The NM Mental Health Care Audit: Out of the Frying Pan

The state of NM has yanked Medicaid and Medicare funding from fifteen agencies that provide mental health care services all across New Mexico. This represents 30,000 patients, many of them children, some of them the very sickest of the population of people with psychiatric illness.

I don’t use the word “yanked” accidentally or lightly. There was no warning; not for patients, not for providers, and not even for the administration and management of these agencies. The NM state government announced in June that it would halt funding to the agencies and hand over their administration to five Arizona agencies.

We’re flying our flag upside down. We’re on our knees, begging someone in power to come and save us. Our newspapers and media outlets, from Albuquerque to Taos to tiny Quay, NM, are suing our government, trying to force them to offer some transparency, some little hint of what has happened and where we’re going, and they are silent. New Mexico, like every state in the US, has its own auditor, but NM contracted with a Boston company to conduct the audit at a cost of $3.2 million. Why? We’ve heard no reports of corruption in the auditor’s office, so why did they do that? Were we just in the mood to send a whole lot of our money to Boston and Arizona and we needed to find a way to do that? Because for all the information we’ve been given, that makes about as much sense as anything.

The line we have heard again and again from the NM Human Services Department (HSD) has been that there will be no disruption of services. Even as the stories have begun to circulate indicating that the transition of management has been anything but smooth (and in some communities and families it has been disastrous), HSD has continued to assure us that all is well. Everything is fine.

I was on a conference call last week that was advertised as a “listening call” so that HSD and representatives of the Arizona agencies could hear consumer concerns. My alarm bells sounded right away, because contrary to the commonly held conception of people with mental illness, many patients do have jobs, and the meeting was held from 1:30 pm to 3:00 pm on a weekday, so that cuts one significant population of consumers out immediately. Next, the call was conducted in English, with no plans to conduct another meeting in Spanish or Navajo or with translation services available for speakers of other languages, removing many more people from potential participation. The announcement about the meeting went out via email, cutting out the many people in our state who don’t have access to a computer, and the fact that a phone was required for participation again removed a large group of people. Finally, many people who are very seriously ill just can’t. To expect a person with severe thought or mood disorder that isn’t under control to participate in such a call is laughable.

But maybe that’s part of how such a terrible thing is happening: its victims are a population that is less able to advocate for itself than many others.

To be blunt: everything is not fine, and every word spoken on that “listening” conference call by anyone who isn’t paid by HSD made that clear. There are children who are not in school because agencies that provided behavioral management services to children so they could attend school (commonly known as 1:1 services, and provided via Medicaid instead of the public schools in NM) don’t have them. There are families whose children are in foster care who can’t do the items on their family action plans because there are no providers to oversee and provide for those plans. The overflow from the agencies that are part of the audit is creating profound pressure on other agencies that receive public funding, so that service is reduced for nearly everyone across the state.

For perspective: I wrote A Dislocation of Mind, about the many weeks it took to get my daughter some psychiatric care in this state, over three months before the audit started. It’s not like the situation in mental health care and addiction treatment was good before this started; we’ve gone from abysmal to catastrophic. What I have detailed here are just a few hints to the horror that the audit is for the people on the ground: the patients and providers who live with the reality of mental illness and addiction every day of the year.

And yet, with all this, we’re having a very hard time getting any attention to this crisis. My friends, I’m asking you, please, if you live in NM, write to the governor and all our legislators and to HSD and insist that they put patients first. If there is money missing, certainly we need to find out where it went and what happened, but not at the expense of people who are sick. (By the way, does it seem unlikely to you that there is vast wrongdoing in mental health care but all the agencies that deal with broken bones, skin cancer, and the flu are pure as the driven snow? Yeah, me too.) The NM congressional delegation has asked US HHS Secretary Kathleen Sebelius to set up a public forum, but no date for that has been announced.

If you’re not in NM, please send a note to anyone you know in national media. No one seems to be all that interested, and I am no cynic, but it’s hard not to think that few people care because people with mental illness are a little weird and scary and not always likable (Just like the rest of us, but don’t people with mental illness make the handiest scapegoats?). We need the federal government to pay some attention to us, and my fingers and those of my advocate friends are about raw with all the letter writing.

Watch this.

Read this.

Watch this space for links to a radio series on the audit, which will include part of an interview I did with Tristan Ahtone, the public health reporter at Fronteras. If you’re in NM, you can listen to it on KUNM tomorrow during Morning Edition in the am and All Things Considered in the pm, or you can stream it if you’re not in NM.

A Dislocation of Mind

Right now, millions of people in the US cannot access needed mental health care. My daughter is one of those people, and her life is at risk.

My 17 year old daughter, Abbie, broke her leg the other day; a bad break in her femur. She was in terrible pain, begging me to make it stop, to help her feel better, so I took her to the emergency room. We went there, and we waited for 6 hours, and finally a Bone Health Specialist came and told us that we should go home and make an appointment to see an orthopedist.

“I can’t take her home like this!” I said. “She’s in too much pain, and she can’t walk! Can she at least have some medicine for the pain?”

The Bone Health Specialist was aghast. “A doctor can’t prescribe medicine without seeing the patient. That would be unethical!”

I brought Abbie home and made her as comfortable as I could before I got on the phone. I called every orthopedist whose number I could find. Many of them didn’t return my calls, and of those that did, more than half told me that they were not accepting new patients, and the few who I spoke to who were accepting new patients made appointments 4-6 weeks in the future or put her on waiting lists that were months long.

