The Mental Health and Mental Retardation Authority of Harris County

Ration: a fixed portion — as a verb: to restrict to limited allotments.
Now the verb itself — to ration — doesn’t sound so bad as it stands alone. But, when you pair it with another word, care, as in healthcare — it suddenly takes on an emotional overlay of significant proportions. Rationed Care. The words we in the public mental health and mental retardation system have tended to avoid for years. Or, we speak them in hushed tones like a big secret. Well — it’s not a secret when almost everyone knows the reality. The public MHMR system has been rationing care — in fact, the rationing of care has been going on for years.

In the absence of a defined package of benefits for the uninsured coupled with financial pressures intensifying over the past decade, we have experienced the serious erosion of the services and supports truly being accessible and available to persons who are indigent (defined as lacking personal financial resources to pay the actual cost of the healthcare services and having no third party health insurance coverage such as Medicaid or Medicare) — at the time the condition is identified and care sought out. Rather, over the course of several biennia, the Texas Legislature, in its efforts to attract other funding streams to constrain or reduce the need for additional state tax financial support, have sought to transfer more and more of the revenue requirements to the federal healthcare coverage system (primarily Medicaid). Strategically, the sharing of expenses with the federal government makes sound business sense and maximizes the “bang” realized from the limited tax generated resources available to the Legislature each biennium (Texas is, purportedly, one of the lowest per capita tax states in the nation). Additionally, this strategy does provide more adequate coverage and benefits for a percentage of the population with mental disabilities, who, prior to acquiring federal third-party coverage, had been indigent.

The problem with this strategy is twofold. First, the state “gatekeepers” to the federal healthcare coverage apparently have had a history of restricting/denying eligibility at a rate well above the national average. This revelation surfaced in a number of articles in the Houston Chronicle (and other media) resulting in a significant effort to look into this matter by local elected officials concerned with the availability of such coverage. Supposedly, things have improved and the level of stringent criteria relaxed and brought more into line with those used by other states. The basic problem, of course, comes back to money. The more people made eligible for Medicaid coverage, the greater the drain on State General Revenue tax dollars to “match” the federal portion. So, while the coverage is increased, and the benefit package available to the consumer enhanced above that available to the fully indigent person covered only by State General Revenue (better both in services available and frequency — although the Medicaid package is not unlimited and it too is rationed), the more people on Medicaid the greater the “costs” to the state because of the required “match” which pushes the limit of General Revenue funds actually appropriated for the “match” in the fiscal year. Particularly in light of the tragic events of September 11th and the after effects on the economy, with jobs being impacted, and unemployment up, more people have had to turn to federal healthcare coverage, and more General Revenue funding has been and will be required. In fact, recent informal advice out of Austin indicates that the Legislature may be facing an appropriations process as a part of the 78th Legislative Session that has to address a state deficit in the billions (that is with a “B”) of dollars. If so, the next session is going to be an absolute “bear” and certainly one of the most difficult in recent times. With an increasingly expanding population (Texas is one of the fastest growing states in the United States and Harris County is projected to continue to be one of the fastest growing counties in Texas), coupled with Texas having the highest, or one of the highest, percentages of its population who are uninsured (Harris county has the second highest percentage of its residents who are uninsured), stagnant or reducing resources to serve more people needing services can only result in seriously increasing pressure on the public “safety net.”

