THOUSANDS OF THE MOST SEVERELY AND  PERSISTENTLY MENTALLY ILL AND/OR ADDICTED PERSONS IN NORTH TEXAS FACE CUTBACKS IN TREATMENT (beginning November 1).

Below see three responses from leaders in our public mental health system which were sent to the North Texas Behavioral Health Authority Board  (NTBHA) and which express serious concern about the care and treatment of the mentally ill and addicted in North Texas.  

 1.      ”I reviewed VO’s summary of potential medical expense reductions and the reactions from a couple of other providers.  Its hard for me to judge the merits of any of those until I truly understand the magnitude and source of the financial issues.  I do have grave concerns about the value or wisdom of VO’s recommendations that further reduce our ability to meet the communities’ needs in the outpatient programs.  It only seems to reinforce the downward spiral that increases the number of emergencies, crises and bad outcomes for clients.  In order, however, for us to determine which adjustments are the most productive and least destructive, we must start with a common understanding of the actual financial changes from last year.”    ~ J. Randy Routon, Ph.D., Chief Executive Officer, Life Path Systems 

2.       “NorthSTAR is spending less and less real dollars on out patient community based services as each of the last five or more years have gone by. Five years ago we spent more than four years ago, four years more than three years ago, three years ago more than two years ago. Am I not reading this data correctly? We have a  runaway increase in crisis expenditures. It is time to redesign crisis services with the goal to spend less and less dollars while maintaining current out patient expenditures.”  ~ James W. Williams, Director Mental Health, Lakes Regional MHMR Center

3.         “Respectfully, here’s what NTBHA should do instead of approving the cuts, caps and closings:

Ask  VO to propose a crisis services redesign that spends less money on people in clinics, offices and ER’s and more money on clinicians out in the streets with our police

Ask VO to propose a  homeless/justice redesign that incentivizes VO and its provider network to get people off the streets and keep them out of jail

Ask VO to propose an outpatient services redesign that spends more money on the types of services for children, families and adults that address community priorities identified by BHLT

Help VO tie every redesign idea to a NTBHA or BHLT goal and outcome measure

Assure that the redesigns also significantly cut VO’s costs and so help meet its fiscal goals

Help  VO shift its risk-reward curve toward more risk, thereby offering it a greater chance of the reward of achieving its profit goal, through more utilization review and less fixed rates and “cap” agreements.”

 ~ James G. Baker, MD,MBA  Chief Executive Officer  Metrocare Services

Here are the proposed cuts in an already deficiently funded system which are being proposed by value options (VO), the insurance company that runs our public treatment system:

*Proposed cuts, caps and closings for implementation on November 1st and contingent cuts proposed for March 1st are listed below.  Our models show that the November changes represent a 20% cut in outpatient service dollars available, leaving too few doctors and other clinicians for viable treatment programs.  Access and quality will go down.  Crises will go up — and so will homelessness, ER visits, and jail stays.  The proposed March cuts would reduce outpatient service dollars by another 6%.

Cut doctor, hospital and case worker rates by 5% “across-the-board”
Cap the dollars available for emergency room services (23-hour program)
Cap the cost of hospital care
Close Metrocare after-hour clinic
Close Centro de Mi Salud after-hours
Cut out the supported employment that helps patients find jobs
Cut UTSW funding for psychiatrists in training in public sector settings
Cut funding to Transicare for case management and patient transportation
Close The Club (“Dallas drop-in center”)
Close transitional housing (“rental subsidies”) for patients just released from the hospital
Cut low-intensity outpatient services (SP1) case rate to $70 per month
Cap low-intensity outpatient service duration (SP1) at 90 days per patient
Cut physician-only services reimbursement to $40 per month
Cap the number of patients who can get higher-intensity services (SP2 and SP3), in March
Cut Transicare even more, in March
Cut peer services, in March

North Texas Psychiatrists & Psychiatrists in Training – Contact your state legislators (www.capitol.state.tx.us) and/or the NTBHA Board expressing the need to prevent these cuts and to put treatment back in the hands of doctors with other mental health professionals.

 NTBHA can be reached at:   North Texas Behavioral Health Authority, 1201 Richardson Drive, Suite 270, Richardson , TX  75080.   Attention: Alex Smith – Executive Director and Judge Michael Chitty- President NTBHA Board    Tel. 214-366-9407   fax 214-366-9417  or email: bruckdeschel@ntbha.org.

