released after his heart rate and blood pressure were checked. He was given no medication, no treatment plan.
"He told them what he had done," Betty says. "The psychiatrist -- I don't know her name, she was an Indian woman -- told him this was normal behavior after 14 years of marriage and that he just needed counseling."
Six days later, as Maria arrived for work at Delta Airlines, Steve confronted her in the employee parking lot, shooting her twice. Then he put the barrel of the gun in his mouth and pulled the trigger. Maria was able to drag herself 40 yards, where two Southwest Airlines employees came to her aid. She survived. Her 34-year-old husband was dead.
MHMRA will neither confirm nor deny that Chesser sought treatment at the facility. But Dr. Steven Schnee, the authority's executive director, says it's unlikely NPC's staff would ignore such an obvious cry for help. "If somebody comes in and says, "I'm going to kill myself, kill my wife,' don't you think the psychiatrist would do as thorough a job as possible evaluating that person?"
Few people who suffer a severe mental breakdown pose a violent threat. But the tragedy of Steve and Maria Chesser underscores a grim reality in Harris County: Receiving treatment for mental illness is often a hit-or-miss proposition, particularly if you are poor or uninsured.
Access to most public mental health services in Harris County is controlled by MHMRA, which receives roughly $80 million a year in state and county funds to treat adults with "severe and persistent mental illness." As patients and mental health advocates point out repeatedly, that's not nearly enough to care for people suffering from a chronic and, in many cases, life-long affliction. Texas spends just $14.61 per resident on the mentally ill, compared to a national average of about $27. And at a paltry $11.65 per capita, Harris County -- one of the largest and fastest-growing regions in the nation -- simply cannot meet the demands for medication, psychotherapy, housing and employment assistance or, for those in crisis, a few quiet days in the hospital.
On August 31 MHMRA ended its budget year more than $2.7 million in the red, a deficit that prompted the agency to start rationing care to adult patients who can't pay. Last month MHMRA cut services to the poor and uninsured by laying off 29 caseworkers and reducing the size of its clinical teams. Most of the agency's resources were shifted from indigent patients to those with private insurance or Medicaid benefits. This budget year MHMRA's contract with the state requires it to treat 8,800 poor and uninsured adult patients each month. Only 980 will receive a full range of services. The rest will have to make do with medication and an occasional appointment with a physician.
Melvin Corsey, a patient and consumer adviser at Northeast Community Service Center, says the cutbacks will have a significant impact on those seeking MHMRA's services for the first time. "Once you have [patients] to refer, where are you going to refer them to?" Corsey wonders. "There is no safety net for the incoming consumer."
Some blame state lawmakers and the Texas Department of Mental Health and Mental Retardation, which funds nearly all public mental health services in the state. Two years ago the department reported a $30 million shortfall. Shelly Hayes, a private psychiatrist and member of the county's Adult Mental Health Planning Advisory Council, believes the department is trying to balance its budget by forcing local agencies like MHMRA to generate more of their own revenues.
"Basically they have told a public agency, "You are to go into business,' " Hayes says. "So we have this totally stratified system based on whether you have money or you don't. I find that offensive."
Gerry McKimmey, TDMHMR director of community services, denies that the state wants local agencies to serve insured people at the expense of the indigent. However, he concedes, "economics often force the choice."
Everyone agrees that one key to better mental health care for the poor is more public money. But MHMRA could do a better job with the money it has, say some patients and advocates. They were outraged to learn, for example, that MHMRA had offered to return $2 million in state funding for the latest antipsychotic medications because the agency was slow getting the drugs to the people who need them.
MHMRA also has been criticized for its handling of federal housing grants awarded between 1993 and 1996. A local committee charged with monitoring the grants in June 1997 found that MHMRA had spent little of the $5.4 million it had received. Subsequently, MHMRA's application for a grant renewal was ranked 31st out of 31 proposals. Unless federal housing officials decide to reject several higher-ranking proposals, 113 mentally ill people could lose their $437-a-month housing allowances.
To many critics, MHMRA is strangely out of touch with the reality of mental illness. The agency has discontinued or scaled back education and training programs that help the mentally ill lead more stable, independent lives. And while many mentally ill people are eligible for Medicaid or disability insurance, less than a quarter of the patients who applied for those benefits through MHMRA last year were approved by government reviewers. Robert Hager, an attorney who handles disability claims for the mentally ill, says MHMRA doesn't aggressively pursue these all-important benefits for its patients. "If they wanted to live up to their mission statement," says Hager, "MHMRA would be getting every damn person they can in the safety net and out of uninsured status."
