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CMHS National Advisory Council
Meeting Minutes

U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services

EIGHTH MEETING
CENTER FOR MENTAL HEALTH SERVICES
NATIONAL ADVISORY COUNCIL MEETING MINUTES

Holiday Inn Bethesda
8120 Wisconsin Avenue
Bethesda, Maryland

September 12 and 13, 1996

Council Members Present:

Council Members Absent:

Guest Speakers:

Other Staff Present:

Minutes From the Center for Mental Health Services
National Advisory Council Meeting
September 12 and 13, 1996

Day 1-September 12, 1996

Bernard S. Arons, M.D., Director of the Center for Mental Health Services (CMHS), reviewed the agenda and introduced two new Council members: Dr. Steven P. Shon, M.D., Medical Director of the Texas Department of Mental Health and Mental Retardation; and Dr. Daniel Gottlieb, Ph.D., a psychologist, writer, and advocate for people with disabilities.

The minutes from the previous meeting were adopted.

Director's Report

Dr. Arons introduced the theme of listening, and the Center's commitment to listening to the advice and recommendations of the Council. In addition, he stated that the meeting would focus on information about children with serious emotional disturbances.

He reviewed the challenges of the previous fiscal year and the difficult task of keeping our focus on what is really important. He noted that the Center had many accomplishments. "CMHS is now widely recognized as a visible, reliable, and timely source of information. We have emerged as national leaders in the technical assistance area. We have made many new friends in the field, in the Administration, and on Capitol Hill- people who understand the importance of our work at CMHS and appreciate the impact we have on the field."

The Council reviewed the President's 1997 budget proposal, which Dr. Arons explained in detail.

Dr. Arons commented on the ongoing need to educate the field about the importance of our work and how every dollar administered by CMHS translates into an improved quality of life for someone with mental illness.

He discussed the parity issue and its accompanying debate, one that has resulted in policy makers and advocates underscoring the fundamental issue at the heart of this debate. "The cost of parity should not be measured only in dollars and cents but in common sense." He noted that the issue of parity for mental health coverage had reached National debate, underscored by a letter from President Clinton urging Speaker Gingrich to act quickly to enact three important health reform provisions enacted by the Senate.

He concluded by describing upcoming activities and programs, two of which included the development of an online application process for emergency and disaster relief programs offering crisis counseling and a proposed meeting of the Center's technical assistance and research centers to discuss increased collaboration.

In response to Dr. Floyd H. Martinez's question about the trend to promote collaboration between the substance abuse and mental health fields, Dr. Arons stated that SAMHSA has tried to get its three Centers to work collaboratively. In the field, he noted, the movement toward behavioral health care as an approach to the delivery of services has aided in the integration of mental health and substance abuse services. The extent of co-occurring disorders, especially recent data from the National Comorbidity Study, points to the need for integrated treatment services.

Consumer Affairs Update

Dr. Arons introduced Paolo del Vecchio, Consumer Affairs Specialist with the CMHS Office of External Liaison. Mr. del Vecchio introduced Iris Hyman, Consumer Affairs Specialist, who recently joined the Office of External Liaison. He noted that the staff will eventually include a third consumer affairs specialist. Ms. Hyman will write a quarterly consumer affairs newsletter.

Mr. del Vecchio mentioned that the grassroots organizations have responded favorably to the managed care pamphlet for consumers.

In the ongoing effort to encourage more consumer participation in CMHS and SAMHSA, Mr. del Vecchio has met with all Center divisions and offices to develop 1997 priorities. He is revising the plan, which will be available at a later date.

Mr. del Vecchio mentioned the following ongoing activities:

• Consumer publications from the CMHS Programs;
• A consumer teleconference on issues for people of color;
• A joint meeting of consumers and psychiatrists to discuss common issues;
• A Veterans Administration advisory group on mental health issues for veterans;
• Development of a consumer database on the Information Center Web site and BBS; and
• A CMHS survey of self-help groups nationwide.

Mr. del Vecchio mentioned recent study results reported by Ron Kessler, a University of Michigan researcher, who noted that 40 percent of all visits for mental health services are for self-help groups; the number of people participating in self-help groups has doubled in the last decade and may be as high as 12 million people.

Charles A. Kiesler, Ph.D., said that he thought the 12 million estimate was low and mentioned a task force report on self-help from the President's Commission on Mental Health.

Mel Haas, M.D., CMHS Associate Director for Medical Affairs and the Center's AIDS Coordinator, introduced Adolfo Mata, SAMHSA's Acting Associate Administrator for AIDS. Mr. Mata reported that he would be willing to attend future meetings to discuss HIV/AIDS issues, and that he could provide briefings on SAMHSA-wide HIV/AIDS activities.

Respect and Recovery: An International Perspective

Dr. Arons introduced Council member, Joel C. Slack, Assistant to the Commissioner and Director of the Office of Vision Implementation at the Alabama Department of Mental Health. Mr. Slack recently returned from a trip to Europe, where he lectured on consumer issues to caregiver groups in the Czech Republic, Hungary, the Netherlands, Sweden, and Denmark.

Mr. Slack said that he had hoped to describe some very unique dynamics comparing respect and recovery in Europe with respect and recovery in the United States. However, because the differences were insignificant, he spoke instead on the activities and mission of groups in other countries.

Mr. Slack traveled to Europe to attend the World Congress on Psychosocial Rehabilitation in Rotterdam, the Netherlands. He emphasized that our mental health systems and activities are connected, and that we have a lot to learn from what is happening in other countries, and vice versa.