Thank you,
Edgar P. Nace MD     epnace@gmail.com
NTSPP Immediate Past President, Media Chair, & Co-Chair of the Public Psychiatry Committee 

The NTSPP Advocacy Bulletin of the North Texas Society of Psychiatric Physicians  (NTSPP ) Executive Council   May, 2011

Texans need your help to overcome the crisis in mental health treatment in our state.

Please consider the following facts:
*Texas ranks 49th in per capita mental health funding at $34.57. The national average is $103.53.
*Cost of community-based mental health treatment: $12 per day.
*Cost for state hospitalization: about $400 per day.
*Cost of incarceration: about $137 per day.
*Cost of  emergency room visit: $1,265 per visit.

Untreated Texans will be caught up in a revolving door of jail, emergency room visits or hospitalizations.  This is unlike any other health problem.   Proper treatment saves dollars and saves lives.       Texans deserve a humane response when afflicted with mental illness: Texans in the public mental health system are living, on average, 29 years less than the rest of the population.  These people are our fellow citizens, neighbors, and family members.   Modern psychiatric treatment is effective and should be available to those in need.  Help our State to provide what can be life saving, cost effective and restorative of lives—namely, adequate funding for the treatment of those with psychiatric illnesses.

Thank you for your attention. Please contact us for further information on the treatment and prevalence of mental illness.

Edgar P. Nace, MD
President, North Texas Society of Psychiatric Physicians
12700 Hillcrest Rd., Ste. 260Dallas, TX 75230
972-716-9678 (phone)   972-789-9324 (fax)   epnace@aol.com

Osman Ali, MD
Chair, Public Psychiatry Committee, North Texas Society of Psychiatric Physicians

Texas Mental Health Treatment Crisis
The advocacy bulletin
The Advocacy Bulletin will be published periodically in order to inform legislators of mental health and addiction issues. We welcome comments and requests for information on specific topics. Contact NTSPP at: ntsppchapter@gmail.com.?

NTSPP Advocacy Bulletin January 2011:   Assisted Outpatient Commitment: Getting Beyond the Barriers to Appropriate Care ~ Considering a Solution to a Serious Problem

Why do some people with severe mental illness and/or addictions refuse appropriate treatment? Do they truly prefer to wander the streets and deteriorate in health and social functioning? As physicians we know that there are people who do not have the family or personal mental capacity to choose to obtain appropriate services, even if they were available to them.

Further, they cost society significant dollars in frequent hospitalizations, arrests, and jail time.

Assisted Outpatient Treatment (AOT) is a court-ordered treatment utilized by forty-four states (including Texas) and can be referred to as “Outpatient Commitment.” This court-mandated treatment is critical to save the lives and restore many individuals with persistent mental illness. Those individuals who have a history of medication non-adherence are in particular need of AOT.

The Evidence that it Works
In New York State, after five years of implementation of AOT, only 22% of those under AOT were hospitalized compared to comparable patients who were not court-ordered to receive treatment (including medications), with the result that 97% of the latter were hospitalized.

In a North Carolina study, intensive outpatient treatment without court-ordered services did not reduce hospital admission. However, when court-ordered services included three outpatient visits a month and use of appropriate medications for at least six months or longer, hospital admissions were reduced by 57% and those who were hospitalized had significantly fewer days in the hospital (Swartz et al., Can involuntary outpatient commitment reduce hospital recidivism? American Journal of Psychiatry, 156:1968-75, 1999).

Enacting Outpatient Commitment in Texas

Keep in mind that health care quality and safety ought to be of utmost importance in the minds of the legislators this cycle. Having considered the criticisms of coercion in treatment extensively, experts have concluded that “patient-centered care aims to promote patients’ engagement in their own treatment to the extent consistent with their abilities.” (Monahan et al., Mandated treatment in the community for people with mental disorders, Health Affairs, 22(5):28-38, 2003).

In Texas, outpatient commitment criteria are:

1) The presence of a severe and persistent mental illness;

2) If untreated, the person is likely to suffer from severe and abnormal mental, emotional, or physical distress and deterioration of the ability to function independently, leading to an inability to live safely in the community;

3) The person is unable to voluntarily and effectively participate in outpatient treatment (Summary for “State Standards for Assisted Treatment in Texas” as provided by the Treatment Advocacy Center, www.treatment advocacycenter.org).

AOT is largely underutilized in Texas, perhaps because families, medical personnel, and the courts are unaware of AOT and its utility. We are providing this information to you in the hope that your office can inform constituents should such a need arrive.