Such problems could not have come to light at a worse time for MHMRA. Since taking over as executive director in 1992, Schnee has kept local mental health advocates focused on a common goal: more state funding. Indeed, MHMRA is part of a statewide "community coalition" whose goal is to convince the Texas legislature to add more than $1 billion to the state's mental health budget by 2007; MHMRA wants $50 million more a year for Harris County.
"I don't know how many times I can say that the state of Texas is 43rd per capita in the United States," Schnee says. "Or that Harris County is $10 million a year below the average for the rest of the state in per capita funding. Ten million would buy a lot of services for the uninsured."
No one disputes that. But MHMRA's harshest critics contend that money isn't the agency's only problem. They believe the failure to deliver new drugs to patients or to manage a federal grant to keep 113 of them off the street reflects a public mental health system on the verge of collapse.
"It's the perfect opportunity to ask some probing questions," says Joe Lovelace, a former president of the Texas chapter of the National Alliance for the Mentally Ill, whose son suffers from schizophrenia. "Is this how we want to do business with finite resources? What model do we use to get this money, which we certainly hope to get more of, to the customer?"
One Friday in September, word came from MHMRA's executive offices that 28 of 29 case managers at the agency's six adult mental health clinics were being let go. One case manager remained at the Bayshore clinic. Two weeks later she was gone too.
Most of those workers have been reassigned within MHMRA. But more than 9,000 patients are now without a service they had used perhaps more than any other. Case managers help patients keep their appointments, arrange transportation to the clinic, track down leads on jobs and housing and, in general, navigate people with mental illness through MHMRA's daunting bureaucracy.
"They are much more important than any doctor or medication," says Kristi Huddleston, an MHMRA patient who was so overcome by the change that she wept openly at a September 11 meeting of the Adult Mental Health Planning Advisory Council. Huddleston says nurses are expected to handle some of the case management duties -- news that wasn't welcomed by at least one nurse who, according to Huddleston, left MHMRA after 20 years.
At the Bayshore clinic, the agency reassigned the only Spanish-speaking caseworker and gave translation duties to a bilingual clerk. But clerks aren't supposed to know anything about the patients' medical conditions or treatments, Huddleston says. In her view, patients would be better off if MHMRA had kept the caseworkers and cut administrative positions.
"Why not start with the people who do not serve the consumer?" she asks.
That's what Patricia Tamedy wants to know. A licensed psychologist at MHMRA's southwest Houston clinic, Tamedy says she was fired for openly criticizing the decision to eliminate case management services. She also protested the reduction of clinical teams from eight members to three: one physician, a so-called licensed professional of the healing arts (a therapist or social worker) and a clerk. The move was supposed to create more teams, thereby reducing each team's caseload from 450 patients a month to 350. The result, Tamedy says, has been "chaotic."
"They told the clinicians they had to enter their own data," Tamedy says. "But if you're seeing 15 patients a day, all day, you get behind in your documentation. Anybody who works for that agency will tell you, you can never stay caught up with everything."
Schnee acknowledges that MHMRA's staff is stretched too thin. Ideally, he says, clinical teams should handle 50 patients a month, a ratio that would require millions upon millions of dollars in additional state funding. MHMRA has let unlicensed employees go because they couldn't bill the government and insurance companies for services. Meanwhile, the agency can't recruit enough qualified clinicians. MHMRA is short five or six psychiatrists, and each clinic is short at least three LPHAs. The staff shortage has the greatest impact on the poor, Schnee acknowledges, who are losing their place in line for services to insured patients.
"It's not like we said, "Whoops, we're missing physicians, so we're not going to serve people,' " Schnee says. "We serve them, but we have to space them out more. There may be less time with the physician." Patients "may not be getting the attention we wish they could."
As a result, perhaps, patient complaints about surly and disrespectful staff are on the rise. Rose Childs, MHMRA's deputy director of the adult mental health division, says she hasn't heard of anyone being "really nasty," although she understands that not everybody is happy with the new system. "I'm not going to deny that," Childs says.
Unlike other state-funded health and human services, access to public mental health care is a matter of diagnosis and disability, not income. Local agencies like MHMRA are required to spend their state funds on a "priority population" -- children with life-threatening emotional or social disabilities; and adults with schizophrenia, major depression, bipolar disease or other disorders that require long-term care.
