October 22, 2009
Host: Ted Simons
Mental Health Overhaul
- Responding to a court order in the decades-old Arnold v. Sarn lawsuit, Governor Jan Brewer has filed a proposal in Maricopa County Superior Court to make structural changes to Arizona’s behavioral health care system. Hear what Dr. Laura Nelson, Acting Deputy Director for the Arizona Department of Health Services Division of Behavioral Health and Anne Ronan, an attorney representing Arnold v. Sarn plaintiffs have to say about the Governor’s plan.
- Dr. Laura Nelson - Acting Deputy Director, Arizona Department of Health Services Division of Behavioral Health
- Anne Ronan - Attorney representing Arnold v. Sarn plaintiffs
Ted Simons: This week governor Jan Brewer respond to a court order by filing a plan to improve Arizona's system of health care for people with mental illnesses. It's part of the lawsuit known as Arnold V Sarn, filed nearly three decades ago. As David Majure reports, lawmakers took time earlier this year to review the case that continues to shape Arizona's mental health care system.
Jan Brewer: This is a history lesson. I would suspect that they are not eight people in this legislature that really understand the history of Arnold versus Sarn it.
David Majure: It’s a lawsuit that was filed in 1981 and the nation and the state were moving people out of mental hospitals into community-based behavioral health treatment.
Chick Arnold: I'm the institutional memory revolving around this case. I was a guardian as the Maricopa County Public Judiciary of 600 people with serious mental illness.
David Majure: He tried to help them obtain the community-based mental health services that were mandated by state law.
Chick Arnold: There weren't those Services in place. And with that, I became one of the five named plaintiffs in the center for law and the public interest effort to fix that.
David Majure: The case went all the way to the Arizona Supreme Court, which in 1989 affirmed that the state and Maricopa County have a statutory obligation to provide a wide range of Services for the seriously mentally ill.
Laura Nelson: Over the course of the lawsuit, as far as Services, it's been close to 2.2 billion dollars.
David Majure: Two decade and billions of dollars later, the lawsuit remains unresolved. Performance criteria required to end the lawsuit have not been met. And the company that manages Maricopa County's mental health system keeps changing.
Richard Clark: I am Dr. Richard Clark, the CEO for Magellan of Arizona.
David Majure: Magellan is the latest company selected as the regional behavioral health authority for Maricopa County. It was awarded a three-year, $1.5 billion contract in September of 2007.
Richard Clark: We do believe that significant gains have been made.
David Majure: But according to an audit conducted in 2008 by the court monitor assigned to the case, Services are declining.
Ted Simons: Governor Brewer hopes to improve the system by integrating physical and mental health care. She wants Access, Arizona's Medicaid program, to manager those programs for Access eligible adults. Other health clients and people with serious mental illnesses will still be served. The governor is also calling for a pilot program to serve the physical and mental health needs of people with serious mental illnesses through an integrated Service model. Joining me to talk about the governor's plan is Dr. Laura Nelson, acting deputy director of the division of behavioral health for the state department of health Services, and Anne Ronan, an attorney with the center for law in the public interest, which representatives the plaintiffs in Arnold v. Sarn. Good to have you both on the program. Let's get the basics. What is wrong with the way the state is care for mentally ill patients?
Laura Nelson: I think it's important to start out by -- to back around to the Arnold lawsuit and remember that that lawsuit is focusing only on the adult population with serious mental illness. That is the population that seems to be most in focus and under discussion around the state. The children's system has been let scrutinized of late, and the Services for general mental health adults and adults with substance abuse. The concerns that have been raised around working with the adult population that has serious mental illness lives back to the expectations and the court orders related to the lawsuit. And the various administrations that have been in place, the various providers that have been in place and the various regional health authorities that have been in place have at come out with -- at this with the same goal. We all have the same goals in mind, including that of the plaintiff and the monitor. We really want people to get the best care possible. It's how we go about structuring that system to make that happen and how we monitor appropriately to see that the outcomes are being achieved, has been at the crux.
