Published December 1996	Michael J. Vergare, M.D., was recently appointed by Governor Ridge to serve as a member of the Advisory Committee for Mental Health and Mental Retardation. He is chairman of psychiatry and associate vice president at Belmont Behavioral Health. PND: What is the function of the Advisory Committee for Mental Health and Mental Retardation? MV: The committee advises the Governor and his agencies that deal with mental health and mental retardation about policy matters that relate to the various counties around the state. Each county has a county advisory board for mental health/mental retardation. Those boards interface with the statewide committee, and that provides the conduit for ideas about the kind of care and services that folks throughout the community feel are appropriate in their communities. We report to the deputy secretary for mental health and the deputy secretary for mental retardation. We really need to get to various regions of the state and find out what their concerns are.
'The counties have a more vested interest in treating people over the long run because ultimately their needs fall to the counties anyway.'	PND: What is the committee's outlook for the HealthChoices Medicaid HMO project? MV: We have been supportive of the idea that mental health services for the HMO Medicaid population should be carved out to the counties. Philadelphia County will be managing the whole population of about 400,000 lives. The county itself has assumed more responsibility to make sure services are delivered to people in the manner that they want rather than relying on an independent contractor to set those standards. That's particularly important for the mentally ill whose needs tend to be ongoing and sometimes chronic. The counties have a more vested interest in treating people over the long run because ultimately their needs fall to the counties anyway. Our community-based care has gotten a lot of really positive national review. They have in place very intensive case management, residential programs, crisis intervention models, mobile treatment teams_all of those things are currently in place in Philadelphia. PND: Is a county better positioned to oversee such a program than a private company? MV: Presumably, the counties will do this in a manner that is most consistent with community needs, albeit living within the confined budget. Criticisms of some of the carveout companies are that they have been distant from the local needs, and have tended not to spend the dollars allocated for the mental illness on the mentally ill. There are some pretty blatant examples of where the state was passing along a certain amount of money each month per member for mental health care, and some of the HMOs were spending no more than a third of that amount on that care. So, this is a way to make sure that the dollars stay in the system and are re-invested in new programs. I think that counties are much more accountable to the citizens than you would have in a private company.
'The danger in the county system is if care isn't given early enough and isn't appropriate enough early on, then what should be an acute condition becomes a chronic condition.'	PND: Who picks up the tab if the county's cost exceeds what the state allocates? MV: Realize that Philadelphia County has had to manage a sizeable budget every year for mental health care and has done a reasonable job of that. I think that some counties are wise to recognize that they are not able to do that. The danger in the county system is if care isn't given early enough and isn't appropriate enough early on, then what should be an acute condition becomes a chronic condition. If you know that you are ultimately responsible for what goes on with the patient, you start to become much more aggressive and creative in designing community-based programs for a lot of patients. That's what the Philadelphia County had to do when the state Hospital closed. PND: What efforts will be made to enhance access to follow-up care? MV: One of the things that we hope to see improved is when we see a patient and we are looking for access to other services, we are able to talk to someone who is knowledgeable and available in a timely way, rather than having to wait for a day or so before someone gets back to you when you have a patient with acute needs. In the current scenario, you would call up the plan to get approval. You would provide the services, look for referral and sometimes you get an answering machine or voice mail. What we're hoping to get is a discussion with people who can understand the patient's needs. PND: What other key behavioral health concerns has the committee identified? MV: I think one of the things that comes through is a growing coalition between professionals and family members and patients. I think that we've gotten ourselves to the point where there's pretty good consensus about what good care is and how we're focusing on how to insure that people who need it can access it. There is a growing consensus about what constitutes good and bad managed care. We expect much more activism at the county level as these plans are implemented, where there needs to be input from the providers and patients and their families. I think that that's the most important thing that has occurred, and I think it has helped shape some of the ways that policies and programs have been designed at the state level.
'All of the newer contracts have caps on profits and rules about how much of the health care dollars go towards administrative costs.'	PND: How do these concerns compare between rural and urban counties? MV: Most other counties are watching closely to see how all of this unfolds in the Delaware Valley and the greater Philadelphia region because we know that, depending on how this goes, this may be a model that will be implemented in other parts of the state. I think that one other consensus issue was that these services should not be provided with the opportunity of large profiteering. So, all of the newer contracts have caps on profits and rules about how much of the health care dollars go towards administrative costs. That's something we're hearing from all counties. PND: What has become of the Pennsylvania Mental Health Parity bill to make mental health care coverage as portable as physical care? MV: I was one of the ones that got the state society involved in that when I was president two years ago, and the Mental Health Association has also taken up that cause. I should add that I'm on the board of the Southeastern Pennsylvania Mental Health Association and they have been very active in trying to promote various pieces of legislation to deal with that. To date, there is really nothing that we have been able to float at the state level, significantly. What we would like to see is that mental illness is treated the same as any other kind of illness with respect to any deductibles or lifetime caps on benefits. PND: Would the behavioral health component of HealthChoices be a step closer to these goals or further from them? MV: In a way, the public system has been less discriminatory than the private system. I think HealthChoices is, in the public domain, going to define what truly comprehensive health care should provide. And in the mental health area, I think we're going to see these coalitions and counties defining more what kind of services we want to treat, so I think it's going to help. What has happened to date, the state has given enough money to health care, it's just that the insurance companies have kept it. There have been terrible abuses. I think that door has been closed. The other issue is that if you only have responsibility for someone who may dis-enroll in a month, in spite of all the gobbledygook about preventive care, you're just not going to invest in it. And that's what was happening with some of these plans. Now, with the county responsible, the county has a longer term view of illness. And I think that's going to help. I think the counties have more concern about the quality of benefits because when people run out of insurance they end up in the public domain. So in reality, the lack of parity has been an added cost of our state programs because the state ultimately becomes responsible for these people who have not been able to get adequate care.

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