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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

National Advisory Council Meeting Minutes

December, 1997

The Center for Mental Health Services (CMHS) National Advisory Council was convened at 9:00 a.m., on December 4, 1997, in Washington, D.C., at the Omni Shoreham Hotel. CMHS Director Bernard S. Arons, M.D., chaired the meeting. The meeting was open to the public as announced in the Federal Register.

Welcome and Opening Remarks

Dr. Arons convened the meeting, welcoming all in attendance, and introducing the new members of the CMHS National Advisory Council: Frank Burgmann; Dolores Subia BigFoot, Ph.D.; and Ian Shaffer, M.D. He followed by introducing several individuals who had joined CMHS staff since the last Council meeting: Rolando Santiago, Ph.D., of Albany, New York, joined the Children's Mental Health Services Program; and Ms. Teddi Fine, M.A., formerly special projects director for the Office on Women?s Health in the Office of the Secretary, Department of Health and Human Services, recently became Special Assistant to the Director.

Dr. Arons also introduced a number of guests: Leslie Sauers, a former feature reporter for the Houston Chronicle and now a visiting journalism fellow from the Carter Center for Mental Health; and Joseph Rogers, director of the Southeast Pennsylvania Mental Health Association and principal investigator for the National Mental Health Consumers? Self-Help Clearinghouse.

Dr. Arons continued his report by discussing a number of CMHS initiatives to stimulate solutions to practical problems through a broad range of programs, particularly those within the larger context of Knowledge Development and Application (KDA). He reminded Council how KDAs are creating a cycle of activity that starts by identifying topics where information is needed, moves to topic-related knowledge development, then synthesizes that knowledge, generates exemplary practices, and finally stimulates communities to replicate these methods and/or programs. Dr. Arons emphasized the critical role of the Council in providing direction as CMHS creates field-driven systems of care.

He then described a number of other CMHS programs and activities:

• The Criminal Justice Diversion Program for individuals with co-occurring substance abuse and mental illness. This 3-year, multi-site study evaluates the relative effectiveness of two kinds of programs. One kind identifies people with co-occurring substance abuse and mental illness before they are booked in order to divert them to treatment programs instead of jail. The other kind identifies such individuals, who already are incarcerated, and directs them to treatment either within the corrections facility or in a separate treatment center.
  
  
• New consumer-directed initiatives that are enhancing CMHS understanding of how to improve services, and are helping consumers develop advocacy skills, identify and analyze consumer operated services, counter stigma, and improve quality assurance.
  
  
• Continuing public awareness initiatives, many of which are winning awards, among them, a National Merit Health Information Award for the CMHS booklet, Managed Mental Health Care: What to Look for, What to Ask, and a second place award from the Blue Pencil Competition of the Association of Government Communicators for the family brochure, Your Child?s Mental Health: What Every Family Should Know.

Council Initiatives

Council Secretary: Council unanimously voted in favor of Steve Shon, M.D., as Council Secretary with responsibilities such as helping to review past meetings, plan future meetings, and set the Advisory Council Meeting agendas.

Outcome Studies: Council members Steve Shon, M.D., Floyd Martinez, Ph.D., David Yamakawa, Jr., and Thomas Horvath, M.D., have agreed to be on the new subcommittee to focus on outcomes. The subcommittee will report to Council with recommendations on issues such as cost effectiveness guidelines, outcomes definitions, and outcome measurement instruments. CMHS staff Ronald Manderscheid, Ph.D., and Mike English, J.D., will work with this group.

Long-Term Care Issues: Council and other participants discussed the difficulties of coordinating physical and mental health services for people with long-term illness. Dr. Arons pointed out that, as a first step in grappling with this problem, a possible grant announcement is being developed to examine the availability of and access to mental health services through primary care to the older population. The grant may also look at the ways in which managed care does or does not enhance access and availability. CMHS also is planning to work with the Health Resources and Services Administration (HRSA) on a contract to provide training in mental health in primary health care.

