A Mental Case
Even as doubts grow about using performance data in budgeting, mental health agencies provide fresh evidence of the benefits.
You know what really frustrates us, aside from rudeness, disloyalty and bad grammar? People who do things that hurt others, even when those actions go against their own best interests. Consider waiters in restaurants who are unpleasant, despite the fact that it'll hurt their tip, or telephone solicitors who refuse to let you disconnect, even though it's clear that they're wasting their own time.
Included in that list are state agencies that have decided there is no value in gathering information to optimize performance. We understand that performance-based budgeting has disillusioned many sensible men and women. It's very hard, and it may even be impossible in some cases. But there's a trend we see developing in a fair number of states in which the very idea of using good information to manage and budget is out of favor.
Even as some may grow disenchanted with developing and using performance indicators, however, there's growing evidence of their potential benefits. Examples of this are cropping up in the mental health arena. Of course, lessons learned in mental health may not be universally applicable, but they certainly showcase the kinds of payoff other agencies can receive.
Texas, for example, has taken note of the extreme variations in the types of treatments administered to mentally ill men and women. In fact, when patients changed clinics, they often found their medications were switched as well. Was there any benefit? No one could tell. So, the state began its Texas Medication Algorithm Project. Don't stop reading. The title may sound impenetrable, but the idea isn't: If you assume that one treatment is likely to be better than another, wouldn't it be a good idea to study which ones produce which results?
Makes sense, and recent findings demonstrate that patients with major depressive disorder--a problem that accounts for up to 60 percent of psychiatric hospitalizations--showed more than twice the otherwise anticipated improvement when they were treated with a particular regimen.
Not only can good information lead to better results, it has the potential to protect agency budgets in times of fiscal distress. There is powerful evidence to support that idea. Two thoroughly dissimilar states--Connecticut and Alabama--have been hit relatively hard by the economy over the past few years. Yet both states' mental health departments helped their fiscal cause by providing substantive and persuasive performance-informed information to the legislature and the executive branch.
"Quite frankly, I have stayed with the performance-based management and budgeting because it's helped me to interpret our needs to others," says Kathy Sawyer, commissioner of the Alabama Department of Mental Health and Mental Retardation. Sawyer says legislators are able to see the direct correlation between service needs and funding, and when they speak to certain levels of funding, "we can say what would be deliverable at those levels."
So, for example, one of the indicators that Alabama uses to measure the success of its psychiatric facilities considers their accreditation and certification. "We were able to say that with reduced funding, we could not meet that performance indicator," says Sawyer. "We might not be able to keep certification in two of the centers."
Largely as a result of this kind of information gathering--and despite 18 percent across-the-board cuts in Alabama last year--the mental health/mental retardation department received a slight increase in funding.
In Connecticut, the Department of Mental Health and Addiction Services has been particularly successful at tracking outcomes for individuals who make use of its services. Have they needed the same level of care again in a short time period? Are they steadily moving to less expensive kinds of treatment? Says one legislative analyst, "We see in legislative testimony that when the department is asked questions in hearings, they are very good at linking decisions to outcomes of patient wellness."
Officials in Connecticut have, for example, been concerned about proper access to care--keeping waiting lists short enough to assure that people are treated in a timely manner. "We were clearly having significant backup with people staying in emergency rooms for too long a time," says Dr. Thomas Kirk, commissioner of the state's Department of Mental Health and Addiction Services. "We went to the Office of Policy and Management and talked about the challenges we were having. We were able to get the finances to do a couple of different things that were helpful."
Neither Connecticut nor Alabama has been known as a national leader in the use of performance measures. Yet both Sawyer and Kirk have discovered their benefits. Others should take heed.
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