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have an option as to mental health services, and I think it is very important that mental health centers begin negotiating with these HMO's, these health centers, so we do develop mental health services there and have income in that way. I think if it is looked at carefully, the centers are in a much better position to negotiate with health centers than other agencies that are in existence.

I know that in my current negotiations I almost scared the director of the health center off when I said I was getting community chest funds. I did not get to the point that I was getting Federal, county funds. That might have ended it there. In any event, I think it is a very important bridging.

Congressman Hastings' district covers the poorest county in New York State, Allegheny County. Categorical grants are meant to meet the needs and carry the services to people who can't get services, the poor. They are meant to develop different systems of delivery that fit into communities as we have heard before. I think it is important for Allegheny County, for the continuance of the Community Mental Health Centers Act. One further point is I think as centers grow older, as they have been around longer, there will be a need and a demand for them to develop services in rural areas or areas outside of their home. We have had some experience with this in Wayne County which is a poor county, east of Monroe which is relatively affluent. I think the structure and form of the service that develops there might be quite different than the present mental health centers. I think in terms of Allegheny County that this is an area that we might well eventually look into maybe not for the development of mental health centers but some type of mental health services.

Finally, as director of mental health services, I figure I spend around $100,000 a year in regulatory agencies. I think it is very necessary that there be a central movement toward centralizing these so I don't spend $100,000 on site visits and this type of thing that takes away from patient care.

From this standpoint, I propose that the comprehensive health planning of the agency become the major agency and that other agencies piggyback on that.

Finally, there are several other points and my time is up. I think on the whole issue of the Federal money that it should continue to continue the impetus of the community mental health centers movement which I think is the first movement in a long period of time to radically change mental health services.

Thank you.

[Dr. Hart's prepared statement follows:]


The continuation of federal support via the Community Mental Health Centers Act is necessary until National Health Insurance becomes a reality. I would recommend at this time that the present eight year limit on funding of Centers be extended to eleven years. Also, there should be a continuation of new Center funding so that more Centers can be developed. The complete phasing out of federal "seed" money can have a disastrous effect on a community. Federal support can build up a program that cannot be supported in its full form by local funds or cannot be supported at all. This program, when it has failed, creates a great deal of stress not only on the persons to whom the program was directed,

but also the agencies that were administering the program. The principles that I am going to speak to below, although directed to the Community Mental Health Centers Act, should also be woven into any National Health Insurance that is made into law.

The National Council of Community Mental Health Centers have a detailed blueprint for a new Community Mental Health Centers Act. I believe that you have it, or if not, I can see that you are provided with it. I do not intend to cover all are facets of the Act as proposed by the National Council, but will speak to certain philosophical underpinnings for the Act that have become_apparent to me as the Director of a Center. The Center came into existence January 1, 1967 and I have been the Director of the Center since that time.

Categorical grants were devised to meet neglected needs in human areas that local communities for some reason had not attended to. Without continued federal support, I feel that at this point of Center development we would revert and these needs would again become neglected. Revenue sharing that theoretically should help satisfy these needs actually enforces the "old" attitudes of the community by coming through traditional channels. It is molded by the traditional attitudes of those channels. Categorical grants, however, addresses itself directly to the specific unmet need.

It is necessary to continue federal support to preserve the independence of the Mental Health Centers that offer a varied spectrum of services that are geographically accessible and available to all with markedly decreased stigma as compared to the older services. The Centers have moved services from inpatient services at State Hospitals to outpatient services within the local community and to day care and inpatient services. This occurred when the patient impinged upon them to such an extent that they could no longer tolerate it. I see no evidence that the public at this time is any more willing to buy more progressive services such as outpatient services than they were in the past without the stimulus of federal support.

The State Hospital system is very large and powerful and tends to reabsorb patients and services and staff back into itself. In New York State, $580 million per year are spent on State Hospital services versus $10 million State dollars going to Mental Health Centers. Without continuing federal support, the difference in funding would tend to reduce the flexibility that the Centers have. Patients and staff do not want to leave the State Hospital system. The patients and staff are used to a way of life and without an outside agency to stimulate the painful change it will not be done. The Unified Services Act recognizes this and attempts to provide this outside stimulus.

Public opinion resists the movement to a new system of delivery. This opinion will impinge at the many points where revenue sharing comes down the pipeline and prevent a change in the system. Many relatives have developed a habit of hospitalizing a certain member of the family and will have difficulty breaking this longstanding tradition. Large hospitals have become a very important economic resource to the area in which they are established. A short time ago I heard a legislator attacking the closing of a large State facility in the area in which he lived and the adverse economic impact it had on that area. Mental Health Centers provide for the development of other types of services into which this staff can move and alleviate the economic impact upon both the staff and the local community.