Medication Issues: Council also discussed the possibility of programs to investigate adherence to medications. Dr. Forstein raised concern, for example, that people with severe mental illness, especially those with HIV/AIDS, may be denied access to certain classes of medication, on the assumption that frequently hospitalized people with mental illnesses might not be medication compliant, an assumption with no basis in the research literature.

Presentation by CMS Administrator

Dr. Arons introduced SAMHSA Administrator Nelba Chavez, Ph.D., who in turn introduced Ms. Nancy Ann Min DeParle, the recently confirmed new head of the the Centers for Medicare and Medicaid Services, the agency that manages both the Medicare and Medicaid programs.

Council received her formal remarks:

• Medicare and Medicaid benefit 1 in 4 Americans-more than 72 million-with a $360 billion annual budget and over 4,000 employees nationwide. In recent years, there has been a sharp increase in the use and cost of Medicare and Medicaid mental health services and benefits.
  
  
• In an era of concern about accountability and quality, CMS's goal is to ensure that the services purchased for beneficiaries are of high quality and can improve their health status. The agency is trying to change from simply being a payer of claims into being a purchaser of health care services that ensure quality, a direction facilitated by provisions of the 1997 Balanced Budget Act emphasizing choice, payment reform, customer service, preventive care, and an end to fraud and abuse. Similarly, the agency is implementing both the Medicare Plan Choice Program to provide beneficiaries with greater choice of health plans and the Children's Health Insurance Program to extend health care to uninsured children nationwide.
  
  
• CMS is emphasizing program integrity-better controlling benefits and payments-through such mechanisms as prospective payment systems and more health care settings, bundled payment options, and risk adjusters for risk-based plans. However, applying these methods to mental health care, especially in purchasing ambulatory mental health care, is one of CMS?s greatest challenges given the potential conflict between cost containment and consumer need for quality care. Managing the conflict requires strong oversight by both Federal and State Governments, particularly in the utilization of the Medicare partial hospitalization benefit. Review of community mental health centers in Texas, Florida, and Illinois by the CMS Inspector General found a high level of fraud and abuse in the Medicare Partial Hospitalization Program.
  
  
• Home health care is another ?hot button? issue for fraud and abuse. The Medicaid Managed Behavioral Health Care waiver program presents similar challenges. While States have broad leeway in designing and selecting services, CMS still has the obligation to set standards that can be monitored. The larger problem is defining and targeting mental health services covered by Medicare and Medicaid.
  
  
• SAMHSA and CMS are collaborating on several projects: (1) collecting quality performance measures in selected States; (2) reviewing and commenting on proposed Medicaid waivers; and (3) contracting for studies on managed care, as well as on designing and implementing quality improvement systems in managed care.

Council members engaged Ms. Min DeParle in spirited discussion. In response to a series of questions by Drs. Steven Shon and Marshall Forstein, Ms. Min DeParle concurred that standards for State oversight of managed care partial hospitalization services clearly need to be addressed, since as Dr. Shon had pointed out, States bear the responsibility for this review. With respect to their questions regarding new-generation psychiatric medications, she noted that CMS has asked the National Institute of Mental Health (NIMH) to summarize the research on the newest antipsychotics to help CMS clarify issues regarding availability both for States and beneficiaries. Consumer advocates also have been contacted; Federal guidelines for reimbursement for such medications are also being examined.

Ms. Min DeParle concurred with Dr. Shaffer's assessment of the inherent tension among the payer, the beneficiary, and the provider in managed care and the need to concurrently examine not only the funding stream but also precisely what the practitioner wants to provide and what the individual may need. It is unacceptable to deny care based simply on insufficient dollars.

Ms. Min DeParle responded to a question by guest Mr. Joseph Rogers acknowledging familiarity with the NAMI report card on managed care, observing that many of the waivers have just begun, and emphasizing that concerted action is being taken to correct them.

In response to a request by Mr. Randall Feltman that CMS establish a focal point for mental health policy and priorities to foster system-wide discussion, Frank Sullivan, Ph.D., SAMHSA Associate Administrator for Policy, Planning and Coordination, and now the mental health liaison to CMS, responded that CMS recently established a working group on mental health and substance abuse. The group will be handling waivers as well as providing policy direction at CMS.

