Rx for Failure?
For years, Harris County's public mental health clinics have doled out medications to treat schizophrenia, bipolar disease and other serious psychiatric disorders at on-site pharmacies. The policy has obvious benefits: Patients don't have to make a separate trip to fill their prescriptions, and county physicians are assured that patients receive the drugs they need to stay out of the hospital.
But in a policy change that took effect August 1, local health officials have cut pharmacy services to mentally ill people with Medicaid coverage. While the uninsured still can fill their prescriptions at the eight clinics operated by the Mental Health and Mental Retardation Authority of Harris County, about 3,300 Medicaid patients now have to go to private pharmacies such as Eckerd and Walgreens.
The new policy is necessary to offset the agency's continuing budget problems, which have been compounded by the rising cost of prescription drugs, says Dr. Steven Schnee, MHMRA's executive director. The federal government encourages private pharmacies to serve Medicaid patients by reimbursing them for the full cost of prescription medications, although MHMRA must use funds it receives from the state to cover roughly 40 percent of drug costs for those patients.
"We found that we could not continue to absorb this [cost] within our budget," Schnee says. "To do so would have seriously curtailed other services in our already limited care system."
The pharmacy cutbacks, announced last month at a meeting of mental health advocates, are expected save MHMRA about $1.7 million, a relatively small amount of the agency's $120 million budget. Meanwhile, the new policy could have dramatic consequences for a mental health system already stretched to the limit.
Nearly 9,000 patients visit MHMRA's eight clinics every month. Last August, after MHMRA ended its budget year with a $3 million deficit, the agency cut clinical staff and began rationing care. Indeed, the need for psychotherapy, job training and housing assistance so exceeds the available funding -- only three states spend less than Texas on mental health services -- that dispensing medication has become a critical component, if not the primary function, of the clinic system. For one thing, it reduces the demand for more expensive emergency and hospital care that, in any event, is increasingly unavailable.
In February MHMRA closed the 16-bed hospital at the new NeuroPsychiatric Center, citing the facility's $300,000-a-month operating deficit (see "Mental Lapse," by Brian Wallstin, March 1). While the center's "crisis intervention unit" remains open, it too is losing money and is already handling about 210 emergency cases a day -- twice what MHMRA had anticipated. About one in four of those cases require hospitalization at the Harris County Psychiatric Center, which has about 200 beds set aside for the agency's patients; all of those beds are usually occupied.
Given the lack of treatment options, some advocates have challenged the wisdom of making it more difficult for patients to get their medications. Robert Hager, president of the Houston Area Mental Health Advocates, says many people with serious mental illness can't drive and often have trouble arranging transportation to their clinic appointments. Hager also points out that patients who, for whatever reason, don't take their medication are often denied services by MHMRA for failing to follow their treatment plans.
"I wonder how carefully MHMRA looked for other areas where they could save $1.7 million," Hager says. "Especially for a change that will probably result in fewer people actually getting their medication."
Hager is also critical of how MHMRA handled the policy switch. Medicaid patients weren't notified until two weeks before the change went into effect. Nor, apparently, did MHMRA consult the Harris County Mental Health Needs Council, a group of local experts who report to county Commissioners Court. Although Schnee announced the policy change at a meeting of the Adult Mental Health Planning Advisory Council, the state-mandated panel of care providers and advocates wasn't given an opportunity to come up with an alternative.
"They circumvented the normal process by simply doing it without consulting anyone else," says Hager, who is a member of both groups. "They gave us no notice, no ability to form a committee or even discuss whether this was the right thing to do."
Schnee says both advisory groups will have a chance to weigh in on the new policy once MHMRA determines the impact it has on Medicaid patients. He says agency staff members have been given special training to help patients with the transition and that MHMRA will, "within the limits of our resources," watch for increased caseloads at emergency rooms and psychiatric hospitals.
More than likely, though, most local mental health advocates will simply have to accept what they've known for a while now: The Harris County mental health system is in an advanced state of collapse.
A lack of adequate state funding is primarily to blame, but MHMRA's budget woes have been compounded by its own failings. Late last year the agency returned $5 million to the Texas Department of Mental Health and Mental Retardation after failing to execute a state-mandated program to distribute the latest antipsychotic medications. A few months later the agency forfeited another $800,000 for not meeting performance targets set by the state.
The agency's next budget year, which begins September 1, promises little relief. Legislators found an additional $41 million for statewide mental health care last session, although MHMRA -- the largest mental health agency in the state and one of the largest in the country -- is slated to receive little more than $1 million of that windfall.
If anything, telling Medicaid patients to get their prescriptions filled at private pharmacies suggests that the agency's patients haven't seen the end of the service cutbacks. All but a few hundred indigent and uninsured patients are ineligible for most MHMRA services and have to wait three months for an appointment to see a doctor. However, Medicaid patients have not had to endure the hardships wrought by the agency's policies. Until now.
"For people who aren't mentally ill, this probably amounts to 'Oh, well, they can just go to the grocery store like the rest of us,' " Hager says. "But for people who are basically hanging on by their fingernails, anything that makes life more difficult can be overwhelming."
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