The Mental Health and Mental Retardation Authority of Harris County

It seems like I have been focused for months on writing about the financial issues and needs of the public mental health and mental retardation system for Harris County and the attention necessary within this, the 77th Legislative Session. At times, it almost feels like an “obsession” as the Legislature is actively involved, as we speak, in sorting through the myriad of requests for Fiscal years 2002 and 2003, and working up the Appropriations Bill both within the Senate and the House. The agencies of the State of Texas – the business of Texas government requests for the next biennium far exceed the available revenues currently certified by the Comptroller. We have recently learned that the state costs for Medicaid (state general revenue match for the federal funding) will be over $600 million above the funds budgeted for FY 00/01 (this current biennium).

The needs of the state are enormous (i.e., teachers health insurance costs, benefit costs for retired state employees, public and higher education needs, adult and juvenile justice needs – to name but a few) in light of the reduced available revenues to address these needs. So, we should be throwing up our hands and back away because the needs of the mentally disabled can’t compete with these other aspects of State government? Right? No – wrong! Dead wrong! This is the time to redouble the efforts to help the Legislature make as much room as possible under the State financial “cap” for FY 2002/2003 to address the needs of the mentally disabled as possible.

Why – because of the consequences of the alternative. First: the $30 million deficit within TDMHMR each year of the current FY 00/01 biennium was real. $10 million has been short each year to cover the current community mental health services – which was papered over, “bridged” this fiscal year, primarily through additional Mental Health Block Grant funds received by TDMHMR. However, the deficit is still there for FYs 2002/2003 and no “magic” exists to cover the costs unless the Legislature funds the Exceptional Item rank number one request from TDMHMR.

Second: TDMHMR has recently announced a delay in the Rehab Medicaid Rate adjustments from April 1st (the originally proposed date of implementation) to September 1st of 2001. These rate adjustments as currently anticipated will remove an estimated $12 to $20 million out of the funding mix currently by the Community Mental Health Centers (CMHCs) across the state to pay for current mental health services. Many of the CMHCs, like MHMRA of Harris County, have already had to virtually eliminate or substantially reduce, rehab services for indigent persons with severe and persistent mental illnesses because the state general revenue now available simply does not cover the cost of providing such rehab services.

In fact, the lack of state general revenue has virtually eliminated individual or group counseling, case management, service coordination, and other such wraparound services and supports for indigent priority population consumers. In reality, the state general revenue doesn’t even cover the costs of providing the psychiatric medications for the indigent population at the total number required to be served under the annual Performance Contract with TDMHMR. Without serving Medicaid and Medicare consumers, the Adult Mental Health Division would be in an even greater deficit than currently experienced over the first four months of this fiscal year.

Can you picture the impact on the public mental health system in Harris County if the TDMHMR Community Services deficit is not made up and the Medicaid Rehab rate adjustment takes out another $12 million to $20 million? The picture is not pretty! Harris County’s pro rata share will be significant – the impact will be devastating!

I am trying here not to be melodramatic or histrionic. I am trying to face the realities we experience today (TODAY!) in attempting to piece together adequate funding for our already limited, seriously constrained services and supports for the uninsured (indigent) priority population as well as for those who are under insured. Under insured? Who are these you ask? Where do you think the money comes from to provide psychiatric medications for the Medicare priority population and make up the revenue to cover the costs of providing these medications (physician, nursing, lab costs, LPHA plan-of-care services, etc.), not fully reimbursed by Medicare – the answer: the state general revenue in the CMHC Appropriations Bill line item. And, where do you think the money comes from to match the Rehab and Service Coordination services provided to priority population consumers under the Medicaid program? The answer: the state general revenue in the CMHC Appropriations Bill line item. These general revenue funds impact not just the truly indigent but the Medicaid/Medicare covered SPMI population, as well.