*          *          *

Oh, wait, no, sorry. I got a little confused for a second there. Actually, I took Abbie to the ER for an asthma attack. She was terrified, begging me to help her breathe, so I took her in hopes of getting her some relief and making sure she didn’t die. We went there, and we waited for 6 hours, and finally a Breathing Specialist came and told us we should go home and make an appointment to see a pulmonologist.

“I can’t take her home like this!” I said. “She can barely breathe, and she could die! Can she at least have a nebulizer treatment?”

The Breathing the Air Specialist was aghast. “A doctor can’t prescribe medicine without seeing the patient. That would be unethical!”

I brought Abbie home and gave her every kind of over-the-counter medicine I could think of to help her breathe better before I got on the phone……

*          *          *

Oops, no, wait, it was diabetic shock, and after we waited we saw a Blood Sugar and Insulin Specialist who told us to go home and make an appointment with an endocrinologist……

*          *          *

Gosh, sorry, I just don’t know where my head is. I took her to the ER because she was in a car accident and she was unconscious from head trauma, and after we waited we saw a Consciousness Restoration Specialist who told us to go home and make an appointment with a trauma surgeon……

*          *          *

Or wait, no, I did take my daughter to the ER, and we did wait for hours, but what was really wrong was depression. She felt suicidal. I had already called more than 30 psychiatrists by the time we went, and had already discovered that I could not get her an appointment in a reasonable amount of time. 6 weeks, 2 months, 3 months, we’ll add you to the waiting list…and in the meantime my daughter begged, “Please, Mom, can’t you make it stop? I just want it to stop!”

It is always awful to witness one’s own child suffering. From a baby’s first cold, there are few things in life that feel worse. Part of the way I endured excruciating pain after a surgery in 2007 (a stitch had slipped and I was bleeding internally) was to chant over and over to myself, better me than one of my kids, better me than one of my kids. But when there is treatment for what ails that child; when we know exactly what would bring some relief but we cannot deliver it despite our best and biggest efforts, there is an extraordinary anger that could change the path the moon travels in the sky if only I could figure out where to point it.

I took Abbie to Kaseman Presbyterian in Albuquerque because it is one of two hospitals in the city that has a psychiatric emergency department. I took her to the ER because, as I have been busy trying to get her an appointment with a psychiatrist, she has gotten more depressed. When left untreated, illnesses more serious than common viruses have a tendency to get worse. Untreated diabetes causes organ damage (or death); untreated asthma causes scarring in the lungs (or death); untreated depression causes more acute depression (or death).

We waited some 6 hours at the ER and finally we saw a Behavioral Health Specialist (BHS). She interviewed Abbie, and then she spoke to me. “She’s clearly very depressed,” said the BHS, “but she doesn’t meet the criteria for admission. She has some suicidal ideas, and she knows what she would do if she decided to end her life, but she hasn’t definitely decided to do it. Criteria for admission is an immediate suicide plan or extreme psychosis. You should take her home and make an appointment with a psychiatrist.”

“Won’t she see a psychiatrist today?” I asked.

“No, there are no psychiatrists in the emergency department.”

There are no psychiatrists in the psychiatric emergency department.

There are NO psychiatrists in the PSYCHIATRIC EMERGENCY DEPARTMENT.

“I can’t take her home without a prescription or an appointment or something,” I said.

The BHS looked horrified. “She can’t have a prescription. No doctor will write a prescription without seeing the patient. That would be unethical!”

Unethical.

Let’s talk about ethics.

Let’s talk about the ethics of insurance companies that reimburse so little for mental health treatment that hospitals have no incentive to keep their psychiatric units open.

Let’s talk about the ethics of a mental health funding system that pays psychiatrists less than most other doctors so medical students enter other specialties in hopes of paying off their student loans before they reach retirement age.

Let’s talk about the ethics of having a psychiatric emergency room with no psychiatrists in it, ever.

Let’s talk about the ethics of naming psychiatric care “behavioral health care,” as if the issues were in one’s actions instead of in one’s brain.

What about my ethics? How ethical is it for me, as a parent, not to get my daughter the medical care she needs? It doesn’t feel quite ethical to go to sleep at night, posing as it does the risk that she may hurt herself when I am unavailable to supervise. No, that doesn’t feel ethically sound at all.

When Abbie dislocated her knee at school 18 months ago, an ambulance transported her from there to the ER. At the ER, they put her knee in place, put a brace on her, gave her a dose of pain medicine and a prescription for pain medicine to take at home, and we walked out with a follow-up appointment with an orthopedist for the very next day.

There is no equivalent care for a dislocated mind. There is no method to deliver care immediately to a person who is suffering deeply but who has not quite gotten to the place where she seals the garage, or swallows the pills, or puts a blade to a vital artery.

By all means, let’s talk about ethics. Let’s talk about the ethics of a mental health care system that meets the needs of such a small minority of suffering people that suicide is the third leading cause of death among teens and young adults in the US, in spite of the fact that most people with mental illness can be successfully treated with appropriate care, and 90% of people who complete suicide have a diagnosable mental illness at the time of their deaths.

I sure am glad the doctor who “treated” my daughter the other night got to protect his ethics. Now how about we get busy protecting people’s lives? How about we talk about systemic ethics? How about we talk about treating suffering that originates in the brain the same way we treat suffering that originates in the heart, the liver, and the bones?

How about someone out there with a prescription pad helps me keep my daughter alive? How about we all start treating this like the emergency that it is?

My daughter will get the treatment she needs. I found someone to see her in two weeks (still an outrageous amount of time, but we’ll manage), and in the meantime we’ll do what we have to do to keep her safe, somehow.

The same cannot be said of the nearly 40,000 Americans who will end their own lives this year.

There are no disposable people, but we sure as hell act as if there are.