The second problem with the strategy building on Medicaid as the answer to providing the necessary healthcare for the indigent is imbedded in the criteria for eligibility. Not only does the person have to be impoverished! Not only does he/she have to provide clear evidence of a diagnosable Axis I mental illness, but the person must prove that his/her mental disability makes him/her so functionally impaired as to not be able to work at even the most basic of jobs — and that this functional impairment will last for at least 12 consecutive months. The advent of new, improved medications coupled with clinical services allow persons with significant levels of mental impairment to more fully develop the personal, social, and vocational skills needed to more fully interact in constructive and productive ways. Thus, many people with serious mental illness who have qualified for SSI and received Medicaid benefits have found themselves confronting a cycle across long segments of their lives where they qualify and receive Medicaid benefits; then lose those benefits due to one or more disqualifyers (i.e. functional improvement, making too much money at their job); lapse back into indigency; destabilize due to the unavailability of services and supports; and become more functionally impaired — and the cycle starts again. It’s a cycle that drains the personal and family resources beyond imagine — resulting in immense frustration with the public care system which often carries the “blame” as the messenger — providing “too little” service under the indigent care system to maintain the level of stability needed.

The reality is clearer then ever, and face it we must. There has not, and will not be sufficient resources in the foreseeable future to meet the needs of all the people who qualify for services under existing criteria. So, what’s to be done? Well, ration care we must. But how will this be done? The advent of managed care including the full array of policies, procedures, and practices are, in essence, society’s effort toward a rational, thoughtful approach to rationing healthcare resources. TDMHMR, under direction from the Texas Legislature, is moving to develop a managed care system for both persons with mental illness and mental retardation.

This managed care system under TDMHMR is being framed out, or defined, under the mantra of “Authority” functions — the State Authority, being TDMHMR — and the Local Authority (LA) being the community contract entity which qualifies under the Department’s terms, conditions, and expectations. Note, I didn’t immediately say the Community MHMR Centers as the Local Authority. As it appears to be shaping up at this time, the local Community MHMR Center will be given the opportunity to prove that it is capable of meeting the requirements to be a Local Authority — not as a provider of services (although the LA may continue to provide services) but as the ensurer of service provision. This is an important difference, which is complex in nature. Mechanisms will have to be in place to identify: “who” gets access to services (each person qualifies for coverage under the criteria for General Revenue services and supports as provided under the TDMHMR system of the future); “what” services are covered under the benefit plan (the benefit plan(s) are currently in development on the mental health side of the house — the mental retardation side is currently, heavily built around the Medicaid package); “how long” will such services and supports be provided (the duration will ultimately be tied to clinical criteria, frequency, duration of time, and, hopefully, outcomes — changes in the person’s condition); at “what cost” (defining the range of permissible costs) across this complex and varied state from one section to another recognizing the variance at the local level which influence the cost of care will be a challenge all by itself in establishing realistic and justifiable rate structures — probably on a capitation basis tied to the severity of the consumer’s condition; and; to accomplish “what outcomes” (what is the impact on the consumer’s condition).

There are significant discussions, which have not yet occurred but need to under this developmental process:

What is expected to occur by providing these services and supports? What will define acceptable outcomes for the consumers, for their family members, and, ultimately, for the payor (TDMHMR)?

Is the expectation that the person will attain the level of functioning present immediately prior to deterioration (for the mentally ill population) or is there an expectation that he/she will more fully attain his/her potential to function as a contributing member of the community?

This latter question is critical for persons with mental retardation — what is the level of functioning that will be defined as reaching “maximum benefit” and, thus, qualifying the person as moving into a “maintenance” mode or, perhaps, to exit a specific service/support.

These questions significantly influence the answers to the question: “what is medically necessary” (clinically justified) in providing an array of services/supports, at a specific intensity and frequency, and a given point in the persons clinical career.

Undertaking this change process is a major challenge for all of us involved in the system of the future. The debate is critical to shaping the “system” and increasing the likelihood that Legislators buy into and support the new system. Otherwise, we’ll be in a position of just managing costs — potentially driving down the quality, adequacy, and satisfaction of the care provided with outcomes that won’t justify the financing necessary to ensure the value for our society of persons with mental disabilities as contributing, participating members. Remember, managed care is most successful in acute healthcare environments. TDMHMR’s challenge is to develop meaningful and appropriate modifications to apply to a system serving long-term conditions which may have acute episodes. More to come — this is a work in progress.