History of Michigan’s Mental Health System Continuing Crisis

Yesterday, July 2, 2015 I gave credit to a medical innovator and systems analyst, a physician, and a plastic surgeon, at that, at Henry Ford Macomb Hospital in Clinton Township MI, Dr. Vikram Reddy MD MAHS who as medical quality of care director of the hospitl, wrote in the Free Press and Bridge Magazine there locally of his pilot project to try to address the long standing, not improving problem of “frequent flyer,” high cost, not resolving ER patients that represent one of the growing and worst public health care crises in this country that plague every hospital in the USA large or small. He is making a superb effort to organize, energize, find and locate appropriate medical management services for these problematic medical consumers who seek highest cost care in the most inappropriate place, the hospital ER. This relates to many nationwide problems growing since the Reagan years that I will refer to later. But Dr. Reddy is trying an approach being looked at nationally as a solution to this issue, i.e., diversion/referral to appropriate services outside the ER that do much more good, are able to give these patients long term, continuing, consistent disease management that they need and deserve and that is where the healthcare dollars are really saved while at the same providing health maintaining and promoting care, care that prevents relapse of their conditions, and keeps them from going into crisis and having to seek inpatient care which is usually at least 10 to 20 times the cost of outpatient care. Now don’t you think that would motivate the planner and governments to seize upon these sensible solutions? “Not hardly” as they say here in the South.

Who are the patients? They can be easily identified as falling in approximately these groups: (and I apologize right now if my brain leaves out/omit significant groups as I will comment upon those I know and see the best and most and may omit others); 1) the drug prescription abuser/addict who has or utilizes inappropriately a pain condition to repetitively doctor shop, and nowadays “ER shop,” in  order to gain more prescriptions for opiates, to abuse until they run out and start all over again at the same or a different ER: 2) the chronic substance abuse who is not in recovery whether having been in “starter” substance abuse programs, like inpatient detox program/units, or AA/NA etc., and come in for acute treatment of intoxication and consequent often legal problems (assaults, disorderly conduct, impulsive threats while “out of their (rational) minds making temporary suicidal or homicdal or assaultive threats, or for worsening of many extremely serious comorbidities [accompanying serious recurrent medical problems from continued substance abuse: delirium, worsening of liver disease going into cirrhotic crisis, hepato-renal renal failure, bleeding from the esophagus’ enlarged “varicose like” veins, acute pancreatitis, comatose states from alcohol poisoning or just plain old overdosing on sedating, respiration suppressing drugs ranging from opiates to anti-anxiety medications like Xanax, 3) the young adult who is developmentally disabled and psychiatrically ill  who goes into acute psychiatric crisis, assaults their parents for no reasons, becomes destructive, leaves the home and starts dangerous behaviors like wandering in the woods and on the sides of high speed highways; and lastly 4) the mentally ill who come from homes, the streets, shelters and now ever increasing from the local jails, in acute psychotic crisis and demand immediate attention as much as patient having a myocardial infarction in progress.

So that is what Dr. Reddy is facing in his hospital in Clinton Township MI. Where did this start in Michigan? It started in the recession of the 1980’s when the Big Three automakers were really losing business to the foreign carmakers, especially VW and the Japanese brands who were building better quality cars, that were more efficient and cost less. As the American auto industry suffered massively so did Michigan since guess what? Michigan was ill suited to weather economic change ever if it were positive and revolutionary. Its economy like so many states in the South who suffered even more for even longer, was not diversified; it was based largely on manufacturing with a huge percentage of the machine shops all over SE Michigan serving the auto industry, and agriculture. Tourism, the state higher education university system and big time sports helped but not that much in reality. So the state had to cut revenues and one of the places it placed emphasis upon was the mental health cost center of the state government. Gov. Engler as is known slashed services all over Michigan and by 2000 was planning to privatize the entire system to get the state out of the mental health business which had become an article of faith by then at the National Governors’ Conference in those years. “Cut and Privatize Mental Health.” Nowadays the new mantra is to dismantle the state employees’ unions and workers’ associations and somehow transmogrify a pretty dedicated work force in the McDonald’s restaurant model of the not long term, disposable, LOW paid employee.

By 1999 and certainly by 2000 the Detroit Free Press had been running a series of articles on the dismantling of the mental health system since approximately 1992 or thereafter as the “privatization” ethos of those times from the era of Reagan deregulation as the solution to labor problems and inflation had taken hold of many politicians and policy planners, mostly of the Republican persuasion.

