Friday, December 12, 2008

Could last resorts spur action on Milwaukee's mental health complex problem?

High on the list of "fiddling while Rome burns" situations is the plight of Milwaukee County's mental health complex.

For years, the county's Behavioral Health Division (BHD) has been trying to provide emergency, acute inpatient, and long-term mental health care services to indigent county residents in a sprawling complex that is falling apart and no longer meets its needs. In the meantime, it's hemorrhaging dollars it doesn't have (a $3.9 million projected deficit for 2008 after several previous years of budget holes), and its efforts to pursue a new home that might produce overhead savings and better quality of care have been bogged down by infighting between the county executive and county board.

For insight into what types of options might get tossed around if things get really bad, county policymakers and special interests who have been brawling over this issue may wish to consider what's going on in Georgia. There, the state is seeking to embark on what the Atlanta Journal Constitution calls an "uncharted course": full privatization of the state's psychiatric hospitals.

Understandably, this proposal has attracted considerable concern, primarily based on fears that the only way the private sector could profit from providing mental health inpatient services for largely uninsured individuals would be to significantly cut staffing and services. Given Georgia's already poor history of service delivery, that is a troublesome possibility. State officials, however, are touting this as the only option for attempting to provide better care within existing budget constraints due to the private sector's alleged ability to provide higher levels of service at lower cost.

Could such an approach be attempted in Milwaukee County? Interestingly, some county mental health officials looked long and hard at "getting out of the inpatient business" several years ago, as it became clear to them that the dollars needed for community-based care and supports would not be available as long as they were forced to pour increasing amounts of property tax dollars into inpatient and long-term care operations. The biggest obstacle at that time, however, was the perceived impossibility of securing a private sector entity to step in given the large uninsured population served at the mental health complex.

Might those circumstances be different today, in light of new Badger Care coverage for childless adults and a push for mental health "parity" at the federal level, both of which could lead to broader coverage for mental health services? That's hard to say, but it's not hard to imagine a scenario in which the county again would have to contemplate the privatization option - at least for some of its inpatient or long-term care operations - despite concerns about impacts on service capacity and quality.

The sad reality is that the county has few options left. While it has not moved forward on the proposed move to a renovated St. Michael hospital, and is now entertaining the thought of building a new mental health complex, the fiscal situation at BHD - as demonstrated by the size of the 2009 deficit - has grown worse. The structural problems that have created budget deficits for several years are no secret to policymakers, yet they have not been addressed (with the exception of an initiative to outsource dietary services) and are likely to cause another sizeable budget hole in 2009. In the meantime, it is now logical to ask whether either a move to a renovated St. Mike's or building a new complex is practical in light of the county's deteriorating fiscal condition, which is worsening by the moment as its pension fund assets shrink and its infrastructure and service needs grow.

None of this is to suggest that privatization of inpatient mental health services should be viewed as anything but a last resort or is even viable. However, unless county policymakers do something soon to reduce overhead costs at BHD to make the cost of care more affordable, last resorts may be the only resorts left on the table. That should be reason enough for them to start working together to identify and implement a realistic solution to their mental health complex problem.

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