"Severely mentally ill patients are at risk not so much for unnecessary use of medical services as for receiving insufficient or inadequate medical care."
(Olson et. al. 1999, p. 81)
Public funding for SMI patients in Arizona comes from three "categorical" programs that assign patients to categories according to both eligibility and diagnosis. Five Regional Behavioral Health Authorities (RBHA) administer the mental health services for the state and receive funding according to state and federally determined categories and payment approaches.
Title XIX, the federal/state Medicaid program known in Arizona as AHCCCS (Arizona Health Care Cost Containment System)
A total of 7,550 open AHCCCS SMI clients were reported by ADHS for 10/1/98. In the 1999 budget request, ADHS reported 48 percent (5,321) of all those classes eligible for atypical medications were served through AHCCCS. Newer anti-psychotics and anti-depressants are prescribed for Title XIX
(AHCCCS) eligible patients (Interviews). AHCCCS eligible patients are covered for both their medical
and mental health care, but they are covered through two separate systems of care contracted to serve AHCCCS patients: the medical health plans and the RHBAs. The mental health budget has steadily increased since mental health services were first covered in 1990. A process exists for increasing the budget for mandated services based on the number to be served. At each budget cycle, however, the debate
is renewed about the appropriation of funds to cover services, including medications (Interviews).
State-funded seriously mentally ill services
A total of 11,223 state-funded SMI clients were reported open as of 10/1/98 (ADHS). Of those patients, 5,760 were estimated to need atypical antipsychotic medications in the 1999 ADHS budget. Newly diagnosed patients are usually placed on the newest medications. Long-term patients may still be receiving older drugs due to a lack of outreach and case finding by the mental health providers (Interviews). Unlike the AHCCCS patients, state-funded SMI patients are not provided general medical care. They must purchase their own private health insurance or find some other way to obtain care. Important complementary medical care is not part of the care offered this very ill and vulnerable population. Unless new state money is appropriated, state-funded SMI patients without health insurance will lack necessary medical care.
General Mental Health (GMH)
ADHS reported 7,294 open cases under state programs as of 10/1/98. ADHS requested funding for
779 GMH patients in need of atypical antipsychotics in its 1999 budget request. Limited state funding restricts the number of new patients enrolled, availability of costly medications, and the scope of services offered (Interviews). These patients are expected to share in the cost of their care where possible, and must provide their own general health insurance. If mental health and medical care access is to improve for this group of patients, new funding will be needed, particularly as Arizona's population grows.
Medications are becoming an increasingly large part of the SMI state budget. Between state fiscal years 1995-96 and 1996-97, the average medication cost increase for AHCCCS SMI patients was 35 percent; 10.78 percent for state-funded SMI patients; and 14.38 percent for GMH (non-AHCCCS) patients (ADHS/DBHS). Variances are due to RBHA decisions for priorities in treatment, the cost of drugs, and differences in population growth. State funding approved in 1999 ($10 million) should reduce some of the variation, but there is still no financial mechanism for accounting for the growth in the SMI population by area, or for assuring that patients in different RBHAs have access to the same quantity or type of services (Interviews).