Poor children in Arizona may finally get the mental health services they need now that the state has agreed to restructure its managed mental health system as part of the settlement of a 10-year-old, class-action lawsuit.
The March settlement stands to benefit an estimated 20,000 children covered by Medicaid in Arizona. The agreement was brokered by attorneys from the Bazelon Center for Mental Health Law, the Arizona Center for Disability Law, and a Phoenix law firm.
"When these principles are implemented, it will significantly change the culture of Arizona’s behavioral health care system," said Burnim.
The principles emphasize partnering with families and children, interagency collaboration, and individualized services. Services must also be accessible and timely, and outcomes must be measured in terms of improved functioning at home and school, as well as avoiding delinquency, according to the settlement agreement.
Mark Wellek, M.D., a child and adolescent psychiatrist in Phoenix, told Psychiatric News, "These principles are considered the standard of practice within the field."
"My impression of the Medicaid system here is that kids with mental health problems are getting basic counseling and occasional medication checks," said Wellek.
He complained that managed care companies restrict Medicaid children’s access to psychiatrists and recommend medications based on their cost. This is despite the fact that children on Medicaid often have severe mental illnesses and emotional disturbances, said Wellek.
Federal Medicaid law requires states to provide a range of services including inpatient, residential treatment, intensive rehabilitation, day treatment, case management, and medications, according to Burnim.
But in Arizona the Medicaid system, which has been managed since 1990, has consistently failed to deliver those required services, according to Ivor Groves, Ph.D., a behavioral psychologist in Tallahassee, Fla.
Groves and a team of experts evaluated the Medicaid mental health system in Maricopa County, which includes Phoenix, in 1998. The county serves two-thirds of the state’s children with mental health needs.
The team found numerous deficiencies and made several recommendations based on the 12 principles eventually included in the settlement.
However, a follow-up evaluation in 2000 revealed that little had changed. In fact, Groves’s team found that in some areas, service delivery had worsened, according to the June 2000 report.
As in 1998, "about half the number of children eligible for Medicaid who need mental health and substance abuse services failed to receive them on a timely, consistent, and adequate basis. Children being served by multiple agencies are at greatest risk,’’ says the team’s report. In addition, the services are not of the type, intensity, scope, and duration to meet minimal standards of adequate behavioral health care practice, it noted.
"The quality of psychiatric practice is uneven, and too often the assessments focused only on medication interventions," the report stated.
Nor, it added, are mental health and substance abuse services coordinated enough to meet minimum standards of practice.
Groves told Psychiatric News, "Another problem is there are too few providers who are well trained, experienced, and supervised adequately to provide quality services that meet the child’s needs."
He also concluded that the Medicaid mental health services were underfunded and that the regional behavioral health authorities who administered the program locally were not supervised adequately by the state mental health authority.
The 1998 evaluation was triggered when ComCare, the contracted managed behavioral health company, declared bankruptcy in 1997, and the Arizona Department of Health Services’ Division of Behavioral Health Services (DBHS) took over the system.
The DHS, DBHS, and the Arizona Health Care Cost-Containment System were named as defendants in the lawsuit, which was filed by a father on behalf of his son J.K. in 1991 in federal district court. The father filed the lawsuit, which was certified as a class-action suit in 1993, after he was unable to obtain recommended services for his son under Medicaid, which led to the son’s suicide attempt and then psychiatric hospitalization, according to Burnim.
To ensure that the scenario in J.K.’s case doesn’t repeat itself in the future, the settlement also requires the defendants to take these actions:
• Conduct a pilot training program of frontline counselors and supervisors in the assessment, planning, and delivery of mental health services.
• Designate $2 million over three years to implement statewide training of frontline counselors and supervisors based on the lessons learned from the pilot project.
• Hire master’s-level mental health counselors including specialists in treating sexual offenders and victims of sexual offenses and developmentally delayed individuals.
• Designate $600,000 for the pilot program or similar services.
• File annual action reports.
The Arizona Center for Disability Law will monitor the state’s progress according to timelines set forth in the agreement. If a dispute arises, the parties are required to go through a mediation process. Only if that fails can they use the courts, according to Burnim.
The Federal District Court for Arizona is expected to ratify the settlement in the next few months.
The 12 principles outlined in the landmark settlement are available at the Bazelon Center’s Web site at www.bazelon.org/jkprinciples.html. ▪