Mr. Slack presented slides and discussed his experiences traveling through Eastern Europe. For example, under the former communist regime in Czechoslovokia, extensive data were collected. People were categorized as either "neurotic" or "psychotic." He noted that neurotics were classified by gender, unlike psychotics; he added that alcoholism is a huge problem and is equally distributed among men and women.

Describing communism as "the most unique form of managed care we've ever seen," Mr. Slack said that the Eastern European countries are moving toward private delivery systems.

Mr. Slack pointed out that under former communist governments, intellectuals and doctors did not receive much respect, consequently, their salaries are low. Even so, social problems are prevalent and they want the doctors to cure these problems and resolve them, but the government is unwilling to value and honor them in any particular way. He also noted that because doctors are paid so poorly, they are able to empathize with their patients, who are also poor! Czechoslovakians were dismayed by the way some States commit people to psychiatric hospitals in the United States. The Czech Republic has a more evolved process of committing people. Even after an individual is committed, the next day he or she is permitted to become a voluntary patient.

Mr. Slack showed several slides of historic Prague and the city's treatment facilities. He described an annual celebration in which the ex-patients get together in the old town square, dress in different costumes, and then dance and celebrate in an effort to find some degree of joy and celebration from the pain that they have experienced.

Mr. Slack visited a State-run hospital in Prague where -because of the open-door policy, unlike in the United States-patients are able to walk through beautiful grounds. Visiting hours are all day and relatives can visit at any time. The hospital was open to alternative therapies, such as massage therapy. Mr. Slack said, "I've always felt that one of the reasons people sometimes even remain mentally ill is because they're never touched, they're not massaged in a very constructive way. They never even get a hug." For example, a patient received a massage after having a reaction to Haldol. In the United States, this type of reaction would have been treated with additional medications. The hospital also offered "animal" therapy, allowing patients to work with horses on the grounds.

Mr. Slack noted that in other aspects, the Eastern European hospitals lag behind their American counterparts. For example, specialized services for women are not available. Drugs are slow to arrive: the hospital identified 17 patients who needed risparidone but could only supply it to 3.

In Budapest, Mr. Slack met Dr. Lajtavari Lazlo, a psychiatrist and neurologist who is the leader of the Hungarian consumer movement. Mr. Slack also met consumers who were forming a support group and developing articles of incorporation. Under communism, psychoanalysis in Hungary was illegal. After the revolution in 1989, there was a wave of psychoanalysis. The current government has created its own formulary; outpatients receive medications for free, while inpatients must pay for it.

The consumer movement in Europe, known as the "European User Movement," is fairly sophisticated and is involved in self-help and consumer-run programs, as well as in policymaking decisions. Three percent of funds for mental health in the Netherlands are dedicated to developing innovative practices. Mr. Slack visited the Magnus Stenbach Hotel in Sweden, which is entirely consumer-run and is one of the largest consumer-run initiatives in the world.

Despite the hotel's success, Mr. Slack stated that Sweden reflects some of our past in mental health-tokenism is abundant. Because of the socialist government, advocacy organizations do not exist and there are no mental health advocacy lawyers or compulsory rights. He mentioned that the traditional system does not view certain things as a problem, such as forced ECT or overuse of neuroleptics. "The legal system is not a vehicle for change in Sweden."

In conclusion, Mr. Slack said that although he had previously traveled to Europe, this trip was especially important because he represented the United States and had the opportunity to learn about other mental health systems. He added that the term "recovery" is just as present and used just as much in Europe as it is in the United States. Basically, anyone who receives any kind of mental health service, no matter where they are in the world, measures the quality of their care over the long term based on whether or not they felt respected when they were in the treatment process. The most long-lasting indicator of quality care was whether they felt respected.

Council members asked Mr. Slack about the problems of stigma in Europe. He stated that stigma is just as present in Europe and, in particular, in the communist countries. He added that self-directed stigma is also a problem, in which people are afraid to take a stand and express themselves.

Dr. Getka asked Mr. Slack to discuss how alcoholism is treated in Eastern European nations. Mr. Slack explained that Eastern and Northern European nations have a very high suicide rate, and the rate appears to be linked to alcoholism. However not much treatment is available, in part because alcoholism was tolerated under communist regimes. The countries are turning to doctors to solve the problem. However, in another study, 50 percent of doctors reported that they themselves had alcohol and substance abuse problems.

Dr. Gottlieb remarked that despite the stigma of mental illness, the people Mr. Slack described seemed to have been treated with respect. Mr. Slack attributed this, in part, to the fact that doctors and patients in former Soviet republics are part of the same socioeconomic groups.

Dr. Arons remarked that he hoped CMHS could build on what Mr. Slack had described, working with other nations to address substance abuse and mental health problems.

Interagency Sources of Funding for a Children's System of Care

Randall Feltman, a Council member, is director of the Ventura County Mental Health Department in California. Ventura County was a pioneer in the effort to introduce systems of care for child mental health. Mr. Feltman discussed interagency sources of funding for children's systems of care. His remarks focused on the future sources of funding.

Mr. Feltman remarked that this is a very difficult time for mental health services and, specifically, for innovation in children's mental health services and systems of care. He stressed his concern for the future of mental health services in the public sector. Mr. Feltman contrasted future funding for children's mental health in communities with and without systems of care. In the former, single agency sources of funding for children's mental health services and systems of care are threatened. He described three forces that influence funding. The first force is health reform, which has not yet had a positive impact at the local level. For example, in Ventura County, 48 percent of people who are employed do not have health insurance; for those with health insurance benefits, many do not have mental health coverage or have restricted access to coverage.