According to a 1999 study by the local Mental Health Needs Council, 160,000 Harris County residents have symptoms that qualify them for public mental health services. At least 55,000 of them go untreated, either because they can't afford private care, have no insurance, don't seek treatment because of the stigma, or the MHMRA system can't handle them. Many end up in the county jail or the state prisons, where they get at least some care. Others are in and out of state hospitals.
But an increasing number of Harris County residents are getting mental health care under the worst circumstances: in the emergency room. Because of staff shortages, MHMRA can handle only 270 to 300 appointments a week, which barely covers the number of patients discharged from Harris County Psychiatric Center. The agency is obliged by contract to see HCPC patients within five days of discharge, but that hasn't happened regularly in more than a year. In the last three months, four out of ten patients discharged from HCPC didn't get an appointment within five days, and nearly half of those didn't get one within two weeks.
"We don't have the data yet, but I believe a large percentage of our patients never make it to MHMRA's first appointment," says Dr. Roy Varner, HCPC's medical director. The longer a discharged patient has to wait to see an MHMRA physician, the greater the likelihood he'll stop taking his medication, Varner says. Invariably, the patient's symptoms return and he ends up seeking emergency treatment.
For years that meant a trip to Ben Taub Hospital, which is run by the county. That changed a year ago, when the crisis unit opened at the new NeuroPsychiatric Center. At the time, MHMRA anticipated the crisis unit would see 20 to 25 patients a day. More than 40 are coming into NPC daily, and a quarter of them are new to the MHMRA system. One in five cases is serious enough to merit hospitalization. The rest have to be stabilized and released within 24 hours. Sometimes they leave NPC with a prescription for antipsychotic medication. But rarely are they given an appointment for follow-up care.
"That's treating them and streeting them," says Kristi Huddleston.
Undoubtedly, NPC's crisis unit fulfills a significant need. Ben Taub, which also has a 20-bed psychiatric ward and an acute-care lockup, was so busy that it was on "drive-by" status, or filled to capacity, nine days a month. The crisis unit has eased that burden on the county hospital.
But NPC is also a source of considerable frustration, especially among patients and advocates who lobbied Commissioners Court in 1997 to build the $5 million center. NPC was proposed as a crisis unit, plus a 39-bed short-term hospital. The crisis unit opened last October, a year late. The second-floor hospital opened eight weeks ago, two years late. And as it happens, the second floor isn't a 39-bed hospital as planned, but a 16-bed "acute-care facility."
As an acute-care facility, NPC is not regulated by the Joint Commission on Accreditation of Healthcare Organizations, which sets staffing, record-keeping and procedural standards for hospitals. The lack of accreditation means NPC can get by with fewer employees, but it also limits how long most patients can stay before being transferred to a regular hospital. Barbara Dawson, NPC's administrator, says the acute-care facility was designed for patients who need three to five days in bed before they are stabilized. Beyond that, the patient is typically moved to HCPC, a state hospital or, if the patient has insurance, a private hospital.
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."
Inspectors gave Cresthaven two weeks to comply with state health and safety standards. The facility failed two inspections and was denied state certification until August 1994, after which Schnee immediately laid off the additional staff from Nursefinders, claiming the need to cut costs. Eventually Cresthaven was taken over by state health officials, who appointed trustees to assume operations.
At the time, Schnee complained that investigators' findings were taken out of context and pointed out that Cresthaven's patients were severely retarded, some bedridden and incontinent. He blamed the state's failure to increase Medicaid payments that would have funded improvements. "This facility has always been held to be an example of high quality," Schnee told the Houston Chronicle at the time. "That doesn't mean it was perfect."
At least one local advocate called for an inquiry by the MHMRA board of trustees into Schnee's dual role as head of the agency and operator of a private nursing home for the mentally retarded. Schnee denied any impropriety, saying he had never referred an MHMRA patient to Cresthaven and that, in fact, he had no control over who was treated there. Apparently that was enough for trustees, who declined even to discuss the matter. In a prepared statement, the board said that because "the issue concerns a private non-profit facility in Austin not part of Harris County MHMRA," it would be "inappropriate" to comment.