Remarks by SAMHSA Administrator

Dr. Arons thanked Ms. Min DeParle for her remarks and SAMHSA Administrator Nelba Chavez, Ph.D., updated Council and guests about SAMHSA activities since the last meeting.

• SAMHSA 1999 Appropriations: Congress has increased the SAMHSA budget for the first time in many years, up more than $25 million over the 1997 level. For CMHS, that translates into an additional $3 million earmarked for children?s mental health services and another $3 million more for the PATH Program. Neither the mental health block grants nor the KDA Program received additional funding for FY 1999.
  
  
• Program Initiatives:
  
  **The KDA Program is helping to support a new SAMHSA drug prevention partnership with State governors to survey State funding streams for drug abuse prevention (e.g., Department of Housing and Urban Development, Department of Justice, and the substance abuse block grants) in order to identify gaps and develop a cohesive collaborative plan based on individual state needs.
  
  **The first 12 SAMHSA Starting Early, Starting Smart grantees were named, the program goal: to address the needs of young children from birth to age seven years who are at risk for developing substance abuse and/or mental health problems. The initiative is undertaken in partnership with the Annie E. Casey Foundation, which will continue to fund some of these programs after Federal dollars are gone.
  
  **Seven new SAMHSA grants will design and test short-term prevention and intervention strategies for HIV/AIDS, as well as identify the best methods to help young people and women to use these strategies.
  
  **Nine new grants are dedicated to identifying successful workplace employee assistance programs that can be adopted by businesses nationwide.
  
  
• Reauthorization: SAMHSA reauthorization is a priority for Senator Bill Frist (R-TN), Chair of the Subcommittee on Public Health and Safety, Senate Labor and Human Resources Committee, and may occur early in 1998. Focus of both reauthorization and future appropriations are performance measures, data reporting systems, and Federal/State partnerships rooted in quantifiable, successful outcomes. SAMHSA ability to generate new resources or keep the resources it has likely rests on demonstrable outcome measures.

When Dr. Chavez mentioned the upcoming Walk the Walk, Joseph Rogers (invited guest) argued for greater consumer involvement, since feelings of exclusion and agenda-setting have led to a proposed counter-event to coincide with the "Walk."

Dr. Chavez entertained further questions and was thanked for her participation by Dr. Arons.

The Council then recessed for luncheon.

Report of the NIMH Liaison

When it reconvened following lunch, the Council received a report from David Shore, M.D., Associate Director for Clinical Research, NIMH, who updated Council on NIMH activities.

• Appropriations: In the recent appropriations NIMH received a 7percent research funding increase. The agency also undertook a major reorganization.
  
  
• Program Activities:
  
  ** Access to safest, most effective treatments available: Three new atypical antipsychotic medications are available; more are expected in the next few years. NIMH is working with CMS to ensure that people who depend on public mental health services for treatment receive these new medications. NIMH further convened a panel to provide the National Bioethics Advisory Commission with expertise from individuals who conduct clinical trials and review research decisions on a day-to-day basis. The recommendations that have emerged include (1) greater representation of consumer and family members on institutional review boards; (2) a more robust approach by local internal review boards to using already existing safeguards; (3) the clear need to develop a ?gold standard? regarding protocols; (4) the need to better inform potential participants about the purpose of the research, potential risks, anticipated benefits, and alternatives to research; (5) standardized means to indicate advance directives for treatment and participation in research; and (6) better communication between the data safety and monitoring boards and the local institutional review boards.
  
  
• NIMH Goals: The central goals articulated by the new NIMH Director include:
  
  **Emphasizing basic research in genetics, molecular biology, neuroscience, and behavior;
  **Translating basic scientific findings into clinical research;
  **Focusing on interventions in research; and
  **Exploring policy-relevant research and targeting some research dissemination activities.
  
