The Mental Health and Mental Retardation Authority of Harris County

This has been one strange summer. The 76th Legislative Session finished with a flurry of activity and accolades as to the positive financial standing of the state and its agencies. Then, it surfaced. A little-discussed "glitch" under the Texas Department of Mental Health and Mental Retardation (TDMHMR) section of the Appropriations Bill reflected some $30 million in other revenue (not Texas tax-based revenue) which was not expected to be available in FY2000, nor able to be made up. TDMHMR began the budget-balancing and allocation process by proposing reductions in areas, which appeared to make the most sense, spreading the shortfall where the Legislature left some flexibility (which translates into no instructive rider language).

After seeking input to minimize the impact, the Department ultimately proposed reductions which were adopted by the TDMHMR Board: approximately $6 million less for mental health general operations; $3 million less for mental retardation general operations; $5 million less in new appropriations for new generation medications; $2.3 million less in new appropriations for intensive mental health wrap around services; delaying the implementation of the new 300-plus HCS community slots for persons with mental retardation; reducing the state hospital operating budgets by $2.3 million, thereby eliminating 60 state-funded beds a day to the system; and Central Office reductions, including several information system projects. The budgets of the community psychiatric hospitals and the state schools for the mentally retarded were not impacted.

As this budget crisis surfaced and the proposed reductions moved to the State Board for action, a number of concerned individuals and organizations stepped up to the table to express concern and assist the department in finding an alternate approach which would not reduce funding or services. Advocacy organizations, concerned citizens, the Texas Council, several key legislators (including our own Rep. Garnet Coleman), and Commissioner Don Gilbert of Health and Human Services worked hard with the Department to bridge this impending financial crisis. Fortunately, thanks to Departmental efforts along with these other players, bridge funding was identified in the middle of August to completely restore the full allocations for new generation medications and mental health wrap around services. The first quarter’s proposed cuts for general revenue operations funding for mental health and mental retardation services also were restored. Much work continues to be needed to find the resources to restore the remaining "cuts" for the balance of the fiscal year. The state hospital budgets will still be reduced so community centers will have 12, not 13, state-funded beds per day per 100,000 population in FY2000. Financially, it appears we may have dodged a bullet — at least for the first quarter — although we’re not out of the woods yet.

Now, the second shoe drops — the performance targets required by the Legislature were increased. Not just increased where new funds were provided, the targets were increased in most, if not all, categories with level funding. (We all know funding is not "level" when adjustments to revenue have not been provided to offset inflationary forces over a two, now four-year period.) You ask the most logical of questions: How can we be told to once again do more with less? How can quality and effectiveness of services as well as consumer and family satisfaction not suffer? Well, the truth is they will suffer — the person who is truly covered under the State Performance Contract exclusively with General Revenue (GR) funding may experience certain service reductions. The "safety net" funded with Texas tax dollars will continue to be stretched thinner and thinner. How did this happen? We have no place to look (or to blame) than ourselves. We have done this. How? By our inability to reflect the true service package and costs for the State GR consumer. We served more people than contracted, trying to stretch the dollars a little bit further each year then contractually required because we didn’t want to establish waiting lists, if at all possible. (The needs for services are so much greater than the resources will adequately address.) We were not clear about the Medicaid funding picture. "Swapping" State GR dollars with Medicaid funding often causes the Centers to disengage the State GR consumer "slots" and seek out additional Medicaid eligible consumers because many State GR consumers are not and may not be capable of attaining eligibility. And, we did not attain a level of credibility with the Legislature that we operate as efficient businesses — that the "fat" has been appropriately squeezed out of the system such that additional "cuts" really are into sinew and bone.

We at MHMRA will be taking serious steps to reverse as much of this picture as we can over the next two years. (We’ll be starting with the MH divisions at the start of the fiscal year and begin to address the MR division by mid-year.) FY2000 will be a different budget than you have experienced before — although, it will now take us several months to define and implement the changes. The Agency is redefining its front door (Authority functions): identifying specific staff with responsibilities to assess all incoming mental health consumers; ensuring that their individual eligibility is established as a State GR, Medicaid, or other funded consumer; developing an initial Plan of Care (POC) consistent with the benefit package available under the person’s third-party funding (State General Revenue, Medicaid, or other source), and obtaining authorization for the POC. Service coordination will be accessed at the front door or "gate" as clinically indicated and resources permit. (We will have to designate how much State General Revenue is available to fund service coordination for the State GR consumer versus how much service coordination will be funded through Medicaid.) Once the POC is finalized, the consumer will be assisted to choose his/her providers, appointments established, and the person linked with the provider system for services.

Each of the providers in the system will be funded for State GR service "slots," Medicaid "slots," or a combination of the two. We, as a system, will ultimately be much, much clearer as to the number of consumers under the TDMHMR Performance Contract who are truly funded through State General Revenue, for what services (type/array of services), and, in some cases, for how long (duration of care). The balance of the contract targets will have to serve Medicaid consumers to ensure the revenue needed to operate the system is actually available. We should anticipate that the result of this process, painfully so, may be a two-tiered system, with the Medicaid consumer having an expanded benefit package over the State GR consumer. Waiting lists on the State GR side of the house should be expected to grow. State GR consumers and families will justifiably be increasingly unhappy with the capabilities of the system to respond.
The public system is increasingly being compared with and expected to respond like the private sector. Each component of the Agency’s operations will be evaluated throughout this year as to its costs of service, earnings (both revenue generated and value of service), impact on consumer condition, satisfaction, as well as quality of care and documentation. The Anasazi implementation occurring with the start of the fiscal year should go a long way toward removing a significant portion of the burdensome paperwork from the staff, although accuracy of the data will fall squarely on the shoulders of each of our practitioners. These next two years will be a time of substantial change, refinement, and clarification. We must, ultimately, paint a picture that is clearer in defining and describing the public mental health and mental retardation system.

We must do everything possible to not have another session where we are told to do more with less. It falls to us to create these clarifications and definitions such that the advocacy and consumer groups, concerned citizens, and, ultimately the members of the Legislature, may respond appropriately.