When mental health advocate wheels, governor deals (Part 2)

Along with the agreement, signed by the defendants (the state) and the plaintiffs (people with SMI) in Arnold v. Sarn, comes $39 million in new money. Gov. Jan Brewer requested $39 million for non-Medicaid eligible adults with SMI specifically for community-based services, something this population has not had access to for two years. The agreement says that the state will make its “best efforts” to provide these services, which are crisis services and stabilization, supported employment, case management, ACT teams, family and peer support, supported housing, living skills training, health promotion, personal assistance, respite care, and medication services.

 

“Governor Brewer said she wanted to target these services,” said Laura Nelson, M.D., director of the Division of Behavioral Health with the Arizona Department of Health Services. These services will become available in mid-July for non-Medicaid people with serious mental illness.

 

While the extension of the Arnold v. Sarn agreement applies only to Maricopa County, the $39 million is to be spent statewide, said Nelson. The funding will be allocated across the state based on a complicated formula that combines the percentage of the population with the historical expenditures on these services in the region. About 60 percent of the money will probably go to Maricopa County, because of the impact of Arnold v. Sarn, said Nelson. “There’s been such scrutiny on Maricopa County because of the lawsuit, more monitoring linked to it, more attention paid to it, there’s been more support for housing, peer, and employment support.”

 

 

The Arnold v. Sarn lawsuit resulted in a 1981 court order requiring Arizona’s Maricopa County to pay for treatment for people with SMI regardless of cost, as state law required. However, the implementation of this court order ran aground two years ago when Gov. Jan Brewer threatened to repeal the underlying state law, in part due to huge state budget problems. The suit was stayed for two years, and the office of the court monitor charged with observing the court order’s implementation was abolished. 

 

On May 17 (as noted in Part 1 of the story), another two-year agreement was announced.  This agreement stayed the court order an additional two years. The hope is that this additional time will give the parties – people with SMI and the state of Arizona – time to negotiate exit criteria from the 30-year-old lawsuit, said Nelson. These negotiations will begin in July of 2013. She explained that “The question on the table will be, ‘How do we want to modify this agreement?’”

 

While the Arnold v. Sarn court order applies only to Maricopa County, the governor is now also a defendant, and, in Nelson’s view, everyone in the state should have the same benefits. “My perspective has always been that it’s not appropriate to treat individuals with mental illness better in Maricopa County than elsewhere in the state,” she said, noting that had it not been the Maricopa County public fiduciary Charles (Chick) Arnold who had brought the case more than 30 years ago, it could have been a statewide lawsuit. “To the extent possible, we do not set separate performance criteria for Maricopa County – the benefit package is the same statewide.”

 

The lawsuit has served a purpose over the years, said Nelson. “Let’s be honest, it has brought funding to the system.” But she questions whether the lawsuit alone has driven the innovations and recovery-oriented approach Arizona has embraced, including a robust Medicaid benefit, the expansion of peer support, and a strong crisis system, with 14 ACT teams.

 

 

The $39 million in new money must be balanced against cuts of the past two years: in fiscal year 2011, 50 percent of the state’s funding for adults with SMI who were not eligible for Medicaid was cut. “That was the last thing the governor was willing to see reductions in, but by then, there was no where else to turn,” said Nelson. So for the last two years, the only services offered to people who don’t qualify for Medicaid have been medication management and crisis services. In addition, there has been a freeze on enrollment of childless adults. 

 

Resuming community based services for more people with SMI is cost-effective, said Nelson. Expanding access to high quality services in the community will reduce the need for more costly inpatient services. “That’s not to say you don’t need any inpatient services,” she said. “But we have seen that having true access to peer support is one of the most valuable services we can offer. We are convinced that this is the place to focus our attention and our money.”

 

People with mental illness have been traumatized and are scared as a result, said Nelson. They have been discriminated against as well. Peers – people in recovery from SMI – are an ideal way to help these people, said Nelson. “Just treating people with respect is so important.” With 2014 approaching and the possibility of a huge increase in the number of consumers due to the Medicaid expansion, Nelson asserted that peers will be essential to help meet workforce challenges. “We want to tap into people who are in recovery.”

 

 

One of the sticking points of the latest agreement – and the reason for Chick Arnold being involved with the negotiations again, despite the elimination of the monitor’s office which he represented – was the question of who would conduct Quality Service Reviews (QSRs). The original agreement called for the state to review its progress; when Governor Brewer asked for Arnold’s support, he refused unless the agreement said an independent entity would do the QSRs. Ultimately, the agreement did. (See part 1 of this series.)

 

Nelson, who did not take part in the negotiations over whether QSR would be internal or external, would have preferred it stay internal. After so many years under the scrutiny of the court monitor for Arnold v. Sarn, she was hoping that her department could be free of what seemed a contentious process that pitted it against the community (the lawsuit is, after all, the government versus people with SMI). 

 

“I’m fine with an independent entity,” she told Behavioral Healthcare. “But one of the reasons that I would have preferred the department be responsible [for the QSR process] is that we’ve been working terribly hard during the stay in the litigation to garner the support and the confidence of the community. When we had the office of the court monitor involved, there was this ongoing negativity about the department, and this [fed a] lack of trust in the agency’s ability to monitor the system itself, and to be forthright with the results. It undermined the ability for the agency to do what we should be responsible to do.” Noting that the department has an auditor, Nelson said she had been looking forward to taking on the QSRs, because she thought this would help her department gain confidence from the community. 

 

But the agreement calls for the QSRs to be external; now it’s just a matter of determining who will perform it. While Arnold is pushing for Arizona State University, Nelson said that the state needs to agree on who will be used. “I’m pleased that we aren’t going back to having a court monitor at this point,” said Nelson. The court monitor’s office was abolished out of financial reasons when the suit was stayed two years ago. “Previously it was the monitor’s audit that carried all of the weight about the way the system was working,” she said. “I think the system is doing well.” 

 

Long before there were out-of-state vendors in Maricopa County (currently the vendor is Magellan Behavioral Health, almost at the end of its 5-year contract), local regional behavioral health providers struggled financially to meet the expectations of Arnold v. Sarn, said Nelson. “People can talk about the disadvantages of corporate for-profit entities and the perception of a lack of local presence, but on the flip side, these agencies are able to leverage important resources. It’s a balance.”

 

Governor Brewer is committed to helping people with serious mental illness, and she and Arnold “go back a long way,” said Nelson. “To what extent he’ll be involved I’m not sure. But I’m very happy with this agreement.” 

 

A public fairness hearing is scheduled for the interim agreement on June 14, after which the agreement will be official.