  
• NIMH Reorganization
  
  **Grant proposal review system changes: All neuroscience-related proposals, whether in substance abuse or mental health, will be reviewed by the NIH Center for Scientific Review. NIMH intramural research programs now at St. Elizabeths Hospital will be relocated to the NIH campus; laboratories will move to Bethesda.
  
  **Extramural program: Three divisions now include: (1) Basic and Clinical Neuroscience; (2) Services and Intervention Research; and (3) Mental Disorders, Behavioral Research, and AIDS. NIMH is also taking a closer look at the definition of outcomes to include performance at school, work, personal and family relationships, quality of life, and utilization of health care resources.
  
  **Portfolio review: The NIMH clinical and services research portfolio will be reviewed gaps, under-researched areas, and opportunities for future research.

Drs. Arons and Shore reaffirmed their commitment to open communication and cooperation between agencies.

CMHS Block Grant Feasibility Study

The Council received a briefing on the performance indicator projects being supported by the Mental Health Statistics Improvement Program from Dr. Ron Manderscheid, Chief, CMHS Survey and Analysis Branch; Mr. Tom Barrett, Colorado Commissioner of Mental Health, and Chair, NASHMPD Task Force on Performance Indicators; and Vijay Genjn, Director of Planning, Texas Department of Mental Health and Retardation, and Chair of the Mental Health Statistics Improvement Program Advisory Group. They advised Council that:

• The data infrastructure is largely in place as a result of the Mental Health Statistics Improvement Program, with CMHS funding to 31 States to work on outcomes and report card activities designed to lead to pilot projects on performance indicators. With CMHS support, NASMHPD is assessing three major dimensions for performance: access, quality assurance, and outcomes. The goal is to have a set of comparable, agreed-upon, national performance indicators for use in direct State management and for Federal input. While the framework will be standardized, it will be sufficiently flexible to allow State-level stakeholders to adapt indicators to their particular needs.
  
  
• Further, the relationship between performance measures and planning was articulated. Strategic planning and performance measures define the mission and goals of the system. Outcome measures and performance targets establish the objectives. Various strategies determine how to achieve the objectives. Efficiency measures will help explain a good deal of what is going on in these contexts. Performance measures can be used for planning and budgeting, monitoring contracts, assuring quality, and ensuring accountability to both payers and stakeholders.
  
  
• Detailed information about issues critical to the development of performance measures is being delineated: what information systems technology should be used; how should the data flow; what kinds of reports should be produced and how can they be used as feedback in clinical settings; how clinicians, stakeholders, information systems managers, and others should be trained; how to implement indicators uniformly in States with varying levels of capacity; and how to ensure that systems will be flexible yet capable of producing standard data sets.
  
  
• Because developing and using performance measures demands a deliberate, thoughtful process, the CMHS 5-State feasibility study is focusing on what is doable today. Among the indicators under consideration are: level of functioning; reduction in symptoms; percent of consumers contacted within seven days of discharge from the State hospital; percent of those receiving case management, supported housing, or employment services; and the use of restraints and seclusion in hospitals. The next step will be a pilot study with the goal of collecting data, and applying that data to improved policy and planning in public mental health services.
  
  
• Finally, the CMHS block grant program can become a major player in assuring performance and accountability. The Government Performance and Results Act (GPRA) indicators being developed by the CMHS 5-State feasibility study are to be included in a data-driven draft of the 1999 block grant application.

Hope and Remembrance Video

The Council viewed the above-titled video regarding remembrance and rituals in recovery from losses incurred from disasters or traumas. Council members concurred in the power and strength of the video to evoke considerable emotional response and urged that its power be considered in any distribution and/or screening plans. They suggested that a manual guiding use of the video for various audiences might be a welcomed tool to those using the video for a variety of potential populations-whether disaster/emergency planners, teachers in a school confronted with violence, mental health therapists working with victims of a natural disaster, etc. A number of other suggestions were made:

• Ensuring cultural competence of such a manual would also be critical, particularly since the video was not.
  
  
• While the film forces viewers to bear witness in a powerful way, it might contain more information about the healing effects of bearing witness itself.
  
