CMHS NATIONAL ADVISORY COUNCIL MEETING MINUTES
September, 1995
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
CMHS NATIONAL ADVISORY COUNCIL MEETING MINUTES
The Center for Mental Health Services (CMHS) National Advisory Council
convened at 11:30 a.m. on September 11, 1995 in the Versailles conference
room at the Chevy Chase Holiday Inn, Chevy Chase, MD. Dr. Bernard S. Arons,
Director, CMHS, chaired the meeting. In accordance with Public Law 922-62
U.S.C., Appendix 1, the portion of the meeting held between 8:30 a.m.
and 11:30 a.m. was a closed meeting dedicated to grant and contract
reviews.
Palladian Ballroom
Chevy Chase Holiday Inn
5520 Wisconsin Avenue
Chevy Chase, Maryland
September 11-12, 1995
Council members present:
Bernard S. Arons, M.D., Chair
Anne Mathews-Younes, Ed.D., Executive Secretary
June Jackson Christmas, M.D.
Marshall Forstein, M.D.
Rosa Maria Gil, D.S.W.
Gloria Johnson-Powell, M.D.
Floyd Martinez, Ph.D.
Elisabeth Rukeyser
Eleanor Schorr, J.D.
Joel C. Slack
David K. Yamakawa, Jr., J.D.
Council members absent:
Charles Keisler, Ph.D.
Evelyn Robertson
Randy Feltman
Ex officio members present:
Patricia M. Collins, Department of Defense
William Van Stone, M.D., Department of Veterans Affairs
Laurent S. Lehmann, M.D., Department of Veterans Affairs
Welcome and Opening Remarks
Dr. Bernard S. Arons, Director, Center for Mental Health Services
(CMHS) called the fifth meeting of the CMHS National Advisory
Council to order at 11:30, welcoming all CMHS National Advisory
Council members, guests, and staff. Dr. Arons introduced the three new
Council members, Marshall Forstein, Rosa Maria Gil, and David
Yamakawa.
Dr. Marshall Forstein is a clinician who is nationally recognized as an
expert working with HIV/AIDS. Dr. Forstein is the chair of the
American Psychiatric Association's commission on this epidemic, and
his work on the mental health and psychosocial aspects of AIDS has
been widely published.
Dr. Rosa Maria Gil is the Vice President of the New York City Health
and Hospitals Corporation, and is responsible for the development and
implementation of policy, planning, oversight and management of the
largest public psychiatric and addictive disorders treatment delivery
system in the nation. Her experience in the public sector motivated her
to create a not-for-profit organization to test innovative programs to
reduce costly hospitalizations of patients with tuberculosis, HIV, and
mental illness through community-based strategies. Dr. Gil is also the
founder and past president of the Association of Hispanic Mental Health
Professionals.
David K. Yamakawa, Jr. is an attorney-at-law and a consultant. He
has a successful legal practice in San Francisco and brings a great deal
of community involvement experience to his role as a member of the
Council. He currently serves on several community boards including
the Board of Trustees of the Mt. Zion Medical Center at the University
of California--San Francisco, the American Red Cross Board of
Oversight of the Northern California Earthquake Preparedness Fund,
chief financial office of the Friends of San Francisco Human Rights
Commission, legal counsel to the Hispanic Community Foundation in
the Bay Area, vice president of the Mt. Zion Institute on the Aging, and
chair of the trustees of the United Way of the Bay Area.
Continuing Council members and other persons present introduced
themselves. The minutes from the previous meeting were put on the
table for consideration. A motion was passed to approve the minutes.
For the first time, immediate electronic dissemination of these approved
minutes was made available to the field via the CMHS Electronic
Bulletin Board.
CMHS Director's Report
Dr. Arons began his presentation to the Council members by stating:
"At your request, we have a lot of information on managed care to share
with you during this meeting. Our new Council members join us at a
pivotal time in the Center's brief history. We are experiencing a new
Federal re-engineering in which every single Federal program is being
re-evaluated and retooled to satisfy a new set of priorities. To the
degree possible, the climate dictates a shift in responsibility and dollars
to the States and the private sector. The Council has come together
during a period of change that, for some, presents new opportunities,
and for others, new challenges and uncertainties."
