Suspect’s Release From State Mental Hospital Exposes Cracks in System

Russell Eugene Weston Jr.’s release from a state mental institution in December 1996 came just as Montana was embarking on a tumultuous transition to privatized mental health care--the most comprehensive such transition in the nation and one whose debut has left mental health services for the poor in profound disarray.

Although Weston was hospitalized under the old, state-run system, his release underscores the difficulty everywhere in ensuring that patients--especially mobile ones like Weston, who shuttled between Montana and Illinois--receive adequate follow-up care, several analysts said.

Caregivers at the state mental institution in Warm Springs, where Weston, who is accused of killing two Capitol Police officers, was involuntarily hospitalized for 52 days, made follow-up appointments for him with mental health providers in Illinois, based on Weston’s assurances that he was returning to live there with his parents. But there was no mechanism in place to ensure he kept those appointments, Montana officials said.

“I think the mental health system in general, not just in our state, has a problem with that linkage from when people leave inpatient treatment into community treatment in making sure that there’s follow-up,” said Randy Poulsen, who has overseen the transition to private managed mental health care for the Montana Department of Public Health and Human Services.

“For instance, if the person is prescribed medications, that somebody is making sure that they take the medications. That they have supportive case management. That’s a problem for all states . . . and when the person leaves the state, there’s a real problem of coordination,” Poulsen said.

In Weston’s case, some neighbors raised questions about whether the state’s April 1997 transition to managed mental health care could have allowed Weston to slip away. Was there someone available, wondered neighbor Cathy Maynard, to ensure that he took medication to control his paranoia?

“He could very well be one of those people who fell through the cracks in not having a system that’s been created to help them,” Maynard said.

More than half a dozen states across the nation--including Iowa, Utah, Colorado and Massachusetts--have moved to managed health care for the mentally ill. But Montana led the way in a comprehensive transition that took in patients served under federal Medicaid and block-grant funding, in addition to state mental health programs and the state mental hospital.

Previous fee-for-service programs were escalating at the rate of 10% a year, and state officials believed they could control costs while significantly increasing the number of poor people covered under state and federal-sponsored mental health programs by turning them over to private management.

But the entire network perched on the brink of collapse during its debut last year after the private contractor, overwhelmed in paperwork and undergoing a corporate buyout, failed to pay claims and sign up health care providers.

Patients complained they were being forced to take cheaper medications with more side effects, and nearly everyone feared access to mental health care was getting worse, not better.

“We expected some start-up problems, but we didn’t . . . expect that it would go on this long,” Poulsen said. “Certainly, I can’t say that accessibility has improved, and I think maybe it has worsened.”

While Montana always has had a problem with mental health care in rural communities--a third of the area of the state has no resident psychiatrist--the access problem also has shifted to some cities with the advent of privatization, Poulsen said.

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In Helena, where Weston’s follow-up services would have been undertaken if he had remained in Montana, some psychiatrists have been “alienated” by managed care and have been reluctant to serve the indigent, Poulsen said.

“I think that will change; they will come around if they can see that claims are being paid and the paperwork headaches are lessening. But just to be real frank, I’d have to say in some aspects, access to services has declined,” he said.

Patients have resisted the idea of a private management company deciding what services they should receive.

“We already know what we need. We don’t need them telling us,” said David Cockrell, a Missoula, Mont., resident who has been receiving state-sponsored treatment for schizophrenia.

“There’s been a lot of doctors who’ve prescribed medications, and then the privatized funding sources would not authorize that. Or, certain people would want certain services, and the managed care companies would not approve it,” Cockrell said.

“I think that the psychiatrists and counselors are competent, and they know what’s appropriate for the clients that they’re serving, and I don’t really think that they need somebody standing over them who really doesn’t know anything about it, telling them what services we need,” he said.

The transition has proved politically controversial, with Democrats going on the attack against Republican Gov. Marc Racicot, whose administration also has moved to privatize prisons.

Bob Ream, the state Democratic Party chairman, has written editorials against the privatization movement. “Privatization is fine, but there are some of the very basic services of government that I think have to be continued by government: police, fire protection, prisons and taking care of the very worst-off citizens in our civilization, those that are worse off than you or I, that absolutely need help. Obviously this guy did,” Ream said of Weston. “I don’t know anything about his medical history or what he was going through, but certainly he was in need of help.

“I guess I just see more of that happening. Not necessarily shootings, but if you leave the very worst people, let them fall through the safety net, they’re going to break out somewhere else.”

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Still, there is widespread agreement that no one could guarantee that Weston would seek follow-up care or take his medications.

“It’s like, if a person doesn’t want help, there’s nothing that anybody can do. In order to really make the system work for somebody, they have to really want your help,” Cockrell said.

Jackie Bergen, a longtime friend of Weston and his family, said no one could ensure that he continued to take his medication.

“He’s a paranoid schizophrenic, and his mind just got the best of him. He really needs help, and he just never got it, mostly because he just didn’t believe he needed it,” said Bergen, who is a nurse. “You can’t force somebody to take a medicine to make them better, and unfortunately that was the case of Rusty. When he took medicine, he was fine. But he just didn’t believe he had a problem.”