Mental Health Audit

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A court-ordered audit reveals the private, for-profit company that has managed Maricopa County’s behavioral health care system since 2007 has shown �a pattern of regression and significant declines in a number of areas.� The court-assigned monitor joins us to talk about the audit.

Ted Simons: Hello and welcome to "Horizon." I'm Ted Simons. The price of comfort will soon go up if you fly U.S. Airways. The airline announced today that starting February 16th, it will charge $7 for what it calls a "power-nap-sack." The kit includes a blanket, neck pillow, eye shades, ear plugs and a $10 coupon off a purchase in the sky mall catalog. The airline says the fees are needed because of a downturn in travel caused by the recession. Over nearly three decades Arizona has failed to provide the level of services for people with serious mental illnesses as dictated by state law. A recent audit of behavioral health services in Maricopa County indicates the quality of care may be getting worse. More on the audit in a moment, but first, David Majure takes us to the State Capitol, where lawmakers gathered yesterday to learn about a lawsuit that continues to shape, and it continues to take shape Arizona's system of behavioral health care.

Woman in court: This is a history lesson. I would suspect that there are not eight people in this legislature that really understand the history of Arnold vs. Sarn.

David Majure: It's a lawsuit filed in 1981 as the nation and the state were moving people out of mental hospitals into community-based behavioral health treatments.

Charles "Chick" Arnold: In deed, I'm sort of the institutional memory revolving around this case. I was the guardian as the Maricopa County Public Fiduciary of 600 people with serious mental illness.

David Majure: As their guardian, Chick Arnold tried to help them obtain the community based mental health services that were mandated by state law.

Charles "Chick" Arnold: Gee, there were no services in place. And with that, I became one of the five named plaintiffs in the center for law in the public interest effort to fix that.

David Majure: The case went all the way to the Arizona Supreme Court, which in 1989 affirmed that the state and Maricopa County have a statutory obligation to provide a wide range of services for the seriously mentally ill.

Speaker in the court: Over the course of the lawsuit, as far as services, money that has gone to services has been close to $2.2 billion.

David Majure: Two decades and billions of dollars later, the lawsuit remains unresolved. Performance criteria required to end the lawsuit have not been met and the company that manages Maricopa County's mental health system keeps changing.

Doctor Richard Clarke: I'm Dr. Richard Clarke, the CEO for Magellan of Arizona.

David Majure: Magellan is the latest company selected as the Regional Behavioral Health Authority for Maricopa County. It is awarded a three year $1.5 billion contract in September of 2007.

Doctor Richard Clarke: And we do believe that significant gains have been made.

David Majure: But according to an audit conducted in 2008 by the court monitor assigned to the case, services are declining.

Doctor Richard Clarke: The court monitor compares the results of 2008 to 2006, which is a full year before Magellan even came into the picture and so if one compares from 2006 to 2008, you can see a tremendous decline, but if you take a look from 2007 forward, you notice that there's been a significant improvement on 71% of the indicators on the provided class, ranging from anywhere from 3% to 46% improvement in performance.

John Hokanson: The system really has degenerated quite badly actually since Magellan took over.

David Majure: As a Maricopa County resident with Bipolar Disorder, John Hokanson speaks from experience.

John Hokanson: I've had a difficult time getting services; I had to fight for pretty much everything that I have right now. I have had to fight to get the monthly doctor's appointments; I've had to fight to get into therapy.

David Majure: He even had to fight for a case manager.

John Hokanson: I went for two months without any contact at all from this case manager at all and I didn't receive any updates to my I.S.P., it's called an Individual Service Plan, it's supposed to list what services that the client needs and everything; it expired and they didn't update it or anything.

David Majure: Hokanson was able to fight for his rights but he worries about people sicker than him, who can't.

John Hokanson: You know it's one thing, if you know you're being hurt by this and you don't -- and you don't know what to do, but there's people out there that don't even know they're getting hurt.

David Majure: Meanwhile, John has quietly taken on the role of advocate; emailing his lawmakers, attending meetings like this, watching, listening and waiting for the system to improve.

John Hokanson: We're going to have to do something else here, ok; just talk alone is not going to solve the problem.