Clinical care standards compete with financial incentives, Mr. Feltman remarked. In Ventura County, for-profit and not-for-profit hospitals compete for funds, with insurance companies and providers vying against one another for market share and lower rates. Ultimately, public mental health funding is a more attractive target for powerful health forces whose revenues are decreasing-and children with serious emotional disorders are not an attractive market.

The second force at work in funding issues is managed care. Mr. Feltman stated that in California, managed care providers want to offer essentially an acute care medical delivery system that emphasizes volume and lowered costs as the basis for competition. He remarked that this approach does not work for people with long-term illness and broad- ranging needs who might require an interagency or collaborative approach beyond health care.

The managed care model does not currently include interagency collaboration. In addition, local governments cannot afford a system of care without State and Federal subsidies. Without those subsidies, the system of care does not exist.

He added that managed care companies in contact with his agency have stated that they want to restrict their areas of liability and responsibility to a health continuum, and want to avoid hospitalization. If a child enters a foster home, juvenile hall, or a residential placement facility, this shifts the cost burden, but does not provide the child adequate care or treatment.

The final force at play, he stated, is that the safety net is under attack in this country. Human services are being cut in many areas across the board. In regard to this safety net, there seems to be a new voice, an ideology for self-reliance that seems to be a code for selfishness. Local government is being asked to do more and more-and to be more and more accountable-with fewer resources. Given these forces, communities without systems of care will be at tremendous risk.

Mr. Feltman presented a list of opportunities that a system of care provides and recognized other meeting participants whose work has been instrumental in shaping and advancing child systems of care. He said, "I think that advocacy [by CMHS] has been, and continues to be, vital for the system of care to remain a viable force in the country. It's really been a Federal Government success story."

He stated that systems of care are vital to securing funding for children with serious emotional disturbances. The Federal Title IV (E) program pays for children to be placed in foster care or group homes. In California alone, the cost of maintaining such facilities for 15,000 kids is approximately $500 million. By reducing out-of-home placements by 20 percent, $100 million could be invested in community-based systems of care.

In summary, systems of care offer opportunities to redirect funds from expensive and ineffective programs to cost-effective and successful programs; encourage interagency collaboration to achieve common goals; promote public health partnerships; and create cost-competitive contracts within managed care systems to generate revenue for systems of care.

After a brief recess, the group reconvened.

New Child Prevalence Data: Methodology and Estimates

Thomas Bornemann, Ed.D., introduced Judith Katz-Leavy from the CMHS Office of Policy, Planning, and Administration and Robert M. Friedman, Ph.D., from the Florida Mental Health Institute. They presented new data on the prevalence rates for children with severe or serious emotional disturbances. Dr. Friedman is a clinical psychologist specializing in research and policy analysis for children and families and is Professor and Chairperson of the Department of Child and Family Studies at the Florida Mental Health Institute at the University of South Florida. He is the Director of the Research and Training Center for Children's Mental Health. Ms. Katz-Leavy is a co-founder of the CMHS Child and Adolescent Service System Program.

Ms. Katz-Leavy summarized the legislative acts that led to the development of programs for children and adolescents, including acts mandating that CMHS develop definitions of children with serious emotional disturbances, and standardized methods for estimating of the overall incidence and prevalence of serious emotional disturbances among children. This step was critical. For example, without standard reporting criteria, Pennsylvania reported having 500,000 individuals with severe mental illness in its total population of 11 million, whereas Florida, with the same population, reported having 55,000.

CMHS defined children with a serious emotional disturbance as people from birth to age 18 who currently, or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the DSM-IIIR. These disorders had to result in functional impairment which interferes with or limits the child's role or life in the family, school, or community. The complete definition was published in the Federal Register.

CMHS then convened a large group of researchers, service system researchers, mental health program administrators, advocates, stakeholders, and families to discuss ways to "operationalize" the definition.

Ms. Katz-Leavy stated that the group discovered a disparity between the level of research and epidemiological work accomplished in the adult field, as opposed to the child field. National epidemiologic studies for children do not currently exist.

Instead, the group had to make projections from seven community-based studies. As a result, the group is recommending that States look at a 9 percent to 13 percent range in the prevalence rate for children and adolescents with serious emotional disturbances.

She explained that this rate, which appears to double the previous 5 percent rate, is based on a rigorous look at various scientific methodologies.

The rate is correlated to poverty. CMHS will recommend to States with high poverty rates use the prevalence rate at the higher end of the scale-as much as 13 percent for States with high poverty rates, and 9 percent for those with lower poverty rates.

Dr. Friedman discussed some of the technical difficulties encountered in developing the prevalence rates; a key barrier was the lack of a national study of children. The group also found it difficult, after prevalence of disorders was established, to find good measures of functional impairment. The committee recommended that more time be spent studying and measuring functional impairment and its relationship to serious emotional disturbance in children.

He explained that unlike the data for adult populations, which result in one figure for prevalence estimates, data for children cannot be so limited; estimates must also consider developmental stages. Of the seven studies used to develop the current study, only two included data for children under the age of nine. An NIMH study is currently developing methodologies for studying prevalence in children over the age of four.