Fiscal Year 1996 Budget
Dr. Arons reported that the President's Fiscal Year 1996 budget proposal
calls for merging the Mental Health Services Block Gant program and
the Projects for Assistance in Transition from Homelessness (PATH)
program, under one legislative authority, to be called the Performance
Partnership Grant. The President's proposal also calls for consolidated
demonstration authority that would combine all of CMHS's knowledge,
development, and program management activities into a single
legislative authority funded at a slightly higher level. While the
President's proposal calls for consolidating the demonstrations, there
will still be a separate mental health demonstration and training cluster,
and a separate substance abuse cluster.
The Protection and Advocacy program and the Children's Mental Health
Services program were proposed to remain as separate line item entities
under the President's plan, with a slight reduction in the Protection and
Advocacy budget.
However, according to Dr. Arons, on August 4, when the House of
Representatives passed the appropriations bill that affects SAMHSA's
budget, there was some good news and some bad news. The House
called for a $2 million cut in the Protection and Advocacy funds and the
elimination of the PATH program. The House budget proposal did not
specify funding amounts for the CMHS demonstrations except for level
funding for the HIV/AIDS Mental Health Services Demonstrations. It
provided no funding for the AIDS Training program, the Community
Support Program, the Homeless demonstrations, and other activities and
programs that had previously been funded at about $52 million during
Fiscal Year 1995. All of SAMHSA's demonstrations were combined
into a consolidated SAMHSA-wide demonstration program, and $142
million in funding was proposed for these consolidated initiatives. The
House proposal represents a cut in the demonstration agenda for
SAMHSA of more than $364 million over FY 1995 spending.
According to Dr. Arons, "The budget battle between Capitol Hill and
the White House is far from over. While the President has not talked
specifically about Federal funding for mental health programs, he said
repeatedly that he will veto any congressional budget plan that calls for
draconian or harmful cuts."
SAMHSA Reauthorization
In other news, the Senate held a reauthorization hearing for SAMHSA
on July 27th, which went very well. Dr. Arons then shared information
about Senator Kassebaum's proposed "civil commitment" proposal.
CMHS Activities
Dr. Arons reported that CMHS has launched several new initiatives,
such as the Community Support Programs' Employment Initiative,
which has been expanded to a five year, $20 million program. CMHS is
also laying the groundwork for a national launch of the Children's
Mental Health Campaign.
Through a cooperative effort with FEMA, CMHS was actively involved
in the relief effort in Oklahoma City in the wake of the bombing of the
Murrah Federal Building. CMHS staff were on site for an extended
period following the bombing to assist FEMA and the State mental
health authority in needs assessment and program design for services to
those affected by the bombing.
For the first time ever, CMHS convened an informal meeting with a
group of consumers representing nearly every sector of the mental
health system, and received input on a broad range of issues.
Dr. Arons also shared the CMHS 1996 demonstration agenda. "The
most pressing question concerns determining which models are most
effective in delivering quality mental health services under managed
care. This demonstration project will be a collaborative activity with
CSAP and CSAT, in large part because managed care companies are
moving more towards covering behavioral health."
Dr. Arons concluded with an announcement about the upcoming
Partners for Change Conference chaired by Mrs. Tipper Gore. The
conference will focus on the delivery of quality mental health and
substance abuse services in a rapidly changing State environment. To
facilitate this conference, CMHS has invited State Mental Health
Directors, State Substance Abuse Directors, and the State Medicaid
Directors. The goals of the conference are to bring together State
Mental Health, Substance Abuse, and Medicaid officials to share
knowledge and ideas with one another and with representatives of the
the Centers for Medicare and Medicaid Services as well as our major constituent
organizations.
"We hope that by bringing all these major players together, we can
facilitate the knowledge exchange process and enter a new technical
assistance arena. We also hope to foster partnership, collaboration, and
networking between and among the States. We are very proud of all
that we have been able to accomplish, and hope that our important work
will continue in this area without interruption," reported Dr. Arons.
Managed Care Exchange
Managed Care and Health Care Reform
In the brief absence of Dr. Arons, Dr. Bornemann, the Deputy Director
of CMHS, introduced Dr. Ron Manderscheid and Dr. Jeff Buck, who led
the discussion on managed care.
Dr. Manderscheid offered a brief introduction to managed behavioral
health care, emphasizing the many resources that CMHS makes
available to mental health programs across the country.
According to Dr. Manderscheid, two major factors have contributed to
the impetus for national health care reform. "One has to do with the
distribution of insurance in the U.S. population. Of the 255 million
people in the U.S., there are about 40 million [at a given point in time]
who have no health insurance. If you look at that over the period of a
year, the number becomes about 57 million people. So one major factor
in the efforts toward national health care reform was to bring insurance
to people who currently did not have health insurance. Another factor in
national health care reform is the rate of increase in our health care and
mental health and substance abuse expenditures. In 1990, we spent
about $800 billion on health care in the U.S. and in 1995, we will spend
around $1 trillion on health care. By the year 2003, our health care
costs could be about $2 trillion. The rate of increase for mental health
and substance abuse services will be comparable."
