System for mentally ill spurs worry

The safety net for Maricopa County's poor and mentally ill has frayed to the point where advocates worry not just about patient care, but also about public safety.

Records, interviews and state reports show that physicians and case managers are overwhelmed, patients are getting lost in the system, treatment is delayed and the county's sole public psychiatric crisis center is full and turning patients away.

"It's been a very rocky year with them," said Nancy Diggs, court-appointed monitor in the case.

While the mentally ill are more likely to be a danger to themselves than anyone else, and far more likely not to be a danger at all, officials with Magellan Health Services, which took over the county's public mental health program a year ago, say tragedies can happen no matter who's in charge or how well people are monitored.

On July 20, police say, Jill Manahan was released from Magellan's urgent psychiatric facility in Phoenix and driven to her Scottsdale condominium by Comtrans, which provides transportation for Magellan clients.

Later, according to police, Manahan broke into her neighbor's home and stabbed the 83-year-old woman to death.

Three days earlier, police had taken Manahan to Scottsdale Healthcare Shea to be evaluated because of her behavior, and she was transferred the next day to the Urgent Psychiatric Care Center.

A state licensing investigation was launched and a medical director for the state health department looked into the matter, said Susan Gerard, who was director of the state Department of Health Services until August.

"The woman had responded to medication. She was rational," Gerard said the doctor told her. "There really wasn't any indication she was going to do this. And because of the way she was behaving, they couldn't really hold her."

They never got the chance with Bernard Allen, who was reported to have seen his Magellan psychiatrist two hours before police say he plunged a knife into a young man's back in a Fiesta Mall bathroom in March.

The day before, Allen stabbed another Fiesta Mall shopper in the neck, according to police reports, but the victim escaped.

"There are legions of these cases around," said Phoenix attorney Charles "Chick" Arnold, the original plaintiff in the Arnold vs. Sarn lawsuit, whose settlement governs mental health care in Maricopa County.

"It's the little stuff that's just as troublesome because it becomes the big stuff," Arnold said. "It's not OK."

SERVICES FALLING OFF

Cases like Manahan's and Allen's don't reflect on the services Magellan has been providing, said former CEO Dr. Chris Carson. What's worse, he said, are people who go without any mental health care at all.

"We should be right next to anybody in this county who has a mental illness, on good days or on bad days," said Carson, now chief of medical and clinical services.

"Our job is to make sure people get the best care they can get," he said. "These are events that are tragedies, and that we want to avoid."

Carson said Magellan is making substantive changes that will result in lasting benefits to the mentally ill, including better supervision, more comprehensive services and a focus on recovery.

But pressures have become so great that physicians are complaining privately that they don't have time to see their patients. The doctors are referred to by some as "prescribers" rather than psychiatrists.

"The doctor shortage is so serious that the patient death rate has significantly increased from 9/1/2007 until the present, from both suicides and other issues related to poor mental health care," wrote an anonymous blogger who claimed to be a psychiatrist for Magellan.

The blog - www.betterbehavioralhealthaz.com - was launched last month by a dissatisfied patient.

Minutes from Magellan board meetings show board members, providers and the public expressing concerns about budget cuts, lack of access to food boxes for clients and chronic problems with data collection, which can lead to failures of eligibility, treatment and follow-up.

State and court records show complaints from consumers and providers are up significantly from a year ago. Magellan has the highest rate of denying claims, and having its denials reversed on appeal, among the six administrators statewide.

FINES LEVIED

State health officials have fined Magellan Health Services four times in the past two months. Magellan is beginning the second year of a $1.5 billion three-year contract, the largest of its kind in the nation.

The Connecticut firm fought hard to wrest the contract from ValueOptions, another for-profit company that operated the clinics and ran the system for nearly a decade.

As a new Arizona CEO took over late last month, he was greeted by two state fines, totaling nearly $95,000, for failing to supervise case managers and follow clients. That was on top of two other sanctions, worth $65,000, that the state levied weeks earlier because Magellan wasn't coordinating care between primary care doctors and psychiatrists, leading to potential drug overdoses.

Auditors are fanning out across the Valley this month to complete an annual court-ordered evaluation required under the Arnold vs. Sarn settlement. And expectations are low.

"The state has been doing their periodic reviews and they have not been good," said Arizona State University professor Jose Ashford, hired by the court to evaluate the audits. "So people are projecting the overall audit will be poor."

Now, longtime advocates, providers and administrators are wondering if the county's 70,000 poor and mentally ill weren't better off under ValueOptions, which was vilified before it lost the contract in June 2007.

