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Mental health

Mental health reform began in 2001 with a goal of moving from a hospital-based public system to a community- based public system but has had disappointing results. Despite claims to the contrary, privatization is not the problem. The main problem is hubris among reformers who too often have forgotten the first rule of medicine — do no harm. Each reform so far has provided an initial shock to the system followed by new problems and another round of revisions. Even when well intentioned, these changes have tended to make the system more complicated and less responsive to consumer needs.

Reforming mental health the right way depends on establishing responsibility at the right level and providing the right incentives for everyone in the system to seek better patient outcomes. Although there is no perfect system to emulate, many states have achieved success in one area or another. Some local management entities (LMEs) within North Carolina, such as Piedmont Behavioral Health, which operates under a Medicaid waiver, have also developed practices that the state can fruitfully expand to other regions.

Key Facts

• Discharges of patients who had been hospitalized for longer than one year rose quickly after reform but have declined since 2002. Discharges for all patients have declined since 2007.
• Piedmont Behavioral Health has some of the best mental health outcomes in the state at lower cost than the state's traditional fee-for-service programs. Every state hospital has been under federal investigation or had federal funding cut at some point in the past two years.
• State and private mental health management has been lacking at times. Examples include the Charles Franklin's $319,000 salary as a contract employee with the Albemarle Mental Health Center LME, the Mental Health Association's unpaid taxes, and millions of dollars spent on unnecessary community support services.
• An estimated 16 percent of prison and jail inmates have serious mental illness.
• Inmates with mental illness cost more to detain per day and have longer detentions than other inmates.
• Crisis Intervention Teams (CIT), which improve treatment outcomes and public safety with less recidivism, have been adopted by 151 law enforcement agencies in every LME except Johnston County.
• Medicaid pays 60 percent of mental health costs in state.
• Seventeen counties have no psychiatrists, and 65 counties have less than one psychiatrist per 10,000 residents.

Recommendations

1. Continue to expand Medicaid waivers that pay local mental health agencies (LMEs) for managing care instead of paying providers for services. PBH (Piedmont Behavioral Health) has worked under this system and had better care and cash results than other management entities.
2. Allow LMEs to compete and expand across geographic boundaries.
3. Encourage more counties and cities to adopt crisis intervention teams (CIT) as a way to improve the community-care system, improve public safety, and allow jails to be used for other offenses. Only the Johnston County LME has not yet implemented CIT.
4. Ease restrictions on scope of practice that limit the ability of nurses and other doctors to provide access to psychiatric care in more places at less cost.
5. Keep Dorothea Dix Hospital open indefinitely and adjust staffing and training at state mental hospitals to the evolving role of hospitals as crisis centers with some long-term patients.