As we sit in FY 01, trying desperately to meet inflated, unrealistic “production” targets from the last session, we have an ever-increasing deficit. Following upon the deficit from last fiscal year – a year that we had the highest level of earned revenue in this Agency’s history – we are seeking additional economies, increases in “production” and further efficiencies – which often negatively impacts the actual services provided to the priority population who need more service and supports to ensure that the ever improving clinical technologies available (i.e., new medications) can truly “work” and enable these people to be much more able to function in society. Our current system is virtually pushing people into a cycle of reoccurring emergency and inpatient admissions (incurring some of the highest costs in the system) due to “flare ups” in their conditions in the absence of adequate services and supports to intervene earlier and more consistently.

Sadly, last month MHMRA had to close the recently opened second floor 16 bed Crisis Stabilization Unit (CSU) of our emergency services system – The NeuroPsychiatric Center (NPC). Why – because funding was simply not available to support its operations. This unit for voluntary “inpatients” with a 4-day average length of stay enabled persons in crisis to more fully stabilize and return to outpatient care at a lower per episode cost. This unit demonstrated its effectiveness in its short five months of operation – thanks to the hard work of our NPC staff. It was closed because funding couldn’t be identified, fast enough, with the rest of the Agency’s operating deficit to enable it to continue. Thanks to the efforts of the leadership at HCPC to identify certain efficiencies, we have a temporary solution to try to bridge this unit closing, absorb this area of patient need, and, hopefully, not see the public inpatient system “back up”. Will this work over the long term? Don’t know. But everyone is pitching in an effort to avoid serious constraints being experienced by those needing access to publicly funded psychiatric inpatient care.

Additionally, a few weeks back, our state hospital, which provides more extended inpatient lengths of stay for involuntary psychiatric patients, had to promulgate new, revised medical exclusion criteria for admission into care. Why? Because the state hospital budget has been hemorrhaging, covering the extra costs for physical medical care of involuntarily committed patients, which eat away the revenues provided by the Legislature to fund indigent psychiatric inpatient services. The state hospitals didn’t receive a general revenue allocation to cover the medical expenses for patients provided through contract community medical facilities and resources. Where will these patients who are so psychiatrically ill with significant medical conditions go? They can’t go to the state hospital. They can’t go to HCPC due to the severity of their medical condition. To Ben Taub then – at the County taxpayers expense – but whoa. The Ben Taub Psychiatric Inpatient 20 bed unit stays almost full –all the time. To the general med surgical units of Ben Taub? How will their psychiatric care needs be met? By whom? This picture is getting worse, if you see what I mean!

But – hey – let’s not forget about the mental retardation side of the house. The picture is more than bleak here, too. There are over 2,500 persons on the waiting list in Harris County for just the Home and Community Services (HCS) – with over 14,000 on this waiting list statewide. The Supreme Court Olmstead decision about the availability of appropriate community care looms ever larger. Rumblings about the growing waiting list and limited options as families “age out” and go into placement crisis are leading to suggestions in a number of areas of the state that a class action lawsuit against the State of Texas may be the only way to get meaningful change and attention to the necessary match funded through the Appropriations Bill. Such a lawsuit would take valuable millions of dollars away from the care needed (to fund the legal representation and administrative support) and tie up the state from more directly shaping its own direction. Does Texas once again want a major class action lawsuit against TDMHMR?

People waiting for services come in all shapes – some are on clearly defined waiting lists. Others are not on lists but so frustrated or angry over the lack of or reduction in services that their conditions have intensified – often requiring some of the most expensive and intensive of the public services. Still others are, with increasing frequency, ending up in the adult and juvenile justice systems. In the absence of appropriate community services, mentally disabled persons often are arrested for “nuisance” crimes.

Just like the population of Texas is growing faster than in most states in the union, the needs of its mentally disabled population are growing. The cries of thousands of people across the state and within Harris County are getting louder. They won’t fade away. The options are shrinking in the absence of adequate Legislative attention. Let us be vocal now – let us be clear – Rome really is burning. The “Safety Net” is unraveling. We, as a state, will pay a price. But nowhere is the price felt more deeply than by our local residents with mental disabilities and their families. For them – speak out.