The data did not adequately represent racial and ethnic groups, which limits the accuracy of the prevalence estimates.

Dr. Friedman summarized the following report findings:

• Children with serious emotional disturbances are four times as likely as other children to have received mental health services in the previous year;
• A large number of children with serious emotional disturbances do not receive services they need;
• Common diagnoses included depression, attention deficit disorder, conduct disorder, and oppositional disorder; and
• Children with the most severe disorders are much more likely than those with relatively mild disorders to become involved with the juvenile justice system, to become teenage parents, and to be unproductive at school and in the community.

Dr. Friedman responded to Council member questions. Dr. Kiesler remarked that to get managed care companies to write contracts that include the needs of children with serious emotional disturbances, researchers need to develop firm data and best practices, and they need to include this information in contracts. Dr. Friedman agreed, although he noted that this is a moving target. For example, the diagnostic system changes regularly, and as a result, we develop new diagnostic categories. Then the instrumentation changes. We need to focus on service utilization as related to the definition, he added.

Gloria Johnson-Powell, M.D., noted that because of the correlation between poverty and serious emotional disturbances in children, the issue had become politicized. She remarked that some people think that we should not finance poverty as a mental health service. She added that separating culture, race, and ethnicity from class is problematic in diagnosing childhood disorders. She concurred with the Council's recommendation that more needs to be done into assessing childhood disorders and taking into account age and development.

Mr. Feltman asked whether any databases on utilization might provide information on prevalence data. Dr. Friedman answered that because of the problem of underutilization, such databases are hard to find. He noted that the Fort Bragg CHAMPUS Demonstration project eliminated barriers such as access and cost, and that 7 percent of children accessed services-and that these children really needed these services.

Council Member Discussion-Focusing on the Future-The Knowledge Development and Application (KDA) Agenda for 1997

Michael English, J.D., Director of CMHS' Division of Knowledge Development and Systems Change, presented the basic strategy for promoting the KDA agenda in 1997.

Mr. English remarked that because of a Senate subcommittee decision, it was unlikely that there would be much of a budget for KDA activities. He distributed a paper that described the basic ideas behind the KDA approach to demonstration programs. His Division concluded that it was essential not only to identify useful information, but to ensure that it "gets into the right hands at the right time for the right purposes." He added that our real measure of success is the extent to which positive services through change are accomplished.

In response to Council member recommendations, the Division had taken a more targeted approach to its proposed consensus building grants. These grants would be targeted toward specific decisions about system implementation.

The new agenda relies on interagency collaboration. He described current collaborative activities being funded by CMHS or in which CMHS is participating.

Dr. Arons emphasized that the KDA plan is headed in a good direction. He believes that CMHS should continue to push the plan, year after year, despite the flat-line funding it received. He added that the plan is solid and that it fits with past, present, and future activities.

Dr. Martinez stated that the fundamental issue is marketing. In the guidelines, the guiding principle is a field-driven agenda. He asked the question, "What is the field?"

Mr. English defined the field as a combination of consumers, families, associations, providers, State and local government, and people with very diverse interests.

Dr. Kiesler stressed that if a program becomes completely field-driven, it becomes a mere political process. Independent judgment is needed. He explained it is essential to develop best practices, document them, and then distribute the material. He asked whether any efforts had been made to create partnerships with the private sector.

Dr. Arons answered that CMHS had and that Jeffrey A. Buck, Ph.D., the CMHS Associate Director for Organization and Financing, would discuss these matters with the Council the following day.

Dr. Kiesler remarked that CMHS is in a good position to track what happens in managed care and to use the information it collects.

Dr. Martinez concurred, adding that it is important to be aware of what is happening in the field across the board, as well as with those aspects of managed care that are within one's area of influence.

Dr. Kiesler stated that managed care firms might be willing to "loan" executives to the public sector to better understand what is going on and where problems are. Based on his experience, he remarked that many would welcome the opportunity to make that kind of contribution in the public sector.

Dr. Shon mentioned that mental health stakeholders had met the previous month in Texas to discuss legislative strategy. Participants identified two issues as key to promoting mental health-parity and alternatives to managed care reform.

Mr. English stated that, to some extent, the problem with the KDA agenda is that it is a learning agenda as opposed to a policy agenda.

Dr. Feltman remarked that CMHS needs to make its site on the Internet the most important destination for mental health interests in the country. He stated that something similar to the Information Center could be accessed at local offices to help community-based programs do their jobs.

Mr. English stated that CMHS is working toward this goal with the Information Center. He added that another issue is defining a "knowledge product." Not only does it involve a synthesizing activity in which knowledge is gathered, but it also involves packaging.

Dr. Martinez suggested that CMHS respond to the ongoing need for standards of practice and guidelines.

Dr. Getka remarked that distributing standards of practice and guidelines is useful in terms of securing funding. However, the information is outdated by the time it is distributed. A better strategy would be to project, from the demonstration programs, future trends in mental health services.

Mr. Slack asked that CMHS develop a better way to present its community support program diagram, one that would seem more empowering to consumers, rather than confining them within several circles.

Dr. Shon stated that it is important to consider how systems change, not only in reaction to any given intervention, but in terms of other factors as well. He remarked that the move of Medicaid systems into managed care is a burning issue for so many of us who are involved with service delivery systems."

Mr. David K. Yamakawa said that in trying to "sell" the agenda to Congress, one had to appreciate that Congress is working with very limited funds and that it is no longer interested in funding everything just because it may have some peripheral good for this country. Instead, he stressed that Congress is sold on programs that can be shown to have a positive effect on the country and that CMHS needs to find something in the pipeline that has already had a positive effect on America.

