As soon as the current North Carolina MH/DD/SAS system of care was built, 30-plus year ago, efforts were begun to reform it. One might observe that there have been several cycles of reform. The premise of this paper, however, is that in the last two decades there has been one continuous reform effort. There have been various overview names and specific named programs, and the individuals involved have come and gone. But the point of this writing is that the same issues and questions, the same options, and the same barriers to reform have been consistent over the last 20 years. There is no mystery about what options we have. The only question is whether we have the will to choose among imperfect solutions.

The Early 1980s     In a document entitled "Community Based Alternatives to Regional Hospitalization" (October, 1984) one finds an early description of the fundamental issues facing reformers today. This document describes the efforts of planners in the north central region to redirect resources from John Umstead Hospital (JUH) to the community programs. In it the phrases "funding follows the patient" and "unified system of care" are offered as guiding principles. Three steps were outlined to enact the principles, as follows: first, increase funding to the community, in order for step two to occur, that is, reduce the census at JUH by reducing admissions and bringing people out of long-term hospitalization, and step three, close wards at JUH.
    For a variety of reasons having to do with philosophical differences among leaders and a state budget crisis, this specific plan was never completed as written, and no wards were ever closed at the state hospital. However, there was some success in bringing patients out of the hospital into the community, and new service capacities were created locally, including enhanced emergency services and alternatives to hospitalization. Those directly involved with the effort continued to believe in the fundamental strategy, believing that the concepts delineated were valid.

The Late 1980s/Early 1990s     Beyond the specific experience of the north central region, many individuals and organizations were coming to the same point of view. This collection of people from the Division of MH/DD/SAS, local programs, and advocacy groups ultimately enlisted the aid of the Mental Health Study Commission, a creation of the General Assembly, to begin an intensive five-year study of the needs of the system.
    These collective efforts of many people resulted in the creation of a "Comprehensive Long Range Plan for Adults With Severe and Persistent Mental Illness" and the "Child Mental Health Plan." These plans were completed by the Mental Health Study Commission in January 1989, and accepted as a goal by the General Assembly in June of 1989. Key elements of this report and the actions of the General Assembly were as follows:

A conceptualization of new services and programs, essentially for the population with severe and persistent mental illness

Assumed increased state funding is needed to accomplish set goals

Referenced the state Medicaid plan as anticipating significantly increased federal funding from Medicaid as a way to fund it

Created the "Integrated Funding Task Force" to evolve and ultimately implement the long range plans

Provided for an audit by the "Government Performance Audit Committee" or GPAC

Integrated Funding Task Force Report
    The task force delivered its initial report in September 1990. A summary of this report is as follows:

Acknowledgement of the need for increased funding to ensure success of the concept, stating in the text of the report that "although integrated funding may be expected to enhance the effectiveness and the efficiency of the service delivery system, implementation of the concept will not by itself, close the gap between unmet needs and current resources."

Defined an ambitious and generous array of services as needed, emphasizing continuity between hospital and local service.

Conceptualized a management mechanism through which local programs managed all state appropriations and made decisions about services to be "purchased" from all sources including state institutions.

Conceptualized a system of funding known as "Pioneer," explained as a "purchase of services" model, and created a "utilization management" document named the "Level of Eligibility" form, or LOE.

(Note: at this point there were no written discussions about change in governance for the area programs.)

1991 Mental Health Study Commission Press Conference     In February of 1991, the Mental Health Study Commission formally announced the sum total of the study and plan to implement the work of the past years.     They entitled their effort a "Comprehensive Program to address the Mental Health Needs of the State." In addition to using the language of "crisis" as perspective, they described an effort that included all disability and age groups, conceptualized increased services and put forth the goal to "fund and fully implement these major initiatives."     The MHSC report also placed a price tag on the effort. Needed was $632.9 million in new state, federal, and local dollars over a 10-year period.

Specific Initiatives: Pioneer and Medicaid Waiver Pioneer:

"Purchase of Services" model

Dollars are earned by providing delivery of specific services to target populations - based on the "Comprehensive Long-Range Plans"

Carried out through annual agreements between Area Programs and the MH/DD/SAS Division

Provided age/disability-specific definitions and criteria for eligibility for state funded service - "Level of Eligibility" (Editorial note: criteria were very inclusive and "forgiving")

Result: Pioneer was conceptualized as the mechanism by which all funds would ultimately be distributed. This never happened and good people disagree about why. Some say the citizen/taxpayer/legislator did not keep the promise to purchase what was agreed upon. Others say a mechanism to appropriately manage resources to the intended population was never put in place and money was not spent as intended.

