As a result of the review and analysis of the relevant research and interviews with health professionals and others in Arizona, the following prescriptive conclusions are warranted:

• New psychotherapeutic pharmaceuticals offer true innovations in the treatment of SMI patients and hold out the promise of an improved quality of life and health outcomes. Whether patients achieve the promise, however, depends on more than access to medications. Studies already show that patients who improve clinically need other mental health and coordinated services such as counseling, support to relearn social and vocational skills, safe housing, and diversion programs to keep them out of the criminal justice system when their illness feeds into criminal behavior. State legislators have judged the value of new medications to be worth the cost and have provided new funding to improve access to these new drugs for the SMI population. Legislators will need to reaffirm that judgment, however, at each budget cycle and expand funding to meet the need for medications and services for Arizona's growing population.
  

• Not all SMI patients who might benefit from the newer psychotropic medications have access to them. New state funding, as important as it is, remains inadequate to meet the demonstrated need. Access to medical care for this population is guaranteed only for those covered under AHCCCS.
  

• There is evidence that the use of newer psychotropic medications with SMI patients results in a shifting of costs from one segment of the mental health care system to another. Whether the cost offsets or shifts result in greater or lesser overall costs for services to the seriously mentally ill remains unclear. Evidence does not yet demonstrate that treating SMI patients with newer medications results in cost offsets or savings in the area of general medical care (verses mental health care). "Cost offsets are relatively unlikely to occur in connection with the mental health treatment of schizophrenia, bipolar disorder, or the other most severe mental illnesses." (Olson 1999 p.8) If more information is wanted, studies will be needed to show how newer medications specifically affect SMI patients, mental health care systems, medical care systems, families and society over the longer-term.
  

• Because the new psychotropics are designed to treat and manage a particular mental illness, they should not be judged by medical offsets for other medical care and services alone. The same criteria used to judge the effectiveness of other "halfway" medical technologies should be applied to the new psychotropics as well. They should not be mistaken for "full" technologies and tied to medical offset criteria simply because they affect mental conditions.
  

• The state is the major purchaser of SMI care through managed care. It is responsible for assessing the value of services received and holding contractors accountable. An ongoing monitoring process that assesses defined performance indicators for SMI patients, such as the number on newer medications, is needed. ADHS is to pilot such a program in 1999.
  

• The approach ADHS and the AHCCCS Administration take for financing and delivery of mental health services is a model for insurers and providers in the state. Arizona led the nation in developing an innovative Medicaid managed care program when it created AHCCCS. It could now lead the nation in developing an integrated mental health and medical care Medicaid program focused on improving patients' mental health outcomes and health status.
  

• Kessler (1994) estimates that almost one third of the adult population experience some impairment due to a behavioral health problem in any one year. Estimates suggest that "mental health and substance abuse problems are comparable in magnitude to cancer and heart disease." (IOM 1997, p.78). "It's estimated that over one half of all episodes of care is provided in primary care settings, not in specialty programs. Despite clinical practice guidelines, continuing education courses and other training programs, primary care providers tend to underdiagnose depression, substance abuse, and other behavioral health problems." (IOM 1997, p 3) AHCCCS medical health plans, like many private health plans, do not want to absorb the cost of mental health medications and seek to shift the costs of mental health medications in the general medical care setting to the state's mental health programs.
  

• General practice physicians, mental health specialists, ADHS, AHCCCS, private managed care/insurance companies and the RBHAs should jointly address how to plan for and treat the behavioral health needs of the state's population. Ensuring appropriate care within and between different private and public systems is necessary if people are to fully benefit from the availability of new medications and treatments.
  

• Whether there will be expanded access to treatment innovations for the seriously (and not so seriously) mentally ill is ultimately determined by whether treatment for the mentally ill is valued as much as treatment for the physically ill. The largely organic nature of both mental and physical illness dictates that they be approached in essentially the same manner. One impact of the availability of new mental health medications has been the expanded use of the drugs beyond the mental health community, patients and their families.
  

The public is coming to understand that mental illnesses can be controlled with medications and other therapies. Consumer demand will change the approach to mental health, both in behavioral health specialty settings and in general medical practice. Consumers will demand that their care no longer be "divided" and parceled out, not just to different treatment settings, but to different levels of treatment for the same "body." The dollars that Arizona spends for both mental and physical, health care will provide limited value for the money expended unless there is access to systems that treat the whole person.