Mr. English remarked that managed care executives are looking at programs that demonstrate cost offsets, an effective way to market programs to Congress.

Dr. Kiesler offered his rule of thumb: "If you're talking to a Democrat you emphasize needs, when you're talking to a Republican you emphasize cost effectiveness." Day 2-September 13, 1996

Council Member Round Table: CMHS Feedback and Recommendations

The purpose of the roundtable discussion, Dr. Arons noted, was to tap into the resources the Advisory Council offers-that is, as "the eyes and ears" of CMHS. By reflecting on what Council members see happening around the country and by voicing their concerns, they serve as a crucial link to the field and provide ideas CMHS can learn from.

Issues For Behavioral Health Managed Care Programs

Elisabeth Rukeyser started the roundtable discussion by highlighting some of the difficulties the State of Tennessee is experiencing in behavioral healthcare as its Medicaid program moves to a public managed care system. Ms. Rukeyser serves on the boards of a number of healthcare organizations, including the largest health care system in the State, which includes one of the behavioral health organizations (BHOs) now operating in Tennessee.

Two managed BHOs have contracts with the State. One BHO, Premier, is a consortium of three BHOs that share risk equally. The second BHO, Tennessee Behavioral Health, bears full risk. All 29 community mental health centers (CMHCs) contract with the BHOs. Some contract with Tennessee Behavioral Health on a capitated rate to provide services. Others contract with Premier on a per-case basis.

BHOs concede that without the CMHCs, there are not enough providers to ensure a Statewide network. However, BHOs would like to see the administration of those CMHCs consolidated by about one-third. In fact, such a consolidation seems likely.

One consequence of the negotiations between the BHOs and the CMHCs is that the CMHCs were brought to court by the State of Tennessee for antitrust practices. The charge was price setting. However, the case has been settled with no blame accepted or given.

Dr. Arons noted that the CMHCs had been asked to play a role in this new system. To do so, they were encouraged to join together as though they were one entity to negotiate with the BHOs.

Ms. Rukeyser mentioned that until CMHCs know how many people they are going to serve and the services they need to provide, many services are discontinued. Eighteen CMHCs responded to a survey on the issue of discontinuing services and disclosed the following information:

• 61 percent of the CMHCs will close or reduce day treatment.
• 50 percent will close or reduce therapeutic milieu programs.
• 39 percent will reduce outpatient psychotherapy services.
• 33 percent will close or reduce other client services, such as transportation, adult group homes, continuous treatment, transitional programs, support groups, indigent medication, and services to children and teens in State custody.
• 28 percent will reduce administrative services such as sliding-scale fees.

Dr. Arons mentioned that CMHS has reviewed several hundred managed care contracts. CMHS has found that many BHOs will contract for discrete services. For example, it may enter into a contract with one CMHC for day treatment, but secure medication followup elsewhere.

Dr. Arons, Ms. Rukeyser, and Dr. Martinez discussed the fact that Tennessee basically has two systems. With Tennessee Behavioral Health, control is with the CMHCs because they pay for hospitalization. As a result, CMHCs under contract with Tennessee Behavioral Health will seek alternatives to hospitalization. On the other hand, Premier is the gatekeeper for the hospital because it pays these costs. In addition, it owns a lot of hospitals-facilities they want to use.

Ms. Rukeyser added some general comments on ways in which the State had created unanticipated problems. On July 1, 1996, the State notified 1.2 million people that they were now entitled to behavioral health services. Many of them had never been entitled to such services. The phone lines were jammed with thousands of people calling not only to make their first appointments, but also to arrange transportation, which is provided if medically approved. Mobile Crisis has been inundated because it now precertifies all hospitalizations.

No one is quite sure what to do with previously eligible clients who are no longer eligible for service. The State asks that they continue receiving treatment. CMHCs are leery of assuming that risk because there is no guarantee that they will be paid. They do not have funds to provide free services indefinitely.

And with the incentive to keep people out of hospitals, housing becomes a major concern. Another issue is that primary care and mental health services have yet to interface. None of these issues is insurmountable, and long-term options are evolving.

Dr. Martinez described how Oregon has taken a different approach to managed public behavioral healthcare. Its first step was to decide how to ration care. Following a Statewide dialogue, Oregon created a list of 734 diseases, including mental health diagnoses, that it will pay for.

The basic struggles in Oregon, Dr. Martinez noted, are similar to those occurring in almost every other State: Do you integrate mental health into the MedServe (Medicaid) system, or do you carve out? If you carve out, do you carve out on a Statewide basis or on a regional basis?

The other basic question is, what is the role of local government? What do the counties, for example, remain responsible for, if the county is also the Medicaid provider? If so, then is it in a position to use whatever funding resources are available to create an infrastructure to provide the range of services?

If the counties are not the Medicaid provider, then they do not have the comprehensive infrastructure to provide a variety of services-services no one else wants to provide. Health plans are not interested in expanding benefits beyond the narrow benefits required by Title IX.

A number of related mental health needs, Dr. Martinez noted-such as mental health services in correctional facilities-do not have a clear home in terms of who funds them, who provides those services, and under what conditions.