Six years later it's clear that the current MHMRA board -- and for that matter just about everyone else in the local mental health community -- continues to faithfully defer to Steve Schnee. Schnee dominates the monthly meeting of trustees, explaining state regulations, fielding questions about service delivery and, especially, pointing out the consequences of inadequate state funding.
Schnee is also the controlling force of the Mental Health Needs Council, whose members are appointed by commissioners court. Unlike the MHMRA board, which is a mixture of professionals and laypersons, the needs council consists of representatives from organizations that work with the mentally ill, including Baylor College of Medicine, the hospital district and, of course, MHMRA. Advocacy groups such as the Mental Health Association of Greater Houston and the local chapter of the National Alliance for the Mentally Ill are also represented.
The role of the needs council has been a matter of considerable debate lately. Advocates such as Robert Hager and David Clark say council members should be watchdogs who protect the interests of MHMRA's patients. Council chairman Bill Schnapp calls the council "an information-sharing group not an advocacy group."
These competing views have led to a few tense moments. In August, Hager and Clark asked the needs council to look into MHMRA's failure to spend federal housing grants. Hager and Clark say Schnapp agreed to create a task force. But the following month Schnapp turned the housing issue over to the Mental Health Association. Steve Johnson, a lawyer and consumer advocate, says Schnapp was shielding MHMRA from scrutiny when he reneged on his promise of a task force.
"David Clark demanded accountability, and it just shocked the hell out of everybody," says Johnson. "The minutes of that meeting were so sanitized that you couldn't even tell it was the same meeting. They have become almost paranoid about protecting MHMRA."
Johnson says that because MHMRA's policies affect how everyone else does business -- and they all do publicly funded business with MHMRA -- the agency is "like a bull in the china closet."
"When commissioners court has a question dealing with the MHMRA of Harris County and refers it to the needs council, basically what they get back is a reflection of what MHMRA of Harris County wants to have reflected," says Johnson.
Jack Callahan of Advocacy Inc. of Houston says the needs council is "a providers council" and that as the largest source of state funds, MHMRA has managed to "co-opt" most advocates of the mentally ill into becoming apologists for the agency. "Dr. Schnee is a very friendly and personable person," says Callahan, a former trial lawyer with bipolar disease. "The advocates want to be invited to sit at his table."
Schnapp argues that as the chief provider of mental health services, MHMRA naturally dominates the needs council's agenda. However, he insists, that doesn't mean Schnee or MHMRA's policies are immune to criticism. If it seems that way, it's because Schnee "is very good at working with other agencies," Schnapp says. "He works very hard and very diligently to work out continuity-of-care issues."
Despite all his defense of MHMRA and its chief administrator, Schnapp acknowledges concern over the agency's inability to deliver new-generation medications to indigent patients, a complex issue he has begun looking into independently. "I'm clear on all the problems," he says. "I just haven't been able to add them all up."
In 1999, after heavy lobbying by a statewide coalition of patients, physicians and advocates -- including Representative Garnet Coleman of Houston, who has bipolar disease -- Texas lawmakers earmarked $50 million over two years for the new drugs, which are more effective and have fewer debilitating side effects than old standbys like Haldol and Thorazine.
The legislative mandate was to the point: In Harris County's case, MHMRA had one year, until September 1, 2000, to put 2,043 indigent and uninsured patients on the new antipsychotics. Failure to do so could lead to forfeiture of unspent monies, as well as a possible reduction in future funding for the drugs.
Advocates and mental health consumers were delighted that the new medications would soon be widely available. David Clark says that unlike the older drugs, the new antipsychotics don't give patients a permanent case of the shakes or cause saliva so thick it leads to tooth decay. With the new medications, the mentally ill are "indistinguishable from other people," he says. "They can suddenly blend in."
As the September deadline approached, however, it was clear MHMRA would fail to meet its state-mandated target: Only 626 eligible patients -- 31 percent of the agency's target -- had received the medications, a failure that caught the attention of those who had advocated loudly for state funding for the drugs.
Joe Lovelace, former president of the Texas Alliance for the Mentally Ill, came down particularly hard on MHMRA in a series of e-mails to advocates and providers across the state. Angry over what he called MHMRA's "sorry" performance, Lovelace rattled cages at the state mental health department, which sent Heather Hajovsky, interim director of community programs, to meet with Schnee.