Medicaid Waiver:

Begun as one age/disability-specific pilot, for child and adolescent MH, to "capitate" Medicaid dollars

Attached to a 1991 memo from MH/DD/SAS, announcing the agreement with the Division of Medical Assistance, there was a summary of the waiver that stated "the purpose of using the (waiver) in this State would be cost containment." (Editorial note: up until now all the discussion has been about expanding services and adding money. Could this be the first sign of a lack of agreement or a lack of communication between /among planners?)

Waiver not renewed by HCFA because it could not prove superior cost effectiveness over a fee-for-service mechanism

Current disagreement among many parties about whether or not the effort was a success. Most participating programs appear to believe that the effort to provide services was enhanced by the initiative.

The GPAC Report
The Government Performance Audit Committee, which was authorized by the General Assembly in conjunction with the creation of the Integrated Funding Task Force, issued its findings in late 1992. The reader of this history is reminded that Pioneer and Medicaid Waiver were moving forward by now. A document was in preparation by MH/DD/SAS Director Mike Pedneau, actually issued on Jan. 20, 1993, with instructions as to how to begin implementation of the long-range plans conceptualized by the Mental Health Study Commission.
The GPAC report recommended an aggressive downsizing of institutions and redirecting of the money to communities. The Division of MH/DD/SAS responded with a general agreement with the concepts delineated but disagreed with the savings projected and the ability to redirect money from the institutions to accomplish the goals in question. Clearly in focus here was the question of whether or not there would be sufficient increases of funding up front and beyond current overall levels, or whether or not any new community money must come from savings from the institutions.

A Turning Point?
The writer of this history would like to suggest, or at least ask, whether or not the GPAC report does not represent a real change in the discussion of the reform issues. It seems important that what soon followed from the Integrated Services Task Force was a name change of the initiative to "Unified System of Services" presented in a May 1994 interim report of the task force. More substantially, the task force also produced one month later a supplemental report that dealt with cost projections. The report states "Instructions were given to area program work group representatives to only respond to needs of clients who had been served by institutions in the past…not to address unmet community needs."
Is this not a "sea change" in the discussion? Prior to this the focus was on enhanced resources and ambitious programs, and the vital need for increased funding if not an implicit assumption that greater resources were to be forthcoming. The discussion seems to have changed from "success depends on additional resources" to some version of "there's enough money in the system, we're just spending it wrong." One must ask whether or not the sum total of these changes represents the de facto abandoning of the long-range plans as originally conceptualized by the MHSC.

This Is Now: The Campbell Report
State Auditor Ralph Campbell has now produced his report on the MH/DD/SAS system and has called it the "first comprehensive look at mental health delivery in thirty years." It came about in the context of the failure of Pioneer and Medicaid Waiver, an aggressive stance from HCFA about fraud and waste, probably in direct response to the efforts of states to shift cost to federal resources. The sense of crisis described in the MHSC press conference in 1991 has only grown stronger.
What has the audit produced? It is said to provide mechanisms for more control over programs and expenditures, better definition of statewide policy and procedures, and increased accountability. The writer of this history believes that it may be a more comprehensively written version of the issues, but there is nothing fundamentally new here. The essential questions and options are as they have always been, and are as follows:

1. What does the citizen/voter/taxpayer want the Area Programs to be? Originally conceptualized as "free clinics" and prohibited from denying services to anyone regardless of ability to pay, they have been encouraged over the last few years to develop more of a "business focus." However, they still operate under a "Statue of Liberty" mandate (give me your tired, your poor...). If they are to continue this ambitious, generous outlook, as represented by the long-range plans of the MHSC from 1991, they will need the $600 million, plus interest, to do it. If however, the citizen/taxpayer/voter/legislator does not want to pay this cost, Area Programs must be given a different mandate. They must be told not only who they are to serve but how they can legally, ethically, and politically close the door to some of those now served. They must be given an effective utilization management system that enacts the priorities set by the system and allows them to tell the others to go away.

2. Those who advocate for MD/DD/SAS services must ask themselves whether it continues to be rewarding to go time and again to the taxpayer/citizen/voter with grand-scope plans that are dead on arrival at the General Assembly because of cost. Those who so advocate must ask themselves what is realistic, gear expectations accordingly, and find different ways to solve problems.
Therefore, collectively we must decide whether it will be more money or a more limited mandate. Up to this point we have not had the political will to choose and to accept the consequences of our choice. It is time to decide.

---

Drew Bridges is a psychiatrist in the mental health office serving Vance, Granville, and other counties north of Durham.