These expenditures, according to Dr. Manderscheid, "cannot be
sustained either by the Federal Government or by the economy.
Sustaining these costs takes money away from education and
infrastructure development. It is these economic facts that pushed us
into the initial foray into health care reform. While opponents to
Clinton's initial plan focused on the 'harm' that proposal would cause
and the plan was abandoned... the problems have not gone away, and
managed care is growing rapidly in the absence of any federal or State
regulations."
Dr. Manderscheid then presented the data that showed that out of the
185 million insured Americans, 107 million are in managed care
programs. The changes in the organization of health care have been
extremely rapid. In 1988, 71 percent of private plans were conventional.
In 1994, 37 percent were conventional. This huge growth has primarily
occurred in preferred provider organizations and point-of-service plans.
"Preferred provider organizations are providers that contract with
managed care entities to deliver reduced fee-for-service care. Point-of-
service plans are an extra "bell and whistle" on preferred provider
organizations, wherein the client, for an extra fee in the insurance, can
have the option of going outside the network and using their own
providers. Those types of plans grew from 11 percent in 1988 to 40
percent in 1994."
According to Dr. Manderscheid, "In health care reform it doesn't make
much sense to create a capitation system for individuals and then put a
global cap on your budgets, because the two things run in opposition to
each other. And I think that's kind of where we are."
Dr. Manderscheid then described the major differences between the
"carved-in" and "carved-out" provision of mental health and substance
abuse services. He pointed out that the "Carved-out" scenario simply
separates out the contracts for behavioral health from primary care. In
the "Carved-in" plan, the manager can control the resources devoted to
behavioral and primary health, but within the same contract, so there can
be efficiencies gained from this that cannot be gained in a straight
"Carved-out" plan. In this version, the provider can reap the "primary
cost offset effect," which is the impact on primary care of the delivery of
adequate mental health and substance abuse care. The fully integrated
plan has primary health care, mental health care, and substance abuse
care in the same contract with no financial distinction.
"These current changes," proposed Dr. Manderscheid, "will impact the
'safety net' we wish to have in place for our citizens. As we begin to
privatize the public sector of mental health and substance abuse, we
confront the provision of emergency care, which is provided by the
public sector in times of natural disasters ... As you create multiple
tiered systems, you have a private sector of managed care, [and] you
have a privatized public sector of managed care. People will obviously
start falling through these various levels. What is the safety net for the
privatized public sector managed care?" Dr. Manderscheid noted that
there is not much discussion in the field about this potential problem.
Will behavioral health care be medical or social? Dr. Manderscheid
pointed out that "You get into this issue as we evolve toward 'carved-in'
and integrated type plans; mental health and substance abuse services
will become the behavioral wraparound for a medicalized system. Will
we be providing the housing and the social services and the vocational
rehabilitation for primary care physicians who are operating the
system?" Dr. Manderscheid cautioned the Council to think about the
impact that managed care has on persons served in the public sector.
"Persons served in private sector plans frequently need less services.
They don't need the full spectrum of services the way somebody in a
community support program would need." In light of nearly half of the
current public system moving under managed care, we need to
determine how we want the public system to look.
"In mental health and substance abuse we are saying as the purveyors of,
the representatives of, the public here in the public system, we want to
contract with you for this care and eliminate our own direct involvement
in care. We're selling the system, so to speak."V
Areas of concern to CMHS include the role of practice professionals in
this process and how to assist the more than one million mental health
and substance abuse professionals in making the transition to this new
system. According to Dr. Manderscheid, "there are many preferred
provider organization plans that have no psychiatrist in them at all."
Another general area, Dr. Manderscheid pointed out, is the impact of
managed care on the performance of public health functions. "Basic
functions include assessment procedures, identification of problems in
people living in the community. In addition, we need to determine the
role of the public sector in the formulation of public policy that is based
upon good empirical data as well as the role of the public sector in
quality assurance processes--the development of clinical standards, the
development of quality assurance procedures. Each of these areas
represents a potential vehicle of countervailing abuses that might occur
in managed care and may warrant the involvement of PHS."
