THE RECENTLY CREATED President's Commission on Mental Health was charged with the task of evaluating mental health services and planning for the future. Like most commissions, it travels throughout the United States, yet while it does so the biggest disgrace in American mental health sits right under its nose. Public psychiatric services in the District of Columbia are probably the worst in the nation, a testament to 10 years of federal-local-private sector partnership.Ironically, this is the kind of partnership HEW likes to talk about in planning general health services for the future.
The public psychiatric services consist of Saint Elizabeths Hospital and four community mental health centers. The former has a uniquely consistent record of poor patients care, poor management, waste and inefficiency, leading HEW Secretary Joseph A. Califano Jr. recently to label it "inexcusable."
In 1975, when the Joint Commission of American Hospitals removed its accreditation (the basic seal of approval of American hospitals) it cited 106 separate deficiencies. The General Accounting Office recently chastised it for poor management, including the renting of seven cottages on its grounds ot staff members for less than the cost that the hospital spends on the cottages' upkeep. These cottages incidentally, could have been turned into homes for elderly patients whom the hospital claims it cannot return to thecommunity because it cannot find homes.
The finances of Saint Elizabeths Hospital approach Alice-in-Wonderland quality. One of the wealthiest public mental hospitals in the United States, its budget almost tripled (to $90 million annually) over the past 10 years at the same time as patients were decreasing from 6,000 to 2,500, and its accreditation was being lost. Last year, for example, almost $2 million was wasted in overtime pay alone through poor management. Maryland cares for twice as many admissions with the same number of personnel at four state hospitals, all accredited, for a total cost $30 million less than Saint Elizabeths.
One of the community mental health centers is part of Saint Elizabeths. The other three have consumed more than $16 million in federal money, which finally was cut off to all three because of the centers' failure to develop the basic mental health services intended by the legislation.
Federal site visit reports have consistently noted two of the centers (Areas B and C) as among the most poorly managed of the 650 funded centers in the United States. And a 1974 Nader report on community mental health centers singled out these two centers as notably mediocre.
THE FEDERAL-LOCAL-PRIVATE partnership has been a variation on the three monkeys who see no evil, hear or evil and speak no evil. The National Institute of Mental Health, part of HEW, has let Saint Elizabeths run downhill under its direct jurisdiction for 10 years.
In an act of hypocrisy unusual even by Washington standards. NIMH has supervised the accreditation of public mental hospitals for Medicare payments while its own public hospital could not obtain the basic accreditation of ther Joint Commission of American Hospitals.As described recently by Rep. Stewart McKinney (R-Conn.) before the House District Subcommittee: "We've given these people (NIMH) the mandate to run every mental hospital in the country with federal participation, and here they can't even run their own."
NIMH has provided virtually no personnel or expertise to either Saint Elizabeths Hospital or the centers; most NIMH professionals have not even visited them. The Division of Mental Health Service Programs of NIMH, under which all U.S. community mental health centers are funded has a research unit whose purpose is to demonstrate good community mental health services. Rather than affiliating this unit with a local center and turning it inot a national model for good services, NIMH has kept it safety away from the District, languishing in a shopping center in Prince Georges County. This is apparently as close as NIMH wishes to get to the local community mental health centers which it has funded.
The Department of Human Resources (DHR) is the local government's part of the partnership. It has had direct responsbility for the three community mental health centers which lost federal funds; one federal official publicly described the "sheer frustration in trying to get them (DHR) to come into compliance."
For example, from 1973 to 1975, the District government decreased its support of Area B Community Mental Health Center from 78 per cent to 43 per cent of its revenues; this was exactly the opposite direction of most other centers and of the intent of the original legislation creating the centers.
DHR currently is cutting back services at the centers still further, reducing them to community mental health centers in name only. Since this is the same DHR that has managed Forest Haven and D.C. Village (whose mediocre services have been well described by the Washington Post) and D.C. General Hospital (which also lost Joint Committee of American Hospital accreditation), most people just shrug and ask what else is new.
The private sector consists of 1,100 Washington psychiatrists, or roughly 35 per 100,000 population for the metropolitan area. The nationwide average is 10 per 100,000, and the second highest metropolitan are is New York City with 16 per 100,000.
Thus, as a recent report from NIMH notes: "There are more psychiatrists in the Washington, D.C., area than any place in the world." That might be nice for District residents if the psychiatrists were equitably distributed. However, according to the 1975 Directory of the Washington Psychiatric Society, only three psychiatrists have chosen to practice out of private offices in either northeast or southeast Washington.
And none - not one - of the 1,100 volunteers a single hour a week at either Saint Elizabeths Hospital or any of the community mental health centers. Saint Elizabeths, in fact, has had major difficulties recruiting the local psychiatrists to its paid positions, despite the fact that starting salaries range as high as $39,600. The money is greener on the outside.
THE MAJOR SOURCE of income for the private psychiatrists in Washington is the generous mental health insurance benefits for federal employees under Blue Cross, Blue Shield and Aetna.
A recent analysis of this insurance by Dr. Steven Sharfstein of NIMH revealed that, although the D.C. area has 19 per cent of the persns covered by this insurance, it accounted for over 37 per cent of the mental health care costs. Aetna was found to be "paying out one-half of its nationwide mental health care costs in the Washington, D.C., area alone."
Long-term and psychoanalytic psychotherapy were disproportionately concentrated in this area because of the benefits. Sharfstein's report, entitled "So Much for So Few; Insurance for Intensive Pshchotherapy," concludes that in terms of mental health insurance, "The cost of mental care in Washington is about double the nationwide figure."
The staunch defenders of the goose that laid the golden psychiatric egg is the Washington Psychiatric Society. Showing no interest in the pathetic plight of public psychiatric facilities in the District, this "professional society" instead hired a lobbyist (utilizing 40 per cent of members' dues) to defend its economic interests before Congress.
The Internal Revenue Service recognized the true nature of this "professional society," classifying it as a business league, "an association of persons having some common business interest."
Another noteworthy contribution of the Washington Psychiatric Society to District residents in recent years was in 1974 when the president of the society urged members not to cooperate with the Health Research Group's preparation of a consumer's guide to psychotherapists, a guide which has helped consumers identify more effective and less expensive psychotherapeutic help. Such lack of cooperation typifies the contribution of the private sector to public psychiatric services in the nation's capital.
The current state of mental health services in the District, then, provides many lessons for those who wish to learn: (1) More money does not necessarily produce better services. (Exhibit A, Saint Elizabeths Hospital). (2) Increasing health manpower does not produce a better distribution of services. (Exhibit B, the concentration of psychiatrists in northwest Washington). (3) Local government is not necessarily more effective in administering services. (Exhibit C. DHR).
There are answers to these dilemmas, of course, but since most of them involve highly paid professionals leaving their air-conditioned offices and going back to work, they are not of much interest locally.
Public psychiatric services in the District should be kept carefully in mind as Secretary Califano introduces his health proposals. The current situation rivals the Postal Services or the Veterans Administration hospitals in giving one confidence in the federal government's ability to organize and deliver services.
And unless the President's Commission can propose solutions to the problems under its nose, don't look for much else to come from its deliberations. Its fate will be the fate of most such commissions which, in the words of Cervantes, merely "cover a dunghill with a piece of tapestry while the procession goes by."