Georgia's Care for Mentally Ill Unravels

Georgia's system for aiding addicts and mentally ill and mentally retarded people has been so mismanaged and underfunded that sometimes it does the people who rely on it more harm than good, state officials and patient advocates acknowledge.

Currently, two of the 25 community service boards set up 10 years ago in an attempt to localize treatment and reduce costs are under criminal investigation, including for possible Medicaid fraud. A third board has been taken over by the state because of money problems, and several others are struggling financially.

Problems with the boards, which serve 183,000 people a year on an annual budget of $500 million, are not new, but they seem to be getting worse and more prevalent, the advocates say.

The 10-year-old system, they say, depends too much on well-meaning but often inexperienced volunteers, does not receive enough state supervision, and is short of money because of statewide budget problems or, in a few cases, suspected graft.

Mary Sloan, executive director of Georgia's chapter of the National Alliance for the Mentally Ill, says the system is a failure.

"We have criminal investigations. We almost went bankrupt," Sloan said. "They have had inefficiencies, some degree of underfunding. Funds that have been provided have not been spent wisely, and the big loser is the consumer and society. There is a cost to society when people don't get the medical attention that they need."

The community service boards are a system of agencies staffed by doctors, nurses and mental health experts, with some oversight by the state Department of Human Resources.

Their creation by the Legislature in 1993 was part of a national trend and the "first real time the state had turned over to the locals policy-making responsibilities," DHR Commissioner Jim Martin said.

Last month, Gov. Sonny Perdue expressed concern about the system and asked state Auditor Russell Hinton to make an extensive review of the system.

"I continue to be troubled about problems that seem to be inherent within community service board operations," Perdue said. Hinton said the first phase "should be finished by the end of this year."

Concerns about financial mismanagement have been borne out by Georgia Inspector General James Sehorn, who has been reviewing the operation of a number of boards. Sehorn has completed his investigation of the Augusta board and is looking at the Highland Rivers board, which serves 11 counties in northwest Georgia, and at other boards.

Sehorn would not comment about the specifics of his inquiry. Even so, he said he believed the entire system was in trouble and suggested its problems ran deep. "If you look at where the big money is found, you can probably find fraud, waste, abuse and corruption," he said.

The evidence is overwhelming that the system is not working. For example: > Criminal investigations by the GBI or the FBI of possible Medicaid fraud are proceeding at the Community Service Board of East Central Georgia in Augusta and the Highland Rivers board. > Even while the state is stretched financially, taxpayers are spending $158,700 on consultants hired to correct problems at the boards in northwest Georgia and in Columbus, DHR officials say. That money should be spent on patients, advocates contend. > Earlier this year, DHR took over the Gateway board in Savannah after its debt reached $6.5 million. For $750,000, a "turnaround specialist" is running the $42 million-a-year agency, which serves 12,500 people. > Advantage Behavioral Health Systems, the board based in Athens, faced a $1.4 million shortfall earlier this year until it temporarily reduced services, cut salaries 10 percent and froze all purchasing and training. > Also earlier this year, the Augusta board was on the brink of bankruptcy, according to state records. Medicaid was billed for medications that were donated, and payments were made to contractors for services that were not delivered. The initial findings of the continuing joint FBI-GBI investigation also include allegations of kickbacks to the politically connected. > Nine community service boards have repaid Medicaid almost $1 million since October 1999 after a state audit found mismanagement, below-standard services and poor record-keeping.

Throughout the state, the boards' residential programs are being discontinued, transportation has been eliminated, and substance abuse programs have been combined.

Clinicians are leaving, and managers are finding it difficult to recruit replacements because of the turmoil. Consequently, many of the recipients have been forced to make longer drives, sometimes of more than an hour, to get help.

If the system collapses, the people who rely on the boards would have little left, Sloan said. Only the insured would get treatment, and because of limits in private insurance, even many of those people would wind up depending on the state, she said.

"The public health system is the safety net," Sloan said. "If that safety net was not there for folks, they'd be on the streets. Their families would be under terrific stress trying to care for them when they are on medications. They'd be homeless. They'd be in jail." And she wonders if the state's budget crunch will make things worse.

Those problems are not confined to this state. "The things that are happening in Georgia are not unique," Sloan said. "Some states are better. Some states are worse. . . . Mental health has just not been a priority for the public."

Per capita, Georgia ranked 42nd nationally in 2001 in spending to treat mental health problems, at $46 for each resident of the state, according to the latest data collected by the Henry J. Kaiser Family Foundation.

The problems are taking their toll on the mentally ill and their families. Patients reveal problems

Terry Warren, a 46-year-old Calhoun man who is paranoid and schizophrenic and dependent on medication, has received poor, unreliable care, said his father, Leonard Warren. "He has no problems, but without medication he goes berserk," his father said. "He can miss his shot twice and he doesn't know who he is."

Because the local board, like many others, has quit providing transportation services to save money, Leonard Warren and his wife must find a way to get their son to the clinic for shots.

"He went over and got his shots and had to wait two hours," Warren said. "They didn't have a doctor. They didn't have a nurse, and they had to call one in. This goes on continuously."

Constant staff turnover aggravates his son's condition, Warren said. He complains about the wait, the way he is treated, and the constant personnel changes that require him to repeat his story many times to different clinicians who "don't listen to you."

Terry Warren expressed frustration about turnover. "They go through doctors and nurses like some people go through clothes," he told a reporter.

"I think I'm going to go somewhere where they can't find me," he said.

Cindy Sue Causey, 45, has been hurt by the problems at Highland Rivers. She is severely depressed and has not been able to work in almost two years.

Causey, who lives in Talking Rock in Pickens County, said she would arrive for appointment times that also had been given to someone else. When she saw counselors, they sometimes would use that time with her to carry on personal telephone conversations. It would take weeks to get an appointment, she said, even when she was in crisis.

"I'd come home and cry and cry," Causey said. "I have been so shamed and humiliated by it. I've lost two years of my life. They aren't dealing with a broken finger or a couple of stitches. They're dealing with people who get to a point [that] you don't think right."

It was to help people like Terry Warren and Cindy Sue Causey that lawmakers and advocates dreamed up community service boards.

Each board is governed by a panel of appointed volunteers, many of whom either receive services or have relatives who do.

John Davis, a member of the board in the Athens area and president of the Georgia Association of Community Service Boards, said he was frustrated at the negative light cast on the agencies. "I really do believe we are making some progress," he said.

But Davis understands why the news often is bad. "I think there is a lot wrong with it," he said. "Instead of the state really taking responsibility, they said what we're doing is not working.

"I'm not interested in laying blame," Davis said. "I'm interested in resolving problems and making them work better. But I don't want to paint a rosy picture because the picture is not rosy right now."

Stephen Jessup, a McIntosh County commissioner who serves on the Gateway governing board in Savannah, said he might resign once the problems there are worked out.

Already more than half of the 22 slots for volunteers on his board are empty. "You don't do it for the money," Jessup said. "You do it because you have a soft place in your heart for the people you serve. But it's a thankless job."

Volunteers appointed to the oversight boards have quit. Davis blames criticism by other advocates and the families of those they serve.

"I have looked at myself and said, 'Why am I continuing to do this?' " said Davis, a retired school administrator who has been on the Athens-area volunteer board since 1998. "I've taken more abuse as a volunteer, been told how stupid we are and how lazy we are and how dishonest we are."

Timothy Horton, who was appointed interim director of the Augusta-based board after top management was fired earlier this year, said the system was based on laudable ideals even if it hadn't worked as expected.

"The system, in theory, is a good one," Horton said. "Where you have representation by not only professionals but families of consumers and consumers themselves, that's a good coalition. The question is, how do you get it to run?" Reimbursements ordered

The problems are not new. At almost any time in the past decade, one or more of the boards have been under some kind of criminal, financial or administrative scrutiny.

Highland Rivers was the subject of a scathing DHR report in late January. The report said the deaths of six disabled people might have been caused by mismanagement at the board, which spends $36 million a year to serve 7,000 adults and children. The report also cited payments to employees who might not exist and long delays in serving patients. In six months last year, 133 people were fired and 92 resigned, according to the report; overall, staffing declined by 41 percent.

Even though investigators have not finished their work, Highland Rivers already has been told to repay $2 million to the state because it overbilled for treating alcoholics, according to the state.

The only follow-up review of the Highland Rivers operation was in a consultant's report in May that focused on the board's management structure and stressed the need to bring in more Medicaid dollars. Further state reviews were planned for this month.

The ongoing state and federal investigation of the Augusta board centers on suspected unauthorized Medicaid billings, corruption and cronyism. At the least, the Community Service Board of East Central Georgia might have to repay Medicaid as much as $770,000, officials have said. At most, someone could go to prison.

Some advocates curse the system but in the next breath say they fear what might --- or might not --- replace the boards. Programs ended

For example, mentally ill clients who once attended a day program in Cartersville, part of the Highland Rivers board, now are driven 25 minutes in a van to Calhoun for the same service. In the area served by Georgia Mountains Community Services, a Gainesville-based residential program for addicts and alcoholics was closed several months ago. And a similar long-term program in Cedartown, under the Highland Rivers board, also is being discontinued.

Charles Fetner, the state employee who serves as the regional coordinator for Highland Rivers and three other boards in metro Atlanta and west Georgia, said money was one reason for ending that particular program. Sometimes there "are more effective ways to offer the service, like through an outpatient day program," Fetner said.

"With public money, we're always having to look for ways to do things more efficiently," he said. "But when you look at a relatively small program in Cedartown that in a year's time serves over 1,500 people, if that service didn't exist they would go unserved or have to go to the state hospital. When you're looking at some of the shortcomings of the CSBs, you can't overlook that they are providing a very valuable service."

Advocates also complain that, even though services have been reduced, the boards still collect state and federal funds for them.

"While decentralizing sounds like a good idea, the [people charged with] oversight weren't doing their jobs," said Sloan, one of Georgia's leading advocates for the mentally ill. "So money was wasted. It was squandered."

DHR's Martin acknowledges problems with the boards. "We were overly optimistic they would be successful," said Martin, who as a legislator was one of their architects and now heads the department that provides some funds and oversight for the boards.

"Those [boards] that have not been successful have not seen to their responsibilities. Those that have been successful have strong management," Martin said. "But I don't think it was a mistake to create the CSBs. I believe the system . . . could work."

But it is clear that is hasn't worked yet, said Sloan.

"When you look at that, all you can say is, somebody has been asleep at the wheel," she said. "It's unfortunate. It hurts the consumers. It hurts the families."

Copyright 2003 The Atlanta Journal-Constitution