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Reality Check

Fishkind says the state can fund better mental health care and save money in the long term.
Margaret Downing

Jesus, Mary and Joseph would feel right at home in Houston these days.

The county's mental health agency is turning away new nonemergency patients. The NeuroPsychiatric Center has gone on drive-by status three times since May -- no matter how sick the patient trying to get in to receive its emergency services. And a shortage of specialized trauma beds in hospitals throughout the region means some critically injured patients aren't getting where they need to go in time to do them much good. It's life-threatening and already life-damaging, doctors say.

There's no room at the inn all over town. Our own little Bethlehem West.

Money, of course, is cited by various experts as the root of all this evil. Dr. Steven Schnee, head of the Mental Health and Mental Retardation Authority of Harris County, called a press conference on short notice last week to make it clear that this is a time of "crisis."

"Going on drive-by status puts the community and the consumers and the family members that count on NPC at risk," Schnee said to reporters at NPC. He noted that Ben Taub's emergency room, which has psychiatric services, has had to go on drive-by also. Patients who cannot get treatment, he said, can get "quite agitated." Some of this agitation may be coming not just from the emergency room shutdowns but from MHMRA's decision to not take new nonemergency cases on an outpatient basis as of July 1. Some people are becoming more ill before they receive care, he said.

Betsy Schwartz, executive director of the Mental Health Authority of Houston, a patients' advocacy group, rushed in to the meeting and declared: "This is really an outrage. All of us should be ashamed of a city of the size and wealth of Houston to allow a mental health crisis to exist." If NPC were properly funded by the state, she said, there would be no crisis.

Dr. Guy Clifton, chief of neurosurgery at Memorial Hermann and one of the founding members of Save Our ERs, has his own crusade going. Starting in 1999, hospitals in Houston began to have emergency room saturation, diverting patients away 12 percent of the time. Patients aren't getting the care they need riding around the city looking for a hospital or sitting in most emergency rooms, which are not equipped to undertake the intensive measures needed to save these people's lives.

The pleas are heartfelt, the points valid. It is barbaric that Texas comes in 43rd in the nation when it comes to per-capita spending on mental health. Houston is a financial center, but it can't handle the vast number of uninsured patients that are sinking its medical system. It is maddening that we have the expertise to save people and aren't. We might as well all be wearing T-shirts saying Welcome to Houston, the greatest third-world city on earth.

But the likelihood of Texas ponying up some dough -- the state comptroller has projected a $5 billion shortfall when the legislature meets in January -- is about zip. Legislators didn't parcel out more money for those services when they were flush with cash. Why would they do it now?

Tragedy, Schnee said. "Somebody will do something really tragic and involve other people." Clifton said the state may come through with more money for trauma care after some legislator's child dies needlessly. Maybe when something really, really horrible happens, then the state won't be able to look the other way about its commitments to mental and physical health care.

Of course, since most of the mentally ill are not dangerous to themselves or others, it is more likely that the vast majority of the untreated will just sink into quiet depression and wasted lives.

It's ancient times brought to life in Houston. A human being is going to have to be sacrificed, laid out on a rock, split open, his or her life's blood pouring out. Losing their life, losing their mind. It'll be splashy, it'll be tragic. People will say they didn't know.

And Betsy Schwartz, Steven Schnee and Guy Clifton will shout in anger, sigh in resignation or cry in frustration. But then maybe something will be done.

In the meantime, we need a plan B.


It's five o'clock in the afternoon and Dr. Avrim Fishkind, medical director at the NeuroPsychiatric Center, needs a lift. He's clutching a cup of coffee from the Starbucks on Montrose; it'll keep him awake. Last week he put in 84 hours on the job. At a certain point, people just run out of gas.

At first glance, it would be easy to dismiss Fishkind as some kind of outsider who doesn't understand how things work in Texas. He's a graduate of the University of Maryland who got his medical degree from Johns Hopkins University. Fishkind was chief of the Comprehensive Psychiatric Emergency Program in Washington, D.C., when he got a call from the Mental Health and Mental Retardation Authority of Harris County to head up its new psychiatric emergency hospital.  

He knew exactly what he was getting into. He'd worked for the Austin-Travis County MHMRA and knew the state's strengths and weaknesses. Moreover, his wife was expecting twins and wanted to be closer to her family in Austin.

Fishkind, president-elect of the American Association of Emergency Psychiatry, said he tries to stay focused on providing better care and doesn't let himself get angry. He wants to see Texans move to an understanding that sometimes you invest money to save money -- just like in a business.

He's one of the group that huddles up to decide whether NPC should go on drive-by status. He stresses that in each case this was just for a matter of hours and that they worked with other area hospitals to find places for these people. Most NPC patients are of the "23-hour care" variety, meaning that technically they are there for less than a day. Eight beds have been reopened on NPC's second floor, which houses patients for three to five days.