Mr. Yamakawa discussed the concerns of community-based providers in the San Francisco Bay Area. He explained that San Francisco Bay Area providers first organized in response to possible national healthcare reform. They felt the need to band together to form a "critical mass" of providers, Mr. Yamakawa noted, to improve their chance of survival. Providers in both physical and mental health recognize the need to have large numbers of clients.

Dr. Gottlieb commented that although outcome planning is a phenomenon whose time has come, the risk is that practice will be driven by outcome and no longer driven by relationship-where real behavioral change comes from.

Mr. Slack remarked that positive relationships are built on respect- something that can be offered at no additional cost in both stabilization and long-term environments.

Mr. Feltman also pointed out that the mental health field is experiencing huge downsizing. In San Diego county alone, 3,000 practitioners will have to move to another location or stop practicing. As a result, many colleagues are anxious and depressed, which can affect their clinical judgment.

Dr. Shon added that one of the benefits of this downsizing is that many physicians are now going to rural areas where people previously could not get medical or psychiatric care.

Dr. Getka noted that a tremendous amount of money is flowing into primary care group equity models of health care delivery. This activity has significant implications for mental health care because it sets the stage for primary care providers to become the main drivers of health care.

Dr. Shon responded that Texas is testing several models, including a primary care case management model. The State should have data on these models in the next two years.

Dr. Kiesler noted that managed care in the private sector is sweeping the country. We need to differentiate between managed care in the private sector and patients in the public sector, who are there largely because of poverty.

It makes sense to carve-in psychiatric care in the private sector, he stated, because primary care lends itself to being an entry point into the system. This benefits the patient by getting him or her help more quickly and saves money.

In the public sector, good access is lacking, and oftentimes good detection. Dr. Kiesler emphasized that we need to rethink what we are doing in the public sector so that we are not trying to mindlessly draw concepts and approaches from the private sector and apply them to the public sector, which is a very different environment.

In the public sector, not everybody gets care. To the extent they do, it is disproportionately physical health care. If you carve in, more people will get the mental health care they deserve. But this terrifies some people at a public legislative level because of the concerns about costs increasing.

Parting Comments from a Founding Member and Consumer--Mr. Joel E. Slack

In Mr. Slack's farewell comments, he thanked everyone for the opportunity to participate in the Council. As a consumer advocate, his objective was to increase awareness and to articulate consumers' concerns and suggestions. Mr. Slack encouraged CMHS to continue to embrace the consumer perspective, as diverse as it may be, because it can enrich the decisions made by all stakeholders.

In addition, until serving on the Council, Mr. Slack perceived CMHS staff as "the Feds." Now he views the staff as colleagues and, in many cases, as friends.

As part of the shift to managed care, Mr. Slack observed, more services are going to be provided in the community. He cautioned that the Protection and Advocacy (P&A) system must change to ensure that it extends into community services.

Dr. Arons thanked Mr. Slack for his invaluable participation on the Advisory Council. He also invited Mr. Slack to help CMHS develop a new legislative strategy for the Protection and Advocacy system.

Findings from the Urban Issues Group

June Jackson Christmas, M.D., remarked that carve-in produces better access, earlier detection of problems, and a closer connection between physical and mental aspects of health.

She also shared her experience with people in the Bedford-Stuyvesant community regarding changes in health care. Bedford-Stuyvesant is a well-established Brooklyn community of people of African descent with many new immigrants from the Caribbean.

Dr. Christmas is part of the Urban Issues Group, a policy institute that looks at issues related to people of African descent in New York City. One area of concern is the lack of race-specific data.

Dr. Christmas noted the need for more health education-finding what people's views and perceptions of health care are, what their distortions are, and what cultural factors come into play-to ensure that people use health care when it is available.

Dr. Christmas expressed the concern that in the era of managed care, even less attention will be paid to the areas of prevention and cultural sensitivity than in the past.

Dr. Johnson-Powell spoke on managed care from the perspective of both an academic and as a provider of services to children in a racially, ethnically, and linguistically diverse community.

She observed that managed care companies appear to assume that what you do for adults, you can also do for children. There is no realistic appraisal of what it takes to assess developmental psychopathology or the developmental processes that children are experiencing as presented in a psychiatric setting, school setting, or post-challenge setting with a behavioral, emotional, or social problem.

Dr. Johnson-Powell also expressed a concern about the managed care systems that are developing to take care of children and families that do not take into account the differences in developmental psychopathology, and make no consideration for the cultural diversity in our country.

Texas Medication Algorithm Project

Dr. Shon discussed the Texas Medication Algorithm Project. He stated that Texas is addressing a long-standing complaint of consumers and families; the diagnoses-and the medications-of individuals who receive mental health services change every time their doctor changes. Therefore, two years ago, Dr. Shon and his colleagues initiated a study to investigate this complaint.

They found that in Dallas County, 50 percent of the diagnoses, when tested against the same patient and after a Structured Clinical Interview for DSM-IIIR (SCID), did not match with the SCID.

As a result, they developed, for the State of Texas, a uniform set of assessment instruments for adults. They are in the process of developing assessment instruments for children, too. Through the State authority, every community center, State hospital, and psychiatric prison unit is now required to use the same set of instruments, the Multnomah Community Assessment Scale to measure functioning.

Dr. Shon and his colleagues have moved from looking at the diagnostic issue to looking at the medication issue. For example, if you ask six different psychiatrists to treat the same consumer with the same symptoms, those psychiatrists are likely to prescribe six different medications for that same individual.