Ms. Wendy Wendland-Bowyer in the early 2000’s for the Free Press did creditable reporting on this evolving issues for a number of years. An example of an article of her, “State to unveil new plan for mental health system,” is a great example. In this she notes indirectly that at that point in time she state was having to “reverse” itself and retreat from its full privatization plan. This article ran on Sept. 1, 2000. But it noted the overriding principal was to convert the county mental health center based systems all over the state to full private competition in which privatized for profit mental health care provider business entities would eventually take over the delivery of mental health care. This was coming after the decade in which Gov. Engler had closed several state psychiatric facilities, Pontiac State, Clearwater, etc. She wrote: “the first phase of the waiver [a permission process from the Feds to do all this] required county mental health agencies to be run like manage care plans. The second phase was to open the county services to private competition.”

There was a feature based on population density, designed to promote business efficiency that has been coped in almost all states by now to eliminate small, supposedly inefficient service units in counties with sparse populations. “The new plan does require that county agencies meet certain goals in order to avoid private competition. For example, the agencies must have at least 20,000 Medicaid recipients in the geographic area – something 12 to 14 of the state’s 49 agencies have…” Of course the unforeseen consequence to this rule, was that with regional “centralization” of mental health centers usually into the county with the largest population of the several that had merged, services access became distant in all these mini-catchment areas for nearly a majority of clients, forcing them to travel longer distances to their ordinary appointments. Compliance went down, more appointments were not kept and guess what, clients ended up in ERs by the hundreds suddenly to all the bean counters’ surprise and have now been perplexing and occupying people like the good Dr. Reddy of Clinton Township with how to fashion a local solution to what is a state imposed system error.

I will apologize at this point. I have included the link to Ms. Wendland-Bowyer’s article, but it is hard to reach and you have to do some real “Search Box” or “Archive” searching to find it on the FREEP website as in the ensuing years the newspaper’s digital online edition has archived or taken down many many of the articles from that era. My sincerest apologies if it is no longer available.

In my next post on the history of the mental health plans and crises in Michigan, which serves as instruction and one of the true original examples for what has and is happening in most of the other states in this country currently, I will talk of the defunding issues of other sectors of the mental health care delivery system that the non provider, ordinary observer would not likely think of, nor realize who vitally important they are and always have been, and what enormous negative consequences they have also had behind the scenes further worsening the dumping of the mentally ill into systems that are not designed to adequately care for them.

 

Plastic Surgeon Describes Michigan Mental Health Delivery Issues: Mirrors Nationwide Problems

I would like to give creidt to Dr. Vikram Reddy MD MHSA, a plastic surgeon, NOT a psychiatrist who has lately been advocating in print for renewed reforms in the state of Michigan which is now over 20 years after the slash and burn cuts in that state’s public mental health care surgeon. You may find his timely and very thoughtful article in The Bridge Magazine or the trusty, still surviing Detroit Free Press.

You may ask why and how would a plastic surgeon of all physicians become so concerned about little ol’ mental health issues? Many reasons: 1) first and foremost he is a dedicated and committed physcician whose first priority is patient care, and primarily ensuring delivery of quality care; 2) he is “medical director of quality and clinical integration at his home hospital in Clinton Township, part of the Henry Ford Macomb Hospital system of great Detroit. His timely article, entitled, “Mental health care in has room for improvement, but will it?” says it all.

Dr. Reddy described a well thought clinical-analytic-management effort by his staff and himself to identify the problem patients of any kind who account in any hospital, especially in the ER departments, for utilizing, or in a more sarcastical-critical way of characterization, “using up,” the largest portion of such services for less than bona fide indiacation for the services they seek. And many of these services are costly procedures, and huge sinkholes of constantly recurring costs that do solve anything and ultimately do not “satisfy” or clnicmally meet the needs of the patients. Drug seeking pains who  claim pain, requires expensive workups by multiple specialistis, imaging studies, and then frustrating nonproductive earnest time spent with them thrying to divert them to more appropriate, and ultimately cost reducing services that appropriate address the problems of drug addiction. Also psychiatrist patients, for whom, like most every other state, there are not enough psychiatri residential or true 24 hour acute inpatient psychiatric beds and services manage and correct the issues that bring them repeatedly into ERs in crisis to get often the only timely help available to them. Dr. Reddy correctly alludes to, but does not specify, one of the historial causes of these typical nationwide problems, that has resulted in shorgages of outpatient services for psychiatric clients. I would inject the fact Republican Governor John Engle through the 1990’s’ reduced the statewide publc mental delivery system to a fraction of its former size. He, for instance, closed all but five of the major psychiatric state funded hospitals in the state. And like just about everywhere else, nowhere near a sliver of replacement community based services were responsibly created by the state. In fact this state was one of the first to start the Wild West, open the doors and let the private large and small business, not clinically oriented, agents of public psychiatric services take over. One would think that had this model worked which was exported by the same cadre of planners in Michgian to other states, notably the very next, North Carolina in 1999-2000 with very similar results except that NC did not close abruptly the four state hospitals, but instead “revamped” the community service universe by eliminating the county by county based mental health care delivery system, which while flawed through inadquate funing and other factors peculiar tot the geography and absurdity of having ONE HUNDRED often rural little bitty counties, and letting the privateeers decied what they would cherry pick and put in place. Buth states as well ass many others now face the second half of the equation of mental health care devliery, providing adequate and large, comprehensive multi-disciplinary relapse prevention of illness, whether it is substance abuse based, psychiatric or that of the developmentally disabled. North Carolina’s now causative “exacerbator,” was reducing almost by two thirds the public psychiatric beds in the whole state instead of closing hospitals, in order to save money.