Ted Simons: Why are the outcomes not being achieved? What is wrong with Arizona's mental health care system?
Anne Ronan: Well, from our perspective and when the most recent audit came out towards the end of last year, early 2009, we stepped back and said why do we continue to see the outcomes not be good, not be what people are expecting? Primarily the biggest concern was that the monitor's audit continually showed that the persons with serious mental illness needs were not being met. Which is the fundamental purpose for the behavioral health system, to meet the needs of these folks. What we feel quite strongly is that there are too many layers of infrastructure in the system in Maricopa County, and it makes it very difficult to actually hold anyone accountable for quality of the Services delivered. There are providers that have direct contact, there are Reba directors, then the state office at the department of health, and then there's the Access administration for that part of the population that are Medicaid eligible and very, at every given point somebody can say it's not really our fault things didn't work it's the folks below us or above it. We were advocating for fewer layers, direct responsibility from the state office to the consumer.
Ted Simons: It sounds as if the governor's plan has consolidation here. Access takes care of mental and physical care. Does that not get rid of some of the layers you're concerned about?
Anne Ronan: The proposal has the population of persons with what they call general mental health and substance abuse issues being transferred to "The Arizona Republic" health plans. It doesn't deal with the population that is the subof the Arnold lawsuit except are in a pilot. We don't actually -- we don't actually see from the pilot and from what little we know about the pilot, that there is actually going to be a change.
Ted Simons: Is that a legitimate argument, that the governor's plan focuses on an area that needs less focus than another area?
Laura Nelson: I think the governor has done a lot of work in the last eight months. She's met with various stakeholders, including plaintiffs and the monitor in the case, she's left with other regional behavioral health authority representatives, providers, advocates, she and a small group of legislators did their due diligence to gather as much education -- as much information as they can to educate themselves about what's working and what's not working in the system. They use that information to look at numerous options, and this was the decision that the governor made as being the best approach at this time.
Ted Simons: There are some critics, though, that say when you consolidate this mental and physical health care system in the way the governor has proposed, when other states have done this the results haven't been so hot . Is that a valid argument?
Laura Nelson: I think certainly part of the reason for wanting to do this as a pilot rather than wholesale move, physical health and behavioral health together is so we can absolutely take am good assessment and evaluation of what those outcomes would be. If we can structure our system in a way that we do achieve better physical health care as well as behavioral health care outcomes, we would be able to move forward. But I think she's being smart and wanting to pilot this project here in Arizona to see if we can achieve good outcomes.
Ted Simons: Does that make sense? Go ahead with a pilot program, see how it works, take it from there.
Anne Ronan: The problem with the pilot program is that first we don't know how many people are going to be included, but if we can assume it's not going to be most of the people, it's going to be a smaller number of the enrolled persons with serious mental illness, the pilot itself wouldn't even be operational in the best case scenario until sometime a year from now. The plan is to study the pilot for a couple of years, once it gets rolling, and in the meantime for thousands of persons with serious mental illness, there will be no change. And that is a very serious concern to us. Because we believe there needs to be a restructuring and greater accountability for the whole population. And to wait three years is not acceptable.
Ted Simons: Can you respond to that? Does that sound like -- did that make sense to you?
Laura Nelson: Ted, I'd like to respond to that. I think one of the things we need to keep in mind is that when the current provider, Magellan, came on board, they responded to a drastically different request for proposal than had been in place of that. Proposal was developed after consulting with the community W. stakeholders, with plaintiffs to talk about how we could restructure the system at that point. So we are already in the middle of and finishing a pretty significant restructuring process. The regional behavioral health authority has spent the last two years contracting with community-based providers to actually run the SMI Clinics here in Maricopa County. Previously the contractor themselves was directly responsible for those Services. So there has already been a significant restructuring that's taken place. It's important to also not assume that time has stood still since the last review of the system was done. There has been an enormous amount of effort going into establishing dashboards, looking at outcomes, increasing the staffing ratio, looking at the quality of the Services in the system.