As a result, Dr. Shon and his colleagues are developing a set of clinical protocols-or medication algorithms-for the public sector. The protocols are being developed for three major disorders: major depression, schizophrenia, and bipolar disorder.

Compounding consumers' difficulties regarding seemingly arbitrary changes in their medication is the fact that managed care companies are developing medication protocols of their own. Every provider within a company's network is required to use a particular protocol, and, as managed care companies profile those providers, they track their use of that protocol. If a physician does not use that protocol, he or she may be removed from the network the following year.

The problem with these protocols, Dr. Shon stated, is that cost often is the driving factor: the cheapest medication first, the next cheapest second, the next cheapest third. For example, although we know that the newer medications for major depression, the selective serotonin reuptake inhibitors, are more effective for a range of symptoms and are safer when someone takes too many, the older tricyclics, which are much cheaper, are often the ones doctors are required to prescribe first.

It is important, Dr. Shon asserted, to develop protocols based on science, empirical evidence, and best practices. Otherwise, consumers in the public sector will be forced to live with guidelines determined by insurance companies that risk being driven by cost.

Texas plans the following three-step process in developing these protocols:

1. To define the medication protocols;
2. To test them with the goal of finding out whether they work well in the real world of public mental health; and
3. To conduct a clinical trial to look at clinical outcomes, cost, cost- benefit, and outcomes outside of the system, such as criminal justice and welfare.

Dr. Shon also remarked that they hope to include language in the regulations granting State Medicaid contracts to managed care organizations that requires protocols to be based on scientific and empirical evidence. In effect, managed care organizations will be forced to adhere to the protocols established by the State of Texas.

Public Comments

Rita Vandervort, representing the National Association of Social Workers (NASW), addressed NASW's concern about funding cuts to mental health programs and consolidating programs into performance partnerships-"anti- demonstration grants," as she referred to them. This approach to streamlining Government, she stated, has submerged the identity of some programs so that it is harder to rally the troops in constituent efforts.

Furthermore, the industrialization of mental health providers under managed care reduces mental health providers from artisans to factory workers, making it more difficult for them to speak out in legislatures, gain respect, and have influence.

Ms. Vandervort asked CMHS to look at the following issues:

• The push in managed mental health care toward the primary care site. NASW is concerned about the linkages between mental health and substance abuse. It is also concerned about cultural competency.
• The decrease in funding of professional trainees. Managed care organizations often will not reimburse for visits conducted by a trainee. People cannot get trained if they do not have clinical practice.

Ms. Vandervort urged CMHS to retain its role as the organization that stands up for principles. She commended CMHS for the direction it is taking through knowledge development and application grants because they will continue to enhance principles and best practices.

Mike Faenza, representing the National Mental Health Association (NMHA), distributed an executive summary of a position paper on mental health parity and health insurance.

It is unjust and poor public policy, Mr. Faenza stated, to allow the following to occur:

• Discriminatory limits on health care benefits for children and adults with mental health needs;
• Discriminatory copayments; and
• Discriminatory annual lifetime limits targeting mental health services.

In addition, he stated, medical necessity, not specific diagnoses, should determine access to mental health benefits. Mr. Faenza remarked that limiting parity provisions to specific adult onset disorders discriminates against countless people, especially children who have serious mental health needs. Mr. Faenza urged CMHS to stand up and articulate what is right in parity.

Mr. Faenza also affirmed NMHA's support for CMHS programs. Although NMHA supports research, the association has made a huge investment in CMHS because, as a society, we know more about giving treatment and support to people with mental disorders and their families than we actually deliver.

Mr. Ron Thompson, board member of the Maryland Protection and Advocacy Association and On Our Own in Maryland, an ex-patient group, also addressed the Council on the topic.

Jeffrey Buck, Ph.D., distributed some preliminary data on parity.

Dr. Buck focused on the managed care initiative that CMHS and the other centers within SAMHSA are collaborating on. One of the projects under this initiative is a series of studies conducted by the Center for Health Policy Research at George Washington University. This study analyzed the following two sets of contracts:

• Contracts between States and managed care organizations through their Medicaid managed care programs; and
• Contracts between managed care organizations and community providers- generally the community mental health centers and substance abuse treatment centers

In an analysis of 50 contracts between managed care organizations and community providers, the group found that most of these contracts are "at-will" contracts. This term means that either party may terminate the contract for any reason at any time.

On the surface, Dr. Buck noted, that sounds like a fair and equitable arrangement. However, this can have a potentially damaging effect on the behavior of the provider. Dr. Buck illustrated this point using the issue of the "gag clause." With an at-will contract, a managed care organization does not need a gag clause because it can terminate a contract if it does not like what a provider says about the managed care organization or finds the provider troublesome in any way.

The study also highlights the fact that many contracts do not support the range of services that a community mental health center can provide. Instead, most contracts are for very discrete services provided by specific mental health professionals within mental health service organizations. In other words, Dr. Buck stated, a contract typically will identify a limited number of services-such as medication management-which can only be provided by a psychiatrist.

It also appears that the managed care organizations-not the mental health or substance providers, nor the primary care physicians-serve as the gatekeepers for services.

Especially troubling, Dr. Buck noted, is the fact that most contracts do not require providers to supply encounter data to the managed care organization. This makes it extremely difficult to get data about what is actually happening to people in terms of the service they receive, access, and so forth.

In summary, Dr. Buck stated that these studies highlight the need for oversight of these managed care contracts.

