DC residents who need mental health care worry about closing of public clinics

From The Washington Post:

The District's plan to close six public mental clinics and send the clients to private facilities is a money-saving move that eventually will increase the number of residents who could receive services, city officials have said.

But Emma Dent is worried. Dent, 53, has spent the past three years using the Spring Road clinic in Columbia Heights, and these days -- like more than a dozen other clients interviewed -- she's distraught over the idea that her world could be overturned.

Plus, Dent said, she's had her fill of private clinics. In the 1980s, when she began hearing voices and having visions, she got private care. "When I really needed help, they discharged me," she said.

The city's Spring Road facility has given her better care, Dent said, adding: "My doctor is fantastic. I love her to death."

Dent's story is a case in point for some in the mental health-care industry who argue that private clinics can be inadequately staffed, can cherry-pick patients and sometimes even close unexpectedly, leaving clients hanging.

The city sees things differently and notes that it already successfully has more than 8,000 residents in private care. The D.C. plan calls for closing the six city clinics by March 2010. The city would then enter into contracts with about 30 private clinics.

The D.C. Council will hold an oversight hearing on the Department of Mental Health on Thursday.

City officials have said that privatization could save $14 million a year, funds that can offer treatment to more than the 4,000 or so Medicaid recipients who get it now. Residents who are indigent because of a psychiatric disability qualify for federal Supplemental Security Income, which comes with Medicaid, according to the Department of Mental Health. About 45,000 low-income residents with mental illness who don't qualify for supplemental income and cannot afford other insurance go untreated.

"I think this . . . will benefit consumers in the long run, and it's going to benefit a lot more people who need mental health services," said Shannon Hall, executive director of the D.C. Behavioral Health Association.

But there is evidence of success and failure on both sides of the debate, and the difference, some say, can be how well a system is planned and monitored.

Critics of the District's plan to transfer 4,000 clients say that the staffs at the public clinics are better paid, are better trained and tend to stay on the job longer than at private clinics. Those critics -- clients, psychiatrists, caseworkers and union leaders representing workers who stand to lose their jobs -- have a vested interest in keeping the clinics open. But others, such as Ken Duckworth, medical director for the National Alliance on Mental Health, also raise similar concerns.

"Outpatient mental health is notoriously difficult to fund," Duckworth said. "The clinics soon realize that doctors are expensive and want fewer of them. Doctors get overwhelmed and say, 'I didn't come here for this.' "

Privatization raises ethical questions about the government's role in caring for mentally ill residents, Duckworth said. "If the government doesn't take care of the most severely ill people, who does?"

The D.C. government started operating mental health clinics in 2001 as part of a court-ordered plan to provide community services to the mentally ill rather than confine them in hospitals such as St. Elizabeths in Southeast. But the plan was never intended to last this long. A court monitor requested that within three years the city determine whether private providers could do the same work. Last year, an audit commissioned by the city concluded that private clinics were more cash-efficient than public clinics and could do the job if the city helped them build their staff and facilities.

Responding to critics, D.C. mental health officials said that many of the city's 30 private clinics have operated for more than 40 years in some cases, decades longer than public clinics. Phyllis Jones, spokeswoman for the department, points to the contracts with private clinics that the city already has to deliver services to a majority of federally insured clients.

"We have confidence in the excellent private providers in the District and intend to help them expand capacity" for the clients who would be transferred. "Private providers already serve . . . about 64 percent of the people who use the public mental health system. DMH certifies and monitors private providers now and will conduct regular audits," Jones said.

Florida is an example of privatization success, some say. In 1998, the Florida Department of Children and Families privatized the South Florida State Hospital near Fort Lauderdale after a series of court battles over its conditions. Ten years later, some who feared privatization now praise it. "I was aggressively opposed to it," said Anita Godfrey, chief executive of the Mental Health Association of Broward County. "I don't want to sound like their paid marketer, but what they've done has made such a difference." The deal worked for Florida because the hospital "identified top-notch people" and the state has done well with its monitoring of care, Godfrey said.

Labor representative Vanessa Dixon said D.C. officials have not earned the same level of trust when it comes to contract oversight, pointing to D.C. General Hospital as proof. In 2001, city officials ended outpatient services there and promised to monitor Greater Southeast Community Hospital as part of a contract.

Months later, the corporation that supported Greater Southeast went bankrupt after its chief lender was caught up in a financial scandal. Greater Southeast has since been purchased and revived as United Medical Center.

North Carolina is also cited by privatization foes as an example of what can go wrong.

"Some people think it was a complete failure," said Rep. Verla Insko (D), a retired health program administrator and a member of the state's General Assembly.

The state privatized in 2001. Blinded by poor oversight by the Department of Health and Human Services, North Carolina officials stood by as private providers overbilled the state and avoided the most severe cases. An audit showed that North Carolina overspent its Medicaid allotment by $400 million, a figure that could balloon to $700 million in the next audit, Insko said.

"I think the shortcomings in our system were due to a lack of sophistication," Insko said. "We didn't know what we didn't know. We failed to ask for a strategic plan."

Insko said that such a plan should set goals that privatization would attain in the first year and a separate road map for the next five years. She said goals should be set to treat the most serious mental health patients who some private providers tend to avoid. "They want people who never get sick, not the serious cases of mental illness," Insko said. "There are plenty of private providers out there who say they won't serve that population."

In some cases, private clinics were certified as Medicaid providers, even though their staffs were not qualified to treat all patients. Overlook the issue, Insko said, and "you'll end up with a lot of people in hospital emergency rooms."

"It created a heavier burden" for law enforcement, said Eddie Caldwell, executive vice president and general counsel for the North Carolina Sheriffs' Association. "When they can't get treatment through mental health clinics, they wind up in the emergency room and hospitals. They engage in antisocial behavior. Law enforcement gets called."

Jones, of the mental health department, said the District is not North Carolina. She reiterated that private providers such as Green Door, Woodley House and Community Connections are highly qualified.

Moving forward, the department will sponsor consumer fairs to link clients at city-operated clinics with private providers starting in March. Jones said the city discussed the plan with workers, union leaders and clients in focus groups in May and June.

"This is news to me," said Vonette Davis, a 34-year-old college student who is being treated for anxiety and panic disorder at the 35 K St. NE center. "The only person I talked to about this was a social worker a few months ago. I never got a piece of mail, never got an e-mail, never got a phone call. Nothing. I'm kind of offended that nobody came to me and asked my opinion."

Davis said the city is overconfident in its plans. In her opinion, mental health clients won't easily leave doctors they trust at city-operated clinics to receive treatment at private clinics.

"They have trust issues," Davis said. "I see it in the clinic all the time. When we have an upsurge in homelessness, an upsurge in crime and an upsurge in suicide because of this, they'll look silly. I've had the same doctor for 11 years. I don't want that to change."