But most NPC patients who need hospitalization go to the University of Texas Harris County Psychiatric Center. MHMRA contracts with HCPC for 143 beds. Those institutions talk among themselves hourly when patients back up. As soon as HCPC discharges someone, NPC moves another patient over, opening a slot for someone new. Sometimes beds open up in Rusk, the state hospital, said Barbara Dawson, head administrator at NPC.

It's a gigantic game of human chess.

Based upon population, Harris County should have six or seven public emergency psychiatric facilities, not just the two it has with Ben Taub and NPC, Fishkind said. Some hospitals such as Methodist have staff to provide emergency psychiatric services, he said. And the Memorial system has a crisis response team that Fishkind describes as excellent.

Still, Schnee said, Memorial Hermann Southwest just closed its psych unit. In fact, more than 500 private psychiatric beds have closed in Harris County, Schnee said. With the vast number of uninsured patients in Texas, hospitals find psychiatric beds and psychiatric facilities unprofitable, so they close, Schnee said. "It's a business decision, not a question of whether or not the treatment is needed."

With job layoffs, people lose health care benefits. People used to dialing the 1-800 number on their insurance cards are now clients of the public health system, walk-ins with cell phones and no way to pay for life-sustaining medicines. And Harris County can't handle all this new popularity.

In fiscal 2003, there is no additional money for mental health services in the county, Schnee said. In five years, HCPC has not received any significant increase from the legislature, he said.

Commissioners Court has continued to generously fund local mental health needs, but its resources just don't match those of the state's.

Increased cooperation among the county mental health agencies will be crucial in coming months, Fishkind said.

And hospitalization isn't even the desired goal in most of these cases. Dawson is proud to say that of the more than 12,000 NPC patients in the last year, only a quarter of them had to be hospitalized. The goal is to see to patients' needs and put them in the least restrictive environment.

The Ben Taub psychiatry department has worked up one proposed program that holds promise, Fishkind said. "Partial hospitalization," as it is called, would bring patients into the hospital setting during the day for treatment but would allow them to sleep in their own homes at night. Again, this would take tremendous pressure off the system and make most patients a lot happier.

It also stretches mental health dollars to serve a lot more people.

HCPC, which is now attracting streams of walk-in patients, has already changed its way of doing business, spokeswoman Geri Konigsberg said. A month ago, HCPC began moving patients into a new discharge unit where they can watch television or movies and play games while waiting for relatives to pick them up after work. "It keeps them in a safe environment and frees up beds," Konigsberg said.

At MHMRA, Schnee said his agency is working hard to get more people on third-party or Medicaid coverage.

Whenever there are funding shortages, there are also questions about whether an agency is managing itself correctly. A 1997 investigation discovered MHMRA lost track of federal housing funds and spent little of the $5.4 million it had received from 1993 to 1996. This, when housing continues to be one of the crucial problems for the area's mentally ill.  

Fishkind said a new chief financial officer and deputy executive director are trying to make the most of every bit of funding. He acknowledged that all mental health authorities are moving toward different models of operation and delivery and MHMRA will be no exception if it wants to survive.


Over time, there has been increased outcry that insurance companies cover mental health at a fraction of what is provided for in medical coverage. A congressional bill would broaden mental health insurance coverage -- a bill that the insurance lobby is fighting.

Even if it passes, of course, it won't help the uninsured, of which Harris County has far too many.

Mental health coverage in Texas will change, Konigsberg said, as more people demand improvements for their children. HCPC just signed a contract to provide services to kids in Head Start. That's kids from birth to five years old. As Konigsberg puts it, would you rather pay for prevention now or jail later?

Fishkind said the change will come "when people begin to understand the lost productivity and costs of not treating mental illness. When fiscal factors hit enough people in a broad enough scale."

But waiting for the legislature to act is no solution.

"I think everybody has got to learn to live with less," said Konigsberg, pointing to the example of the Harris County Hospital District. The district has taken on a lot more of the indigent, particularly with HIV and AIDS, and done a good job without additional funding, she said.

"You have to look at what you have and be creative," Fishkind said. If all else fails, people use churches, Fishkind said. "They use spiritual systems, and there's a lot of evidence that can be just as effective." He also said that even putting off people on their appointments -- as long as you give them an appointment -- doesn't do that much damage. "As long as people have hope for an intervention, that gives them a resource."

Groups also need to generate additional money through other funding sources, Konigsberg said. Of course, competition for stray dollars may put a damper on cooperation among agencies. Just as the need for trauma beds competes with the needs for other kinds of beds in facilities.

"The only way to solve the problem is to have an open, honest dialogue clean of politics," Konigsberg said.

While and until all this gets sorted out, emergency rooms will continue shifting critically injured patients around the region, hoping to get the worst ones to the few trauma centers in time.

And the Mental Health and Mental Retardation Authority of Harris County, as Steven Schnee himself has said, will be rationing care. Is someone a little bit crazy? A lot? A new crazy, an old one already on the books? Dangerous? How dangerous?

And everybody has got to guess right every time.


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