Dr. Reddy has initiated a pilot project to identify frequent flyer costly mostly non=medically appropirate patients in the ER systems, and to responsibly divert, refer and get them to the services they need but often avoid, to stamp out maintenance of opioid additions through naive physician prescripbing and I suspect drug diversion but finds the outer system that needs in poorly organized and not up to the task.

He notes positively that the succeeding Democratic Governr Jennifer Granholm had to attempt to correct her predecessor’s Cossack approach, and I recall  her having to bravel condemn her political future by having to wring out of the state legislature and ailing economy, $500M to begin reorganize and stabilize the system. Dr. Reddy also refers to the more sensible long term positive approach of the current Governor Rick Snyder’s now comprehensive Mental Health Commision report and impetus of 2014 to begin to further “rehabilitate” the crippled Michigan system.

The reader who is intersted in the current nationahwie crisis of mental health care and its hobbled systems, both private and public would well advised to follow closely the developments in Michigan as the politicians, citizens, patients and their families, and their adovates and the providers, labor now to effect positive appropriate and responsible changes, that WILL cost money no matter what, and see if they are successful and can be a good example of a state’s corrective efforts for the rest of the states faciling simiilar issues.

 

We Need the “Asylums” Again Believe It Or Not

On January 16, 2015 the American Medical Association issued a press release giving notice of an article that asserted the current model fo treating the mentally ill as “ethically unacceptable and financially costly.” It was walking about the decades old failure of “de-institutionalization” that in in its second or third cycle of failure, being re-enacted in states all over the country once again, with similar and predictably disastrous results. I have the feeling that its title and byline in the press release was a little bit intentionally inflammatory to call attention to the importance of this issue.

This article was startlingly timely in that this author had just this week launched this blog on the broad topic of “mental health reform” and the state by state and national debacle it has become since the 19990’s in Michigan and since 1999-2000 since the same dishonest cruel blueprint was foisted upon the naive and desperate legislators in those states to save monies. Michigan by the 1990’s was in accelerating economic swandive mode because of the near bankruptcy of the Big Three American auto makers at the end of the second George W. Bush Presidency, forcing the surprisingly opposition to the bail out first of the two USA life saving bailouts that were left to the the new Obama administration. One would think that the Republicans would remember the satirical but emblematic motto of the character of “General Bullmoose,” in the old “Lil’ Abner” cartoon series by the great satirist Al Capp, “What’s Good for General Bullmoose is Good for the USA!” General Bullmoose was a character who represented the auto (GM–get it?) and military interests that dominated the country in those decades from the 1950’s onward. Business was supreme and has always been the organizing ideological center of the Republican Party. Michigan was one of the Rust Belt States losing population by the thousands yearly as families fled the loss of jobs in the auto and allied industries foretelling a trend that continues to this day.