  
• Other potential audiences for the film/video might include consumer organizations and the media.

Council concurred that other issues might be conveyed with a lasting message through video. Council member Getka suggested specifically that stigma about mental illnesses and people who have mental illnesses might be such a topic.

Presentations from the Floor

• National Mental Health Association: Michael Faenza, NMHA President and CEO, provided an overview of the second annual National Consumer, Family and Advocate Leadership Conference on State Health Care Reform and Managed Care, supported by CMHS. The conference brought together leaders from each of the major mental health organizations concerned about consumer and family issues in managed behavioral health care. The conference resulted in a shared body of identified risks and opportunities that managed care presents to the mental health community; a shared determination to ensure that health care reforms ensure access to high quality mental health services for all people who need behavioral health services, and that managed behavioral health care systems provide timely, appropriate care to all enrollees; and a commitment increase meaningful participation by consumers and family members in the State health care reform planning process.

Mr. Faenza also gave an account of NMHA activities aimed at protecting consumer interests in State health care reform. One project has provided 40 training sessions and offered technical assistance to consumers and family members in 29 States. The focus has been on contracting, medical necessity, outcomes, and quality assurance. These trainings have increased the understanding of managed behavioral health care and Medicaid managed care in consumer and family advocacy groups.

NMHA also participates in and invests resources in the National Managed Care Consortium. This group seeks Federal assistance to support technical assistance and training regarding health care reform to mental health advocacy groups. The mission is to serve as a collaborative national presence to ensure that the concerns of key mental health constituencies are fully represented in deliberations about State health care reform and managed care policy and program development, as well as in the selection, monitoring, and evaluation of managed care organizations.

The National Managed Care Consortium has developed a core set of values and principles that include approaches to mental health services such as: (1) Strength-based interventions; (2) Focus on individual needs, not systems; (3) Consumer rights, including family member participation, when appropriate; (4) Service access; (5) Quality of care; (6) Accountability; and (7) Quality of life.

Dr. Horvath asked to receive a copy of the core values and principles, for use by the VA as it works to develop a consumer bill of rights.

Dr. Arons recessed the meeting at 12:17 p.m., to reconvene on December 5 at 9:00 a.m.

Dr. Arons reconvened the Council at 9:00 a.m., December 5, 1997.

Update on Cultural Competence and Rural Health

Harriet McCombs, Ph.D., CMHS Public Health Advisor, Special Programs Development Branch, discussed developments in culturally competent services and provided an update on the rural mental health report. She reminded Council that the concept of cultural competence was developed in 1987 by the Community Support Program, then part of the NIMH. Today, cultural competence is reflected in the CMHS grant application requirements and process, particularly in review and award criteria sections that provide guidelines to assess cultural competence. CMHS has also developed a State guideline for cultural competence that includes assessment tools.

CMHS has developed a series of reports setting forth standards of cultural competencies within managed care for use not only in clinical treatment and systems operations but also by State government. The summary report represents a consensus of underserved, underrepresented, ethnic racial populations?African American, Asian American, Hispanic, Asian Pacific, and Native Americans; separate specific documents on each ethnic group were also developed and are available.

CMHS is incorporating cultural competence items into the MHSIP consumer oriented report card and is developing performance measures for cultural competence in managed care. CMHS is also working on ways to ensure that the guidelines and annotated bibliographies it has produced are useful and actually reach intended audiences. Further, CMHS continues to support conferences and institutes on cultural competence, such as recent the National Technical Assistance Center for Children's Mental Health academy on cultural competence and managed care.

Mr. Feltman praised CMHS for its leadership in this area, noting that while cultural competence appeared to be on every agenda during the first half of this decade, it seems to have been replaced by the concept of cultural blindness, and mentioning that very little on cultural competence appears in Federal documents, with the exception of those from SAMHSA. He asked CMHS to engage with other Federal entities to make information on cultural competence available and to help clarify the relationship between cultural competence and racial differences.

