By Andrea Ball
AMERICAN-STATESMAN STAFF
Wednesday, October 20, 2004

View this article on statesman.com

Six weeks after the state's mental health centers tightened their eligibility rules, Austin officials say they're struggling to find help for people who no longer qualify for care.

"We don't know where to send them," said Jim Van Norman, medical director for the Austin Travis County Mental Health Mental Retardation Center. "There aren't many other services for people out there, especially those without insurance. And it's woefully thin for people with Medicaid."

On Sept. 1, Texas' 41 community mental health centers officially kicked off "resiliency and disease management," a state-mandated plan that orders the clinics to treat only clients with schizophrenia, bipolar disorder or major depression.

Everyone else not in crisis -- including those with anxiety, obsessive-compulsive disorder and post-traumatic stress disorder -- must be referred to other sources of care. People accepted to centers before the new rules were enacted must be transitioned out as soon as possible.

The Austin Travis County center started enforcing the new rules July 15, Van Norman said. Since then, the center has turned away 42 new clients seeking help. Another 252 current clients have been deemed ineligible.

Of those 252, 37 were referred to other agencies in the community. The 215 others remain in the system because the center can't find anyone else to serve them, Van Norman said.

Shortage of care is a real problem in Travis County, said Paul Gionfriddo of the Indigent Care Collaboration, an Austin group that tracks local health care trends. Nonprofit agencies are already at or above capacity, he said. Now they're dealing with more pleas for help but don't have enough money to serve new clients.

"That's not something the Legislature decided to invest in when they decided to do disease management," he said. "They didn't put any money behind the rest of the story."

The extent of the problem varies from community to community, depending on nonprofit networks and overall mental health resources.

Some mental health centers have had no trouble finding other sources of care for their clients, said Sandy Skelton, chief executive officer of the Texas Council of Community Mental Health Mental Retardation Centers. But others, like Austin, are having trouble finding alternatives.

"A lot of centers aren't referring people out," he said. "They're trying to serve people anyway."

Texas officials don't expect mental health centers simply to dump clients, said Mike Maples, manager of the program services unit for the state Division for Mental Health and Substance Abuse. If no alternative care is available, centers can keep ineligible clients for as long as necessary, he said.

"There are people who have nothing," Maples said. "We continue to work with them in getting benefits."

But the reality is that centers cannot serve everyone, he said.

The new program emerged after years of complaints about the Texas mental health system. Critics said the centers served too many people with too little money, resulting in inadequate care. In Austin, people routinely waited three months for an appointment with a psychiatrist. Most did not receive any kind of counseling.

Many mental health advocates said the answer was more money. They said that Texas, which ranks 47th in the nation for per-capita mental health spending, could not run an adequate system without more funding.

Legislators disagreed.

In 2003, they cut $14.8 million in funding to the community mental health centers. They eliminated therapy benefits for adult Medicaid recipients.

And they went with disease management as a solution to the quality-of-care problem: Officials think that by narrowing the number of people eligible for help, they can provide more meaningful care to a smaller group of clients. They are also pushing centers to be more efficient with their time and resources.

"I think it comes down to the way you do business," Maples said. "You're going to have to increase productivity."

Van Norman says he's all for meaningful care and efficiency, but he doesn't want to see people hurt in the process.

"We would wish for a state health authority that looks at the health of the whole state," he said. "They're really acting like a private insurer or HMO. We think we have a broader responsibility than that."

aball@statesman.com; 912-2506