THE VIRGINIAN-PILOT
Copyright (c) 1995, Landmark Communications, Inc.
DATE: Sunday, September 3, 1995 TAG: 9508310025
SECTION: COMMENTARY PAGE: J4 EDITION: FINAL
TYPE: Letter
SOURCE: By HOWARD W. CULLUM
LENGTH: Medium: 84 lines
A state proposal to develop a mental-health managed-care project for Hampton Roads has run into unanimous opposition from consumers, families and local mental-health agencies. The Virginia Hospital Association and Virginia Managed Care Association have also chimed in seeking a deferral.
Why all this fuss? Isn't managed care the holy grail everyone is seeking?
The current state proposal has five problems: history, ideology, arithmetic, credibility and vision. The state-agency project is being driven by the twin ideological pillars of managed care and privatization.
This approach ignores history: no knowledge of how much progress the state-local public system has been made over the past quarter century; no acknowledgment that the private sector was not there for the chronic mentally ill once insurance coverage ran out; no understanding of the state-local partnerships forged over the years by thousands of volunteer local Community Services Board (CSB) members with state and local elected officials; apparently, no knowledge of where the real problems are - documented unmet need for community housing and day programs, inadequate oversight of care for mentally disabled and frail elderly in board and care homes, and lack of management of those Medicaid clients and costs not under CSB oversight.
As for ideology, the state commissioner of mental health believes the public sector is automatically bad and the private sector is automatically good. This ideology says squeezing down access to care for chronic mentally ill consumers is the answer. Those with first-hand experience fear consumers will be hurt, jailed or killed on the cross of managed care. Data from other states that jumped blindly into managed care for this population are not good. Limiting access for sick people is risky business, as seen by increases in injuries, suicides and death.
There is an arithmetic problem. Virginia moved some of its community programs into Medicaid funding starting in 1990 to legally draw down federal dollars. This saved the state $100 million in five years. It helped balance the budget during the recent recession. This was the solution. Now it has been made the problem.
Apparently, cutting 15 percent to 20 percent from current low Medicaid reimbursement rates will improve services and bring ``savings.'' This is really cooking the numbers. Questions abound about the arithmetic showing 10 percent to 15 percent of current dollars being siphoned off for a new managed-care bureaucracy. The state is only for outpatient services operated by local CSBs. It ignores the inpatient part, where potential savings are. It is simply the wrong model for the wrong population.
Next is credibility. The State Department says it is moving ahead because of a legislative mandate. The legislators have said in writing that this is not true. The legislature never intended this type of project. Despite this clarification, the state commissioner continues to say he is plowing ahead due to the legislative mandate.
The State Mental Health-Mental Retardation Board was ignored. An Allen appointee resigned because the board's legal responsibilities were usurped. The board recently sent the commissioner back to the drawing board after he submitted a revised proposal without their involvement and comments as required in the state code. Time will tell whether he is even listening to his own citizen board.
The Hampton Roads programs have a counterproposal. It uses a modified managed-care model and commits to savings. Rather than embrace its local proposal - developed with consumers and advocacy groups - the commissioner is still fighting to keep the Richmond bureaucracy and managed-care company in control. The message to the locals is clear. The commissioner's goal is dismantling the local CSB network, not ``savings.''
Credibility is strained when the state says there will be no cost shift to localities when the state backs out of its historical commitment to fund needed housing and other non-Medicaid services. Finally, credibility is stretched to address the statewide waiting list of 10,000 people.
The last problem is vision. Opponents don't have a vision for a new bureaucracy raking 10 percent to 15 percent off the top for administration and profit. Opponents don't have a vision dismantling local control and management that have served Virginia well. Opponents don't have a vision the chronic population - those who need the most help - will be better served.
We are all expected to believe everyone is wrong - consumers, families and local agencies - and the commissioner is right. He is right, and the families and workers in the trenches who have dealt their whole lives with these issues are wrong? Who's fooling whom? MEMO: Mr. Cullum is a former Virginia secretary of Health and Human
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