In an August 7 letter to Hajovsky on the eve of her visit, Schnee outlined a number of "considerations" that hampered MHMRA's efforts, including:
" Caseloads as high as 450 patients per physician, which limited how often patients on the new drugs could be monitored
" Psychiatrists at HCPC, who were reluctant to prescribe the medications because they didn't stabilize patients quickly enough
" A higher-than-expected number of patients who didn't like the new medications and who had refused to take them
Schnee conceded in the letter that MHMRA wouldn't reach its target by September 1, but protested any reduction in future funding to MHMRA for the new medications. However, Hajovsky wasn't impressed with Schnee's reasoning. In a letter written after her trip to Houston, she noted that every local agency in the state had the same problems Schnee described.
Indeed, the state's other large cities didn't appear to have any trouble delivering the drugs to their patients. In Dallas, 1,395 people, 96 percent of the target for that area, were prescribed the new medications. Austin-Travis County MHMR added 161 people, 92 percent of the target. In San Antonio, 562 new patients are receiving the drugs, 70 percent of that agency's target.
At a recent needs council meeting, Schnee shocked some advocates when he said MHMRA had attempted to return $2 million of the $7.6 million the agency had received for the new drugs rather than risk losing future funding. Schnee tried to calm the waters by insisting that he hadn't heard any complaints from patients who were unable to get the new drugs. But one woman, Cheryl Villareal, said her son received the drugs only after she appealed directly to the MHMRA board. Attorney Robert Hager reminded Schnee that two of his clients had been denied the new medication.
Maurice Seiden waited almost a year for his MHMRA psychiatrist to put him on the new antipsychotic medication. Seiden's medical records, which he agreed to share with the Houston Press, show that last year, while taking the old-style medication, Stelazine, he reported psychotic symptoms, including increased paranoia, to his MHMRA physician. According to the records, the physician increased Seiden's Stelazine dosage.
In January, Seiden was browsing in a bookstore when he suffered an attack of dystonias, a sudden cramping of the neck and arm muscles that is a common side effect of Stelazine. Seiden made it to his general practitioner, who gave him an injection of Benadryl and kept him under observation for four hours. Seiden reported the dystonias at his next appointment with MHMRA, but the physician merely reduced the Stelazine dosage. Seiden hasn't had another seizure, but he wasn't prescribed the new antipsychotics until late October when he asked his doctor for them. His doctor never raised the subject in all those months, Seiden says.
John Griffith, a psychiatrist on staff at HCPC, says he considered filing a complaint with the Texas Board of Medical Examiners after MHMRA refused to fill a prescription for a patient with tardive dyskinesia -- a serious side effect of the old medication and a condition that, if untreated, can cause permanent neurological damage. Griffith says MHMRA's failure to honor physician requests for the new drugs illustrates how the agency often makes administrative decisions that are not in the patient's best interest.
"I talk to them about patient needs," Griffith says, "and they respond, "Well, that's a medical model. We provide psychosocial services.' "
Callahan of Advocacy Inc. finds Schnee's claim that many patients refuse to take the new drugs incredible. "Hell, the clients don't know the difference," Callahan roars. "If it wasn't for the new-generation drugs, I'd still be where I was in 1987."
MHMRA has begun to work out the kinks in its new-drug delivery system, Schnee says. The agency has broadened its eligibility requirements and has agreed to share up to $100,000 of state funding for the antipsychotics with HCPC, which discharges 1,700 patients annually who are eligible for the new drugs. Schnee says HCPC psychiatrists have agreed to begin prescribing both the new- and old-style drugs "when appropriate."
But Schnee argues that the reduction in outpatient services for indigents means they will see their physician only every three months. He predicts that as many patients as remain on the medications between appointments will, for one reason or another, stop taking them.
"We try to see them more frequently, but with physician vacancies and resource deficiencies, it has implications," Schnee says. "If I start you on a medication, I don't know exactly what dosage you need to make it work. I've gotta adjust it, readjust it. And if I can't see you with some frequency, I have to proceed cautiously."
Joe Lovelace has come to view MHMRA's failure with new medications as symptomatic of the agency's inability to carry out its mission. The state legislature dug deep for $50 million to pay for the new drugs because they work, he says. Other local agencies have managed to spend their share. There's no good reason why MHMRA couldn't do the same.
"They argue that they're underfunded, and that's why a lot of problems exist," Lovelace says. "It's a convenient scapegoat, but I don't think it works. I think this shows that if the medication was free, they couldn't get it to me."