Concluding Request

We must get past the rhetoric to the judicious use of Assisted Outpatient Treatment (AOT) for those people who are relying on us to help them get beyond the imprisonment of their mental illness. Let’s not ignore them.

Postscript from the President to North Texas Legislators:

This is the second Patient Advocacy Bulletin forwarded to you as a North Texas legislator. Our first bulletin emphasized the inappropriateness of the use of jails and prisons in lieu of adequate treatment for severely and persistently mentally ill and addicted persons. This Bulletin describes a solution for some in the category of the severely and persistently mentally ill. It is our hope that you, as a Texas legislator, will attend to these issues and direct your staff to look more closely at what is happening in your particular community. We fear that there is indifference to these issues and urge you, as a Texas legislator, to initiate a process to correct inequities in funding for mental health services that exist across the state of Texas but which are particularly acute in the NorthSTAR service area, which includes the following counties: Dallas, Collin, Kaufman, Rockwall, Navarro, Ellis and Hunt.

We as members of the North Texas Society of Psychiatric Physicians are willing to answer questions concerning the treatment of the mentally ill and addicted and to provide further information per your request. We appeal to your interest in this topic not just because of the obvious cost savings that would be incurred if proper funding for adequate treatment were made available, but more importantly, we appeal to your conscience to help our citizens who are unable to help themselves.

Thank you very much. For further inquiries contact Edgar P. Nace, MD, at the following address:

Edgar P. Nace, MD
President NTSPP
12700 Hillcrest Rd,. Ste. 260  Dallas, TX 75230
972-716-9678 (phone)    972-789-9324 (fax) epnace@aol.com

The Advocacy Bulletin will be published periodically in order to inform legislators of mental health and addiction issues. We welcome comments and requests for information on specific topics. Contact NTSPP at: ntsppchapter@gmail.com

NTSPP  Advocacy Bulletin  December, 2010:   CAN WE AFFORD NOT TO SUPPORT MENTAL HEALTH INTERVENTIONS IN OUR CORRECTIONS SYSTEM?Did you hear about the recent study* finding that 10% of Texas prison inmates had serious mental illnesses (i.e., bipolar, major depression, schizophrenia, or psychosis other than schizophrenia)? Mentally ill prisoners are more than twice as likely to have repeated incarcerations compared to prisoners who are not mentally ill. Furthermore, the mentally ill are likely to have a longer sentence than the non-mentally ill.

In the coming session, difficult decisions need to be made regarding funding for the criminal justice, court system and public mental health system. In doing so, please consider the following representative fictionalized case scenario:

When Mr. Smith was picked up by police officers,he was off medications for several months and living on the streets. He began drinking heavily to subdue the voices in his head. When he eventually became paranoid and agitated, police officers took him to the emergency room to receive medications. His charges were dropped by the judge who heard his case in the adjacent mental health court and he was transferred to an inpatient facility, detoxified from alcohol, and observed on medications until he was stable enough to be discharged directly to an Assertive Community Treatment (ACT) Team.

If Mr. Smith was written off as someone who is not deserving of attention because he “drinks half the time” and if police officers did not recognize that he likely has a serious mental illness, he may have spent time in jail where he would get worse and perhaps commit further offenses.

Alternatives to incarceration include treatment centers for non-violent offenders (pre-booking) and mental health courts (post-booking) where non-violent mentally ill are placed in closely supervised treatment programs. According to the Texas Taskforce on Indigent Defense**, Mental Health Courts and Mental Health Public Defenders significantly reduce recidivism. In Dallas County, the six-month recidivism rate for people with schizophrenia with no mental health public defender was 18%, but with a mental health public defender, recidivism dropped to 5%. That saves money and saves patients undue suffering from restraint, confinement, or extended sentences.

Mr. Smith was assigned to an ACT Team; its services included illness management, recovery, and rehabilitation which kept him out of more costly state funded services. Because 20 to 25% of mentally ill prisoners will have a history of a violent crime and not be eligible for diversion, there is a need for alternative correctional facilities where those with mental illness can be vigorously treated and rehabilitated.

With our state budget shortfall, we should not neglect the cost-saving measures that are already in place that continue to save Texans money and provide appropriate treatment and diversion for mentally ill offenders.

Two things psychiatric physicians in North Texas request you to do:

1. Support diversion courts for the mentally ill to prevent them from getting caught up in the criminal justice system.

2. Support funding for mental health care providers and resources in the correctional system including rehabilitation and recovery services.

