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By Lynda McCullough
In a sunny town in Southern California, a small dark cloud hovers directly above the newly created Human Services Agency (HSA). It developed early in April, when the Ventura County Board of Supervisors voted to merge the county Behavioral Health Department with Welfare Services, by moving it from the Health Care Agency and creating HSA. Both the HSA and the department of Behavioral Health Administration are managed by social workers. In effect, mental health care has become a part of the county's welfare program.
Some psychiatrists, consumers, and two county supervisors have protested that the merger is not in the best interests of the mentally ill. Following the April 7 vote by the county's board of supervisors, the medical director of the Ventura County Behavioral Health Department, John Wong, M.D., and others wrote letters to the editors of the Los Angeles Times Ventura County section saying the proposed merger would be disastrous for the mentally ill. The president of the Southern California Psychiatric Society, Michael Gales, M.D., wrote the Board of Supervisors saying the merger would "have a substantial long-term adverse effect on the quality of mental health care delivered to the county's mentally ill." Citizens and members of the local Alliance for the Mentally Ill began calling the Board of Supervisors to protest or obtain an explanation of the proposed merger. Controversy has continued to rage in the last few months.
On April 23, the board met to reconsider the issue and to vote a second time. Again supervisors voted to proceed with the merger, and they moved to put the county's top administrator Lin Koester in charge. Supervisor Judy Mikels said that the process of deciding on the merger has been uncharacteristically quick and not well thought out. "Quite frankly, it is a move to get autonomy by the social workers," she said. "This has more to do with control than patient care. When I talk to doctors and find out that their team leader is a social worker and doctors report to RNs and social workers, I go right through the ceiling."
Proponents of the merger say it will lead to a team-oriented approach to working with the mentally ill that would eventually save the county money. "The bottom-line reason for the change is that what we used to call behavioral health-mental health and substance abuse-has more in common with what used to be the Public Social Services Agency," said Lacey." "Treatment will be more effective with everybody collaborating."
Reorganization has proceeded as planned in the midst of the controversy, and it should be complete by the end of September, said Phil Settle, program management analyst in the chief administrator's office (CAO). "We're tying up loose ends, and everything seems doable." In a technical sense, said Settle, many things are still the same. The CAO was always in charge of mental health, just as he was other county agencies, but he now has more direct dealings-attending meetings and signing off on memos sent to the board of supervisors on mental health issues. Reporting lines within the medical system will remain the same until new roles are defined and established, he said, though at this point in time, the office is not certain what new roles will be created.
According to Behavioral Health Director Stephan Kaplan, the rationale for reorganization stems from a reexamination of who the target population for services is as well as the responsibility to enact welfare reform. Eligibility for Medicaid is determined through the human services agencies, he said, and human services is primarily responsible for providing services for welfare families. The population served includes the very poor, homeless, people with substance abuse problems or mental illness, and severely emotionally disturbed children. Kaplan said the county looked at what the clinical and financial responsibilities were and how best to use resources and decided to develop services within one agency.
Another aspect of Ventura County's health system that influenced supporters of the merger, said Kaplan, was that the state of California has given the counties funds for mental health services and also directed that fee-for-service systems be combined with service to the severely mentally ill. "From our point of view it is better to have the mental health plan linked with welfare services," said Kaplan. "When someone in the welfare reform system has mental health issues, mental health will provide services."
Kaplan said he believes the controversy over the new HSA is already dying down, and that concerns raised by psychiatrists and others will prove to be unfounded. "In no way do I think psychiatrists' ability to practice their profession is compromised," he said. Psychiatrists will continue to report to the medical director and participate in the same peer review process that they always have, he said. Psychiatrists are vital members of treatment teams, he added. "We're going to have more and more efficacious medications, and we need to know how to use them-it would be shortsighted not to acknowledge that."
Ventura has had a strong multi-disciplinary, collaborative approach for many years, said Kaplan. The county developed a comprehensive system of care for emotionally disturbed children in 1984 and for severely mentally ill adults in 1989 that has become a model for other counties. Teams made up of a psychiatrist, psychologist, social worker, and nurse develop treatment plans for the mental health and rehabilitation of patients. Responsibilities of each professional are defined by the scope of practice, said Kaplan. "There is value in the team approach," he added. "Medicine alone doesn't solve the problems-you need a comprehensive treatment program."
