The Mental Health and Mental Retardation Authority of Harris County

The public behavioral healthcare system has been, on one hand, required by the Texas Legislature as a policy decision, to care for more consumers with third party coverage and, on the other, pushed by the fiscal necessities of balancing a budget addressing the ever present pressures of inflation, market adjustments, and service needs which exceed resource availability. Simply put, the system, which has historically been a significant part of the “safety net” to care and treat the truly uninsured of Harris County, has had to shift its focus in significant and substantial ways to either attract large numbers of third party covered consumers (primarily Medicaid or Medicare) or to assist uninsured consumers to “convert” to third party status (obtain SSI/SSDI and become eligible for Medicaid).

In the not too distant past, sufficient tax dollars were present to cover the cost of MHMRA service delivery system (cover the provider network costs to deliver the services and supports as requested and required by the consumers and their families). Truly indigent consumers were our first and major priority. In fact, back then, many third party consumers were referred out to the private sector in order to maintain sufficient capacity to be responsive to the needs and requests of the indigent. In 1991, the MHMRA system earned approximately $300,000. In FY 2001, to balance this year’s operating budget, approximately $22,000,000 in revenue will need to be earned through reimbursements for service — around 20% of the budget will need to be generated from earned revenue. Last fiscal year, the system earned around $13,702,741 — obviously, requiring significant redesign of how business was being done, particularly in the mental health divisions to meet the earned revenue targets.

On the Mental Retardation side of the house, we have for years seen virtually no expansion that was not fueled by third party funding (federal coverage that requires a state match). In those fiscal years when the State of Texas appropriated the necessary increased general revenue required match, expansion occurred in the highly flexible, wraparound Home and Community Services (HCS) “slots.” When match was not available, the waiting list grew. Today in Harris County there are over 2,400 persons waiting for HCS services — over 14,000 waiting statewide. Families who have cared for their loved ones for years are “aging out” — nearing the point where they will physically no longer be able to provide this care (which has saved taxpayers a bundle) due to their age, frailty, illness, or death. The aging caregivers have aging loved ones with mental retardation, many who have significant physical complications or, due to the aging process itself, will develop additional needs unable to be met by the family without assistance. The HCS waiting list has no ability to, on an emergency basis, bump people to the front as a crisis occurs. In other words, if the family caregivers reach the point where they are no longer able to provide that care (i.e., they are hospitalized or die), there is virtually no community long-term capacity to respond. Yes, on a temporary basis, respite care could be provided. And, potentially, a long-term state school placement might be found. But, the trauma to people who most often have great difficulty in adjusting to change will be magnified to the “nth” degree. The mourning of the loss (death or separation) of their family member(s), the shift in their life settings, the social skills to interact with people which may or may not be present — these pressures on the person are intensified and, thus, magnify their already existent limitations due to their mental disability. This, in turn, creates even more demand on the new care system, on the provider staff who must now step in and become the new, substitute caregivers. Rather than a gradual process, which incorporates the family caregivers and utilizes the strengths and developments over time within the person, responding in an emergent way with inadequate resources intensifies both the process and cost while, potentially, reducing the effectiveness of those services.

Public policy has increasingly appeared to be shifting the responsibility primarily from the State of Texas into a shared responsibility with the federal government (federal third party/insurance mechanisms such as Medicaid healthcare coverage or HCS). Who can fault Texas for saying we must have our fair share of the federal third party coverage to support the services needed by the mentally disabled? You can’t. It is the right thing to do for the Texas taxpayers — and for the consumers themselves (providing a more expanded benefit package impacting multiple aspects of their lives). However, it only becomes the right thing to do if the policy makers appropriate sufficient state match to permit the federal dollars and the programs they fund to be operational as the needs surface (not have the extensive, lengthy waiting lists we now see — and growing). It is the right thing to do if the state agency (ies) which serve as the gatekeepers into these services — certify that the person is truly eligible (meets the criteria for coverage), understands the public policy for this federal/state shared partnership, and facilitates access to coverage. Currently, Texas agencies appear to make it more difficult for persons with mental disabilities to obtain coverage under Medicaid.

So, here we sit — 2001 — with Texas as a state having the highest percentage in the nation of its population being uninsured — around 25%, which means that about one in four Texans are uninsured. And, worse in Harris County, we have around 34% of our population who are uninsured — about one in three have no healthcare coverage — the second highest percentage in the state. And, here we sit — in 2001 — with the highest percentage of our budget that must be earned — to balance it. It hasn’t been working — last fiscal year we, as an agency, lost approximately $2.9 million. We had to utilize our woefully limited reserves to cover those excess expenses over our available revenues. In spite of major efforts i.e., reductions in staff, again “scrubbing” operating expenses, pushing staff to double book to cover no-shows and cancellations (increase efficiency), increasing caseloads, realigning service priorities, addressing increased needs for support services to document and bill — in spite of our efforts which resulted in record earnings for the system — we lost a lot of money which is not readily replaceable. In spite of the highly successful realignment of Adult Mental Health (AMH) and emergency center personnel in FY 2001, while earning more than ever, we have lost money each month of the first quarter of FY 2001. As an Agency we cannot continue to have monthly losses. Sadly, while the state has not provided the additional tax dollars to adequately (even minimally adequately) support the severity of conditions and array of services to be provided, the required number of unduplicated people to be served each month went up. In FY 2000, the AMH system was required to serve an additional 1,800 priority population adults each month with virtually no additional funding — incredible — and impossible without a negative impact on the care provided in terms of reduced quality and effectiveness.

Our new, expanded psychiatric emergency services system, called the NeuroPsychiatric Center (NPC), has been overwhelmingly successful — serving between 1,000 to 1,200 person per month. Overwhelming is the operative word here because all previous indications during the years of planning indicated that we should be serving 600 to 800 per month (figures we built our budget and staffing around). Our work with the newly implemented Crisis Intervention Team (CIT) within law enforcement has been tremendous, making the transfer of law enforcement-identified persons in a known or suspected acute psychiatric crisis smooth — both for the person in crisis and the officers. We have over 300 persons a month being brought to NPC for evaluation and, as needed, intervention — many of these people would previously have been admitted to jail. Mentally disabled people who, due to their conditions which may result in “nuisance” crimes, should not be in jail — it’s wrong for the person and for the taxpayer. Training police officers to recognize possible mental illness is both the humane and fiscally prudent response. And, NPC is seeing over 100 children and adolescents per month. And, the second floor 16-bed Crisis Stabilization Unit (CSU), which opened some six months back, has been admitting over 60 patients per month, around a four-day length of stay per admission, with a low recidivism (return) rate. The CSU by addressing the short-term inpatient needs of these voluntary patients has created substantial capacity in the Harris County Psychiatric Center (HCPC), our acute care psychiatric hospital. That means HCPC has had more beds available for the involuntary patients needing care identified through NPC, the Harris County Hospital District (HCHD), the Probate Courts, and the private hospitals throughout the county.

The problem NPC has had is too many indigent, uninsured patients accessing care (no real surprise here) and not enough third party covered patients. The operating budget, while trimmed to a lean but adequate (if not stressed) level, was predicated on earning about 30% of its budget this year. It’s simply not occurring and NPC has run a significant deficit each month, substantially but not solely influencing the Agency’s deficit each month. We have sadly proved what the HCHD has long experienced – emergency services don’t pay for themselves. There must be sufficient tax dollars to fund this level of care. We now find ourselves in the critical position of considering closing the CSU, transferring this voluntary inpatient load back to HCPC. The impact on Harris County, both public and private, will no doubt be enormous. Every aspect of the system will experience the “ripple effect”. Sadly, as NPC is becoming more stable in its operations and beginning to more fully realize its potential — its value to the community — a significant component (the CSU) may have to be closed.

Public policy can’t ignore the real and substantial needs of people who, through no fault of their own, have mental disabilities that need the assistance of the public system. Emergency services, first and foremost, among the baseline services of the “safety net” must be adequately funded with tax dollars to provide those clinically appropriate, medically necessary interventions for the indigent, uninsured, or underinsured residents of our County. There are no places to “cut” or transfer money without seriously impacting the lives of existing recipients of service, who often already have seen their benefits (services) seriously reduced. Public policy and funding must be adequate to address the needs of the uninsured or we do pay for it elsewhere, less effectively and, often, more expensively (look at the growing number of mentally disabled now in Texas jails and prisons). The partnership with federal funding mechanisms must be thoughtful and balanced. Sometimes, you can dilute the soup so far that you end up serving water — lacking in value to sustain the life of the person. Sometimes, it’s simply not enough at the end of the day if the state financial resources of Texas aren’t present to pick up its fair share for the needs of our Texas residents.