Medicaid Waivers and Managed Care
The agenda then turned to Dr. Buck to review the impact on Medicaid
managed care and Medicaid waivers.
Dr. Buck pointed out that Medicaid changes are very critical in terms of
their impact on mental health. "Medicaid is the major vehicle of
changing the public health system. Medicaid has a lot of flexibility in it,
but it has some limits in terms of the ability of States to use it to expand
coverage, to eliminate or reduce restrictions on the use of managed care,
and to redirect dollars into managed care arrangements." The 1115
waivers provide flexibility in the implementation of the State Medicaid
program.
Dr. Buck noted the concerns of both Congress and the States about the
rapid growth in Medicaid spending. "Medicaid doubled between 1990
and 1994, and, while the rate has slowed somewhat, it is still well ahead
of the rate of inflation. Medicaid is the largest single program in the
country for mental health and is the most important source of funding
for public services... close to $20 billion. Of Medicaid beneficiaries,
about 10 percent of them are getting mental health or substance abuse
services, which accounts for more than half of all State and local
spending on mental health and substance abuse. Medicaid is the largest
single payer of health services for children and adolescents, and
Medicaid covers 40 percent of the population under 6 years of age."
According to Dr. Buck, Medicaid is a very complex program, and, while
many people believe that Medicaid is a program for people with low
incomes, Medicaid also supports persons who are on Aid to Families
with Dependent Children, persons with SSI, and low-income pregnant
women, infants, and children.
Dr. Buck pointed out, "It is hard to reform Medicaid nationally because
Medicaid has a number of mandatory and optional components. While
inpatient hospital care is mandatory, the optional services include
personal care and clinic services, particularly rehabilitative and targeted
case management." Using the managed care model in Medicaid does
not require a waiver. About 25 percent of Medicaid enrollees are
currently in managed care programs. "However," stated Dr. Buck, "the
1115 waivers are necessary to create HMOs because the current
Medicaid rules do not allow you to have a Medicaid-only HMO."
The "freedom of choice" provision is seen by HMOs to be a constraint.
"Under a regular Medicaid program, beneficiaries are able to choose
whatever provider they want. That is not an attractive feature for HMOs,
because if an HMO recruits an individual to become part of their HMO,
there is no guarantee that they can hold on to that individual, and in the
regular Medicaid program, you can pretty much change anytime you
want." Another provision of the 1115 waiver is that it locks in
beneficiaries for longer periods of time.
The most important provision for mental health is the waiver of the
regulation that does not permit coverage of care if the individual resides
in a psychiatric institution who is between the ages of 18 and 65, i.e.,
Institute for Mental Diseases (IMD) services.
According to Dr. Buck, the 1115 waiver was created to give the
Secretary of HHS authority to pilot a number of demonstration projects
prior to making permanent changes to the Medicaid program.
"Typically States have used this waiver to expand eligibility to groups
that would not otherwise be eligible for Medicaid. States have used
them to add other services, including coverage of IMD services as well
as the development of HMOs that serve only Medicaid beneficiaries.
These waivers can lock in beneficiaries for even longer periods
compared to 1915B waivers. A less frequently used, but important
provision, is that under 1115 waivers, States have been asking for
permission to redirect their disproportionate share dollars--those dollars
that were specifically directed to hospitals that had a disproportionate
share of people who were on Medicaid or who were indigent and could
not pay for their care." According to Dr. Buck, States have wanted to
use those disproportionate care dollars in different ways and waivers
have permitted that option.
Waivers are supposed to be budget-neutral. Cost neutrality under the
current method that waivers are being negotiated is decided on a State-
by-State basis. However, these waivers can focus on aggregate savings,
rather than year-to-year savings. A State may say that it is going to
spend a lot more money in the first year, but that this will be offset by
large savings in the latter years. Some reports suggest that States are not
realizing significant savings.
Dr. Buck pointed out that waivers do not necessarily make a State's
Medicaid program simpler. According to Dr. Buck, "There seems to be
a collision course here between both reorganizing Medicaid and
expanding it to groups and to services that otherwise weren't covered,
and what is currently the emphasis on deficit reduction. The current
proposals for Medicaid in Congress will have a growth of about 10
percent a year. Congress wants to reduce that rate to 4.3 percent by
1999, and in the course of doing so, save $180 billion from the program.
The Administration would also reduce Medicaid, but by a much lesser
amount, $54 billion, and would do it over a longer period, 7 years and
not by block grants, but rather by setting limits on per-person spending
within each program.