These contracts also indicate that templates and models developed in the private sector are being imposed on the public sector. It would make more sense, Dr. Buck asserted, to have private managed care organizations learn from the public system and adapt managed care practices to the public system's special circumstances.

CARING FOR EVERY CHILD'S MENTAL HEALTH: Communities Together Initiative

Valna Montgomery, Manager of the CMHS Children's Initiative, Office of External Liaison, opened her presentation with slides on the Campaign's message and its goals.

Ms. Montgomery described how the Campaign has targeted those who are in a position to open a door to help children and adolescents-the initial audience for its outreach efforts.

She also described specific marketing approaches-such as the syndicated release of camera-ready drop-in columns, primarily to weekly newspapers that represent a readership of more than 6 million.

Ms. Montgomery asked Council members to do their part in the Campaign by performing the following activities:

• Taking the print ad and running it in at least one newsletter or other periodical;
• Displaying the Campaign poster in their own offices and placing at least one in a community location;
• Introducing the Campaign to their professional associations and media connections;
• Sharing children's mental health success stories; and
• Communicating with Campaign staff to let them know how the Campaign can complement and reinforce Council members' work with children.

Mr. Horvath complimented the team on a great public information campaign. He stated that the Department of Veterans Affairs will contact the Children's Campaign staff soon. The Children's Campaign materials can help veterans who are being treated for posttraumatic stress disorder better understand the risk their own children may have to develop mental health problems.

Tracking State Health Care Reforms as They Affect Children and Adolescents with Emotional Disorders and Their Families

Sheila Pires, partner with the Human Services Collaborative, presented findings from the first year of a 5-year health care reform tracking project funded in part by CMHS. This project is looking at the impact of Medicaid and managed care initiatives on children and adolescents with emotional and behavioral disorders, particularly children who depend on public systems of care and their families. The project also looks at the impact of managed care on substance abuse services and the child welfare system.

Ms. Pires shared baseline data collected from 1995. Through telephone interviews with key stakeholders and focus groups-comprising families, front-line practitioners, children's system administrators, and managed care company executives in 10 States-the study indicates the following:

• Seven of the 10 States are involved in some managed care activity, with many States involved in several different managed care activities.
• If Medicaid administrators were taking the lead in integrating physical and mental health, State mental health commissioners were far less likely to be involved, and children's mental health providers were even less likely. Furthermore, administrators and planners from other children's systems-such as child welfare, education, and juvenile justice-were even less likely to be involved.
• Two-thirds of the reforms do not have any differential coverage or special benefit package management mechanisms for children with serious emotional disturbances and their families.
• Most States are using a carve-out arrangement for behavioral health services that essentially is an acute care model. In the case of children, that creates an incentive to dump and cost shift onto other children's systems, particularly child welfare.
• Only about one-third of these reforms use organized systems of care for children with serious disorders.
• In terms of outcomes, these Medicaid managed care initiatives are not yet looking at program effectiveness or clinical outcomes.

In addition, preliminary findings indicate that States are unable to determine what kind of impact these reforms have on children. For example, they do not know whether access to mental health and substance abuse services for different subgroups of children has improved or diminished. They also do not know what impact the reforms are having on other systems in terms of cost shifting.

Most States do report that the managed care initiative has enabled them to cover and provide more home and community-based services, and that inpatient use has declined. At the same time, States report that residential treatment provided in other systems is increasing.

In response to an open-ended question about what States would avoid if they were to engage in health care reform again, most States responded that they would not give acute care responsibilities to the managed care entity and would leave the long-term responsibilities to the public sector.

The challenge in managed care for the children's world, Ms. Pires remarked, is to determine how to use managed care technologies-such as risk structuring-to design a system that blends financing for different populations. This would allow us to realize the goal of creating a seamless integrated service delivery system.

Baseline Data From the Children's Mental Health Services Program and the Early Intervention Project

Gary DeCarolis, Chief of the Child, Adolescent, and Family Branch at CMHS, presented baseline data from the children's systems of care initiative and a brief description of the early prevention program.

The 22 grantees in the systems of care program cover a broad distribution of geographic and cultural groups-from a community in the Bronx, to the entire State of Vermont, to the Navajo Nation in Tohatchi, New Mexico. One of the big challenges, Mr. DeCarolis stated, is to measure systems of care. The program has devised a measure that looks at both infrastructure issues and service delivery components.

All 22 sites are involved in an outcome evaluation. In addition, four of those sites will be compared with four other sites that offer traditional mental health services. This comparison should determine whether a system of care makes a difference.

A system of care is revolutionary, Mr. DeCarolis emphasized. It requires a true partnership among child welfare, mental health, education, substance abuse, and health departments, as well as families. Although easy to describe, it is extremely difficult to create. Trust, turf, and blending categorical funding streams are just a few of the difficult issues that must be resolved to create a system of care.

Along with a host of other Federal agencies and two private foundations, CMHS is tackling the challenge of addressing the mental health needs of children ages birth to 7 years and their families-before problems begin.

This "Starting Early, Starting Smart" initiative represents a family- focused approach to ensuring that children get the help they need early on. It also allows the community to design a uniquely flexible, agency- wide system that appropriately meets its own needs.

This program will undergo a cross-site evaluation similar to the one for the services program.

Dr. Bornemann concluded the meeting by acknowledging that a lot of territory had been covered over the 2 days, especially on some of the emerging issues in managed care and children's mental health. He thanked council members for their thought-provoking contributions which are helping "to get CMHS, as a young organization, off the ground."