Ted Simons: One of the problems I think we all have with covering this story, we're not quite sure what the pilot program entails. There's a lot of mystery there. Can you help us with that?
Laura Nelson: We can certainly talk a little bit about some of the issues that convenient identified. We had a good meeting yesterday where we started to talk about some of those topics that have come up. And they still need to be hammered out. Part of the process is going to be establishing a task force with the expertise at the table that can help walk through the things you need to think about. But as Anne just mentioned, there's questions as basic as how big will the sample size be? How many people will be enrolled? How will you ensure have you a representative group of individuals that are participating? What sorts of outcomes will you be looking at? How will you evaluate that? How will you fund this pilot?
Ted Simons: Do you have enough -- are you getting or do you think you will get enough information on this pilot program to get a better sense of what's going on here?
Anne Ronan: Well, I think definitely over the next couple weeks we'll get more information about the pilot program. But our concern is that by its own design, it's not going to result in change for over three years. I mean, that's how it was explained to us, that's the design.
Ted Simons: We've got a couple minutes. Give me a scenario, a patient, the patient in the system right now, a patient in the system as the governor wants to see it. What's the difference? What changes?
Anne Ronan: Well, we're not really sure except that there would be an entity who would be responsible for their mental health Services and their physical health Services, it would be -- in theory it would be the same organization. You mentioned earlier in some states this is not worked. And they've had some bad experiences in other places. One of the things that has happened when you're talking about such a big system is that could you just as easily get a large managed care plan that does the medical -- the physical health, subcontracting with Magellan or value options which would give us the same system we currently have in Maricopa County. Not real integration, just bigger providers contracting together.
Ted Simons: Is that not a concern to where folks would have much more experience on the physical health care side, and the mental health care side kind of gets the shortened of the stick?
Laura Nelson: Absolutely that's a concern. I know the governor has that concern as well. She's been extremely supportive of behavioral health, and I'm sure that one of the aspects of this whole pilot would be that behavioral health care not be overlooked. And it's important to acknowledge the research that's been done lately around morbidity and mortality for adults with serious mental illness. Individuals across the country are dying 25 -- in Arizona 30 years younger than the general population because they're not getting basic physical health care that everyone else is having access to.
Ted Simons: All right. We have to stop it right there. Great discussion. Thank you both for joining us tonight on "Horizon."
Anne Ronan / Laura Nelson: Thank you.
- Seth Shostak, the senior astronomer at the SETI Institute in California, talks about his agency's search for extraterrestrial life.
- Seth Shostak - Senior astronomer at the SETI Institute
Ted Simons: Is there intelligent life elsewhere in the universe? It's a question many consider, but few actively try to answer. One of those working and wondering is Seth Shostak, senior astronomer at the SETi institute in Mountain View, California. That's where scientists are looking for radio signal evidence of life beyond earth. Shostak recently wrote a book about his efforts titled "Confessions of an Alien Hunter: A Scientist's Search for Extraterrestrial Intelligence." I recently spoke with him about his search for E.T. Thanks for joining us.
Seth Shostak: It's a pleasure, Ted.
Ted Simons: Seti institute, what are you looking for? Are you looking for noise? Are you looking for beings? What are you searching for?
Seth Shostak: What we're really trying to do is prove that we're not the smartest things in the cosmos. That there's not only life out there, but there's life that's fairly intelligent. The way we're looking for that life is by looking for signals, mostly radio signals, maybe flashing lights, that would tell us there's somebody out there clever enough to build a radio transmitter.
Ted Simons: So you're looking for radio signals per se. Have you had false alarms? I know there was -- was it the wow incident at Ohio state? Talk to us about that.