Dr. McCombs clarified Mr. Feltman's last comment, observing that from the CMHS perspective, cultural competence is a programmatic issue, whereas race is a policy issue. Cultural competence is best described as a set of knowledge, skills, attitudes, and policies designed to ensure quality services. Several HHS agencies have produced cultural competence guidelines; Secretary Shalala apparently is convening a group to look at cultural competence from a Department-wide perspective. Dr. Martinez suggested it is important to view cultural competence as a bottom-line issue and that CMHS should prepare a series of brief concept statements on the topic of cultural competence that could be used by organizations such as the National Committee for Quality Assurance. Dr. McCombs observed that the CMHS contract for performance measures looks at the issue in terms of outcomes and the bottom line.

Dr. Forstein asked how and if CMHS is able to ensure that the principles of cultural competence are being practiced on service and training organizations supported by CMHS and suggested using the Ryan White Act as an model. Under that Act, agencies cannot receive support unless they demonstrate consumer participation on their advisory councils and adherence to cultural competence criteria.

Dr. McCombs responded that CMHS will continue to work with professional associations through its contract on cultural competence implementation to discuss training in this important area.

The discussion moved to a recent CMHS report designed to enhance the supply of and improve access to providers in rural areas. The report recommends increasing training programs in rural areas and improving interdisciplinary collaboration. Another recommendation would include consumers and traditional healers as part of the provider network. Both strategies help make better use of existing resources, enhance skills, and build on the existing network.

The report found that among the barriers to effective rural mental health service systems are existing CMS guidelines, such as one that requires a psychiatrist to be present when mental health services are provided, a problem for underserved rural areas. The report proposed a number of solutions, among them: encouraging other Federal health programs, such as federally qualified health centers, to include mental health services as a cornerstone of health; and developing greater use of tele-health services.

Consumer Affairs Presentation

Mr. Joseph Rogers was invited to make a brief presentation. He briefed Council on the June 1998 annual conference of the National Mental Health Association) which will include substantial consumer participation for the first time. The goal: to provide training and to create and strengthen alliances within and between mental health associations and consumer groups. He urged the Council to remain mindful of consumer viewpoints on critical issues, such as involuntary commitment and suggested that CMHS create a special consumer advisory board to meet quarterly.

CMHS Consumer Affairs Specialist Paolo Del Vecchio then provided Council with an overview of recent CMHS consumer/survivor-related activities, including:

• A series of three planned regional meetings for this year to broaden consumer influence at CMHS and to ensure consumer participation in the Surgeon General?s Report on Mental Health;
  
  
• Increasing use of focus groups composed of consumers to provide recommendations on everything from the contents of pamphlets to grant announcements; and
  
  
• Continuing to sponsor training and educational conferences, including a train-the-trainer conference to ensure consumer access to the Internet, another to inform CMS staff about consumer involvement and mental health issues, and another on arts and recovery.

Mr. Del Vecchio also told Council about an important meeting recently between consumers and psychiatrists designed to help break down attitudinal barriers, promote partnerships, and get beyond the polemics that too often separate consumers and providers. This meeting was so successful that CMHS is planning two additional meetings: one between consumers and psychologists, and another between consumers and psychiatric nurses. Moreover, CMHS may develop a ?how-to? manual to help replicate this initiative at the State and local levels.

Mr. Del Vecchio also mentioned other CMHS projects involving consumers: (1) the soon-to-be released report on electroconvulsive therapy; (2) a contract with the Bazelon Center for Mental Health Law to develop self-advocacy groups for older adult consumers; (3) a network of consumer-operated services; (4) a proposed meeting on consumers of color and managed care; (5) training for SAMHSA staff on stigma; and (6) a guidebook on how to write effective letters to the media to respond to inappropriate published information regarding those with mental illness.

Mr. Del Vecchio noted that CMHS especially welcomes consumer and Council recommendations regarding the dialogue concept: Is it worthwhile? Are there particular policy issues CMHS should address in this format?