Meanwhile North Carolina in the late 19990’s suffered enormously from the precipitous “Dot .com” bust of overvalued darling companies of stock hucksters on Wall Street that were innovative but made no money and somehow a free Internet based serviced equalled or guaranteed riches in the future. Conservative economists and stock experts who warned in ever darker tones in those years about that folly were lampooned unwisely by the upstarts of the New Economy that no one could define as old fuddy duddies with their economic heads in the sands of progress. North Carolina was perhaps the third most important “Dot .com” economic engine in the country after Silicon Valley and the Boston Corridor because of North Carolina State University’s technical powers and the graduation of the RTP (Research Triangle Park”) into the tech Big Leagues with dozens of start up tech companies who went bust as funding vaporized when results never appeared and tight money clamped down. Then North Carolina got hit with Hurricane Floyd which devastated an Eastern part of the state and cost the state in short order between one and two Billion dollars to helps its citizens rebuild. Then North Carolina lost a very important legal economic case in the early 1990’s that went all the way to the Supreme Court and cost the state over $900B in one year. North Carolina lost its contention that it could, as it had been for 9 or 10 year years, taxing the federal retirement pensions and benefits of retired federal workers living in the state. The loss meant the state had to refund almost a billion dollars swiftly as NC is a state that requires by its own Constitution that its annual state budget always be balanced, no matter what, no funky borrowing or issuing junk bonds as a way out. So the General Assembly was desperately looking for a way to save approximately two billion dollars quickly and fell sucker to the pitchmen from Michigan and before that Massachusetts in the 1980’s who had saved those states huge amounts of monies but slashing the budgets and costs of the mental health systems with a new plan that was called euphemistically “Mental Health Reform.”

Its basic tenet was to close ‘expensive’ out dated state hospitals and their beds, since everyone knew by that time that being in the state hospital environment was bad for your because of the three decade long promulgation of the modern fallacy of “institutionalization.”

The four state hospitals in Nor Carolina, Dorothea Dix Hospital in Raleigh, Cherry Hospital in Goldsboro, John Umstead Hospital in Butner outside of Durham, and Brougthon Hospital in Morganton in the western third of the state and the largest, had their beds reduced by roughly two-thirds each. The bogus reform plan, a several hundred spreadsheet program utilized in other states notably Michigan, promised the building of comprehensive outpatient services as it dismantled and destrroyed the well functioning local county by county mentalh health services. It was also suppposed to build for a start, sixteen smaller, more regionalized (read local and closer to families) less “isntitutional” smaller “mni” state hospitals. None were built for years by the state except one which was placed in the outskirts of the western town of Sylva without a large enough supportive psychiatric cohort staff of practtioners in an old, converted, rennovated nursing home and one unit housed in a small community hospital in Linville NC.

And the results were predictable, patients lost their long trusted psychiatrists and clinicians by the droves and it took years to replace those. Crises with patient ended up in the ERs of small hospitals all over the state, many with any psychiatrists on their staffs OR any inpatient psychiatric units. Patients also ended up in even greater numbers in the jails, at the country and state levels. Counties suddenly had to find staff, resources and medication budgets to care for at least 10-20 times more mental patients than they had ever had, Jail suicides dramatically increased. And the mental health reform took years to try to catch up.  A prominent then Duke faculty psychiatrist in the mid 2000’s stated publicly for the media in an interview that it would “take 10 years for the state to replace what we had [in state mental health capabilities] ten years ago. A more damning indictment of the the state’s mental health reform effort could not have been verbalized except the description by a Dr. Steve Crane MD a teaching physician for the family practice residency program in Hendersonville and Asheville as “the disaster that just keeps on giving,” which was a satirical take-off on the then current circulating satirical description of Hurricane Katrina and the failure of the Bush Administration to respond to it in a timely fashion which is now a classical study in government and business schools on how NOT to handle a crisis.

To quote the article in the Journal of the American Medical Association published January 20, 2015, “As the United States population has doubled since 1955, the number of inpatient psychiatric beds the United States has been cut by nearly 95 percent to just 45,000, a wholly inadequate equation when considering that there are currently 10 million U.S. resident with serious mental illness.

Continuing, the authors of the article, Dominic Sisti Ph.D., Andreas Segal MS, and Exekiel Emanuel MD Ph.D, wrote “For the past 60 years or more, social political and economic forces coalescent to ove severely mentally patients out of psychiatric hospitals.” They went on to say that the psychological civil rights movement propelled deinstitutionalization and resulted in “transinstitutionalization” which meant the severely mentally ill hit the ERs, jails and homeless shelters and streets around the country in huge numbers.  To further quote, “…most disturbingly, U.S. jails and prisons have become the nation’s largest mental health facilities. Half of all in mates have a mental illness or substance abuse disorder; 15 per cent of state inmates are diagnosed with a psychotic disorder.”

Instead, to quote the press release itself, “the authors suggest that a better option for the severely and chronically mentally ill, and the most ‘financially sensible and morally appropriate way forward includes a return to psychiatric asylum that are safe, modern and humane. They argue the term ‘asylum’ should be understood in its original sense–a place of safety, sanctuary and healing,” and I would add long term care, and long term rehabilitation to permit development of the current mantra ideal goal of “recovery.”