Unintended Consequences of Mental Health Care Delivery Reform

A small town newspaper can often offer a startlingly accurate portrayal of policy governmental changes not noticed, or reported upon by the mega-media in many locales. One such North Carolina very small regional newspaper is the Laurinburg NC Exchange. This town is likely unknown to 99% of my readers unless you are from northeastern NC, an area to the east of Interstate 85 as it curves north from Durham “The City Of Medicine” toward the state border with Virginia. It has a proud heritage of being a center of Scot (not “Scottish”) culture with an annual festival with the wearing of clan tartans and kilts.

The Laurinburg NC Tartans
The Laurinburg NC Tartans

Just three weeks ago, one of its weekly lady columnists that all Southern papers worth their while seem to have to comment on the higher ordinations of life, Ms. Mary Katherine Murphy, published a most perceptive piece of analysis entitled, “State of Mental Health: Barriers Impede Treatment.” As this is what I blog about in large part, this piece caught the ever roving eye of one of now well trained roving Google searchbots, and snagged this piece for persual. Ms. Murphy may be from a small town area and culture but her piece is well worth reading for anyone interested in this 15-20 year crisis in the  social fabric of our country. I would most strongly recommend it if I had the power to do so, to policy wonks and governmental planners, scholars in research and “think tanks” of all political stripes in this country for thorough pondering. It is that good in its brief but very on target two pages.

In barely five short and tightly written paragraphs she gives the long lamented history of the decline of mental health treatment in this country from the asylums and lock-ups, through the age of modern psychiatric drugs, the nationwide mistaken trend to “dwindle” as I pejoratively term it, reduce the number of inpatient psychiatric treatment beds in this state like so many others, both public and private, with the consequence of flooding our jails and ERs and streets with the chronically psychotic individuals now so visible in their misery.

She takes the reader succinctly through the previously well functioning typical country by country of region by region “mental health centers,” of which there were 39 in NC in 2001. North Carolina from its agricultural and overwhelmingly rural days nearly 200 years ago structured itself uniquely in this country by having fully 100 political districts. a state senator for each and according to population and of late, the most blatant political gerrymandering in the country [don’t take my biased word for it, Google it…]. So we have lots more politicians as the native local wags in this state in its collective sense of humor put it: “running all over the place doing as much good for themselves as they can.” This means the most parochial, meaning localized, and at times most anti-scientific, vituperous, personalized arguments and debates can take place in our General Assembly. But nobody throws any fists as has happened in a few states in the last decade or so over aspects of the culture wars. North Carolina’s system, ignoring the usual power of big political machines and pots of money that both national parties have had and use, does permit that “little person” in my view more spokespersons and representation than states such as Arizona that have only a half dozen counties that are bigger that more than several of our states.

Our 100 county system meant for the mental health delivery system that each region had its own local system, its own board of directors, and all the staff from the Boards of Directors, CEOs, and all the other managerial types often were known and from the county or nearby areas. t seemed to me in those days when I worked and consulted in a number of different “MHC’s” from my training years in the 1970’s through the early 2000’s, loyalty to the citizenry, their “mission statements” that we all spout nowadays to be politically and corporately correct, MEANT something. They were ideals that were taken seriously. If someone messed up, ignored the needs of the citizenry, did not make good hearted attempts to at least fill needs as best as possible in that region, or embezzled, or paid themselves narcissistically aggrandized and self inflated salaries, the locals knew and the local governing entities took care of business and sacked the miscreants forthwith. Ms. Murphy noted that we had 39 MHC’s in those days before 2001 when “mental health reform” was enacted as a legislative concept and mandate.

The state comparable to my favorite analogy drawing from my “anti-Commie” cultural experiences as a child of hiding under my school desk so the Russians’ dreaded “A-bomb” would not incinerate me, enacted its first “Five Year Plan” like Stalin did with comical regularity in Russia prompted by the wheat crop famines. MHCs were forced to Stalinize like the huge communal farms [to further stretch this analogy], and merge into very much large entities. The minimum population to form the new mental health managerial entity was initially in the early days of mental health reform, 200,000 souls. The new entities as Ms. Murphy points out were newly termed “Local Management Entities.” I have thought that term had a rather centralized governmental style of management ring to them…

To explain how this came about, in 1999 a few MHCs had been audited for sloppy Medicaid billing and collection practices. One of them was “Trend Mental Health Center” of Hendersonville NC south of Asheville. It was ballyhooed somewhat in the press but strongly and stridently seized upon by the state legislature’s committee of the oversight of the mental health, developmental disabilities, substance abuse services and human services in general, to be the galvanizing reason why the LME’s had to be brought into being and the localized mental health centers abolished. Bigger entities somehow ensured better collections, better accounting etc. The reality was the Trend Mental Health and the other MHCs were run by clinicians and not business people.They did not make for great business managers, and had in their zeal to provide services first and do all the billing second, had fallen grossly behind on their financial tasks. Trend it was reported in those days in the local paper, the Hendersonville Times News,  to have generated an appalling shortfall of over $400,000. Heads rolled and the psychiatric director resigned. As the LME concept and the mental health reform model was moved, virtually all the psychiatrists in that very good clinical agency, including all three of the child psychiatrists resigned within the next year. A psychiatrist who was quite competent was brought in from a Midwestern state to take over and that practitioner lasted around a year before he/she retreated back to the Midwest and a more rational practice system.

