Initiatives and Integration

Arizona makes slow headway in treating mentally ill substance abusers.

The perennial war on drugs turns to the home front in Tucson this month, with initiatives in addiction treatment the topic for two community-focused projects.

Last Thursday, after nearly two years of organizing, the newly appointed joint City of Tucson-Pima County Commission on Addictions Treatment and Prevention held its first public meeting. And this weekend, the Community Rehabilitation Division of the University of Arizona hosts a conference of the American Association of Community Psychiatrists (AACP) in the first national institute on community integrated treatment for people with co-occurring mental illness and addiction disorders. Both efforts enter the scene challenged, once again, to do more with less.

"We need to do a better job with what resources are already there," says Dr. Ken Minkoff of Harvard Medical School. Minkoff is one of the highlighted participants at the AACP conference, and one of the key authors of Arizona's public system for integrated addictions-mental illness treatment. "No state has enough," Minkoff says. "The issue is making the dollars you have work more effectively, and demonstrate the value of service integration."

Service integration is one of the key issues facing the Tucson-Pima Commission on Addictions. With some 20 members drawn from the usual A list of publicly-funded addictions and mental health organizations, five of the commission's members are from the private sector, none of whom directly represent insurers or private behavioral health providers. Publicly-funded behavioral health providers have begun, with some success, a system of care for their clients that integrates treatment for addictions and mental illness. In most cases, the private care system of insurance, HMOs and treatment centers has not. (See "Silos of Care," November 15, 2001.)

"There's no money in MI [mental illness]," says one executive of the PacifiCare network, who was the only insurer who spoke to us on the issue. "And there's damn little more for treating anyone who abuses substances," he adds. "The profit we need to pay our shareholders gets eaten when they come back for treatment, again and again and again."

There was some echo to that view at the Tucson-Pima Commission on Addictions meeting. In a discussion regarding the nature of co-occurring illness, commission member and CEO of the COPE network of public service providers Pat Benchik placed at least some of the burden for treatment failures on the lack of responsibility that addictions-mental illness clients can show. "They've got to take responsibility for their own lives," he said.

Others at the meeting expressed concern for the problem dually diagnosed people experience in their daily lives.

"I'd hope we'll be able to deal with the issue of stigma for those in the workplace," says Jan Lesher, one of the four private-sector members of the Tucson-Pima Addictions Commission attending last Thursday. "One of the stumbling blocks which should motivate the commission's activity is that even those with insurance are not using their benefits to seek care," she adds. "And that happens because there is still the need for safe work environments where people can use their benefits without fear of discrimination."

Treatments for substance-use disorders and mental illness are still only optional components of health benefits offered to workers by employers in Arizona. According to those we've interviewed, attempts to get treatment are often stymied by employee assistance plans used as an initial screen even in crises. More problematic are those instances where the insurance company discourages those seeking care by creating walls of paperwork and call-waiting chains around care providers, or tells the insured that they simply do not qualify under addictions treatment, and fails to tell the insured that they do qualify for the mental health care. Many of these instances go unreported to the Arizona State Department of Insurance, and we could find no independent state survey of incidents other than limited reports gathered by that department from insurance companies, employers or those few insureds able to report in crisis.

"That's an unfortunate, perfect example of what's wrong with the whole system," says Tucson-Pima Commission member Don Jorgensen, who works with private companies in establishing employee assistance programs and health care planning and assessment. "The state should be required to provide a reasonable level of funding for behavioral health," he says. "And there should be quick accountability, independently assessed, for insurers denying care based on dollars."

"The public system in Arizona has made real headway," says Harvard's Minkoff. "It doesn't make sense to have two systems. There should be one system of care for people with problems, and if the public system offers good services, then private insurers should purchase them.

"A two-tiered system is duplicative and wasteful," Minkoff concludes.

"Nothing is likely to change with a state legislature that sees Arizona in the bottom tier for health and wears it as a badge of honor," says Tucson-Pima Commission member Jorgensen. "The dollars spent on the alternative-fuels fiasco could have provided a lot of care for a lot of people."