The Difficulties of Funding Improved Delivery of Mental Health Care

Today, September 22, 2015, the Raleigh News and Observer newspaper revealed and published some very disheartening and totally surprising news that illustrates yet another dilemma in the ever more difficult tasks in improving mental health care public services in this state, and, likely reflects the kinds of dilemmas that other states are and will be struggling with in facing up to their obligations in this area. The article is entitled: “NC budget cuts $110 million from regional mental health,” and can be read here.

It has been announced that the state’s budget will take a ‘one step forward, one step backward’ approach to the mandate to fund and construct, furnish, add, some 250 more public inpatient psychiatric hospital beds in this state. The forward part of the progress has been the improving quality and comprehensiveness of public mental health services all over the state as the now privatized and regional mental health care organizations in NC have perhaps now passed the roughest part of the last 14 years of reorganization of service delivery since mental health reform began suddenly and too swiftly in this state in approximately 2000. In effect these outpatient mental health care delivery organizations, called MCO’s now [the initial term for about the first 10 years was LMEs, Local Management Entities], have “gotten it together” and services are increasingly high quality, more available and comprehensive. The system is finally starting to work as envisioned and hoped. Another most impressive part of the effort in NC has been the effort to replace ALL the old, state psychiatric hospitals, one of whom was WWII;s second biggest Army medical center for wounded veterans on the East Coast and the other three were built in the late 1800’s. NC has undertaken a massive building effort of three new state psychiatric hospitals each costing over $150 million dollars. One has been completed and operating now for over two years and the other two are due to be open in approximately late 2017. No other state in the country has undertaken such an expensive and commendable effort.

The backwards part is that the Legislature told “the state’s eight regional mental health agencies must absorb a financial hit in the form of a $110 million budget reduction that state legislators told them to fill with money from their savings.”

For the coming fiscal year, the reduction in statewide funding will be $110 million. It is also anticipated that in the following year another $152 million of reductions in funding will be required of the eight state public outpatient mental health services provider organizations.

The budget machinations and origin of these financial decisions is detailed somewhat in the article but is still hard to follow and figure out in some ways. Part of the monies gained from the sale of the very old state psychiatric hospital property of the famous Dorothea Dix Hospital in Raleigh earlier this year will be devoted to helping to fund the needed new state inpatient psychiatric beds to be built in as yet unspecified entities. The original mental health reform plan drawn up in NC in 1999-2000 and enacted into law referenced building at least 16 smaller regional public inpatient psychiatric units or hospitals across the state to replace the bed reductions planned for the four existing state hospitals. It was also envisioned that these smaller, more regionally dispersed facilities would serve their catchment areas better, not be so far away from families etc.

The present hope is that up to 150 of these new beds will be utilized to furnish shorter term, more crisis stabilization oriented services. Although this article does not address this issue, one benefit could be to reduce the still state-wide waiting periods that acutely disturbed public psychiatric patients have to spend in local community hospital ERs around the state ill-equipped to handle them. This is one of the unintended consequences that arose from the closure and elimination of hundreds of inpatient public psychiatric beds before and after the mental health reform plan and effort began in NC. It is also amazing to witness still that the same miscalculation has been made in most of the other states in this country in the same time frame. Newspapers all over the country for the last several years have been filled with almost identical stories of patients “stuck in ERs” awaiting bed availability creating enormous strains and liability risks.

The reactions to this “what one hand giveth, the other taketh away” approach can only be imagined and will probably not be welcoming from many quarters. But the head of NC NAMI has already voiced what likely will be a typical reaction and  I quote: ” ‘Telling the agencies to spend their savings to fill a budget hole “is a big concern for us,’ said Jack Register, executive director of NAMI-NC, a mental health advocacy group.”

It still appears that mental health services care delivery is an incredibly difficult task and still faces a rocky and unknown long road to a more ideal state of affairs.



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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