Dr. Shaffer suggested the dialogue format could be extremely useful as a complement to professional training, where consumer interaction and cultural issues historically have not been emphasized. Dr. Horvath concurred, underscoring the importance of providing training to psychiatric residents, interns, psychiatric nurses, and other mental health trainees, so they can develop an understanding and appreciation of cultural competence and consumer perspectives. Mr. Del Vecchio wondered if Council could suggest ways in which current practitioners could gain better understanding and appreciation of cultural competence and consumer perspectives through continuing education and other training opportunities.

Dr. Shaffer observed that managed care organizations have difficulty discerning which consumer-provided services to include in their service package and how best to credential consumer-provider groups to provide services. He also underscored the need to distinguish between consumer and provider rights, an issue that can confuse both managed care providers and public policy makers.

Mr. Burgmann observed that an element missing in discussions about rights is that of responsibility. He has developed a bill of responsibilities to accompany the bill of rights that will become part of a Florida statute.

Dr. Gottlieb wondered if the healing elements of the self-help movement are adequately understood by providers and noted that the imbalance of power in the relationship between the provider and consumer contributes to the problem. The fact that psychiatrists have the power to write a prescription that can help, he said, automatically takes away some dignity and, therefore, some mental health.

Melvyn Haas, M.D., Associate Director for Medical Affairs at CMHS, concurred that consumer-provider dialogues are extremely valuable. He also commented that the discussions between psychiatrists and consumers were one of the most moving times in his life. It was an opportunity for psychiatrists to let themselves be heard by a group of people seldom allowed into their lives. In fact, many of the participating psychiatrists learned they should let consumers into their lives. Dr. Haas asked for guidance from Council regarding the potential value of a similar dialogue between child psychiatrists and child and adolescent consumers.

Dr. Forstein's comments were directed at the issue of power. When providers commit themselves to long-term treatment, he said, the relationship shifts away from one that focuses on power?such as the power of a single pill?to one that focuses on healing. Consumers must address the issue of helping providers stay in places where they work, he said. Even eight visits a year (the limit in many managed care plans) over 10 years with the same provider allows the relationship to grow and issues of control to fall away. He observed that, unfortunately, psychotherapy as a mainstay of psychiatric and mental health practice has been lost. Many people leave residency training knowing how to prescribe medications, Forstein said, but not knowing how to talk with patients. The situation can be altered through practical steps such as giving providers incentives to continue their training. While not a panacea, it is a solid start in the right direction.

Managed Care/Parity

Jeffrey Buck, Ph.D., Director of the CMHS Office of Managed Care, gave a presentation on the Balanced Budget Act as it relates to children, Medicare, Medicaid, and regulations regarding the Mental Health Parity Act:

• Parity does not guarantee needed services; it establishes a necessary, but not always sufficient, condition for getting services. The parity gap?the difference in provisions between medical/surgical coverage and mental health/substance abuse coverage?is getting wider, in part, because of spiraling costs under unmanaged fee-for-service care for mental health and substance abuse treatment in the late 1980s. The public mental health system that serves as a back-up also has contributed. Another factor has been misinformation regarding the efficacy of treatment. One recent study found that mental health and substance abuse coverage in surveyed firms dropped from 9 percent in 1989 to 4 percent in 1995.
  
  
• Many parity laws have passed at the State level. However, many of these laws are not full parity in the sense that they apply both to mental health and substance abuse or that they apply to everyone who has coverage. Moreover, they often use different definitions. So, what constitutes a parity law in one State may be entirely different in another. Substance abuse is often left out of State parity laws; many focus solely on biologically-based disorders or those that are addressed to the seriously mentally ill. Small business is often exempted, and, most importantly, States have limited authority in terms of covering the totality of plans within their States, specifically self-funded plans. What?s more, those covered under Employees Retirement Income Security Act are not subject to State regulation. As a result, no matter how comprehensive a particular State parity law may be, it simply does not apply to a large number of plans within States.
  
