Psychiatrists in Arizona are opposing a new requirement by the state that all patients in publically funded treatment programs—other than Medicaid—provide documentation of their legal residency.

The Arizona Psychiatric Society (APS) wrote Gov. Jan Brewer (R) in October to oppose a new requirement that all patients treated in the state's mental health programs document their legal U.S. residency status by November to remain in those programs.

"Not only must care be suspended, but there has been no provision for the appropriate transfer of care to any alternate heath care entity, governmental authority, etc.," said the letter from APS President Michael Brennan, M.D.

The result of dropping treatment for such patients could leave them vulnerable to suicide and place people in the public at risk of homicide by those whose untreated illnesses lead them to violence, he wrote.

The new policy, enacted through an executive order by the governor, may end treatment for an estimated 7,000 Arizona residents, most of whom are illegal aliens. However, the documentation requirement also could affect U.S. citizens and legal residents who are too poor or too ill to locate or obtain the necessary paperwork, according to Brennan.

"Some people just don't have the documents to prove their citizenship," Brennan told Psychiatric News, and thus the new policy imperils the health of some citizens who are not targets of the new rule.

In addition, the policy change has created a potential ethics violation for physicians under their "duty to protect" their patients from suicide, he said.

"It essentially required physicians to stop their patients' care," he said.

The governor had not responded to the APS letter as of late November, and her representatives did not respond to requests for comment from Psychiatric News.

In addition to the residency policy, the state also recently implemented a series of budget cuts affecting non-Medicaid beneficiaries in state mental health programs who are legal residents and who are able to prove their legal residency status. The cuts, enacted in July to close the state's budget deficit, eliminated those beneficiaries' transportation, psychotherapy, case management, and inpatient psychotherapy and medical treatments. Specific cuts included dropping access for these patients to Assertive Community Treatment and Intensive Recovery Teams, which are case-management programs that follow national models.

Additionally, the budget cuts ended the provision of supported housing for seriously mentally ill beneficiaries in the public system. However, in a Web posting, the governor's office noted that none of the beneficiaries with serious mental illness would have to leave their existing supportive housing "until other safe, stable housing is found."

Of particular concern to psychiatrists treating this patient population was the elimination of reimbursement for all but two brand-name antipsychotic medications.

Karen Sanders, associate director for publicly funded services at APA, said that one Arizona psychiatrist has reported that a patient switched from a antipsychotic for which coverage was halted to a covered antipsychotic went into a coma and required hospitalization before partially recovering.

"This is a draconian measure to enact simply because of budget constraints," said Brennan, about the clinical impact of the severely restricted drug formulary.

Among patients affected by the formulary cut, Brennan said, are psychologically impaired veterans whose disability payments make them ineligible for Medicaid-funded treatment but who need ongoing mental health care.

The governor's office noted that this non-Medicaid patient population will continue to have access to crisis telephone services and mobile crisis intervention services.

Additionally, "if funding allows," then the state's regional behavioral health authorities are authorized to offer inpatient psychiatric stabilization for up to 72 hours.

A future concern, Sanders noted, is that the legislature is considering adopting the restricted antipsychotic formulary for the state's Medicaid program if more budget cuts are needed.

More information on the Arizona budget cuts is posted at <www.azdhs.gov/bhs/updates/documents/Fact%20Sheet%20050310.pdf>.