There was also an ethos behind all this this, that business practices, run tightly and efficiently and applied to all areas of health care enterprises, an ideology now dominant in this country, in all kinds of health care organizations, would be somehow immensely improved by being run as businesses and not as services to the people in need, a concept now at times met with open derision as the soul of healthcare seems to disappear.

By 2011 the state was into its at least 3rd or 4th “Five Year Plans,” the others being minor iterations. This 2011 change as Ms. Murphy reported mandated that the regional mental health care organizations had to be split up and divorced from the roles as mental health care contractors, and transmorgrified into organizations that contracted with and even owned mental health businesses or practices that wished to claim slices of the mental health/DD/SA (substance abuse) pie of services. The MCOs now are very confusing, poorly defined entities who have control over funds and the organizations that provide the services. There are volumes of legal regulations and statues online but ever repeated study does not make clear the boundaries of these entities to a large part.

All over the state the system suddenly changed into an enormously populated hodge podge of counselling practices, offering services that they chose. They became parodies of the modern business even in their answering systems, the ways distressed patients made contact for acute emergent service. In the old days you called your practice group and someone was “on call,” and would you could be patched through to them, page them and they would call you back. Now you get the typical automated robot voice [devoid of empathy in my view]. After hours emergency services have become telephone menus that frustrate and have no human presence or essence. Is this asking too much?

The new agencies adopted the now standard telephone answering systems with long winded announcements telling callers to punch 1 for appointments, 2 for the nurse, 3 for billing etc., and always ending with the liability avoiding announcement to “dial 911 and go to your local hospital emergency room if you have a life threatening emergency.”

Also in 2011 as Ms. Murphy reported in her May 2015 article the LMEs now were required to merge into even larger entities that had to have at least 500,000 persons. This was taken by observers to be a way of handling more effectively the many many small counties in all areas of NC that had only thousands, not hundreds of thousands of residents, given NC’s history referred to above as having 100 counties. Care in this view was inefficient, and economies of scale, another modern business buzzword was assumed to be the reason.

The results were that acutely mentally ill persons had to call central toll free numbers that for years were split among a dizzying array of all different services and practices. For years as agencies came and went out of business, the numbers went dead. Even in functioning, stable agencies, some of them were difficult to find in our ever dwindling system of disappearing phone directories. And patients of course were and still are overwhelmingly confused by this abstract system of accessing care as it has been called in this ‘modern’ era of mental health reform. It does not take a genius to figure out that many would not take this step to even call and access care as it were. Too intimidating. The consequences were pervasive, the same all over the state and others and were indeed huge.  Patients poured into ERs even more than before, overloading ERs in unprecedented fashion. And of course, this process is being repeated everywhere in this country, many times worse in large urban areas.

Some ERs such as Pardee Hospital in Hendersonville NC, Mission St. Joseph Hospitals in Asheville, and Greenville Memorial in Greenville SC, formed their own mini-behavioral health ERs or sections of their ERs that housed and treated strictly mental health/DD/SA patients exclusively costing their budgets heavily. This is not so big a trend and only hospitals that truly have community commitments do this as long as they can afford to. These services though, range from well planned to thrown together services, operating on shoe string budgets often relying on local police to function as psychiatric ER attendants. Stories of patients stuck in ERs for weeks at a time appear in media all over the country every week and this has been commonplace since approximately 2004 in my humble memory in following this national “story.”

I also wish to emphasize one of the last points of Ms. Murphy’s subtle gracious style of reporting that is couched about halfway through her article. She noted a growing phenomena in which under the variability of access to and availability of funds for services in different and even adjoining counties, patients with certain service needs not funded by their own counties of residence or ‘coverage,’ are crossing over to adjacent counties to secure these services. Another one of the unfair, uneven disparities that have demonstrated the power of “unintended consequences.”

One point that deserves a bit of inserting and interpreting to fill out the concept of inept unintended consequences, is that in the early years of the evolution of this massive effort is that outpatient services were simply totally underprovided for. Private service delivery contractors tended to “cherry pick” the less resource draining or intensive services to perform and ensure higher profits and less expense. “Silo’ing” of mental health services has been a persistent and enduring result where one regional mental health service delegating-contracting organization covering several counties will decide to fund some services and not others as implied above. But another more gap with far more telling negative impact has been the fact that the massive outpatient community based mental health services were simply not planned for, inadequately estimated as to scope of need and resources were not largely and are still not, shared among adjacent regions.