On the evening of October 4, Steve Schnee and his staff held their customary public forum to unveil the agency's annual budget at the MHMRA clinic on West Dallas.
Schnee, in shirtsleeves and loosened tie, looked worn out. Earlier that day, at a particularly feisty meeting of the Mental Health Needs Council, he had bickered with David Clark and Robert Hager, whose criticism of Schnee and MHMRA has become increasingly confrontational. At one point during the council meeting, Clark interrupted Schnee's summary of MHMRA's funding woes to crack, "One way to get more money is to spend the money you get well." That evening Clark and Hager were back at Schnee for an explanation of why 113 mentally ill people might lose their rent subsidies.
At issue is a series of five-year housing grants totaling $5.4 million, awarded by the federal government between 1993 and 1996. Every February a committee representing local social-service agencies does a "gaps analysis" to determine where housing assistance is most needed and how to deliver it. In 1997 the committee discovered that MHMRA had spent only $500,000 of $2.6 million in grant funds the agency received in 1993 and 1994.
Apparently no one at MHMRA had noticed the grants weren't being spent until the committee brought it to the agency's attention. According to deputy director Rose Childs, an internal investigation turned up "a flaw in the program design" that has since been corrected. Childs also blamed the agency employees, since departed, who monitored the grants.
Earlier this year, MHMRA applied for a renewal of the $1.7 million grant the agency received in 1993. In large part because of the amount of unspent funds, the proposal was ranked dead last out of 31 applicants. The feds haven't rejected MHMRA's renewal application yet, but Childs isn't optimistic. MHMRA also could have trouble renewing the other housing grants. The agency has spent less than half of the $3 million received in 1998 and 1999.
The housing debacle infuriates MHMRA consumers and their advocates -- for good reason. A shortage of decent, affordable housing is perhaps the biggest crisis facing the adult mentally ill, many of whom end up homeless or living in cramped, unregulated halfway houses. Housing programs like those funded by the federal government do more than provide shelter; they also teach consumers how to budget their money, shop for groceries, even socialize.
"A lot of mentally ill people have no work history and no family," explains Bruce Stohr, a former MHMRA client with bipolar disease. "Medication just isn't going to clear out all the wreckage."
A few years ago Schnee pulled together a coalition that included many MHMRA consumers to convince county commissioners to fund the $5 million NeuroPsychiatric Center. It's difficult to imagine Schnee gathering the same support today. The agency's problems, including the substantial reduction in supportive services, have bred "consumer alienation," says advocate Steve Johnson. Consumers have neither the opportunity for significant input nor an effective outlet for their grievances, Johnson says.
The state requires local mental health agencies to form planning advisory councils, with at least half the memberships set aside for consumers or their family members. But Johnson says the council's resolutions are rarely considered by MHMRA's board. "The resolutions don't even go to the board, but to a committee, which sometimes doesn't even forward it to the full board," he says.
Nor are some consumers pleased with the local groups that are supposed to protect their interests. In 1995 Bruce Stohr was hired by the Mental Health Association, the oldest and most prominent advocacy group in town, to organize a consumer advocacy council. Stohr embraced the job and soon began bringing complaints to the association's executive director, Betsy Schwartz. She invariably sided with Schnee against consumers, Stohr says, and she expected him to do the same.
"I didn't realize I was really working for MHMRA under a different name," Stohr says, half joking. "She wanted Uncle Toms, and I'm no Uncle Tom."
Stohr says Schwartz fired him after less than a year for being "angry" and "uncooperative." He wasn't replaced, although Stohr's consumer advisory council, which included David Clark, evolved into Houston Area Mental Health Consumers. After several years of ad hoc existence, the group recently got nonprofit status and a telephone.
Schwartz is generally well liked and appreciated for her commitment to the cause of mental illness. She declined to discuss Stohr's employment at the association, but defended her advocacy efforts, saying any criticism is coming from "a vocal few." Confrontation isn't her style, Schwartz says, nor is it very effective. "We're quiet, behind the scenes."
Schnee and MHMRA also have lost credibility over the agency's failure to vigorously pursue Medicaid and social security benefits for uninsured patients. MHMRA has increased its reimbursements from the federal programs from $333,000 in 1990 to an estimated $12 million in 2000. But that likely reflects only a fraction of the patients who are eligible for the benefits.
