Sunday, November 07, 2010


Violence was caused by Hawaii’s decision to discontinue adult mental health services

by Larry Geller

The subhead in today’s front-page story in the Star-Advertiser is more accurate than the main headline:

Violence caused by freed patients

Critics say the August slayings by Clayborne Conley exemplify the state's oversight failure

The writer, investigative reporter Rob Perez, probably had nothing to do with the choice of headline. In fact, the violence was caused by a patient who could have benefitted from services that the state is denying its citizens.

The state’s proposed solution, cutting more Department of Health services, could further increase the number of avoidable deaths.

It’s hard to associate the Lingle administration’s cutback in mental health services as responsible for any single case of violence or avoidable death that breaks into the news. The evidence is statistical—an increase in deaths, as was reported to the Legislature in sworn testimony earlier this year. Keep that in mind while reading today’s newspaper report.

The article doesn’t detail the shutdown of the Assertive Community Treatment (ACT) services that provided intensive support to mental health consumers who required that kind of attention.  Perhaps Clayborne Conley could have benefitted from those services, had they been available to him.

Administration balanced the budget on the backs of mental health consumers

Cutbacks began some time ago, and we are seeing the inevitable result of the Lingle administration’s priorities in balancing the state budget.

As soon as the state was released from the oversight of federal Judge David Ezra in the adult mental health lawsuit, the Department of Health began cutting back the services that convinced the court to release the state. The cutbacks predictably resulted in poor oversight and increased deaths.

As usual, the DOH attempted to blame providers. The story indicated that more than 3 1/2 hours of case management time would have been authorized if needed. This is contrary to anecdotal reports that any extra time spent by providers would be to their own account unless authorized by a DOH intent on cutting the time.

Yes, the Lingle administration’s decisions chose death over life. Today’s newspaper story is but one example.

Nor is the state legislature free of responsibility. In March 2010 an informational hearing was called that revealed the damage caused by Department of Health cutbacks in adult services. The report was posted here on Disappeared News:

The first testimony was taken under oath, and after just a few minutes the news came out—a 36% increase in deaths 2009 over 2008 has been recorded.

These avoidable deaths can be attributed to cutbacks in state services to adult mental health patients.   [Hawaii’s deadly cuts in mental health services demand state response, 3/18/2010]

Here is the video clip from that article. Note the silence that follows Dr. McLaughlin’s testimony. Unfortunately, that silence has continued until today. The Legislature took no action on the information it received, and the Lingle cutbacks continued.

The state’s plan to further cut services came out later in that hearing. Services provided by DOH were to be rolled into the state’s QExA managed care system. Unfortunately, it was reported that this could cut off access to psychiatrists on Maui and perhaps other Neighbor Islands..

Cutbacks in service the cause, not solution, to the problem

Today’s article suggests that the problems will be resolved by that transfer. It also highlights the 3 1/2 hour maximum case management allowance imposed by the DOH. Prior to cutbacks, and in particular through the ACT program, a client could be seen every day if necessary. For example, an ACT team might assure compliance with medications, or would provide other supports needed for the client to thrive in a community setting. Neither the 3 1/2 hour DOH limit nor transferring clients away from DOH services substitutes for that kind of attention.

At least one incident reported earlier this year should also cast doubt on the wisdom of the state’s action.

In a high-profile case that grabbed public attention, an off-duty FBI agent shot to disable a man brandishing a toy gun on Tantalus. A whistleblower website linked the report that he was off his meds to an alleged lack of care coordination by the health plan he had been enrolled in by the State (see: Whistleblower confirms lack of care coordination, prescription coverage for Tantalus man, 5/13/2010).

DOH “business decision” endangers all of us

The DOH admitted quite early that its cutbacks in services were a business decision. Here is a 2008 article posted on Disappeared News:  

Today's Star-Bulletin article, State defends change to mental health help, raises questions about DOH's oversight of the contracts serving its mental health clients:


"We have been cast as having made frivolous, overnight decisions, and that is not the case," Michelle Hill, deputy health director for behavioral health and Adult Mental Health Division acting director, said yesterday. "I believe we have made appropriate business decisions ... to better insure good outcomes for consumers and accountability to the public," she said, explaining that ACT programs have experienced problems nationally.

She said providers were not following the ACT model and that the department was paying for a full array of services whether clients needed them or not.

Because ACT services were not being provided, Medicaid had to be billed for a lower level of services, Hill said.


If "providers were not following the ACT model" you have to ask why the DOH allowed that situation to continue. [Now that the federal court isn't watching, the Dept of Health cuts back on mental health services, 6/14/2008]

Simply put, someone determined to have needed 60 hours of intensive services a month cannot be served by substituting 3 1/2 hours of case management. The clinical determinations that intensive services were needed were swept aside by a “business decision,” one that inevitably, predictably, would result in loss of life.

As Dr. McLaughlin’s testimony demonstrated, that’s exactly what happened.

The actions of the professionals in charge of DOH and its adult services present a challenge to the incoming Abercrombie administration: appoint replacement professionals who might more strongly respect their Hippocratic Oath to do no harm. At the same time the new governor must deal with the budget shortfalls that the state is facing.

It’s a question of priorities. Without the oversight of a federal court, Hawaii’s mental health system has historically failed children, adults and prisoners. It’s time that was changed. While there are currently cases in court challenging both QExA and DOH cutbacks, a new administration in Washington Place could go a long way to reforming a DOH that has repeatedly failed its constituency.

And yes, that failure has cost lives.


Health insurance for early retirees has been proposed by the President. Still, you need to take care of your health while you're young to enjoy your savings in the future.

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