Ted Simons: Joining me to talk about the latest audit of Maricopa County's mental health system is Court Monitor Nancy Diggs. She's a past Deputy Superintendent of the Arizona State Hospital and she has previous work experience with the Department of Health Services, and Comcare, a predecessor to Magellan. Thank you so much for joining us on "Horizon."

Nancy Diggs: Thank you for having me.

Ted Simons: You're the court monitor; what exactly does that mean? What do you do?

Nancy Diggs: Well the court monitor actually oversees the status of implementation against the court's orders. I actually report to Judge O'Connor, Karen O'Connor, who is the presiding judge in superior court and it's my duty to monitor the expectations in the court order and the court's order and report to the court about the status of the class members in the case.

Ted Simons: And how do you go ahead and report your audit here? How do you audit who's interviewed; how does that work out?

Nancy Diggs: Well we've actually--I've used Dr. José Ashford, he's my expert, out of A.S.U. School of Social Work and through a predefined process that's been agreed to by the health department, we randomly select -- this year we randomly selected 316 different class members that live in Maricopa County. And we used a pre-agreed to scientific protocol that involves visiting consumers, reviewing records. I just want to note that it's important to me that the system learns how to monitor itself so 88% of my auditors, this year, were actually staff members at Magellan or staff members at the health department. I do that to teach people how to monitor the system and to control the cost at the office of the monitor.

Ted Simons: With that in mind, what did the audit find?

Nancy Diggs: The audit findings were very disturbing to all of us. We found that there's not been progress in the system. There's a variety of standards that were required by the -- by agreement of the parties. And there's significant declines since the compliance in 2006. And more importantly, there has not been any significant gains in the last several years.

Ted Simons: We just heard from the Magellan fellow there and he was basically saying that the process -- the audit was looking more process as opposed to outcome. How do you respond?

Nancy Diggs: Well, one of the things that we actually do look at is there a treatment plan and those things, but most importantly, the most significant thing that the audit measures is exactly how is that individual doing in the community? Where are they living? What kind of services are they receiving? Are they working? Do they have something meaningful to do during the day? Do they have friends? Do they have a social life? And how are they doing in the recovery from mental illness? And all of those things are the kinds of outcomes that you would look for when measuring progress in -- and if people are getting services and are they helping them?

Ted Simons: And that Magellan fellow has a name, it's Dr. Clarke.

Nancy Diggs: Yes.

Ted Simons: And he also mentioned that you were looking too far back. You were looking back when value options was involved, as opposed to Magellan and if you had just looked at '07 to ‘08, you would see great improvements.

Nancy Diggs: I think the point of the audit, how I would respond to that, the purpose of the audit is not to measure the performance of either Magellan or the previous contractor. So in that sense, I'm not comparing their performance. What I am doing is measuring for the court how the defendants in the case are doing and how the consumers that are supposed to be served are doing in the system. And so that's how I would respond. And in some cases, there might have been one or two percentage points improvement since last year but the point is that, for example, 90% of the most ill people were supposed to have a well written treatment plan that describes the services and supports they needed and the audit results found that actually less than 15% of the people had a treatment plan. And so the audit also indicated of the non-party population, 80% of them were supposed to have their needs met according to their treatment plan and the audit found that less than, I think it was less than 15% of them actually were having their needs met. So I used the standards that are required by the court; that the parties have agreed to.

Ted Simons: Your report mentions that a complete overall is necessary. Why? What is wrong with the system now? Why were those results that you found -- why were they there if the system's in place? What's going on?

Nancy Diggs: We've had two different companies, since for, I think for the last nine years. Clearly things are not improving even though there's been additional funding over time. In fact, the services and the supports delivered to people are actually getting worse. And the bottom line is people with serious mental illness really depend on this system of care and they are really suffering right now. And I believe that through the leadership of the new governor, that the community can come together and with the stakeholders and really take a look at how the system is designed, are there fundamental flaws, and what needs to happen to improve the system so that people that really need the services are actually getting the services.

Ted Simons: All right; very good. Nancy, thank you so much for joining us. We really appreciate it.

Nancy Diggs: Thank you.

Nancy Diggs:Court Monitor

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