From the Portland Tribune, March 31, 2011

After more than a year of studying Multnomah County’s system for delivering mental health services, a City Club of Portland committee has reinforced what previous studies have concluded: the system needs drastic overhaul.

The committee’s report[] details a fractured health care delivery system saddled by poor communication between agencies and jurisdictions, opaque accounting practices which make it impossible for outsiders to determine if public money is well spent, and contracts paid by the county to mental health providers which identify goals of treatment but not the means to measure whether treatment is actually meeting those goals.

READ – City Club of Portland report, “Improving the delivery of mental health services in Multnomah County.”
READ – City Club Report Rips Into County’s Mental Health System, Portland Mercury
READ – City Club Report Critical of County’s Mental Health System, The Lund Report

John Swetnam, the study’s lead author, says the committee discovered that Oregon is the smallest state in the country using counties to administer mental health programs, and that in itself leads to problems in care and waste.

Most mental health funding comes from federal Medicaid dollars which go to the state and then are funneled down to the counties.

“You have all these layers of administration that are stacked one on top of another and there’s overhead at each of those levels,” Swetnam says.

In addition, Swetnam says, the setup does a disservice to people in the Portland area who need mental health services, but who may get care in different counties. Different caregivers often don’t communicate with each other.

“The system is fractured,” Swetnam says. “People tend to fall through the cracks.”

A handle on the budget

Tamsen Wassell, committee chairwoman, says the system’s waste of public money due to redundant administration and a lack of transparent accounting is a major cause for concern.

“It’s important for taxpayers to know we have no idea how much money is spent on direct services for this vulnerable population, and we don’t know what we get for what money is spent,” Wassell says.

Wassell says the state should move to either one regional authority for mental health services, rather than three metro area counties, or overall statewide administration of mental health services.

County officials say that may be in the works. According to Karl Brimner, director of mental health and addiction services for Multnomah County, the county is already pursuing what may lead to a regional plan.

Multnomah County along with Washington and Clackamas counties is working on a plan to better implement all health care in the metro region, Brimner says.

Wassell, the City Club chairwoman, says that money issues were also a concern.

“The part that was probably most disturbing to me was the fact that we couldn’t get a handle on the budget,” she says. “We were continually told it was complex.”

Wassell, a management consultant, says she often consults with multimillion dollar companies, and never accepts from them the idea that their budget is too complex. In addition, according to the report, other states have made their line item budgets available online.

“This is not nickels and dimes,“ Wassell says. “This is millions.”

Quality of services

David Austin, communications director for Multnomah County, says that county officials held dozens of meetings with members of the City Club committee working on the report and shared with them the mental health budget.

“We are always happy when new sets of eyes look at the things we do, transparency is our hallmark,” Austin says. “We’re somewhat perplexed at the City Club saying we didn’t provide them with information.”

Swetnam says he was particularly concerned about the lack of a system for measuring whether or not mental health services are being effective. Multnomah County serves about 30,000 people with mental illness, according to the report, and about 21 percent of those people have persistent and severe mental illness. But according to Swetnam, the tools the county uses to measure outcomes wasn’t even designed to measure effectiveness in those with severe mental illness.

“We know we’re buying stuff but we don’t know a whole lot about the quality of the stuff we’re buying,” Swetnam says.

Brimner says the county initiated a pilot program last year that does work for measuring outcomes for patients with persistent and severe mental illness.

Jason Renaud, a longtime activist with the nonprofit Mental Health Association of Portland, agrees with the report’s call for a restructuring of the local mental health administration. But Renaud says the fundamental problem is that there is little political will to make the necessary changes.

“The current county commission has shown no interest in mental health or addiction health issues,” Renaud says. “We’ve been down this track before and the political and management leadership — many of those persons interviewed for this report — betrayed that effort and failed to make the changes people wanted.”