Seth Shostak: The wow signal. 1977, Ohio state had an antenna that was just scanning the skies, 24 hours a day. Just sat there and collected static from the cosmos. And one morning one of the astronomers, Jerry Amon, came in, he looked at all the computer print out, in 1977 that's how you recorded the data, on paper, and he went through the printout and saw this big signal. And he wrote "wow" next to it. So it's become famous. But this is the triumph of marketing over product. This just happens to have a good name.
Ted Simons: Do we know what the wow was?
Seth Shostak: We don't. But the instrument was designed to that it would look in the same spot on the sky a little over a minute after anything had happened. So the signal was found, 70 seconds later it was looked at again, and nothing was found. So maybe that was E.T. and he went on vacation, took a coffee break, who knows? You can speculate until the bovines come home. But the facts are that you couldn't claim that as a detection if you didn't see it again.
Ted Simons: Without that prerequisite, how otherwise do you decide where to look? That's a big sky out there.
Seth Shostak: It is. The universe is vast. That's fairly trite statement. Most people recognize that. The number of planets in our own milky way is estimated currently to be on the order of a trillion with a T. That's a lot of real estate. Most of those planets are pretty lousy, but some of them might be, you know, like earth. So how do we choose where to point the antennas? Fundamentally we look at stars that we think might have planets like the earth, and we start with the nearest ones, because of course it would be more interesting to find E.T. nearby, and the signals would be stronger.
Ted Simons: So the signals are basically, what, something out of the ordinary? Something that suggests there might be something other than everything else out there?
Seth Shostak: Yeah. You have to look for a signal that's clearly artificial. We're not worried so much about the message. A lot of people think, you're looking for the value of Pi or something like that. We're not doing, that but we're looking for a signal that's restricted on the radio dial. It's that one frequency more or less. And it turns out nature does not make signals like that. Nature makes radio noise, but it doesn't make a signal that's just this spot at the dial. If you find something like that, and if it also happens to be coming from a spot on the sky that's just rotating around the earth with the stars, you say, OK, I don't know what they're saying, but there's somebody out there clever enough to be-to-build a transmitter.
Ted Simons: If there were something or someone out there, you would detect it by way of radio signals? Is there any way they could skip around those signals?
Seth Shostak: They may not be using radio. Those are the only kinds of signals we look for. We also look for very brief pulses of light. Maybe they have big lasers and they're trying to get our attention. That could be. So there are some experiments. There are other experimenting as well. But radio one is the traditionally the most important search.
Ted Simons: Talk about the Allen telescope array in California and how important that is to your ideas.
Seth Shostak: Well, the Allen telescope array is a new instrument, a new set of antennas being built by the seti institute, but also together with the University of California Berkeley. And it's up in the cascade mountains, 42 antennas, the idea is to have 350. It's called the Allen telescope array because Paul Allen, the cofounder of Microsoft, supplied most of the money to get that started. But the real point is speed. We've been always having to borrow somebody else's antennas when we do a search. So that's sort of like trying to do cancer research, but always having to borrow a microscope. So by having our own instrument, this search will speed up in the next 10, 20 years.
Ted Simons: I mentioned, where do you focus and how you decide S so far, how much of the sky have you searched?
Seth Shostak: Trivial. It's a very, I have tiny amount of sky. The number of star systems we've looked at carefully over of a wide range of frequencies, it's like 750. This is in a galaxy which has a few hundred billion stars, we've looked at 750. That's like sailing to Africa saying, we're going to look for megafauna, you land and you look at one square yard of real estate and say, I don't see any rhinos, no elephants, I guess there are no megafauna here. But the new instruments will be so much faster than what we've done in the past, I think it's not at all unlikely in the next two dozen years we'll hit a signal.
Ted Simons: That kind of brings to mind the idea that maybe we don't have the instruments yet to figure out what we're being -- there could be a bombardment of messages right now. We're just incapable of detecting it.