While Kaplan and many of his colleagues believe that psychiatry retains an important role, and that the needs of the mentally ill will be met in the new Human Services Agency, others say that physicians are losing the ability to make medical decisions about the mentally ill, and that the mentally ill will suffer as a result. The merger of behavioral health and social services in Ventura County, is the latest event in the "steady erosion of psychiatry in public agencies," said Michael Gales, M.D., president of the Southern California Psychiatric Society. Gales said county-employed psychiatrists had sought help from the district branch in dealing with the merger. Most of the county psychiatrists have in recent years been on a contract basis with no job security, and the administration doesn't have to show much cause to fire them, said Gales.
"Extracting the department of psychiatry from health services and plugging it into social services produces financial and medical problems," said Ronald Thurston, M.D., a psychiatrist in private practice in Ventura County. "Hospital licensing and payment requirements demand that physicians make medical decisions. If laws and regulations are jeopardized by this move, Medicaid won't pay for services." In addition, he said, there are dangers in a system that submerges medical goals beneath social service goals and a democratic approach in which the psychiatrist is just another vote in diagnosis and treatment planning.
The county treats a large percentage of seriously mentally ill people because private insurance doesn't adequately cover psychiatric benefits, said Thurston. Caring for the mentally ill is a big burden and there is little money to spend on it, he said, so that it is hard to maintain a strong medical program. "Strings are being pulled by the larger social and political realities, and treatment of the severely mentally ill has become a pawn of political and funding shortfalls."
"We are moving out of decade of the brain and the medical understanding of mental illness," said Thurston. "It is ironic that just as we are able to do more and more about medical problems of the brain, there is a similar movement of nonmedical people attempting to get authority to diagnose and treat mental illness."
Compounding the struggle for psychiatry to retain the medical model is a confusion in society about whether psychiatry is a medical specialty or not, said Thurston. In California, for example, the position of mental health director in the various counties used to be filled by psychiatrists. "Social workers and psychologists have almost no biological education," he noted. "People with little or no biological education want to make decisions about biological treatment. The problem is bigger than biology, and social services are needed. But psychosocial is taking over the biopsychosocial balance."
The public also still harbors misunderstandings about mental illness and sees it as a moral or social problem rather than a physical disease, he added. Thurston said that it is important for psychiatrists and others to educate and re-educate people about mental illness and available treatment so that they will understand the need for medical approaches. In doing so they have a natural ally in the families of the mentally ill, he said. Many of these families have struggled to find help and have learned that medical approaches are the only ones that work. They form alliances and do much to educate the public and provide information on the physical causes of mental illness.
Psychiatrists are trained medical professionals, said Thurston. They are not just trying to change behavior. "What is behavioral health?," he asked. "There is no such thing-it is the invention of people who want to move away from the medical model to a social one."
"You cannot make me believe this [merger] is a proper move," said Supervisor Mikels. "Mental illness is not a social disease, it is a physical disease. Why in the world would you go back to the dark ages and even intimate that it is a social disease?"
Mikels said her concern now is to implement the board's order in such a way that mental illness patients are in the forefront. "One of the big problems is that there is not going to be a lot of control, oversight, or accountability with everything in one agency. It will be difficult to oversee and understand what's going on," she said. She wants to make sure that psychiatrists run the critical care plan and will demand outcome reports to show whether the needs of the mentally ill are being met. "We have to listen to patients and families, to make sure that the quality of care does not decrease," said Mikels.
Kaplan and others say that psychiatrists are finding that their roles and practices remain the same, and that the needs of patients are being met. "The reality is that people are seeing patients as usual," he said.
As the controversy continues, and the results of the merger for patients remain to be seen, Mikels said, "We need to make sure that the patients don't end up the losers."
This is the first of a two-part series. In the second part Psychiatric News will look at the role of psychiatrists within other counties and states that have merged mental health and social services.