*Baillargeon J., et al. Psychiatric disorders and repeat incarcerations: the revolving prison door. American Journal of Psychiatry 2009; 166:103-109.

**Carmichael, et al. Representing the mentally ill offender: an evaluation of Advocacy Alternatives, Texas Taskforce on Indigent Defense. Office of Court Administration, April 2010.

The Advocacy Bulletin will be published periodically in order to inform legislators of mental health and addiction issues. We welcome comments and requests for information on specific topics. Contact NTSPP at: ntsppchapter@gmail.com.

NTSPP Chapter & Tarrant Chapter  invite all psychiatrists, psychiatrists in training and their spouses/significant others to their Joint Dinner Program

2011 January 27 ~  Thursday 6:30 pm to 9:00 pm

Richard Noel MD, TSPP President Practicing Medicine in the Era of New Healthcare Policy: An Update on Obamacare
And
John Bush, TSPP Executive Director 2011 Legislative Update for Psychiatrists

6:30 to 7:00 pm                            Cash Bar, Socializing

7:00 to 9:00 pm                            Seated Dinner, Program, Q & A

Country Club location available by email

SITE DEADLINE for RSVP, payment, and cancellation for refund:  Saturday, January 22  at 12 Noon

PAYMENT and RSVP Information:

TARRANT CHAPTER AREA Psychiatrists and PGYs: Contact Dan Goggin MD at dagmdpafw@sbcglobal.net, or Joe Burkett MD at  jhburkett@hotmail.com

NTSPP AREA Psychiatrists and PGYs :
1. Identify your status:
NTSPP Dues paid Psychiatrist member and Spouse/SO:  $30 per person
UTSWMC Psychiatry resident/fellow and Spouse/SO:  $25 per person
NTSPP area NON dues paid Psychiatrist and Spouse/SO:  $45 per person

2.      RSVP name, status,  and number attending to Catherin Roberts MD at  NTSPPrsvp@gmail.com before Saturday January 22 at 12 noon

3. Pay using PayPal link below OR send a check made out to NTSPP  to Treasurer Margaret Balfour MD PhD POB 192401 Dallas TX 75219 to arrive  by Saturday January 22 at noon.

Membership Status

NTSPP DUES-PAID member $30.00 NTSPP NONmember $45.00 UTSWMC Resident/Fellow $25.00 Guest of NTSPP DUES-PAID member $30.00 Guest of NTSPP NONmember $45.00 Guest of UTSWMC Resident/fellow $25.00

Name

Late cancellations, late request to attend, or special allergy menu needs? Contact Catherin A. Roberts MD at NTSPPrsvp@gmail.com.

Before you leave to attend: Check www.ntspp.org for any last-minute changes.

Not on the NTSPP email list? Psychiatrists and psychiatry PGYs:   Email NTSPPchapter@gmail.com.

President’s Column from the Winter 2010 NTSPP Newsletter*

            The city of Seattle saved $4 million in hospital, jail and other public services after 95 homeless people moved into one housing project. These 95 people’s visits to hospitals and jails before had cost tax-payers nearly $8.2 million. Other facts concerning the wisdom of providing permanent supportive housing for the chronically homeless can be found in Kim Horner’s Dallas Morning News article of Sunday December 13, 2009. This article focuses on Dallas’s empty Plaza Hotel which a developer has been attempting to make available for permanent supportive housing. The state rejected this developer’s application for tax credits in March 2009, most likely because of neighborhood opposition. As a result, the twelve-story Plaza building remains empty and thousands of people in Dallas remain on the streets or in jail or emergency rooms, incurring costs of tens of millions of dollars, not to mention the human misery.

            Politics and bureaucracy seem to overrule humanitarian and common sense solutions. The American Heritage Dictionary defines bureaucracy as “administration of the government chiefly through bureaus or department staff with unelected officials”; “management or administration marked by diffusion of authority among numerous offices and adherence to inflexible rules of operation”; “an administration in which the need or inclination to follow complex procedures impedes effective action”. The dynamics of a bureaucracy can promote self-protection and self-serving behaviors at the expense of the actual mission of the bureaucracy.

            Can we as individual citizens and physicians, or as a small organization such as NTSPP, have some influence? I think we can but it does require patience, time and study of the issues. Should we not as a medical organization speak more loudly in the interest for permanent supportive housing? I hope that we will and I would welcome your thoughts on what NTSPP could do.

