Mental health care reform:
First, do no harm

Copyright © 2006 Blethen Maine Newspapers Inc.

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In March, the National Alliance on Mental Illness gave Maine a B- grade for how our public health care system met the needs of people suffering from serious mental illness. What's remarkable is that such a mediocre grade -- based on a wide range of measures, including access to beds, pharmacy services, information accessibility, number and quality of those in the mental health workforce -- actually placed Maine among the top five states in the nation. The average grade was a D and many states received an F.

Treating people with mental illness is a difficult proposition. Their needs are often lifelong and acute and since the well-intentioned move away from institutionalizing the mentally ill that was promoted in the 1970s and 1980s, we've seen a massive shift of the mentally ill population out of institutions and onto our streets -- as the homeless -- or into our jails -- as criminals. To many observers, deinstitutionalization backfired; while we no longer house the mentally ill in substandard warehouses for "the insane," we instead condemn them to another form of desperation -- and we still pay for their care, just in different ways.

Now, as our cash-strapped state is on the verge of making a major move to reform the mental health system once again, we join with mental health advocates in urging Maine officials to act slowly and deliberately, lest this highly vulnerable population get further hurt in the process.

The latest proposal stems from budget cuts approved by the Legislature last year. Mental health costs are among the fastest rising costs in the state's Medicaid system, and lawmakers want the state to bring in an outside private company to save money by delivering "managed care" to Maine's mentally ill Medicaid recipients.

"Managed care" in this case would mean a system whereby the private company would, under contract, give designated services to the state's mentally ill Medicaid recipients. It's a move that's been attempted in almost three dozen other states, with mixed results. There have been experiences of both costs savings and cost overruns administering these program, while those on the receiving end have complained of a confusing, fractured system that takes forever to get them the help they need.

Maine legislators budgeted savings of $10.4 million from this move and charged a group within the state Department of Health and Human Services to come up with a plan to move to managed care for people with mental illness.

That group, which did not include representatives of the mentally ill, their families or health care providors, recommended late last year that the the state sign a contract with just one group, Beacon Health Systems, and make the change by July 1.

Last week, however, advocates for the mentally ill visited Gov. John Baldacci to say "Whoa, there!" They asked the governor to slow down the process; to engage representatives for the mentally ill in planning for the new system; to evaluate Beacon Health Care's work managing Medicaid programs in other states; to consider requesting proposals from a range of health care providors and to move ahead on the managed care plan through a pilot program in one region of the state -- before enacting massive changes on a statewide basis. Advocates also asked that accountability for the changes not rest simply within the Department of Health and Human Services, but instead an outside evaluation be done.

These are all reasonable and appropriate requests. Gov. Baldacci acceded to the plea to slow down the process and assured his visitors that he would be "doing no harm." Indeed, DHHS Commissioner Brenda Harvey says her own department had realized that the headlong rush was not in the best interests of the state or those with mental illness.

We still find ourselves puzzled, however, why services for the mentally ill, among our most vulnerable citizens, have been carved out as a way for the state to save money. We've said over the years that cost savings at DHHS, an agency that Sen. Peter Mills calls our state's Defense Department -- for its massive and impenetrable budget -- must be done systematically through a wholesale management audit. We still think that way, and would urge the governor not only to slow down this process, but also to consider making these changes within a much broader context of reform throughout the department that oversees this and many other programs.