The Mental Health and Mental Retardation Authority of Harris County

Some of you may have heard this story before: an older gentleman is walking along the beach at sun-up. In the distance, he sees a young man run to the water’s edge and throw something in. The young man runs back to the beach, stoops down, picks something up, runs back to the water’s edge, and again throws something into the water. Over and over — as the older fellow approaches, he watches the young man go back and forth, the same pattern, ending up by throwing something into the water.

Finally, the older fellow comes up to the young man and calls to him. Approaching, he asks what he is doing. The young fellow stops, holding a starfish in this right hand. He says, “the tide has gone out, stranding all these starfish on the beach. If I don’t throw them back, they will die.” The older fellow looks up and down the beach, which is littered with starfish. He says, “Young man, there must be thousands of starfish on this beach — what difference can you make?” The young man looks at him, pauses, turns, and throws the starfish he was holding back into the ocean and says, “makes a difference to that one.”

I really like that story. Because, I think that’s what we’re about — or, should be about. Making a difference for each person who accesses the public “safety net” through the services and supports network falling under the Mental Health and Mental Retardation Authority of Harris County. Making a difference for EACH person – ah, there’s the rub. Don’t we function in a system that must ration care? Yes, we do! Each and every day! The problem is not so much that we have to ration care, it’s that we don’t have a rational way of rationing. What we have today is an ad hoc system, one that tries — or is forced by the unduplicated targets to be “served” each month, to care for too many people, diluting the resources to the point where the adequacy or effectiveness of the very services and supports may be compromised.

Say, did you ever mix cement to build a brick or a stone wall? Or, a slab for a foundation? (No, I haven’t lost it — there is a point here!) Well, there’s this formula of so much (so many parts) cement to so much (so many parts) sand. If you get confused and mix up the ratio of cement to sand (put in too much sand) what happens? Well, what happens is that very excellent wall crumbles — the bricks/stones collapse when you lean against it. Or, heavy rain compromises the integrity. Or, the slab starts to crumble, compromising the structure built on it. If you dilute the cement/sand formula trying to have a limited amount of cement to create a larger wall or a bigger slab, the structure fails. Contractors, architects, engineers know you can’t build a bigger house with limited resources by compromising the strength of the foundation.

We, in the public mental health and mental retardation, face the on-going dilemma of having too many people who would qualify for services and supports, with extensive, often complex needs which involve housing, food, clothing, medical/dental services, and transportation — and too few resources to meet these needs. The push has been to serve greater numbers of people out of humanitarian concern over their well being and a desire to drive the costs down to bare bones levels. In doing so, in the absence of clear indicators of quality and effectiveness, the impact or outcomes for the individual consumers have been compromised.

The Texas Department of Mental Health and Mental Retardation (TDMHMR) is well down the road in re-engineering itself. The Mental Health Systems Task Force has just completed its report and submitted it to the State Board for consideration. There will, no doubt, be a period of review and comment, followed by some possible “tweaking,” adoption by the State Board, and the movement toward implementation. The Task Force report didn’t prescribe a “model” for the State of Texas Local Mental Health Authorities under TDMHMR. Flexibility was left intact for the local area to define its structure. It did create a definition of tasks or functions and expectations which must be present, which must be operational, for the governmental entity (it must be a governmental entity) to be designated as the Local Authority.

If one reads these expectations closely, one understands that the Local Authority for Mental Health Services in the future (that’s the near-future — over the next several years), will look and act more like a managed care entity (what is currently called a Behavioral Health Organization). There is much benefit that can accrue to more adequately define: who (who actually gets or qualifies for services) — gets what (what services/supports are to be provided to address the person’s condition) — for how long (services and supports will have to be tailored over time — perhaps even time limited) — at what cost (what is the real cost for delivering the services/support needed to attain a stabilized condition) — and, achieving what outcomes (what are the expectations in terms of consumer satisfaction and attainment of clinical objectives).

On a parallel track dovetailing with the above report, TDMHMR has a process underway to define the Benefit Package for persons who qualify for care under their “umbrella” — defining what services, for how long, at what cost. This, too, is critically important to the re-engineering of TDMHMR. With limited resources, the Department is moving to more clearly define its expectations as to what services, which are evidenced-based, (have demonstrated effectiveness) are able to be provided through its resources. The end result should better ensure that people with qualifying conditions who access services under the public “safety net” will be able to connect to a similar package of benefits (services/supports) more appropriately tied to their condition, wherever they live in the state (which is not true today). While much is still to be defined (and, yes, the “devil” will be in the details), there is much opportunity through both these processes to improve the public system and heighten the level of accountability and performance.

Unfortunately, there will still be too many people, with too many needs, facing too few resources. Texas Government simply does not have under its current financial mechanisms sufficient tax dollars to adequately fund the myriad of functions, activities, and operations — and won’t for the foreseeable future. And, depending on the economy, may even have less next Legislative Session. If we better define the Authority system and its requirements (and the costs of operating these functions), and then define the benefits (services/supports and their associated costs), we will much more clearly see just how few people may be served each year with the resources available. Stacking people into waiting lists that span years — years with no real end in sight to access care — offers false hope. Perhaps it is time to “tackle” the third great challenge — the criteria as to who gets coverage under the TDMHMR system. Today’s priority population group definitions really don’t create a mechanism for prioritizing access to care — they really create eligibility criteria which are broad — so broad that the number of people who qualify far exceeds the resources to get services. And, if the Benefits Package and Mental Health System re-design are successful, we will have a “system” which truly is designed to assist people in care to stay in care to reach the point of “recovery.” If people stay in services, how will we absorb the “new” cases who meet criteria in the future? In one of the fastest growing states in the United States, with one of the highest percentages of its population having no health insurance, there will be increasing numbers of persons who will need to access the public “safety net.”

To be able to make a difference for each person who qualifies and get he/she access to care, there must be a means to prioritize access to be able to fund and maximize the impact of these resources. Prioritization in a rationed care system is a “hot potato.” Real, thoughtful definition to prioritize access will be essential to make the existent processes work such that at some point we can, and will, make the difference to each of our consumers, thus enabling them to demonstrate their value to society.