  
• The Federal legislation that passed last session is really a partial parity act. Plans can still cover mental health and non-mental health services differently. The act applies only to the use of annual and lifetime limits on expenditures. Simply put, it means that plans may not have different limits for mental health services than they do for other kinds of benefits. It does not include substance abuse. Employers with 50 workers or fewer are exempt. That alone accounts for approximately half the workforce. Another exemption states that if an employer?s costs to insure workers increase by 1 percent or more as a result of this act, then the employer need not implement the provisions of the Act.

Given the disappointing results of the current legislative mandates, CMHS is taking a number of different approaches:

• Education. CMHS is taking more time to educate groups it traditionally has overlooked, such as employers, benefit consultants, and insurance plan managers. For example, CMHS is supporting a conference focused on employers. The goal is to give them the tools to design mental health and behavioral health care benefits to get the most for their buck.
  
  
• Plan Evaluations: CMHS recently awarded a contract to take a systematic look at the best kinds of limits for a particular actuarial amount of dollars. For example, is it better to limit benefits by having higher cost sharing or by decreasing the number of visits?
  
  
• The True Costs of Parity: CMHS is reviewing a draft of a study that more accurately determines actuarial estimates of the cost of parity. Another project is putting together case studies of both employers and HMOs that either offer or administer generous mental health and substance abuse benefits. Both will be distributed to employers.

Dr. Shaffer advised that CMHS think like employers and benefits managers and arm itself with relevant data. Employers need to understand what will happen if they no longer provide mental health benefits. Similarly, they need to see how such benefits will improve the bottom line of their business. Employers ask questions such as, ?Will absenteeism decrease among employees if they have this benefit??

Dr. Horvath responded that such data exist and that they should be packaged to reach employers and general benefits managers. Drs. Arons and Buck concurred and agreed to work on packaging this information.

Dr. Buck turned the discussion to the Balanced Budget Act and its changes in Medicaid and in meeting the needs of uninsured children. He observed that the reduction in Medicaid's disproportionate share is likely to have a tremendous impact at the local level over the next few years, by affecting facilities that bear a disproportionate share of indigent and Medicaid patients.

Some of the other changes resulting from the Balanced Budget Act reduce State reliance on waivers for engaging in managed care. States will no longer have to seek a waiver to mandate that their Medicaid population enrolls in managed care. Other changes require managed care organizations to have grievance procedures, prohibit prior authorization for emergency care, and remove the gag rules on providers.

Another area of concern is the status of carve-out programs currently operating under Medicaid waivers. In some States individuals have a choice of managed care plans for their general health care. However, if they have a serious mental illness they may not have an option. Similarly, the transition from the waiver process to a State plan process is problematic. Under a waiver, public review and comment are required. That is not the case with a State plan amendment. Also, given the discretion to both CMS and the States, issues of quality assurance and quality standards are unclear.

The discussion turned to the Child Health Insurance Program, a quasi-block grant targeted to uninsured children that requires State contributions to qualify for Federal dollars. The program gives States several options to meet the needs of these children: They can expand their existing Medicaid program; they can create their own insurance program (with mental health provisions); or they can combine the two. In many States, it appears that the first option is being chosen.

Another important provision allows cost sharing not to exceed 5 percent of a family?s income (for people over 150 percent of the poverty line) and cost sharing equal to that in Medicaid (for people below 150 percent of the poverty line). With the severe restrictions on cost sharing, States that want to move in the direction of actuarial equivalence to a benchmark plan will have incentives to limit mental health benefits below current levels. A paradox inherent in expanding Medicaid is that the States with historically less generous Medicaid programs are the ones that get the smallest increase in their matching rates under the Children?s Health Insurance Program. Conversely, States that have been the most generous will actually receive larger increases.

Dr. Arons directed Council member attention to a list of allotments for different States. The list represents a tremendous influx of money that may be directed at mental health services, in part, mental health services for children. He urged Council members, as leaders, to be aware of this and to continue to engage the issues. Dr. Arons also asked Council to identify specific areas CMHS should be tracking that might help enable people to become more involved in State decisions to expand Medicaid coverage.

Adjournment

Following discussion regarding the next dates for Council meetings, Dr. Arons formally thanked participants and adjourned the meeting.