"I really felt that we needed a change. I can't say I was disappointed" that Magellan was chosen, Gerard said. "But by the time I was leaving the department, I was ready to let them out of the contract."

Gerard's successor, acting director January Contreras, said Magellan had been warned for months that it wasn't meeting contract provisions and submitted plans to fix the problems, but little progress was being made.

In the latest quarterly performance report, through June 30, Magellan scored well below the state's six other behavioral health administrators in it's ability to track and coordinate care between medical and mental health doctors, for both children and adults.

While three agencies successfully referred 100 percent of their clients for services within the required 30-day time frame, Magellan managed just 33 percent - less than half of the minimum standard of 70 percent.

"This agency doesn't have the luxury of being an observer," Contreras said. "We have a job to hold them accountable."

But Contreras said she's encouraged that Magellan has finally spun off two of its 25 clinics, including one in Mesa, to a local agency, Southest Behavioral Health, and has reached agreement with other local behavioral health providers.

'OFF TARGET'

Getting out of the actual provision of care was a key part of the new contract, but it's taken longer than expected for Magellan to extricate itself. A state audit during ValueOptions' tenure showed the company, which both administered and provided services, paid itself more than it would have paid local agencies.

"Are things off target? Absolutely," Contreras said.

"(But) Magellan has made a huge leap," Contreras said. "Our clinics are our face-to-face opportunity with the people that we serve every day. They are part of the backbone of the entire behavioral health system. I'm very encouraged that we now have those community-based providers in place."

Richard Clarke, who took over Magellan's Arizona operation last month, said the company is transforming a huge, inefficient system under tight deadlines and difficult circumstances, including the court order. It will take years, he said.

"Magellan is here for the long haul and we have no intention of leaving," Clarke said. "We're excited about the challenge. We're not excited about receiving sanctions."

Many who work with the mentally ill were hopeful when Magellan won the contract last summer.

Since ValueOptions had taken over management from the state in 1998, state and court-ordered audits showed declines in treatment, budget cuts and questionable funding transfers. The company had been sued by its clients and fined by the state in connection with two suicides, and spent millions on medical malpractice, legal fees and state sanctions.

"A year ago, everybody was excited," Carson said. "Inside Magellan, we always knew that this was a difficult contract and that this had been a troubled system for a long, long time. And that our arrival on the scene wasn't necessarily going to change that."

Though the data problems persist, Carson said no one is turned away even if there's a question about their eligibility. Turnover persists, but caseloads are not outside state standards, he said.

Some of the benchmarks set by the state, and agreed to by Magellan, are unrealistic, Clarke said, such as having every case manager receive weekly supervision. Some may be in training, others out on leave, he said.

Magellan was fined $62,500 for failing to meet the supervision standard, able to document that just 42 percent of staff received weekly oversight. That leaves case managers to make decisions on their own, the state said, and "increases the likelihood of poor outcomes and an increase in quality of care concerns."

"There are multiple pressures here. There are standards that I think are too high. Agreements probably should not have been made to have them that high," Clarke said.

"The state has received an enormous amount of pressure from the court system to do something about this," Clarke said. "Sanctions are one of the ways they can do it. I don't think it has long-term impact. But it's a tool that the state has decided to use. We take them seriously."

Clarke said Magellan has not yet decided whether to appeal the sanctions.

Diggs' state audit should be completed in a couple of months. It will follow one of the worst audits in years, which came about a month after Magellan took over in what was billed as a seamless transition from ValueOptions.

"It wasn't a smooth transition at all," Ashford said. "The state said in open court that they had built into the contracting process a transition phase that would not harm the clients. Obviously that wasn't the case."

Given the problems found in the state's contract performance reports, and the anecdotes he hears about almost daily, Ashford was not optimistic about the upcoming audit. A key question is how Maricopa County Superior Court Judge Karen O'Conner, who oversees the case, will respond.

"If they don't comply, what's the answer here?" Diggs said. "You can't sanction them forever."

For all the talk about outcome measures, audits and sanctions, Contreras said her department cannot lose sight of what's really at stake.

"This is more than a contract. This is people's lives. This is the opportunity and, quite frankly, the obligation to help those people improve their lives," Contreras said.

"We don't need to see plans anymore. We need to see results."

Magellan HealthServices:

The publicly held for-profit company, based in Connecticut, manages health services for government agencies, corporations and insurance companies. Its public sector behavioral health segment has contracts with the states of Iowa and Nebraska, five counties in Pennsylvania and parts of Florida and Tennessee.