The Center is idiosyncratic to the area it serves and needs to be responsive to the peculiarities of both the community and the staff that it is able to recruit. The federal grant so far has provided for more variability and more responsiveness to local communities than would have been possible without it. There certainly needs to be central minimum standards but not complete control of a program that makes it conform to procedures that may be irrelevant to the area in which it is operative.

There should also be provision in the law for coordination of the services other than Community Mental Health Centers, probably through comprehensive health planning. In New York State, for example, no Department of Mental Hygiene programs go through comprehensive health planning. So in our community, roughly half of our services go through CHP and half do not.

Also, coordination is necessary to prevent the increasing paperwork concerned with regulations from overwhelming an agency. I spend a minimum of $100,000 a year or almost 10% of my budget satisfying regulatory agencies. This money, of course, comes out of patient care, reducing the amount available. Recently, I had 3 separate agencies mandating me to fill out 3 separate forms

that were almost exactly the same. I felt that it would cost me $6 to $7,000 a year to comply with this request. However, after some correspondence and a meeting, we were able to reduce this markedly. The problem still remains a difficult costly one.

The Unified Services Act that was just passed by the New York State Legislature will in the near future begin channeling some of the $580 million institution money and probably eventually all of it through local government for mental health care. There are no specific references in this Bill to working with Health Centers and it is important that the Mental Health Centers remain independent to negotiate with the developing HMO's so that they develop mental health services. This is a difficult problem to integrate these services in that the HMO is trying to develop services with the least expense to the enrollee and leaving out mental health services would reduce this cost. In my experience they are somewhat cautious about negotiating with a voluntary non-profit organization much less a State organization. However, for effective patient care there has to be integration of both the State Hospital system and the developing health center. The provision for the continuing development of new Centers is another very important point in the renewal of the Community Mental Health Centers Act. At the present time only 15% of the population of New York State is covered. Unless this 85% is gradually covered, the patient pressure on the existing areas covered would lead to the demise of the Community Mental Health Center, to say nothing of the inequity of the situation. The present Centers can lead to the extension of services to areas outside their catchment area in areas that otherwise might not be able to develop independent services. For example, we are in the process of developing consultation services to a rural Center in Wayne County. There are no services there and I do not think they could be developed independently.

Consultation and education are difficult to provide for but very necessary components of a mental health center. With the developing system of health centers providing only payment for direct care, this mode of service will not be acceptable to them because services will go to other than their enrollees. Therefore, there must be some sort of a capitation method of payment for consultation and education possibly with State matching.

Finally, there should be direct grants for training all types of personnel such as psychiatrists, psychologists, social workers, recreational therapists, etc. The University is having a great deal of difficulty financing their training programs and if the Mental Health Center could be a source of funding, albeit modest, this would attract trainees to the program and so expose them to community mental health activities. The community mental health system of delivery is markedly different and when we hire personnel we have to essentially retrain them to be able to work with us. I think the major value of funding that would attract trainees to Mental Health Centers would be to expose them to a service-oriented delivery system. This would then have impact in how they would practice in the various settings that they went into and in turn have impact on those settings. In conclusion, the Mental Health Centers have made a modest beginning towards the development of a new delivery system to meet the needs of the population rather than small isolated groups. To maintain the impetus of this beginning it is necessary for funding that will sustain the existing Centers until National Health Insurance is available and to fund the development of new Centers to reach the total population.

Dr. MILLER. Thank you very much. I am pleased you mentioned the HMO's. I only hope that as HMO's develop, they will emulate what I consider the essential dimension of mental health centers: namely, that they will be responsive to and work with whole populations, rather than just those people who register with them.

I think that approach would make possible the kind of collaboration and synthesis which you described.

I might also say for the record that every county in New York State, including even Allegheny, has a county governmental department of mental health, retardation, and alcoholism. I think that gives us, with Federal legislation helping us, an opportunity really to extend to every citizen the kind of program which we have heard every citizen in the State has a right to.

I would like to call last and perhaps not in that context quite appropriately, Mr. Carman Santor. Mr. Santor is the new president of the New York State Association of Community Mental Health Boards, which are for the counties and New York City the local governmental bodies which bear responsibility for the development of mental health, retardation, and alcoholism services. Mr. Santor.


Mr. SANTOR. Thank you very much, Commissioner Miller. I will be very brief. Following some of these most moving presentations, informative and even provocative, I would like to express appreciation to Congressman Symington's and Hastings' requesting the House Subcommittee on Public Health and Environment for holding these hearings.