              Along similar lines, the possibility of the transfer of authority for mental health services may arrive in north Texas under the aegis of the North Texas Behavioral Health Authority. It is premature to assume that this is a done deal as the authority for mental health services resides in Austin in the Department of State Health Services. Several of us think it is critical that the authority be local, i.e. with the seven north Texas counties served by the NorthStar system. Should this transfer take place, it will be critical that the North Texas Behavioral Health Authority (NTBHA) have sufficient funds and personnel to do the job. NTBHA has a very strong board under the leadership of Judge Michael Chitty and has recently hired and effective executive director, Mr. Alex Smith. In my opinion, an additional positive step would be the creation of a NTBHA medical director’s position. This has existed in the past but not in recent years. Again, the issue of bureaucracy is relevant as the needs of the chronically and persistently mentally ill and addicted in the north Texas area needs to be a focus of concern and not issues of bureaucratic infighting. The Department of State Health Services allocates 38% of its $2,942,000,000 budget to mental health and addiction services. Yet, the Department of State Health Services does not have a psychiatrist with line authority. There is a psychiatrist on board but the position is more that of a consultant than one with authority to design appropriate services. If a psychiatrist or, more appropriately, several psychiatrists were to be included in the Department of State Health Services organization with real authority; it would behoove our professional organizations to consult with such psychiatrists and help assure that bureaucratic procedures do not impede what needs to be done for the individuals for whom the bureaucracy actually has been created to serve. 

            I believe we, as citizens and physicians as well as a relatively small professional organization, can play a constructive role if we are willing to relate to these issues and interact with the entities which carry the responsibility. What is your point of view?

                                                                        Edgar P. Nace MD,  President NTSPP,   NTSPPpresident@gmail.com

*Note:  All psychiatrists and psychiatrists in training  in the Dallas Area for whom we have email addresses  receive the complete newsletter by e-mail.  Didn’t receive one?  Send your name with degree and email address to NTSPPchapter@gmail.com. 

Thursday, September 24, 2009:  6:30 pm to 8:45 pmish

Leslie Secrest MD ~ Advocacy
Location: Usual lovely Preston Road/Northwest Highwayish dinner location with seated three-course dinner and great view.
Schedule: 6:30 pm  Cash bar and socialize, 7:00 pm Dinner and socialize, 7:30 pm Business, 7:45 pm Program with Q & A

CME: Category II

Cost of dinner and program to you:
$30 for NTSPP Chapter Dues-Paid Psychiatrists
$50 for all other Psychiatrists and all Psychiatrists in Training

Reserve your spot with number attending at  NTSPPrsvp@gmail.com and pay by Tuesday noon, September 22  (please look for directions and confirmation by return e-mail from this address. Set your spamblocker to receive from this address).

To pay online: Please complete the form below.  You will then be directed to a secure website to complete the transaction. All credit card transactions are handled safely and securely via PayPal, a subsidiary of eBay. You do not need a PayPal account to make a payment. No financial information is stored on the ntspp.org web servers.

Membership Status

NTSPP dues-paid member $30.00 Nonmember $50.00 Resident/Fellow $50.00

Name

To pay by check: Make checks payable to NTSPP and send to arrive before September 22 to Treasurer Margaret Balfour MD PhD, PO Box 192401, Dallas, TX 75219.  Reserve your spot by emailing NTSPPrsvp@gmail.com before noon September 22. 

To enable a UTSWMC resident/fellow to attend at a greatly reduced price or no charge, please consider a donation to our Memorial and Honor Fund in honor or memory of a colleague.  Each dinner costs $50 at this location.  As contributions arrive, we will alert the residents and fellows and tell them of your generosity.

Cancellations: Must be received by NTSPPrsvp@gmail.com 2 days prior to the event (by 12 noon Tuesday September 22, our location’s deadline) for refund or transfer to another dinner program.

See www.txpsych.org for details. 

In deference to our District Branch Meeting, no NTSPP dinner program will be held in November.

Mental Illness Awareness Week in Fort Worth

Saturday, October 11^th 2:00 – 3:30 pm  Fort Worth Botanic Gardens Lecture Hall

 “Mental Health Issues and Legislative Aspects” 

Speakers: Dan Barrett and Mark Shelton, District 97 Candidates

Dr. Gary Etter (TSPP), Dr. Joe Burkett (MHMR), and Dr. Carol Nati (JPS)

 Sponsored by the Tarrant Chapter of the Texas Society of Psychiatric Physicians