The very latest “Five Year Plan,” now intends that three or four of the “MCOs” will cover the entire state. Once again I would add a comment and interpretation to Ms. Murphy’s “just the facts,” approach in her article which is very well written indeed, summarizing 15 years of tumultuous changes in two very clear pages. That additional thought is that similar to the national trend occurring in the US these days, we are retreating from the smaller regionalized systems to large, larger and near largest mega-corporations who are so big that as in the bank scandals of less than 10 years ago, that not only can they not be subjected to adequate oversight, they cannot be allowed “to fail.” An emerging characteristic of modern corporate business life appears to be the circumstance that the business entities, whatever one wishes to call them, can be so huge in terms of worldwide scope of operations and of income, that they can dominate and make the rules to an increasing extent wherever they operate. Regulation seems to be a nasty epithet in today’s etho. The Age of Regulation decades ago did indeed stifle competition and innovation, [witness “Ma Bell” and the results of Judge Harold Geneen’s courageous anti-trust actions in the 1970’s] seem not only to have waned but have to become almost extinct. It is beginning to approach a business climate seen in partial form in the late 1800’s and early 1900’s where briefly, the new manufacturing giants came to nearly dominate their countries.

This may seem like a hairsplitting sidebar of little import, but at the local level, ‘stakeholders’ of all sizes and at many levels from local to the state level, now can reasonably worry without being branded political wingnuts that what we are witnessing in the evolution of health care delivery organizations into mega-economic powers. They can be seen as closely parallel to what we saw with US Steel, Standard Oil, the Bell System and other dominant systems who become so large that they effectively answer to no one. Those mega-corporations almost came to dominate the entities that created them resulting in the reaction legislatively to regulate them in the Roosevelt era before and during WWII.

There may be reason in the many fields or medicine and mental health care to worry who can control these huge entities. It is certainly not the experts in these fields, the providers, researchers, innovators but rather these now near monopolies or oligarchies. At this level in mental health delivery we see growing disparities in the systems, lack of provision of true 24 hours local emergency service, lack of the other formerly severe legally required and mandated mental health services under the 1962 Comprehensive Community Mental Health Center or Services Act that was the first organized attempt to make up for the dismantling of the public inpatient mental health system. Public states hospital indeed were bad to barbaric, but they were a product of their times, having no effective treatments except ECT until the advent of the modern pharmaceutical era. But they had to be demonized as promoting “institutionalization,” in an intentional malicious manner. As usual the truth was somewhere in between. Living in an institution with no social outlets, no work placements, nothing but utter isolation, locked up status, abandoned by families, easily produced regressed tragic destroyed persons. But as we have learned in decades since, at least some of that heart rending personality destruction is much more part and parcel of the ongoing CNS destruction of the neurotoxicity of schizophrenia, the chronic psychoses. This pseudo-phenomena that was supposed to be eradicated from our guilty consciences is still pervasive and is found in all psychiatric hospitals in which “treatment refractory” patients who are now routinely treated with the most sophisticated medication regimens available, still resemble greatly those “institutionalized” human wrecks that we mistakenly used as the justification to destroy and dismantle an evolving mental health delivery system that surely would have evolved to a more humane system than we have today with daily media tragedies caused by insufficient services nationwide.

In the face of this near avalanche of depressing progression of events, I can honestly and gratefully report that my state of practice, is funding to the tune of over $600M three new bigger, modern state hospitals, and perhaps a fourth located ever so wisely right beside our biggest urban city and area of biggest need. It is also doggedly and determinedly working slowly and inexorably toward retrieving the best out of this state new model of mental health care delivery. I see it daily in my practice in one of the state hospitals, where we work unstintingly at “discharge planning meetings,” to pull all the community based services agencies together to a table, meet with the patients approaching discharge readiness, and their families openly and hash out no matter what it takes, a marshalling of the many varied services that they need to emerge from the ‘confines’ of our hospital, take on more ordinary tasks of life which are still hard for them, support renewed educational efforts, provide family therapy, medication compliance oversight, true vocational support efforts if possible scrounging funds say, from the Golden Leaf Tobacco settlement of the 1990’s and early 2000’s that is doing good for those who have suffered greatly from the regional economic collapse of loss of industry and self and family supporting jobs. It is still incredibly hard, especially when support outpatient services are still lacking, but bit by bit are developing making the past years of poor planning, poorer execution, inadequate funding, the Recessions, etc., seem less onerous and keeps us hopeful and “plugging away,” for our patients and not for agencies.

 

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Author: Frank

I am a older child, adult, geriatric teaching psychiatrist with over 30 years' practice experience in North Carolina, first at Duke as clnical teaching faculty, then in Western NC as a primary child psychiatry specialist. I have taught and supervised child psychiatrists and psychiatrists in training and many other mental health professionals and taught at two medical schools. I have served in many public and private practice settings. My primary interest is in observing and documenting the ongoing mental health reform efforts in the State of North Carolina and documenting its sucessess and failures at all levels. My favorite pastime among many others is spoofing my friends and kids with my deadpan sense of humor.

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