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‘Arnold v. Sarn’: Helping or hurting?

The lawsuit that led to the creation of the modern behavioral health care system in Maricopa County has created what many experts say is an artificial set of standards that ignores the real needs of patients.

But confusion and disagreement over ways to improve the system have delayed the kind of meaningful reform that almost everyone in the health care community recognizes as necessary.

“I suspect not two people in this Legislature understand Arnold v. Sarn,” said Carolyn Allen, a Republican from Scottsdale. “We need a little history lesson before we make any substantial changes.”

The 1989 Arizona Supreme Court decision in Arnold v. Sarn guaranteed county residents access to state-run mental health treatment at a time when Arizona and many other states were struggling to break from an institutionalization model of care that focused on incarceration and ignored the possibility of treatment and a return to society.

The decision in Arnold v. Sarn forced the state to create the community-based system, which focuses on treatment methods that allow people who suffer from mental illness to reclaim a place in society. It also resulted in the release of many people living in the state mental hospital, which from that point forward was used only as a last option.

Yet it effectively made homeless many of the people who had lived in institutions because the state failed to put in place the community health care infrastructure intended to replace the in-patient hospitals.

Nearly 30 years later, though, the case has devolved into a series of court orders that have tangled the system in unachievable procedures that have pulled time and money away from patients, according to mental health care administrators, Magellan caseworkers and even some officials who initially supported the lawsuit’s intent.

Patients in the behavioral health care system and their advocates, on the other hand, say the lawsuit is the only facet of the system holding accountable the Arizona Department of Health Services, the agency charged with operating a statewide mental health care system.

The case was based on a law approved by lawmakers a decade earlier that required the state to care for the thousands of mentally ill people in Maricopa County.

Today, there are an estimated 19,000 mentally ill people living in the county.

Arnold v. Sarn transformed the court into the regulator of the system and included a “blueprint” to help the state comply with the court’s decision.

These improvement measures have been ratcheted down half-a-dozen times since 1995 when the Arizona Department of Health Services failed to make reforms before the court-imposed deadline.

The problem then and now, health department officials said, is that the system in Maricopa County is evaluated exclusively on an annual audit conducted by the court monitor designed to measure how well the system aligns with lawsuit requirements. The design of the audit focuses on the procedures of the system and ignores actual progress toward patient recovery.

State health officials said they are forced to construct a system based on Arnold v. Sarn or risk a second lawsuit.

An audit report released in January showed a significant decline in many of the measured areas when compared to the year before.

For example, the audit revealed that Magellan had developed complete treatment plans – known as ISPs – for less than 20 percent of high-priority patients, which are those deemed most at-risk of hurting themselves or others.

On top of that, only 62 percent of high-priority patients with complete treatment plans were allowed to participate in the formation of those plans. Patients not involved in planning their treatment, Magellan workers said, are more likely to run away or attempt suicide.

Under the previous contract administrator, ValueOptions, by comparison, more than 79 percent of patients participated in the development of their treatment plans.

The audit also revealed only 40 percent of high-priority patients had an adequate clinical team. The rest had received only partial treatment and were more likely to not receive any treatment at all. And clinical teams failed to meet with 36 percent of high-priority patients as frequently as the lawsuit requires.

Concerns over incomplete treatment plans took center stage in many legislative and court hearings called to evaluate the quality of care provided in Maricopa County.

But these concerns are misplaced, said Michael Shafer, director of the Center for Applied Behavioral Health Policy at Arizona State University, because the measures are based on system procedures, not patient recovery.

“We spend too much time focusing on paperwork and whether you have the right kind of treatment team rather than making sure the people are happy, have a roof over their head and are safe,” Shafer said.

And many of the measures that do track a person’s recovery are poorly calculated, said Susan Gerard, former director of the state’s health department.

“If you have a list of 10 questions asking about quality of life and the person responds negatively to two of those, you would think the department would get an 80 percent, right?” Gerard said. “Wrong. Missing even one question means the department gets a zero. What kind of a test is that?”

Additionally, the results of the “quality of life outcomes” are skewed toward how the patients felt on the day they were surveyed.

“It can’t show us how the person has improved over the year,” said Lisa Nelson, director of the health department’s Division of Behavioral Health during a Feb. 9 presentation to lawmakers.

Richard Clarke, CEO of Magellan of Arizona, said the state should consider using national rankings to evaluate the effectiveness of the system in Maricopa County and across the state.

According to a number of studies conducted by the federal Substance Abuse and Mental Health Services Administration, Arizona’s mental health programs consistently rank higher than national averages.

For example, 23 percent of Arizona’s mentally ill are “meaningfully” employed. The national average is 21 percent.

Less than 2 percent of adult mental health care patients in Arizona are readmitted to the state hospital for in-patient treatment, compared to a national average of 21.2 percent.

And, according to the National Alliance on Mental Illness, the level of care in Arizona supersedes care in 27 other states.

Supporters of Arnold v. Sarn agree that the system should focus on recovery, but said the tools used by the court monitor are typical of other state-based measures.

“You could write the rules in one way or the other, but for the most part, the treatment planning process in Arizona is definitely consistent with what most states do and what most professional standards are,” said Steven Schwartz, a plaintiff attorney from the Center for Public Representation. “While some people don’t like it, it is a pretty standard way of doing business.”

John Hokanson, a behavioral health patient in Maricopa County, said the department’s criticism of the lawsuit also ignores the importance of some procedures.

Hokanson was denied treatment for approximately three months during 2008 because he was not assigned a case worker and had an outdated treatment plan. Patients must have both to receive regular treatment.

“I can’t walk into a therapist and say I want therapy here. I have to have it set up by the case manager,” Hokanson said. “That is why the clinical team is so important for getting better.”

The lawsuit’s supporters said the needs of mental health patients would be ignored without regular court hearings and audits to act as their voice.

The state’s managed-care system historically has protected the health department and local administrators from being held responsible for the system’s deficiencies. The model creates separate layers of treatment and administration to reduce costs. The lowest tier – doctors and hospitals – are bundled into “provider networks,” which are overseen by Magellan. Magellan is supervised by the state health department.

The division of responsibilities has frequently resulted in providers, Magellan officials and health department employees pointing fingers at each other when the system fails. The audit helps ensure someone is held accountable.

“The only voice that I see out in the community for the seriously mentally ill comes from the court monitor’s audit. There is no other narrative of service delivery,” Shafer said. “That is an area where the state and their contractors have failed fundamentally.”

For decades, lawmakers have discussed putting an end to the lawsuit and the court’s control over the system by repealing the underlying statute. But calls for change have been louder this year.

Magellan’s attempts to overhaul the county’s mental health system have led many lawmakers and health officials to doubt whether any company could improve the system in the shadow of the court.

“What I think needs to happen now is that we repeal the existing law and put in that same piece of legislation what you want the system to look like,” Gerard said. “It would be a long road to go that way, but I see that as the only way.”

It is unclear whether Gov. Jan Brewer would approve the elimination of the standards set by the lawsuit. Since taking office, Brewer has been holding private meetings with lawmakers and health officials to find a solution to the system’s troubles.

One such solution was suggested during a February special joint hearing of the House Health and Human Services Committee and the Senate Healthcare and Medical Liability Reform Committee. But lawmakers on those committees seemed to agree that no action should be taken until the lawsuit is better understood.

Click here to read Part 2 of this series: “Mental health care: 30 years of broken promises”

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