When Jamie Collidge showed up this week for her weekly therapy at ReVisions, a private mental health clinic in Catonsville, she was acutely aware that the center's future was in jeopardy.
Aware, and scared.
After hearing recently that the clinic was among many in Maryland running huge deficits and threatening to close, she began writing letters and placing calls to officials such as Gov. Parris N. Glendening and Lt. Gov. Kathleen Kennedy Townsend.
"I have a history of being terrified," said Collidge, 42, a former legal secretary who credits the clinic with relieving the paralyzing fear that once made it impossible to cook, clean or bathe, much less leave the house.
"I can't make it out there. Just talking about it is frightening."
In the midst of a funding crisis that has seen 11 clinics across Maryland close their doors, the state Department of Health and Mental Hygiene has taken some steps to ease, if not solve, the problem.
The agency, which has come under blistering criticism over the rates it pays clinics - and the delays and outright denials of payment for treatment - has given several clinics infusions of cash to keep them open at least for the next few months.
And though the Glendening administration holds out no hope of going beyond the 10 percent increase in mental health funding it has proposed for next year, state health officials have in the past two weeks agreed to remove some of the bureaucratic obstacles to getting paid.
These include authorizing six months of care for a patient, rather than the previous three, before requiring a new treatment plan. Also, clinics can get paid retroactively if they continue treating a patient before getting re-authorized.
"I think this will make a big difference in the administrative time and burden on providers," said Herbert Cromwell, director of a statewide trade group for mental health clinics. "But I don't think it's necessarily enough to keep clinics from going under."
The agreement came after a series of hearings and behind-the-scenes meetings arranged by state lawmakers, who stepped in to make sense of a controversy so dizzying that some invoked comparisons to Alice in Wonderland. The House Environmental Matters health subcommittee has been holding weekly hearings, including one scheduled this morning.
Among the clinics that have closed in the past year are two in Glen Burnie, one in Annapolis, one in Reisterstown and one in Baltimore.
When Granite House closed its clinics in Baltimore and Reisterstown, many of the 1,000 displaced patients filtered into other clinics run by the parent company, the Sheppard Pratt Health System. About 80, however, came to ReVisions, which enrolled 50 and put the rest on a waiting list.
"We're getting tons of people, off their medications with nowhere to go," said Jack Neville Jr., director of mental health services at ReVisions. "We're telling them we have no space, go to an emergency room."
It is unclear how many patients have been left without services.
Now, the state is working to keep ReVisions, in business for 19 years, from crumbling under the financial pressures.
After ReVisions' threat last month to close down Feb. 2, the state agreed to pay the private firm about $60,000 to cover three months of anticipated deficits. Meanwhile, the Health Department has hired a private consultant to pour through ReVisions' books to see whether the clinic can be saved through better business practices.
If no cure can be found, the clinic might yet close its doors to the 400 people it serves.
'Open to suggestions'
"We're open to any suggestions to make us more efficient," said R. Scott Graham, the ReVisions president. "But is it going to make up the $21,000 a month we're losing? I don't think so."
His words go to the core of the dispute over who is responsible for the deficits that plague an estimated 80 percent of the private, not-for-profit mental health clinics that serve the poor.
While the Health Department insists that many of the clinics are in trouble because of faulty business practices, such as failing to file "clean claims" and submit claims for all its patients, the clinics contend it is nearly impossible to break even without a substantial increase in Medicaid rates.
"The system is very, very close to collapse," said Nelson J. Sabatini, executive vice president of the University of Maryland Medical System, which operates two clinics in Baltimore that lose a combined $2 million a year.
"The program is underfunded, and it has been set up in a way that has created an incredible bureaucratic maze that you have to go through," said Sabatini, a former state health secretary.
It's a charge that rankles officials such as Health Secretary Georges Benjamin, who maintains that the state has doubled the number of people served by clinics over the past four years.
"We have provided better access and have a broader benefits package than commercial carriers," Benjamin said.
While industry officials say the state's Medicaid rates are woefully inadequate, Benjamin points out that the program pays higher rates than either federal Medicare or private insurers.
Medicaid, which pays for indigent patients, covers about half of the 80,000 people served by the clinics. The remainder are covered by Medicare, which pays for the elderly and younger people deemed disabled and unable to work, or private insurance.
This year, Glendening has proposed to increase spending on mental health clinics by $22 million, though the amount expands to $40 million when federal matching funds are taken into account.
"In the middle of a recession, to increase by more than 10 percent is a fairly significant action," said Michael Morrill, the governor's spokesman.
The controversy is rooted in the state's decision four years ago to revamp the way it provides mental health services to the poor.
Previously, clinics were paid grants - flat, yearly fees - to provide services to a prescribed number of patients.
In 1997, the state switched to a fee-for-service system, agreeing to pay clinics for each patient who walked in the doors.
The idea was to expand services to the mentally ill - and it worked.
'Victim of its own success'
The number of patients served by mental health clinics doubled from 40,000 to 80,000. And while 60 firms operated clinics in 1997, 89 were in business by 2002, according to the state.
"The system is a victim of its own success," said Dr. Steven Sharfstein, chief executive officer of Sheppard Pratt. "What's happened is that many more patients have shown up in this redesigned marketplace than they expected."
While the state has increased spending, it has not done so in proportion to the demand for services, said Sharfstein.
One problem is the large amount of time clinics spend delivering free services - ones not eligible for reimbursement - to a difficult population. These services include intervening when police respond to a disturbance, or helping to settle problems with family members or landlords.
As much as clinics are hurting, the state Mental Hygiene Administration ended last year with a deficit of $16 million and anticipates a shortfall of about $20 million this year. In July, in an attempt to control expenses, the agency instructed the private firm that reviews and pays bills, Maryland Health Partners, to scrutinize claims more tightly.
The crackdown has become a particular sore point for the clinics, which have accused the firm of denying claims for trivial reasons, delaying payments for weeks and sometimes months, and reducing the frequency and duration of treatment for patients.
"They're always finding reasons not to authorize services," said Brian Peake, director of Step Inc., a Baltimore center that trains people with mental disorders to find jobs. "When we get on the phone ... we spend a half-hour just justifying getting services for somebody."
Whether the department's recent agreement to ease payment hurdles will prevent clinics from closing remains to be seen.
To some legislators, just getting the two sides to talk to each other represents progress.
"It was almost like the parties were talking to each other but not listening," said Del. Peter A. Hammen, a Baltimore Democrat and chairman of the House Environmental Matters health subcommittee. "Now, they're listening."