Seth Shostak: True. Maybe they have some physics we don't have that's important for this problem, and they're signaling some of the way that we can't detect, or maybe they're signaling even with radio or light in ways we can't detect. All that's possible. But what you try and resist, at least I try to resist, is the item takes to say, there are lots of ways we can fail, so we won't try. If you don't try, you're almost guaranteed. So we figure, this is a bit like saying to Chris Columbus, forget the wooden ships, wait 500 years, you can cross the Atlantic eating bad food.
Ted Simons: What happens if you try and succeed? What do we do if someone says "hey, hello!"
Seth Shostak: Responding is I think sort of a secondary consideration. Because it's very likely that anybody you hear they're going to be hundreds of light years away, maybe a thousand light years away. Which means that any response you make is going to take hundreds of years to get to them, maybe a thousand years, and then it's another wait before you get their response to your response. If they respond. So there's no hurry to grab the microphone in some sense, and this television program and many others are going out into space right now anyhow. So in some sense we've already respond at some level. I think that they'll recognize that. They will know that this is one way communication really. And consequently I think if they deliberately target us, if they want us to understand them, they'll just sends everything at once so we'll get a whole encyclopedia of information.
Ted Simons: Back here on earth, are we ready in case someone does respond?
Seth Shostak: Well, I don't think that we're ready. I also don't think there's any particular worry there if we respond. As I say, we have -- in particular we have television, FM radio, all of these signals are going out into space. But actually the most powerful signals we're sending are radars. And we are sending those into space. You might want shut down the local airport, because you're worried about the radar signals going into space, but honestly I think you'd rather land at night with radar.
Ted Simons: I guess my question isn't so much are we ready for them, because it doesn't really matter if we're ready for them or not, they'll be ready for us. Are we ready amongst ourselves? Are we ready to deal with the idea that after all these centuries of thought and religious thought, idealistic thought, that we would not be alone -- we're born and raised to think we're alone in the universe.
Seth Shostak: We find that otherwise, that could be a jolt to the system. But I don't think it's such a big jolt. Maybe I'm wrong. I have to say, polls have been made of the American populous, and something like 80% of them think that extraterrestrials are out there. About a third think they're already visiting earth, hauling them out of their bedrooms on these unauthorized experiments. So I think if they were to pick up the newspapers tomorrow, or hear on the news a signal had been found coming from 500 light years away, I don't think they would panic, because I think most people actually already believe that the extraterrestrials exist, and all you've done is substantiate something they already believed was true.
Ted Simons: How do you respond to folks who not only believe it, but say it actually happened? We were visited, whether it's New Mexico or somewhere in the woods of Arizona, they've been here, the government is hiding it, you know better but you're not telling us the truth?
Seth Shostak: This is the same government that runs the Pohl Service, and they've managed to hide extraterrestrials? If you want to believe that, that's OK, all I would say is show me your best evidence. Even though these claims have been made, tens of thousands of them everybody year, tens of thousands of sightings and things, what difference has that made in our lives? What have we learned from that? I think the answer is not too much, it's provided a lot of entertainment on fox television, for example, but have we learned anything from that? No. And I think if we have a really being visited, this would not be just the subject for late-night radio chat. We would know we were being visited.
Ted Simons: Yet on the other side of those critics are those who say this entire enterprise is a colossal waste of time. Why bother looking for life out in the great beyond, you're going to get nothing from now until the last syllable of recorded time.
Seth Shostak: They could be right. But they can't promise me that they're right. They can't guarantee that we'll be right. And I think that in the end this comes down to curiosity. It's like, wanting to know how the universe began. How will that affect your daily life? There's something philosophically profound about asking questions you're just curious about the answer to. That's what makes us different. Just knowing that what's happened on this planet is not a miracle but just something that's happened many times in the history of the cosmos, I think that would be very interesting to know.
Ted Simons: So the search goes on.
Seth Shostak: The search goes on.
Ted Simons: Thank you for joining us.
Seth Shostak: My pleasure.