mental health by and for the community
radically reimagining community mental health

Since February 15th, we have been meeting with politicos and their staffs. We have been talking with leaders in the mental health community. The sausage factory is not pretty.

• We've heard a lot of "we can't do that; we've never done it that way before." ("The way it's always been done" is why we're in this mess!)

• Sacramento County refuses to discuss their plans with the providers and the patients they are pledged to serve. That means that existing providers don't know if they'll be open on July 1st, and the 8,800 affected patients cannot even begin making alternate plans.
  • Update: they're not killing the RSTs entirely, but cutting back to 4,000 patients total -- cutting off care for almost 5,000 neighbors. See the news page for more details.

• There are organizations willing and able pick up some of the slack (without costing the County a dime), except the County didn't give them the timely information they need to build the capacity to do so.

• After squandering $8.3 million in mental health dollars on a computer system that never worked (while ours was in place, functioning, and available to the County for free ), County Department of Mental Health officials have not responded to our invitations to discuss our alternatives.

• The Regional Support Teams have already started refusing to provide services to both new and existing patients.

We're frustrated. I've even written to President Obama.

do we need government?

We haven't given up on government support. In fact, I believe most of the people in government are trying their best in a byzantine system that discourages individual initiative and innovation. Government support will always be essential -- we cannot rely on a free-market health system when sick people cannot participate in the market -- but we cannot count on government to take the initiative or to design the kind of humane, efficient system we need.

Perhaps it is time for us -- patients, families, and providers -- to take the reins.

a unique private-public partnership

So far, government has been unresponsive. We cannot wait for the government to innovate. Private foundations have responded with "submit your grant proposal and we will review it for consideration in our 2010-2011 funding year" -- we cannot wait until 2011 for our medical care!

Several people have commented that this proposal will never be taken seriously because we are asking for too little money. That's right: too little money. If it's so cheap...

community ownership, community control

If every one of the 8,800 people the County is planning to displace contributed only $19 then this program could be set up and ready to start serving hundreds (alas, not thousands) of patients in a matter of months.

Every operation owes allegiance to its funders. Wouldn't you prefer a mental health system allied with patients and providers over one that owes allegiance to government bureaucrats?

how do we operate? how do we grow?

The community contribution would only put the infrastructure in place, it won't pay for any care. Where would the operating budget come from?

I propose we offer for sale a gift card, a golden ticket, good for six months of psychiatric care in our system. The card would have a telephone number and a code with which the patient could access SacDoc's Fast Track same day appointment system and get an intake appointment the same day while activating six months of quality psychiatric medication management. Who would buy these golden tickets? Consider...

• The Centers for Medicare and Medicaid Services (CMS, formerly known as HCFA) requires that hospitals make good-faith efforts to arrange for "safe and adequate follow-up care" prior to discharging someone from the hospital. The Sacramento County Mental Health Treatment Center (SCMHTC, whose web site demonstrates their commitment to timely community outreach) routinely violates this rule by referring patients to a completely overburdened, soon to be nonexistent outpatient mental health system that cannot provide timely care of any kind, let alone "safe and adequate." They do so at their peril: once they're caught, they will lose all Medicare funding for the patients they boot out without follow-up. No more "treat 'em and street 'em." When I worked at SCMHTC ten years ago, I was told that the County estimates it costs about $500/night to keep patients there. I assume that cost hasn't decreased. If SCMHTC could hand the patient a golden ticket rather than keep them another night or two arranging for safe and adequate follow-up care, then everybody wins: The County saves the cost of a longer hospital stay. The patient is guaranteed timely, humane follow-up care. Chronically-overcrowded SCMHTC gets another open bed for another acutely ill psychiatric patient. Net cost to the County: $0.

• Private medical and psychiatric hospitals face similar challenges. Many could save thousands of dollars a month just by having a stack of SacDoc golden tickets on their discharge planners' desks. Net cost to the County: $0.

• The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was passed by Congress and signed into law as a rider on the TARP bailout bill. It requires insurers to maintain parity between mental health and other health services. Insurers both public (Medi-Cal, CMISP) and private will soon start facing lawsuits if they continue to discriminate against their members who have disorders of the brain. How convenient, and cost-effective, if they could simply provide mental health claimants with a SacDoc golden ticket for their psychiatric medical care.

• As the County curtails services, already-overcrowded hospital emergency rooms and community medical clinics will see an increase in patients presenting with psychiatric complaints. With an inventory of SacDoc golden tickets, they will have a tool to quickly provide their patients with quality, timely psychiatric care so they can focus on other urgent medical problems. A SacDoc golden ticket would cost the typical hospital emergency department far less than the money they lose treating a medically indigent psychiatric patient, and provide better and longer-lasting follow up care in the bargain. Net cost to the County: $0.

• Many of us, our friends, family members, neighbors, and co-workers with mental illness have become frustrated with the unwillingness of both public agencies and private insurers to adequately address their needs. Until a better system is in place, a SacDoc golden ticket might prove to be an inexpensive option compared to going without adequate care. Would you pay, say, $50/month to get quality care for you or your loved one? Net cost to the County: $0.

With revenue from the sale of SacDoc golden tickets, the program could be expanded to meet the needs of the community, perhaps even providing scholarships to those truly without the means to get humane health care for their psychiatric illness.

Radical. Audacious. Community health care by and for the community.

Proceed to the need for change