The first half of a longer story in
The Arizona Republic:
Dennis Winters (pictured) sits in his apartment clutching a teddy bear, something a psychiatrist gave him years ago to make him feel less lonely.
Decades of punishing mental illness have often left Winters feeling lonely. Most days he watches television into the night and scribbles his thoughts into notebooks.
"I'm just hanging on by a thread," he said.
Arizona taxpayers spent $360 million this year to help Maricopa County residents like Winters. But a nearly 30-year-old lawsuit, billions of dollars spent and a series of bureaucratic transformations haven't changed a basic fact: Most of the county's 23,000 patients with serious mental illness aren't getting better.
The number of seriously mentally ill people in Maricopa County has exploded in recent years, growing by 94 percent since 2000. It will grow another 45 percent by 2015, according to state estimates.
There are few widely accepted national standards for mental-health care, making it difficult to compare the performance of states or even counties within Arizona. Different systems track data in a variety of ways.
But by the standards it has set for itself, Maricopa County's system has declined.
The annual state audit of the system's performance that was released this year found it fails nearly all of its patients on key measures: placing them in stable housing and providing them with a job or other meaningful activity.
Among those who have not been in jail or hospitalized for their illness, the system failed 86 percent. Among those who have, it failed 83 percent.
Interviews with patients, providers, state officials and company executives reveal instability at every level of the system. Despite multiple calls from consultants to do so, service providers do not track whether individual patients are getting better.
The results are deadly: Nationally, the life expectancy of a mentally ill person is 25 years shorter than that of a healthy person. In Maricopa County, their life expectancy is 32 years shorter.
Without a place to live, a job or supportive friends and family, the county's mentally ill often wind up homeless or in jail.
Winters is 58. He once had a good job and close friends. But after more than three decades in the system, he now holes up in a subsidized apartment, hanging on to his ragged plush toys.
"It's like knowing that this teddy bear is going to love me no matter what," he said. "The worst thing is being alone, and having the risk of that part of me that just wants to give up. Holding on the idea that there's a way out keeps us alive."
Modern mental-health care starts with the presumption that anyone with a serious mental illness can recover, though some will recover better than others.
Most private insurance policies offer limited benefits for mental health, so people who have serious mental illnesses in Maricopa County are likely to wind up in the public system.
The system consists of several layers. At the top is the Department of Health Services, which is responsible for providing care to Arizonans with mental illness.
Since the 1990s, DHS has subcontracted the job to the private sector by creating regional behavioral-health authorities.
Two years ago, the state replaced the company that served Maricopa County, ValueOptions, amid widespread dissatisfaction with the quality of care. Magellan Health Services, a for-profit company based in Connecticut, received the three-year contract to run the system, which also includes patients with more moderate metal illness, children and people in treatment for substance abuse. At $1.5 billion, it is the largest mental-health care contract in America.
Magellan pledged to transform the system. Where ValueOptions had owned the county's clinics itself, Magellan pledged to spin them off into independent networks of providers, giving patients more choices and clinics more control.
Magellan said the move would improve the quality of care.
But the changes brought even more instability. Instead of improving under Magellan, according to the most recent audit, patient care has gotten worse. The declines are substantial and occur in every aspect of care.
• Patients don't have adequate teams of doctors, psychiatrists and counselors.
• Treatment plans, considered the foundation of a successful recovery, are incomplete and often changed without patients' knowledge or input.
• Patients are overseen by case managers whose patient loads can exceed the national standard of 30 cases by 60 percent or more.
Magellan officials acknowledge the need to improve the quality of care on a variety of measures. But they also say the findings do not reflect substantial gains made since late last year, when the audit was conducted.
More than half of the audit's quality indicators have no bearing on whether a patient's condition improves, officials said. Other indicators, such as clinic staffing levels, have improved.
"The system is not in crisis. The system is in transformation," said Dr. Richard Clarke, CEO of Magellan of Arizona.
Magellan has planned several new initiatives to improve performance. Clarke's team is working with the state to post clinic performance data online for public viewing, encouraging better results through competition. Case managers will receive better training on suicide prevention. And patients with multiple recent hospitalizations are beginning to get extra attention from Magellan staff.
Eventually, Clarke said, the system will develop tools to track whether patients are improving - if Magellan remains in place.
The first half of a longer story in The Arizona Republic: