This report analyzes enrollment data and conveys focus group findings about the impact of North Carolina’s freezing enrollment in their SCHIP program.

• Report

Case Study: Michigan’s Medicaid Prescription Drug Benefit

This report describes the legislative process behind and content of Michigan’s Pharmaceutical Product List (MPPL), a selection of preferred drugs available to be prescribed in the Medicaid program with little restriction. Providers would be required to obtain prior authorization from the state to prescribe any drug not included on the MPPL.

• Background Paper

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Henry Kaiser in Antarctica: Video Clips

*Note: You will need a media player (e.g. RealPlayer, Windows Media Player, etc.) installed on your computer in order to listen/see these clips.

Listen to Henry play guitar:

• Ice Cave Talk
• Playin’ an Erebus Ice Cave
• Reason Tatters at Pole
• Rockin’ at Pole
• Slidin’ at Pole
• Slide Guitar Around the World 1
• Slide Guitar Around the World 2

See video from Henry’s dives under the ice:

• Swim Along
• Let’s Go
• Ice on Bottom
• Fish in Ice
• Safety Stop
• Up and Out the Dive Hole
• Fish Chase
• HK Playing with Ice
• Down into #14
• Beneath the Ice
• Kevin & the starfish
• Nice Swim
• Seal in the Dive Hole Doesn’t Look that Cold

Video from the Exorcism of El Gran Chingazo:

• Big John’s Pre-Exorcism Rap
• Big John’s Exorcism Sermon
• Exorcism Guitar
• Exorcism Dance

New Year’s video:

• Orion & Amy Harp Duo
• Chili & Donnie Love
• DYIN’ FLU START
• DYIN’ FLU END
• I’M SO GLAD.MPG
• Icestock Magic Bus
• Icestock Magic Sprite
• Safety Second video clip
• Kiwi NY R&R
• Kiwi NY Spoonful
• Bullhead video clip

Video from Henry’s last performance:

• Ross Island Salegy
• Groovy at McMurdo
• Cortez
• More Salegy
• Rockin’ at Gallaghers
• Watermelon
• Rock Party
• Last Notes at McMurdo

:

• John Cutter, freelance health/aging writer, St. Petersburg, FL
• Robert Davis, medical and science writer, USA Today
• Fred de Sam Lazaro, correspondent, The NewsHour with Jim Lehrer; executive producer; KTCA-Twin Cities Public Television, St. Paul, MN
• Mason Essif, segment producer, HealthWeek-PBS, Washington, DC
• Don Finley, science, medicine and environment editor, The San Antonio Express-News
• Merrill Goozner, freelance journalist and associate professor of journalism, New York University
• Andrew Julien, health/medical writer, The Hartford Courant
• Madge Kaplan, Health Desk Editor/Boston Bureau Chief, Marketplace Radio/WGBH
• Sarah Lunday, health care industry reporter, The Fort Worth Star-Telegram
• Joan Mazzolini, investigative reporter, The Plain Dealer, Cleveland
• Andy Miller, health care business reporter, The Atlanta Journal-Constitution
• Charles Ornstein, health business reporter, The Dallas Morning News
• Joe Palca, correspondent, science desk, National Public Radio
• Jon Palfreman, senior producer, FRONTLINE
• Christopher Ringwald, demographics and mental health reporter, The Times Union (Albany, NY)
• Neil Rosenberg, senior medical reporter, The Milwaukee Journal Sentinel
• Karl Stark, health care business reporter, The Philadelphia Inquirer
• Brenda Wilson, correspondent and editor for public health, healh policy and medicine, National Public Radio
• Linda Wright Moore, editorial writer, The Philadelphia Daily News

John Cutter, freelance health/aging writer, St. Petersburg, FL Project: Alzheimer’s disease–prevention research, access to new treatments, and the impact of the disease on patients and their families.

Forgetful, Fearing Alzheimer’s and Hoping for a Cure, New York Times, June 24, 2001.

Living with Alzheimer’s, Copley News Service, June 20, 2001.

Importing Prescription Drugs Potentially Dangerous Rx, Copley News Service, June 13, 2001.

‘Safe’ Does Not Mean ‘Risk-Free’ to FDA, Copley News Service, June 6, 2001.

Progress on Prescription Issue Will Require Give and Take, Copley News Service, February 07, 2001.

Robert Davis, medical and science writer, USA Today Project: Variations in the nation’s emergency medical systems and their impacts on survival rates.

Speeding to the rescue can have deadly results, USA Today, March 21, 2002.

Health care, without question, USA Today, September 6, 2001.

Fred de Sam Lazaro, correspondent, The NewsHour with Jim Lehrer; executive producer; KTCA-Twin Cities Public Television, St. Paul, MNProject: The role of international medical graduates in providing health care in under-served urban centers and rural areas in the U.S.

Going Home: U.S.-trained foreign doctors and the countries they’ve left behind, The NewsHour with Jim Lehrer, August 23, 2002

Foreign Country Doctors: The effect of doctors with degrees from overseas institutions on the U.S. health care system, The NewsHour with Jim Lehrer, June 18, 2002.

Mason Essif, segment producer, HealthWeek-PBS, Washington, DC Project: The e-revolution in health care–how the Internet is affecting access and quality of health information, communication between providers and patients, and medical commerce.

E-service Keeps Doctors, Patients in Touch, CNN, April 9, 2001.

A Reporter’s Notebook: Perspective on the April 2001 Fellows’ sitevisit to Cuba.

Don Finley, science, medicine and environment editor, The San Antonio Express-News Project: Obesity in the U.S.

The Supersize Crisis: Obesity in America,, a six-part series, The San Antonio Express-News, December 8-15, 2002.

Merrill Goozner, freelance journalist and associate professor of journalism, New York University Project: The sources and costs of pharmaceutical innovation.

Medicine as a Luxury, The American Prospect, Volume 13, Issue 1. January 1-14, 2001.

Andrew Julien, health/medical writer, The Hartford CourantProject: The influence of social and economic forces on children’s health”

“GenStress: A Landscape of Pain,” a four-part series, The Hartford Courant, December 15-18, 2002.

Madge Kaplan, Health Desk Editor/Boston Bureau Chief, Marketplace Radio/WGBH Project: Investigating changes in the health care workforce and their impact on health care delivery and patient care.

When a Heart Rebels: How Health Care Got a Primary Nurse, WGBH, Boston.

Sarah Lunday, health care industry reporter, The Fort Worth Star-Telegram Project: The impact of prescription drugs on the health care industry–financial, ethical, medical and political.

Alcon Receives Warning from FDA: Problems Involving Test Batches are Fixed, Drug Manufacturer Says, Dallas Morning News, December 9, 2000.

Joan Mazzolini, investigative reporter, The Plain Dealer, Cleveland Project: VA health care–how well are veterans’ medical centers serving those who served us?

In Harm’s Way: Some 4 million veterans depend on the Veterans Affairs health system, but attempts to reform the system have been thwarted.

Andy Miller, health care business reporter, The Atlanta Journal-ConstitutionProject: Indoor air quality and its effects on health in the home and workplace.

Sick Buildings: A Special Report

Charles Ornstein, health business reporter, The Dallas Morning NewsProject: The evolving role of employers in the health care system-what role should they play in providing benefits for employees, retirees and their families?

Pension Fund Giant Feels Bite of Medical Inflation: Heavyweight Faces Tougher Health Care Negotiations, Dallas Morning News, March 25, 2001.

Behind-scenes Look Shows How Firm Chose Health Plans, Dallas Morning News, December 24, 2000.

Sleuths Scope Out Benefits: GTE Seeks Quality at the Right Price, Dallas Morning News, December 24, 2000.

Experiments Shifting Decisions on Health-care Plans to Workers, Dallas Morning News, October 15, 2000.

Insurance Grew From a Luxury to Entitlement, Dallas Morning News, May 14, 2000.

Drowning In Expenses, Dallas Morning News, May 14, 2000.

Premiums Put Squeeze On Workers, Dallas Morning News, April 2, 2000.

Bridging Benefit Gaps, Dallas Morning News, April 2, 2000.

Texas Trying To Pass More Costs To State Workers, Dallas Morning News, April 2, 2000.

Jon Palfreman, senior producer, FRONTLINEProject: The development, marketing, and pricing of prescription drugs.

“The Other Drug War,” FRONTLINE, June 19, 2003.

Christopher Ringwald, demographics and mental health reporter, The Times Union (Albany, NY)Project: The challenges and debate facing alcoholism and addiction treatment programs; what works, why, and how to measure results.

The Soul of Recovery: Uncovering the Spiritual Dimension in the Treatment of Addictions, Oxford University Press-USA 2002.

Neil Rosenberg, senior medical reporter, The Milwaukee Journal SentinelProject: Differences in health care treatment due to race, gender and age

Racial Gaps Found in Access to Transplants, Milwaukee Journal Sentinel, April 16, 2001.

Separate and Unequal: U.S. Practices a System of Medicine that Shortchanges Minorities and Women, Milwaukee Journal Sentinel, April 16, 2001.

Racial Gaps Found in Access to Transplants, Milwaukee Journal Sentinel, April 16, 2001.

Sources from Neil Rosenberg’s Project on Race, Gender and Age.

Joe Palca, correspondent, science desk, National Public RadioProject: How clinical trials work-the ethical, medical, financial and societal issues involved

Clinical Drug Trials Helpful or Harmful? Dilemma of Using Drugs to Prevent Diseases in People Who are at Risk but Otherwise Healthy, Especially When the Drugs Have Serious Side Effects, National Public Radio, March 21, 2001.

Continuing Fight on Capitol Hill over a Patients Bill of Rights, National Public Radio, May 11, 2000.

Karl Stark, health care business reporter, The Philadelphia InquirerProject: The quality of medical care–what data can really help doctors provide high quality treatment, and help patients find good care?

In Philadelphia, Malpractice Awards have ‘Gone Haywire’, The Philadelphia Inquirer, November 16, 2000.

Medical Changes Proposed by Firms:A Group Representing Large Companies Says its Three Suggestions Could Save 60,000 Lives a Year, The Philadelphia Inquirer, November 16, 2000.

Taking the Pulse of Medicine: A Local Start-up Offers Ratings of Doctors and Hospitals on the Web. It Sells Them to Employers. The Philadelphia Inquirer, November 6, 2000.

Brenda Wilson, correspondent and editor for public health, health policy and mediciane, National Public Radio Project: AIDS and HIV prevention efforts in South Africa=attitudes toward sexuality, Western medicine, death and disease-and the implications for the U.S.

Sisters Against AIDS, Heart and Soul, December/January 2001

Linda Wright Moore, editorial writer, The Philadelphia Daily News Project: Disparities in health status and access to medical care between black and white Americans.

At the Heart of Race and Health Care, Philadelphia Daily News, November 27, 2000.

New voluntary court system helps mentally ill inmates get their lives back on track

11/24/2002

Jenni BergalReprinted with permission of Sun Sentinel

It’s lunchtime in Room 510 of the Broward County Courthouse, and the judge is clearly worried about the disheveled prisoner with matted hair and glassy eyes sitting shackled before her.

The man has been languishing in the county jail for days on a minor trespassing charge. He’s a schizophrenic and alcoholic who says he’s been living on the streets and not taking medication for his illness.

In the middle of the hearing, Judge Ginger Lerner-Wren picks up the phone and dials a local mental health program. At first she cajoles the administrator. Then she becomes stern and emphasizes that “the court” really wants this man to get treatment and shelter.

Lerner-Wren hangs up the phone and announces that a bed is waiting for him.

“God bless you, judge,” the man yells.

She smiles and calls the next case.

That’s a typical scene at the Broward County Mental Health Court, a unique blend of justice and social services, or as Lerner-Wren often calls it, “therapeutic jurisprudence.”

The county court, the first in the nation when it was created in 1997, has become a model for more than two dozen communities from Anchorage, Alaska, to Brooklyn, N.Y.

In Florida, mental health courts have cropped up in Sarasota, Osceola, Lee and Alachua counties. Palm Beach and Orange counties are seeking funding to start courts and Okaloosa County is launching one in January.

Law enforcement officials estimate the court has saved the Broward jail system at least a million dollars a year.

The goal is to stop mentally ill defendants arrested on misdemeanors such as disorderly conduct, loitering, petty theft and public drinking from rotating in and out of jail and get treatment for them. In its five years of operation, the court has offered help to hundreds of offenders who otherwise would have been in jail, records show.

“The court needs to give our people a sense that somebody with authority cares,” Lerner-Wren says. “On a daily basis, that’s what we’re striving for.”

For defendants who participate, criminal charges are put on hold. The judge evaluates the case, consults with the court’s social workers and issues an order specifying treatment and rules they must follow. “This is not a trial court. This is a treatment court for people who have some kind of mental health condition,” the judge tells new defendants. “It is purely voluntary.”

Some defendants need a case manager. Others require a live-in program and intensive therapy. Many also are substance abusers needing drug or alcohol treatment.

It’s a heavy load, especially because it’s a part-time court. Lerner-Wren maintains her regular criminal docket and holds mental health court hearings during her lunch hour on weekdays. On Thursdays, she schedules a full afternoon of status conferences to monitor defendants’ progress.

The court has no budget and operates with only two employees: a $40,000-a-year county-funded court monitor from Henderson Mental Health Center and a $45,000-a-year licensed clinical social worker from the Florida Department of Children & Families.

Unlike most courts, where a hush falls as the judge appears, mental health court is often a free-for-all. Attorneys and social workers mill about in front of the judge, chatting about defendants’ histories. Nova Southeastern University psychology doctoral student interns screen prisoners who are in manacles, jail jumpsuits and black flip-flops, and report their findings to the judge.

“How many times have you been in the hospital for mental health reasons?” the students ask.

“Do you have a place to live?”

“Are you hearing or seeing anything?”

Some prisoners mumble incoherently to themselves or scream obscenities. Others wait patiently for the judge to call on them. Those out on bond sit on benches in the audience, often with family members or friends.

Lerner-Wren asks how they’re doing and poses the question: “Is there something this court can do for you?”

“The defendants are treated with more respect than they probably ever had before,” says Danielle Levin, a Broward assistant state attorney assigned to the mental health court. “In other courtrooms, people acting inappropriately are either not brought into court or judges don’t want to deal with them. This judge talks directly to them.”

Kimberly Warner, 37, who first came to the court after an indecent-exposure arrest three years ago, was “very, very ill,” as the judge puts it.

Warner, a schizophrenic, says she had suffered a nervous breakdown and couldn’t cope. To make matters worse, she was doing crack. “I was on the verge of suicide,” she says.

Lerner-Wren sent Warner to a residential treatment program, where she stayed for more than a year. But after she was released and got her own apartment, she relapsed and was arrested on lewdness charges.

Lerner-Wren gave her another shot. Warner moved to a different program and stayed clean. After six months, she transferred to a board and care home, but still attended day treatment and took medications.

At an August hearing, Lerner-Wren handed a glowing Warner a “certificate of achievement” for completing treatment and making “terrific progress.”

Around the courtroom, there was a burst of applause.

“This court has helped me a lot,” Warner said, tears welling in her eyes. “It helped me get my life together.”

Jail, release, jail again

Mental health court was born of crisis.

It stemmed from the highly publicized case of Aaron Wynn, a young man who suffered brain damage in a motorcycle accident in the mid-1980s. He couldn’t control his anger and acted out with his fists. For years, his parents had tried unsuccessfully to get him help as he moved between the mental health and criminal justice systems.

In 1993, Wynn was arrested in Hollywood after a woman, 85, he knocked down outside a grocery store hit her head on the pavement and died. Wynn was charged with manslaughter but found incompetent to stand trial.

Wynn’s case prompted a 1994 grand jury report that blasted the jails filled with mentally ill inmates — an estimated 6,500 to 10,000 a year — who got little, if any, treatment from the county’s fragmented mental health system.

The same year, Broward Circuit Judge Mark A. Speiser, then head of the court’s criminal division, created a mental health task force of attorneys, social service experts, police and advocates.

The task force found that mentally ill people were being arrested for minor offenses and locked up in overcrowded jails because they couldn’t make bond, sometimes as little as $25. Some would remain for days or weeks without treatment. Finally, they would plead guilty or no contest and be released, only to be rearrested for similar crimes.

“Severely mentally ill people would sit in jail after being arrested for rummaging through a Dumpster or standing in a parking lot screaming or walking naked into a Denny’s,” says Doug Brawley, the Broward chief assistant public defender who supervises the county court division. “They’d be sentenced to time served, get released from jail and be on their way. And they’d go right back out and do the same thing again. Nobody was helping those people.”

A U.S. Department of Justice study appears to bear out the task force’s findings. It revealed that in 1998, an estimated 283,800 mentally ill offenders were locked up in the nation’s jails and prisons, representing 16 percent of prisoners. Those in local jails who had been arrested for “public order” offenses served on average 1.3 months more than offenders who weren’t mentally ill.

“I was very frustrated as a judge,” Speiser recalls. “Our jails were swelling with people who had mental health issues. By releasing them, we were doing a disservice to them and the community. It was like a merry-go-round.”

Deinstitutionalization, the sweeping movement to empty psychiatric hospitals that started in the 1960s, compounded the problem. The number of patients in state and county psychiatric hospitals dropped from 558,922 in 1955 to 54,836 in 2000, according to U.S. Department of Health and Human Services statistics, but community programs to help treat them didn’t grow to meet the demand.

Chief Assistant Public Defender Howard Finkelstein, who represented Aaron Wynn and was a member of the task force, says he brought up the idea of a mental health court out of frustration.

“Judge Speiser asked what I wanted,” Finkelstein says. “I said I wanted a mental health court. Everyone thought about it — and said OK.”

The court would accept defendants arrested on misdemeanors, but not domestic violence or driving under the influence. It would take those arrested for battery, but only if the victim consented.

And it would not include anyone arrested on a felony charge unless it had been reduced to a misdemeanor.

Most important, task force members had to find a judge to make it work.

They chose Lerner-Wren, who had just been elected to the county court bench in the fall of 1996. She had served as the Broward County Public Guardian, responsible for overseeing the health and welfare of disabled adults who were incapacitated. She also had worked for an advocacy center monitoring a settlement agreement over a federal class action lawsuit against South Florida State Hospital, the region’s mental hospital.

Broward Chief Judge Dale Ross appointed her to run the new court, which opened for business in June 1997.

“The court came to be out of desperation,” says Lerner-Wren, 43. “But it has turned out to be a great vehicle that pulls these bits and pieces of a very broken and fragmented mental health system together.”

Those who work in the judicial system are quick to assert that the court is making a difference in the lives of the mentally ill.

“The mental health court has helped a great deal,” says Broward Sheriff Ken Jenne. “The judge has developed a real good balance. She isn’t getting suckered, but she’s also sympathetic.”

Jenne says the court was badly needed, not only from a treatment standpoint, but also from a fiscal one.

Broward Sheriff’s Office statistics show that it cost taxpayers an additional $638,000 last year to feed, clothe and provide medication to mentally ill inmates in the jails.

From March through October of this year, the county jails made 342 referrals to mental health court, or about 42 a month, statistics show. While sheriff’s officials don’t keep statistics on exactly how much that may have saved them, they point out that it costs about $235 a day to care for a mentally ill inmate.

“At the end of the day, this community is 100 times better having the mental health court,” the sheriff says.

`A lost soul’ saved

For 48-year-old Scott Cormiea, mental health court was the end of the line.

A homeless alcoholic suffering from severe depression, he couldn’t hold a job. He ended up on the streets, feeding himself by rummaging through trash bins. He says he tried to kill himself by walking in front of a bus and by drinking himself to death.

“I turned into an animal living on the street,” Cormiea says. “I kept hearing voices to kill myself because I was worthless.”

Fort Lauderdale police arrested Cormiea on New Year’s Eve 2000 on a charge of trespassing at a gas station. In September 2001, he was cited again for drinking a beer while sitting on a milk crate on the sidewalk.

Later that month, he was brought to jail on a warrant for an open-container charge and was referred to the mental health court.

Cormiea was hearing voices and was suicidal when he first appeared before Lerner-Wren, records show. The judge ordered him into a crisis unit for evaluation.

Once stabilized, Cormiea went to live at “Cottages at the Pines,” a mental health court program based at a cluster of brightly painted houses that once belonged to doctors on the grounds of South Florida State Hospital in Pembroke Pines.

The cottages are designed mainly for homeless mentally ill defendants from the mental health court. Fifteen beds are reserved for court-ordered defendants and nine are for homeless people referred by county staffers.

Participants in the $1.25 million-a-year program, run by Henderson Mental Health Center and funded by the state and county, receive therapy, sign up for disability benefits and work on developing social skills and reconnecting with their families. When they’re done, they usually move into their own apartments or board and care homes.

In April, Cormiea had been living at the cottages for six months. He was attending Alcoholics Anonymous meetings, had signed up for computer courses and planned to get his own apartment.

“I was in such bad shape, but I managed to turn myself around,” Cormiea said. “I’d be dead right now if not for this program. I was a lost soul.”

Cormiea left the cottages in June and moved into an apartment. He hasn’t been arrested since, court records show.

Like Cormiea, about three in 10 defendants who appear before Lerner-Wren report substance abuse problems and an equal number are homeless, according to an annual progress report released by the court.

Many others live with family members or friends. Some are professionals. About a quarter are women, many of whom have been arrested on prostitution, theft or alcohol- or drug-related charges.

One of the court’s biggest obstacles is the lack of treatment beds in the community for defendants in her court, Lerner-Wren says. Nor are there enough programs to help mentally ill offenders who are substance abusers, women who’ve been abused or those looking for work, she adds.

“These are huge problems in the state of Florida,” says Lerner-Wren, who was appointed in May to the 15-member President’s Commission on Mental Health.

About two-thirds of the cases that come before the court are resolved after the initial hearing before Lerner-Wren. The rest are continued and monitored, according to a study by the University of South Florida’s Department of Mental Health Law and Policy.

For defendants who receive mental health services and appear to be stable, Lerner-Wren often withholds adjudication, which means there is no record of a criminal conviction, and closes the case. She usually does the same for defendants who successfully complete treatment.

Court records show that about 12 percent of defendants aren’t appropriate for the court. Some might not be mentally ill. Others may have a violent history.

And some defendants choose not to participate. They might not believe they have a mental health problem or be motivated to help themselves. If the charge is minor and they have no outstanding warrants, Lerner-Wren usually will close the case and order them not to return to the place where they trespassed or shoplifted.

Janis Blenden, the court’s clinical social worker, says that while there’s a good team in place, the court misses many people or can’t find services for them.

“We see a lot of alcoholics and homeless people who are not mentally ill,” Blenden says. “We can’t help them. In the long term, they don’t qualify for benefits.”

Swift-moving process

Most new defendants who appear before Lerner-Wren are sent from magistrate’s court, held via television, in the main jail. Nova doctoral students attend morning hearings to screen inmates and pinpoint those who appear to have mental health problems. Inmates’ names also are matched against a list of current and former clients kept by Henderson Mental Health Center.

Judges, public defenders, assistant state attorneys, police officers, social workers, family members and advocates also can recommend a defendant to the mental health court.

The process usually moves quickly, often within 24 hours of the arrest.

A mentally ill defendant arrested on Monday night, for instance, would appear in magistrate’s court the next morning and could be in front of Lerner-Wren by lunchtime Tuesday.

The whole idea is to divert mentally ill inmates from jail as quickly as possible.

For Lerner-Wren, getting help on the spot is the normal course of business.

When inmates complain they aren’t receiving psychotropic medications, she’ll phone the jail and insist that they get their meds.

“Honestly, when the judge calls and says, `I need you to do something,’ that’s going to jump up on the list of things that need to be done,” says Timothy Ludwig, mental health coordinator for the county jails. “She takes a personal interest in each case.”

Not all cases get to the mental health court quickly, however. Some defendants have a pending felony charge, which must be disposed of before they would be eligible for the court. Others get lost in the jail system.

“If they’re not known by the mental health system, someone has to notice them,” says Levin, of the state attorney’s office. “If they’re quiet and don’t display overt signs, the jail’s not going to recognize it.”

Lerner-Wren requires defendants or their case managers to update her regularly about progress, every week or two at first, then every month or so. A case can remain in her court for up to a year.

Those who continually violate her orders are expelled from the program. Some are transferred back to criminal court or taken into custody if they commit a new crime.

Lerner-Wren frequently tells defendants that it’s up to them to take their medications and manage their illness. Sometimes she’s like a stern parent, scolding those who fail to follow her orders.

To one defendant, she warns: “You’re starting to rack up a history. If you don’t take your medications, there will be consequences. You’re going to see harsher and harsher sentencing.”

Sometimes the judge is like an adoring teacher, handing out certificates to those who have succeeded.

“You have really moved forward,” she tells one defendant. “We’re so pleased with your accomplishments and growth.”

Lerner-Wren is proud of the court, noting that visitors have come from as far as the United Kingdom and South Africa to see it in action. Congress also liked the idea, and in 2000, passed legislation creating up to 125 pilot mental health courts throughout the country.

Evelyn Miller, president of the Broward County chapter of the National Alliance for the Mentally Ill, says her group thinks the mental health court has made a difference.

“It’s a wonderful thing that these people can be offered treatment, rather than sit in jail because of their illness,” Miller says. “You have to help those who need it the most.”

Public safety first

Not everyone is a success story. Some mental health court participants are what the attorneys call “frequent fliers” who keep getting arrested again and again.

At 5-foot-11 and 525 pounds, Kalvin Williams was hard to forget, Lerner-Wren says, when he became one of the first defendants in her court.

Williams, 45, suffers from a “schizoaffective disorder,” in which patients experience severe mood swings and some of the psychotic symptoms of schizophrenia. He has been arrested dozens of times, usually for creating a public nuisance. He often screams at people, using obscenities, in public places, court records show.

The judge tried sending him to intensive case management and residential programs, to no avail. Now Lerner-Wren says she won’t take Williams’ cases.

“I feel very disappointed because he has had many opportunities,” the judge says. “But you have to respect choice. This is not the court for him.”

But mental health court officials are less likely to worry as much about offenders like Williams as they do about those who are violent. They say their deepest fear is that one of their defendants will commit a heinous crime, leading to demands that the court be shut down.

“We don’t want anything bad to happen that could cause all of this good to be placed in jeopardy,” says Lee Cohen, the Broward assistant state attorney in charge of the county court division. “If it did, I hope it wouldn’t kill the court.”

Lerner-Wren says the State Attorney’s Office does a national criminal background check on every defendant and presents her the history. She wants to weed out those with prior serious violent offenses and send them back to regular court.

“We’ve been very sensitive about this,” she says. “Public safety is of utmost importance.”

Unlike drug courts, where success is measured by whether participants stop using drugs, the mentally ill will continue to be mentally ill, so experts have to use other measures to evaluate.

The most obvious is recidivism. Until recently, statistics were hard to come by — the court, which has no administrative unit, never kept them. This year, however, the Broward court administrator’s office analyzed data from October 2001 through September 2002 and found that 27 percent of mental health court participants had been rearrested during that time. Eight percent had returned to the mental health court.

Lerner-Wren says the recidivism is “surprisingly low.”

“It’s awesome that seven out of 10 aren’t re-offending,” she says. “It demonstrates that treatment works and recovery is possible.”

The court does appear to be offering mentally ill defendants more help than a regular court, according to initial findings from the two-year University of South Florida study.

The study compared a sampling of mentally ill defendants processed in a regular county criminal court in Hillsborough County with those who appeared in Lerner-Wren’s court.

It found that mental health court defendants felt they were treated with more respect and fairness than their counterparts, and that it was much more likely they would get follow-up treatment, such as therapy or medication management.

Respect and compassion

“Broward County has clearly been a national leader. This court seems to be a significant success,” says John Petrila, a USF professor who co-authored the study.

Ultimately, how well the mental health court works depends on what you want it to do, adds Norman Poythress, another co-author and USF professor.

“Legislators look at how much does it cost. Criminal justice looks at whether it reduces crime and how many dollars it saves us in bed days in jails,” Poythress says. “Advocates look at whether their relatives are treated with respect.”

Court officials say that the one thing they know is that mentally ill offenders who walk into Room 510 usually leave with a feeling that someone cared about them.

“Whether we’re making a difference, I don’t know,” says Finkelstein, of the public defender’s office. “I just know that on the day-to-day direct human interchange that goes on in that court, the quality of justice and compassion we give these people is something Broward County should be proud of.”

This reporting project was supported by a Kaiser Media Mini-Fellowship in Health.

Jenni Bergal can be reached at jbergal@sun-sentinel.com or 954-356-4592.

Prior to 2003, travel and research grants were awarded to print and broadcast journalists and editors to report on health policy and public health issues for publication/broadcast. For details of the mini-fellowship awards for 1997-2001, see below.

The Henry J. Kaiser Family Foundation

Behind-scenes Look Shows How Firm Chose Health Plans

Fourth in an occasional series

12/24/2000

By Charles Ornstein Reprinted with permission of The Dallas Morning News

“Health insurance is obviously an important decision,” said Mr. Gilmore, 56, a vendor training coordinator for Verizon Communications Inc. “But it’s taken on a little bit less importance because we’ve been satisfied with Cigna, and my kids are older now and they’re both married and I don’t cover them with insurance anymore.”

Mr. Gilmore and many of his fellow employees took little more than a day to make decisions about health coverage, but three regional health-care managers spent eight months vetting health plans and negotiating contracts that will take effect Jan. 1.

The trio’s choices would have to satisfy the demands of 284,000 employees, retirees and their dependents of the former GTE Corp. while fitting within a whopping half-billion-dollar budget eventually approved by chairman and chief executive Charles R. Lee. This particular line item consumed nearly 8 percent of GTE’s operating income in 1999.

Along the way, the three managers encountered steep increases in medical and prescription drug costs, financially unstable HMOs and renewed efforts to reduce medical errors in hospitals.

Typically, employees don’t get to peek behind the veil of secrecy associated with benefits selection, receiving little information besides an enrollment kit each fall. But for this article, GTE provided exclusive and unprecedented access – and candidly discussed the factors that affected decision-making. That included access to internal meetings, visits with health insurers, company documents and employee interviews.

In the midst of an already complicated process, GTE underwent dramatic corporate changes. In one year, it divested itself of two units, spun off its wireless operations into a joint venture with Vodafone Group PLC, and merged with Bell Atlantic Corp. to form Verizon.

Privately, GTE’s benefits staff questioned whether they would even have jobs after the merger. Like many corporations, its partner Bell Atlantic relied heavily on consultants to select insurance programs.

A bad year

From the get-go, regional health-care manager George Crowling and his two colleagues at GTE knew this year would bring cost increases unseen during the mid- and late 1990s.

On a visit to mideastern Illinois, where GTE provides local phone service and employs about 400 people, Mr. Crowling was faced with a 60 percent premium increase for retirees by a local HMO called Health Alliance Medical Plans. That was on top of a 13 percent increase for active employees.

In St. Louis, industry colossus UnitedHealthcare demanded an increase of 29 percent to cover GTE employees across Missouri.

Mr. Crowling and his two co-workers logged nearly 100 visits with health plans this year, developing a strategy that responded to trends they saw across the country.

“They’re atypical in the way they do things,” said Larry Atkins, president of Health Policy Analysts Inc., a Washington-based benefits policy and consulting firm. “There probably are not a lot of companies out there really scouring these HMOs, turning them upside down, shaking them and then making decisions about which one they want to contract with.

“Most companies say: ‘We really don’t want to go to those lengths. If there’s an off-the-shelf product that somebody else is vetting that will meet our requirements, let’s do that.'”

In the 1999 benefit year, the company spent $548.7 million, or $3,653 for every employee and retiree – the same per capita amount paid in 1994. For this calendar year, the company expects costs to increase by about 5 percent.

As for 2001, the benefits year observed for this article, the company expects a net increase of 8 percent, on top of premium increases absorbed by salaried employees.

In the overall scheme of things, GTE’s medical spending will still look pretty good, compared with other large companies, said Mr. Crowling, regional health-care manager for Texas and 13 other states. But that doesn’t mean he and other executives aren’t worried by the trend.

Bruce Taylor, director of employee benefit policy and plans at the newly minted Verizon, brought home the magnitude of the cost increases during a September speech in Toronto.

Verizon, he said, will spend nearly $500 million per year on prescription drugs, including the amount spent by its HMOs. Conservatively, drug spending is increasing at 15 percent annually – or $75 million a year.

“That means … every time you go by a phone booth, a Verizon phone booth, I need to have 300 million more phone calls at 25 cents each just to pay for the increased costs for prescription drugs,” Mr. Taylor said. “If you let me take the price of the phone call up to 35 cents, then it goes down” to 214 million extra phone calls.

‘Wet cement’

On a rainy, unseasonably warm day in February, a team of 26 people crammed into a small, windowless conference room in Coppell to begin the selection process and set key dates in “wet cement.”

The group was divided between representatives of GTE and Hewitt Associates, the firm hired to administer GTE’s behind-the-scenes benefits process. Hewitt, based in Lincolnshire, Ill., processes paperwork, runs GTE’s customer service center, calculates its premium payments to HMOs and helps new employees enroll in the system.

The marching orders from the executive suite largely paralleled those of years past: Hold cost increases to less than 75 percent of the national average; improve employee satisfaction through external measurable means; and prevent labor disruptions over health care.

But the merger with Bell Atlantic prompted two new directives: Don’t make any major changes; and begin aligning plans with Bell Atlantic.

“We make sure that our employees are focused on beating our competitors as opposed to being distracted by hassles of health-care needs or delivery systems,” said Ezra Singer, Verizon’s executive vice president for human resources. “If they’re able to keep their eye on the competitive issue, that’s what we want.”

The job of keeping the benefits selection team on track fell to John Large, project manager for annual enrollment. “The process starts rolling,” he exhorted. “Everybody knows what they have to do.”

For the most part, Mr. Large was correct, and his team met most of the 115 key deadlines, 46 of them considered critical milestones. Among them: Complete a communications plan by the end of April. Identify health plans to drop by the end of June. Determine the company’s share of insurance premiums by the end of July.

All of this, of course, was designed to launch open enrollment for active employees on Oct. 6 and give the team time to notify employees whether they were required to change plans. The selection process ended Nov. 10.

Everybody at the meeting was conscious of the impending merger with Bell Atlantic, the big telephone provider on the East Coast. The deal would create the largest local phone company and move GTE headquarters from Irving to New York.

“We have a lot going on this year that we didn’t have going on last year,” one participant said.

Once the dust settled, members of the health-plan team received preliminary indications that their jobs were safe. Yet Verizon’s health-care strategy remains under development.

“What I want to do going forward is really take the best aspects of Bell Atlantic and GTE, and at the same time, look at what other companies are doing,” Mr. Singer said. “Whatever we do, I want to make sure that it’s sustainable and that it can last for a long while.”

‘An endless pit’

After the introductory meeting in February, the situation was largely quiet for the next couple of months, with teams working behind the scenes. Beginning in May, though, the health benefits managers began holding meetings with health plans, securing bids for 2001 premiums and making changes.

They also spent a good deal of time discussing prescription drug prices, which Verizon’s Mr. Taylor called an endless pit.

“There’s no such thing as too much resources dedicated to managing prescription drugs,” he said.

At their visits to the health plans, the regional health-care managers employed shortcuts to trim costs without sacrificing benefits. Mr. Crowling slightly lowered the premium increase for Health Alliance in Illinois by increasing the patients’ $10 co-payment for physician-office visits to $15. He also raised the price of some brand-name drugs to $15 from $10.

Mr. Crowling reduced the premium increase for United’s Missouri health plan by proposing to self-insure it. That means GTE, not United, would assume the risk for all of its employees’ medical claims. As a result, United reduced its increase to 19 percent, and it remained an insured product.

Using these methods and others, GTE officials said, they lowered its overall 2001 cost increase from an anticipated 11 percent to 8 percent.

The zipper

After Mr. Crowling and the other regional managers collect the data on the cost of the health plans, Mr. Taylor and GTE’s executives determine how much money the corporation will allocate for medical costs. Employees pay the remainder, under a complicated formula known as “the zipper.”

GTE assigns each health plan to one of 14 slots, based on quality and cost, and consumers pay a different amount – or nothing at all – based on where their health plan is assigned.

Employee contributions at GTE have increased slightly with time. The average employee and retiree paid $298 toward medical premiums in 1999, compared with $257 in 1994. The average includes union members, who represent about half of GTE’s workforce, even though they do not contribute to premiums.

Even excluding union members, however, GTE officials said their employees pay lower premiums than employees at most national corporations.

In late August, the curtain rose on the selection process when GTE distributed its first reminders about open enrollment and a wallet-size card with a personal access number for the Internet and automated telephone systems. The benefits staff followed up with an e-mail reminder to all employees.

But several steps remained. Hewitt arranged for the printing, collating and mailing of millions of pages of information. The material went out in three cycles, with about 50,000 people in each wave.

Union workers came first and received a full enrollment kit, complete with descriptions of available health plans. Retirees received a similar package.

Salaried workers got a two-page letter directing them to one of three routes: the Internet, the automated phone system or a request for a full enrollment kit. Of the 42,000 people who received the letter, only 2,000 requested a hard-copy kit.

Any employee or retiree who changed plans had to be sent a subsequent letter confirming any changes. GTE officials say 85 percent of active employees made no changes at all. Of the rest, 58 percent made changes online.

Gail Morgan was one of the employees who decided against making any changes, sticking with Cigna.

“I guess if I had problems with them – if it took me a week to get in to see my doctor every time I called – then I’d probably be looking at the other plans,” said Ms. Morgan, 51, who works on the company’s regulatory filings. “As long as I’m happy with them and don’t have any problems, I don’t even compare the other plans.”

Even though they don’t know the intricacies of the process, employees said they can imagine that the benefits selection process takes a while.

“It wouldn’t surprise me if they’re already working on next year’s,” Ms. Morgan said.

SexSmarts

The Kaiser Family Foundation has teamed up with seventeen, the nation’s top teen magazine, to create SexSmarts, a campaign to provide young people with information and resources on sexual health issues. The on-going campaign, begun in 2000, addresses a range of topics from decision making about sex, including how to say no, to the real facts on HIV and other sexually transmitted diseases (STDs). It includes special articles in the magazine, a monthly column and resources at seventeen.com, and other consumer education materials. Under the partnership, seventeen (a PRIMEDIA magazine) and Kaiser also survey teens quarterly about their knowledge and attitudes about sex and sexual health. These nationally representative survey snapshots help to frame the SexSmarts campaign, and the results are distributed to thousands of media and youth advocates nationwide.

SexSmarts Articles in seventeen Magazine 2000-2003

• “The Double Standard,” January 2003.
• “Don’t You Trust Me?” October 2002.
• “Talk to Me,” August 2002.
• “Sex, Drugs & Rock ‘n’ Roll,” June 2002.
• “The ABCs of STDs,” September 2001.
• “The Vagina Dialogues: Scripts and tips for talking about your sexual health,” June 2001.
• “Control Issues: Eight common myths-and the facts-about condoms and the pill,” January 2001.
• “To have (or not to have) sex,” October 2000.
• “SexSmarts,” a special insert in seventeen in June 2000.
• “What do you know about…sex?” April 2000.

SexSmarts Surveys 2000-2003

Virginity and the First Time. This survey examines teen’s attitudes and opinions about virginity and first sexual activity among adolescents. It covers a variety of issues related to decision making, including when and why some teens hoose to have sex and what issues and concerns influence their decision to wait (October 2003).Summary of Findings Toplines Gender Roles. This survey on teens and gender roles considers many old stereotypes that persist among teens today, reflecting a double standard when it comes to relationships and sexual decision-making (December 2002).Summary of Findings Toplines Relationships. This survey examines the way teens think about sexual activity, STD testing, contraceptive use and condoms within different types of relationships (October 2002).Summary of Findings Toplines Teens and Sexual Health Communication. This survey is about sexual health communication between teens and their parents, health care providers and partners (July 2002).Summary of Findings Toplines Sexual Activity and Substance Use Among Youth. This survey addresses the pressures and decisions faced by teens and young adults involving alcohol, drugs, and sexual activity (February 2002).Sexually Transmitted Disease. This survey examines teen knowledge and attitudes about sexually transmitted diseases, including risk, testing and treatment (August 2001).Sexual Health Care and Counsel. This survey focuses on what teens say are barriers to sexual health care services for themselves, and their peers (May 2001).“Safer Sex,” Condoms and “the Pill”. This survey reveals what teens think about safer sex, what they know (and don’t) about their options for contraception and protection (November 2000).Decision Making. This survey addresses some of the complex issues influencing teenagers’ decision making about sex and relationships (September 2000).

SexSmarts OnlineThe SexSmarts campaign includes a website at seventeen.com – one of the top sites for teens. At http://www.seventeen.com/sexsmarts teens read monthly columns, find online resources and hotlines, and take quizzes testing their knowledge on sexual health issues. The website is promoted in seventeen magazine.

The Henry J. Kaiser Family Foundation

At the Heart of Race and Health Care

11/27/00

By Linda Wright Moore Reprinted with permission of Philadelphia Daily News

Dr. Charles Bridges, assistant professor of surgery at Penn’s medical school and clinical director of cardiac surgery at Pennsylvania Hospital, understands that racial disparities in health care are much more than skin deep.

That premise is clear in his latest research, a study of differences in the death rates of blacks and whites who undergo coronary bypass surgery. His study was published last week in the Journal of the American College of Cardiology.

Bridges and his colleagues found that fewer than 4 percent of all patients studied died as result of coronary artery bypass surgery – but that black patients were 29 percent more likely to die than whites. And that’s even when other known risk factors, such as age, kidney failure and heart failure, were taken into account.

So what’s going on?

“Race is probably a marker for other biological variables that may have to do with cell function that protects people from heart disease,” Bridges hypothesized.

“These cells may work differently in some black patients, so that they tend to have less protection and more severe heart disease at an earlier age. . .So blacks may have higher mortality, not because they are black, but because of a different biology.”

That biological difference might be shared by some black people – and by people of other races as well.

But to sort it all out will require more research.

Expensive, extensive research. And on Wednesday President Clinton signed into law a measure that could help fund research like Charles Bridges’.

The new law could be a foundation and a first step toward eliminating wide and persistent health disparities that cause millions of Americans to live sicker and die sooner than most of their fellow citizens.

First introduced in June 1999 by U.S. Rep. Jesse L. Jackson Jr., D-Ill., the legislation that became the Minority Health and Health Disparities Research and Education Act of 2000 was strongly supported by Democrats. But the proposal was almost derailed when conservative House Republicans circulated a memo claiming the bill contained “several racial set-asides and quotas” for grant and loan programs.

The bill was rescued by Republican Sen. Bill Frist, who represents a Tennessee constituency of low-income blacks and Appalachian whites. Frist expanded the bill to include all health disparities – including those experienced by poor whites.

Now, the new law calls for:

Annual spending of at least $100 million for research on health disparities.

$50 million for studies to identify causes of health disparities and explore strategies for eliminating them.

$21 million for education programs to help doctors learn techniques of “culturally competent” care.

Unspecified funding for repayment of educational loans to health professionals who conduct research on minority health or health disparities.

Add in the budget of the existing Office of Research on Minority Health and the total for research into how race affects health is nearly $250 million per year.

“To address this problem with a more targeted approach, we need better data and understanding of the factors that drive the problem,” said Marsha Lillie-Blanton, an African-American who is vice president of the Kaiser Family Health Foundation, where she directs policy research and grants on access to care for vulnerable populations.

“In the past, most researchers studying us were not people who understand us and our communities. This [new law] will train minority researchers and invest in research targeting the needs and problems of minority and disadvantaged communities.”

Money and a solid hypothesis drive research. Along with new dollars under the minority health and disparities law, the nonprofit Center for the Advancement of Health recently announced a $1.5 million pilot program funded by the W.K. Kellogg Foundation, “to train a new generation of minority scientists” to research and solve disparities in health care.

These new resources will enable scientists like Charles Bridges to expand their research.

“We need to systematically investigate biological differences that we found in black patients, such as more severe heart disease at a younger age,” Bridges said. “We also need long-term studies. What about one-year or five-year or 10-year mortality? That would take years, and it would be expensive.”

Expensive and complicated – because, even if race is a factor in medical outcomes, it’s not in itself an answer to the question of eliminating racial disparities in health. “We cannot treat race, but we can treat biological factors,” Bridges pointed out.

So it becomes essential to figure out how biology, poverty, access and culture apply to minority health by asking an array of questions that have clinical and social implications.

“We need to look at the influence of socioeconomic variables,” Bridges said. “Are blacks getting service from the same surgeons as everyone else, or does a certain, limited group of surgeons treat blacks? Are there differences that correlate to where blacks live and the quality of care available in their communities?”

The only downside to the creation of a center devoted to minority health is the risk of “ghetto-izing” research on minorities into a niche with minimal funding, Lillie-Blanton said. The $250 million authorized to begin studying minority health and health disparities is just 1.4 percent of annual National Institute of Health spending.

“It’s not the answer, but it provides an opportunity we haven’t had before to develop research by people who are more knowledgable about our community,” said Lillie-Blanton. “It’s information that will help to leverage what kinds of research should be done in the other divisions of NIH, with larger sums of money.”

The other big problem underlying the issue of health disparities is access – the problem of being less likely to be referred for bypass surgery, heart transplants, angioplasty or catheterization.

“We need to educate physicians and patients about the benefits of these interventions,” said Bridges, “especially where there is no economic barrier to paying for the procedure.”

Bridges said often poor communication between doctor and patient results in less aggressive care for some minority patients, but attitudes about race are also a factor. “We cannot deny that there is a difference in physician attitudes that gets manifest as patient access,” Bridges said. “I have had several African-American patients who, prior to meeting me, had declined to have surgery.

“When I was able to communicate to them the risks, benefits and alternatives in a manner which they found clearer, less threatening and more sensitive to their views, in several cases they agreed to undergo procedures that were necessary.”

One component of the new law specifically calls for education efforts in “culturally competent” care, to help doctors – who are primarily white and male – learn to more effectively treat patients who will be, increasingly, non-white as the nation’s demographics shift in the 21st century.

Along with money, research takes time. And so does changing the way patients are treated. For now, according to Bridges, the best way to reduce race-based disparities in health is for patients and doctors to decide on the appropriateness of heart surgery and other cardiac treatments based on “established clinical data, independent of race.”

Dr. Thomas LaVeist, a professor and researcher at the Johns Hopkins School of Public Health, is also studying the touchy issue of why whites and blacks get different treatment for cardiac problems.

“The new resources that will flow from the center for minority health are important for researchers who have been toiling for years in the area of disparities in health, and haven’t been able to get the support they need,” LaVeist said.

“Although the center itself has a relatively modest budget now, hopefully, that budget will grow.”

Nearly 10 million children in the United States lack health insurance coverage and over two-thirds of them or low-income. This databook provides baseline data on how many children are uninsured today and on the extent of Medicaid coverage. It provides astarting point to monitor and assess state efforts to reach and insure more children.

• Report
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