Managing Disease – or Money?

State's latest strategy for mental health care looks like rationing

The ironies of the Jackson Ngai story – that only homicide brought him adequate mental health care – aren't lost on Joe Lovelace, executive director of the National Alliance for the Mentally Ill. "There are so many tragedies, I don't think you can even call them tragedies any more," he says. Lovelace has been one of the keenest supporters of the state's new model of mental health care, which was fully implemented on Sept. 1.

"Disease management" – a term borrowed from the lexicon of "health management" organizations – is an approach to chronic illnesses such as diabetes or asthma that aims to prevent acute episodes from occurring. For mental illness, disease management is supposed to provide the full array of services that keep a patient stable. Hospitals and medications remain available. But disease management is also supposed to train the mentally ill to understand and recognize their symptoms, and to act on them – take medicine or call a doctor – before they are out of control. It is supposed to help them find and keep jobs and places to live, and teach them life skills forgotten or never learned: how to stay out of debt, how to pay bills, how to make friends. Perhaps most importantly, disease management dictates that clients receive care whether or not they are experiencing acute episodes of illness. Under the new system – in theory – a person no longer has to be in crisis in order to be seen by a doctor.

"The system has never had the ability to look at the person as a whole person," says Mike Halligan, director of Texas Mental Health Consumers. Disease management is supposed to do exactly that. Best of all, supporters say, disease management will pay for itself. The mental health system will no longer be clogged with sick people who never get well. Some – though by no means all – will eventually "graduate" from the program, making room for others to receive services. As people recover, local authorities will presumably save money on emergency rooms, courts, and jails.

Most experts agree that the theory behind disease management is sound, but view the state's version of the model with considerable skepticism. Disease management may provide better care for a few, critics say, but most will still be waiting months for services that are never quite enough.

Show Us the Money

For one thing, the state has not funded the new model as well as most advocates would like. The per-patient cost of disease management services is much higher than the cost of a few med reviews. To adjust for those additional costs, the new system has narrowed the eligible population to those with schizophrenia, bipolar disorder, and clinically severe depression. People with anxiety disorders, borderline personality disorder, nonsuicidal depression, and other mental illnesses – about 12% of the population served under the old system – must go elsewhere. The official line is that unspecified "resources" in the community will care for them. Many local mental health experts find that laughable.

"If community services were available this whole time, why weren't people getting those services?" asks Lynn Lasky, executive director of the Mental Health Association of Texas. "Someone who has very high needs, what kind of services are your community organizations going to be giving those people? Churches and support groups aren't set up to hand out meds."

Even after the population cuts, most providers and advocates agree, community centers won't be able to serve everyone who qualifies for services. The state gave mental health funding an effective cut of $58.5 million for the current biennium. In Austin, Austin Travis County Mental Health Mental Retardation eliminated more than 500 patients who didn't meet new eligibility requirements. The center also absorbed a budget cut of $3 million last year by cutting staff, selling some of their supported housing units, and cutting the caseload for the Assertive Community Treatment team. Yet the state is now asking community centers to do even more with less.

"Individual by individual, this [disease management] will be a very positive step," ATCMHMR executive director David Evans says. But, he adds, "Even with the minimum services delivered, there aren't enough resources to provide care to the entire eligible population."

Evans says services may be especially hard to come by for those who can't afford to pay for their own care but don't qualify for Medicaid. By law, community centers generally cannot put Medicaid recipients on waiting lists. Evans doubts the center will be able to serve everyone who does have Medicaid, meaning they may never reach the waiting list, and the indigent consumers on it. "I think there's a good possibility that we could see a two-tier system develop – those who have Medicaid and those who do not," Evans says.

Travis Co. has already seen a sharp increase in the need for indigent crisis services since ATCMHMR began instituting state budget cuts last fall. According to data tracked by the Indigent Care Coalition, the county's hospitals and emergency rooms are seeing about 1,000 cases of mental illness a month this year, up from about 600 cases a month in 2003. With the new hospital district already straining to provide medical care for the county's uninsured, there's little room for the mentally ill.

This isn't to say that those who don't qualify for disease management won't receive any care; community centers will still provide crisis services, regardless of a person's eligibility or insurance status. While that's better than nothing, it means that for those outside the priority population, nothing has really changed: If you're "in crisis" – sick enough to hurt yourself or someone else – then you'll get care.

Some in the mental health community question whether the state's new system deserves the name "disease management," even for those who qualify. Disease management, after all, is supposed to provide everything a consumer needs to "manage" his condition. The state's version, some health care advocates say, doesn't come close.

Small Change

Community centers will assign clients to one of four "benefit packages," based on how sick they are. The least intensive package offers medication and "case management." The most intensive, reserved for the sickest consumers, also offers round-the-clock access to medication, medical supervision, and employment and housing supports, among other "rehabilitative services." As a patient's conditions change, their benefits may be expanded or reduced.

The assessment tool used to make assignments – called the Texas Recommended Assessment Guidelines – uses indicators such as past hospitalization or jail time, stability of work and living situations, availability of "supports" such as friends and family, and ability to perform daily tasks. To Mike Halligan of TMHC, reserving the highest level of care for those in the worst condition isn't much different from the old system of care. "I don't see this as a big change," Halligan says. "Disease management is a way to ration services. It's the state's way to say they're doing more, without doing more."

Halligan and many other advocates would have preferred "disease management" to mean a complete overhaul of an old and flawed system. Instead, they say, the state has once again put a system in place that it is willing to fund, rather than funding a system that actually addresses the existing need. "Some of the sickest people will get better services, but others who are equally sick will get nothing," Lasky says. "If the question is whether the situation with Jackson could happen again, I think the answer is yes." end story

  • More of the Story

  • Two Lives Lost

    Danielle Martin and Jackson Ngai shared a close friendship, a passionate love for music, and mental illness. They cared for each other as best they could. And then he killed her.
  • Disappearing Patients

    Mental health, like mental illness, can be a complex proposition.

    Frequent Fliers

    Once they enter the mental health care system, people tend to return

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