Leading legislators say they'll push a state agency to limit a mental health service that wasted at least $400 million during the past two years.

State senators said Monday they would seek changes in the way the government pays for community support, which has cost taxpayers more than $1 billion since March 2006. Legislators also want a law requiring state mental hospitals to report all deaths to North Carolina's medical examiner and give complete information about the causes to patients' relatives.

In 2001, the state instituted a plan to treat more mentally ill people in their own communities and fewer in the state's four psychiatric hospitals. Private businesses were to fill the gap, but costs flew out of control, seriously ill people went without treatment, and the state cut the numbers of hospital beds and staff.

A News & Observer investigation revealed 82 questionable deaths at state institutions since December 2000 and mismanagement of community support programs that allowed costs to explode.

Legislators discussed those issues Monday, but not Gov. Mike Easley, who oversees the state Department of Health and Human Services. A spokesman for Easley said he would not answer questions about mental health.

Private companies charge about $51 an hour for community support, a catch-all service that is supposed to help keep clients out of hospitals. Workers with a range of education and job experience are supposed to help clients, but many companies have employees with GEDs or high school diplomas doing most of the work.

Senate leader Marc Basnight, a Manteo Democrat, said it doesn't make sense to pay the same for a psychiatrist and a GED holder. At least, Basnight said, the state should tailor its rates to pay more per hour for licensed workers' time and less for high school graduates.

"That is a huge error," Basnight said.

Tailoring rates is a place to start the discussion, said Sen. Martin Nesbitt, an Asheville Democrat who has written mental health laws for about four years. But to regain control, the state might have to replace the service, he said. It would be better to replace the broad rules with detailed descriptions of what each worker does, and tie that work to a price, Nesbitt said. Saving money would be a side benefit, he said, while the real bonus would come in better care.

"I think they're not getting the appropriate treatment by these nonprofessional people," Nesbitt said. "You'll get clear oversight and control over what these people are getting."

Report all deaths

Beyond the costs, legislators said they would push for laws requiring hospitals to report deaths and notify patients' family members of the circumstances.

"I would support that," said House Speaker Joe Hackney, an Orange County Democrat.

The hospitals should report all deaths to the Office of the Chief Medical Examiner, said Rep. Verla Insko, a Chapel Hill Democrat who helps lead a legislative committee on mental health. if hospitals are not reporting true causes of death, she said, hospital directors should be held responsible.

Chief Medical Examiner John D. Butts said his office could review all deaths from state mental institutions. The state's medical examiners review about 10,000 deaths a year; the state's 13 mental facilities internally reported 49 deaths in 2007.

Butts acknowledged that the newspaper identified deaths that under current law should have been reported to his office but either went unreported or were reported without pertinent facts that would have triggered further review. Investigators with the state Division of Health Service Regulation cited state hospitals for deficiencies of care in some deaths, but those critical reports were not shared with the pathologists assigned to figure out why those same patients died.

Butts' staff is re-examining records of some of those deaths, he said.

"The parties involved need to sit down and figure out what's the best way, the most efficient way, to ensure each of us gets what we need to find out what happened to these folks," Butts said of mental hospital deaths. "We need to look to see where there are gaps and, like was said in 'Cool Hand Luke,' 'There's a failure to communicate.' "

From the grave

Since The N&O published its list of 82 deaths online, families from across the state have been seeking more information about loved ones who died in state facilities.

Among them was Lauran Nelson of Greensboro, who saw her father-in-law's name.

William P. Nelson was an elderly man who died at Dorothea Dix Hospital in 2002. Nelson was having difficulty swallowing and was placed on a diet of pureed foods. Later, he was fed and given medication through a tube in his nose. His death certificate indicates he died of an infection after inhaling food or vomit into his lungs, circumstances that are often avoidable if medical staff take precautions to prevent aspiration.

"All we were told is that he got a really bad cold, and then he got pneumonia and died," Lauran Nelson said.

She said it was difficult for her family to learn new details of the death so many years later, and she faulted the hospital staff for not being more forthcoming at the time.

"Some things should be in the past," Nelson said. "But some people speak from the grave. Sometimes that's the only way we'll listen."

(Staff writer Pat Stith contributed to this report.)