Between September 1, 1999, and May 1, MHMRA's consumer benefits office received more than 1,360 referrals, most of them from clinics. Almost a quarter of them never followed through with the application process, either by choice or because MHMRA lost track of their whereabouts. Of the rest, only 101 were certified to receive Medicaid or federal disability insurance; another 360 cases are pending.
Attorney Hager, who argues claims disputes for several mentally ill clients, says most of the MHMRA's patients are eligible for subsidized benefits. The problem, he says, is that MHMRA's patient charts don't include the information government reviewers need to approve eligibility.
How government reviewers "evaluate mental disorders requires information that is not in the normal medical record," Hager says. "Doctors don't put down a lot of information about functional limitations, about how you can or can't take care of yourself. But for social security, that's the bottom line."
Hager says he has tried for five years to get Schnee to urge his physicians to include more pertinent information on patient charts, as well as to increase the staff in MHMRA's benefits office. Schnee was unreceptive, Hager says, until late last year. That's when a study by the Rand Corporation, a public advocacy group, showed that only about 50 of 212 severely mentally ill people in MHMRA's supportive housing program were on social security. More telling, perhaps, are the results of a recent analysis by MHMRA: Only 46 of the agency's 326 most acute cases had ever been referred to the benefits office by MHMRA clinicians.
Schnee acknowledges he has no choice but to get more consumers qualified for government benefits. To balance this year's budget, MHMRA needs $22 million in revenues from third-party payers. The upshot is that in order to reap those revenues, MHMRA has had to cut services to those who don't already have some type of insurance and realign the agency's staff and resources to serve those who do.
That's not supposed to be how it works, says Schnapp, chair of the Mental Health Needs Council. Agencies like MHMRA were created to care for the "sickest of the sick, the poorest of the poor," he says. Now, they are being told, in essence, to turn their backs on those who cannot pay.
"Who's going to take care of the non-Medicaid patient who is seriously ill?" Schnapp wonders. "Nobody. Nobody."
It's hard to miss the urgency in Schnee's voice when he talks about the upcoming legislative session; or the frustration when he talks about the ever-weakening safety net. MHMRA's critics are "shooting the messenger," Schnee says, and are ignoring the state's unwillingness to provide decent care for one of its most vulnerable populations.
"Texas is very conservative in the way it approaches health and human services," he says. "We make choices. We fund our prisons well. We probably have one of the best road systems in the world.
"All we can do -- what we are trying to do -- is paint the picture for people to understand, to hear and to listen, and try to influence the policy makers on the significance of putting resources into this."
Steve Chesser was new to the mental health system, but other members of his family weren't. One of six children, Steve told the staff at the NeuroPsychiatric Center that he had a sister with bipolar disease who had just been released from a state hospital. Steve's mother, Betty, says her father had mental problems, and her husband's mother received electroshock therapy in the 1940s and 1950s.
Over the years, Steve drifted from one low-paying job to another. His favorite gig, Betty says, was as a plant security guard. He worked four days on and four days off, which gave him plenty of time to check up on Maria. Steve and Maria tried marriage counseling early, Betty says, but it didn't work. Maria left him, came back, then talked him into a trial separation. The marriage wasn't all bad, Betty says. Despite his problems, Steve could be a kind and thoughtful man.
"He would go for three months and just be so good to everybody," Betty recalls. "Then something insignificant would set him off."
On those occasions, Steve would sometimes beat Maria, Betty says, or threaten his daughters in bizarre ways, like announcing he planned to hire someone to rape them. Steve had just started seeing a private psychiatrist, Betty says, but neither she nor her son thought to call him after Steve bound his wife in duct tape and threatened to shoot her. Instead, they wanted a place that would hospitalize Steve, keeping him safe from himself and others.
A few days later Steve called his mother, who remembers that he sounded happy. "He said, "Mom, I'm going to do what you said,' " Betty recalls. " "I'm going to get on with my life.' "
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The next day, Steve shot Maria, then killed himself.
Steve's ashes are in a nondescript white box in the front room of his mother's house. He deserves better, Betty admits, but she didn't have enough money for an urn, let alone a proper burial.
After Steve's death, Betty called MHMRA, looking for answers. Why hadn't they put her son in the hospital or at least given him some medication? If the psychiatrist at NPC thought Steve needed counseling, why was he allowed to leave the center without talking to a therapist, or at least getting an appointment to see one at another time? Where else was he supposed to go to get the help he needed?
"They told me they were sorry," she says.