The Congress recently voted to extend the act for 1 year, one purpose being primarily to evaluate the continuing need for community mental health services center legislation. At the recently held annual meeting of the New York State Mental Community Centers Board, at Nyack, N.Y., the following resolution was unanimously adopted:

Whereas both Houses of Congress overwhelmingly voted to extend the community health centers for another year, and

Whereas continued responsibility and fiscal support for existing and new mental health programs are desirable and essential to meet the need of the American people-mental retardation, drug abuse and children's services, therefore, be it

Resolved, That the New York State Community of Mental Health Boards go on record as strongly supporting the enactment of H.R. 7806 and Senate 1136. Copies of this resolution be promptly forwarded to President Nixon, Health, Education and Welfare Secretary, Caspar Weinberger and the news media.

As the newly elected board of an organization co-sponsoring the "1973 conference on community mental health services," I feel it is both a privilege and responsibility to attend and participate in this important event being held today.

One of my first important official duties upon assuming this statewide office was to be invited by you, Commissioner Miller, to attend and actively participate the day that many employees were recognized from the State hospitals and the State schools.

It was very moving and it gave me a chance from grassroots as a consumer producer to meet the people "where the action is."

I also felt it very rewarding to also accept Governor Rockefeller's invitation to participate in a unified signing bill, a hallmark in mental health service legislation which you helped engineer through with a lot of hard work.

As we are all aware, the purpose of this bill is to provide unified services, which will grant to the State and the communities opportunities to engage in joint planning activities. It is hoped sincerely that we will have the necessary leadership and financial support so that the needs of the mentally handicapped will be continuously met, nationwide and we will have a true partnership as well as having the consumers and the volunteers and the paraprofessional's contribution so that we can better utilize and strengthen our human resources in this technological and space age of ours.

Again, I would like to thank Congressman Hastings for inviting me to participate on the most important and timely occasion on behalf of the mentally disabled.

Our New York organization of mental health boards will continue to be vigilant in its efforts at all levels of government in these most urgent and pressing matters involving our citizenry.

Thank you.

Dr. MILLER. Thank you very much, Mr. Santor.

I thank all of you who have testified, all of you who have come. I apologize that there has not been more opportunity for discussion this morning, but there will be this afternoon. I thank my colleagues at the head table. I am sorry they did not have a chance to speak further this morning. We are especially appreciative to Congressman Symington and Congressman Hastings, for holding this extraordinarily rich hearing which will provide a report to the national Congress of what people in New York State are thinking and doing. Many thanks.

[The following statement and letter were received for the record:]


The American Osteopathic Association (AOA), the American Osteopathic Hospital Association (AOHA), and the American Association of Colleges of Osteopathic Medicine (AACOM) are compelled to take this opportunity to submit for the record their views on continuing Federal assistance to the development of Community Mental Health Centers. In this regard, the Associations wish to express their grave concern over the fate of the Thousand Hills Community Mental Health Center (THCMHC), which, upon its completion will provide needed health services to approximately 200,000 people in Northeast Missouri. Plans for the development and implementation of THCMHC were initiated by the Kirksville College of Osteopathic Medicine (KCOM), Kirksville, Missouri. This center is geared to provide both inpatient and outpatient facilities and services for comprehensive mental health care for an 18 county catchment area with KCOM being located in the center of said area. THCMHC is to be located on a site owned by the College, immediately adjacent to the Kirksville Osteopathic Hospital.

In early 1969 KCOM applied for a federal grant to assist in the construction of THCMHC, and a Federal Construction Grant of slightly over $600,000 was awarded. The projected cost of the facility is $1.2 million. KCOM has accepted the responsibility of raising $200,000. An additional $400,000 is available from the Commerce Bank in Kansas City contingent upon a Federal Staffing Grant. Therefore, an appropriate grant application has been submitted to the HEW Regional Office.

Unfortunately, the recent decision by the Executive Branch to cut staffing funds from the budget, is in actuality negating the essential objectives of the original legislation. In taking this action, the Admnistration has stressed the availability of state funding through the program of state revenue sharing. In fact however, funds for this needed health service will not be forthcoming from the state; thereby nullifying the highly documented need for such a service.

The problem is further compounded due to the fact that experience has shown that it normally takes 8 to 10 years of operation, before patient fees and third party payments can meet normal operational expenses.

The need for this facility is exceedingly obvious. In excess of 10,000 Northeast Missourians will be affected by some form of mental illness in the forthcoming year. Whether it be from anxieties and fears, tensions resulting in alcoholism, drug abuse, or personal tragedy, these problems are as critical as any terminal disease; for, in fact, they affect the very moral fiber of our country and cannot be ignored. Unfortunately, the closest mental health center in the area to be served is over one hundred miles in distance. The availability of such a center would afford the 19,000 potential patients of THCMHC with their right to receive immediate and proper care in their own community in addition to a tax advantage of untold thousands to the State and the families to be served.

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