Council member Martinez noted the concern about professional liability
that emerges from the clinical responsibility for a person to whom--
according to the managed care company-- you cannot provide services.
"Ethical concerns emerge and in some instances, providers feel they are
being placed in situations where, to operate as the managed care
organization would like them to operate, places them directly in
violation of professional standards." Dr. Manderscheid responded and
explained the "firewall issue" in managed care, which says the provider
has legal responsibility for delivering care to that person, and that
person can sue you for lack of quality in that care. However, the
managed care company, under current law in most States, has no legal
liability to pay for that care, nor does it share in the legal liability for the
lack of quality in clinical care; hence the firewall issue between clinical
responsibility and financial responsibility. "So they can refuse to pay
you for care, but you cannot refuse to deliver care, and you are legally
liable for refusing to do so, if you in fact do."
According to Dr. Manderscheid, it is critical to set standards of practice.
He recommended that the Advisory Council understand the very strong
bias right now that runs through both Congress and the Administration
that clearly wishes most of these decisions to be made at the State level.
This bias makes it critical that CMHS determine the most appropriate
role for this agency. "While action is at the State level, we need to
empower States to act in the best interests of their constituencies."
Councilmember Rukeyser recommended that, in this environment of
limited rule and standards, CMHS should not abandon a leadership
role. CMHS could develop templates for various service scenarios
under managed care and make them available to the States. "The States
very much would hope to have that, and would be glad, I think, to
participate in that process."
Dr. Manderscheid reported that NAMI is planning to do a State-level
report card that will look at the quality of managed care plans that are
operating in the public sector.
Consumer Panel Presentation on Managed Care
Paolo del Vecchio, the Center's Consumer Affairs Specialist, then
chaired a panel comprised of Laura Van Tosh and Maureen Veech.
Laura Van Tosh is the Consumer Affairs Liaison at the National
Association of State Mental Health Program Directors, NASMHPD,
where she insures broad consumer/survivor involvement in major areas
of NASMHPD's policy and program development. Maureen Veech is
affiliated with the District of Columbia Mental Health Consumer
League, and is Vice President of the Alliance for the Mentally Ill of
District of Columbia Threshold, the local affiliate of NAMI.
By way of introduction, Mr. del Vecchio reported that "As recipients of
services, we are the ones who are most directly impacted by these
changes in managed care and health care delivery. As we mentioned
earlier, we are really the people who are in traffic and the ones who
potentially may get harmed as managed care organizations and systems
learn how to meet our needs."
Another major concern that consumers have, according to Mr. del
Vecchio, is access to services. "Managed care often confronts
consumers with the three Ds-- being denied services, being dumped,
and being disempowered. It is important that, as consumers, we be
involved in the waiver process, in contracting, in the decision making of
managed care organizations. Thus far, we have had little voice in any of
these decisions."
Consumers, according to Mr. del Vecchio, are also concerned about
legal rights, grievance policies, restraint procedures, abuse, involuntary
treatment, confidentiality, and privacy rights. "we are also concerned
about housing, vocational rehabilitation and self-help, the consumer-
centered approach in this new system. It is imperative that consumers
be involved in the development of outcome measures, the development
of consumer satisfaction, and the development of the clinical
protocols."
Laura Van Tosh began her presentation by noting the great strides that
have been made in the public mental health system. "we have provided
abilities and assurances for broad consumer/survivor involvement in
public mental health systems. We have many examples, such as the
public laws that have been developed that mandate consumer/survivor
involvement and family involvement, as well, through the State Mental
Health Planning Act and the Protection and Advocacy Act.
According to Ms. Van Tosh, "The public mental health system has
supported consumer-operated services and programs, networks funded
through the community support program, the establishment of offices of
consumer affairs in virtually every State, and opportunities for
consumers to become gainfully employed in local community programs.
Consumer involvement has also reached the areas of research and
policy with the development and establishment of the
consumer/survivor research and policy work group."
Ms. Van Tosh expressed concern that CMHS "So far hasn't identified or
articulated some core principles and values that would need to be
translated to managed care." She continued, AI think the Feds, too,
have so much to share, and an obligation to share it. The people affected
by these changes are not only myself and other people in this room, but
people who may not be out in the community as we know it... still in
institutions, still homeless in shelters."
In stark contrast to the understanding of the Federal Government, Ms.
Van Tosh noted, "The private managed care industry barely understands
what it means to involve consumers. I know from myself when I first
realized that I was in managed care when I changed jobs, I went to my
doctor's office and I wasn't able to sign the treatment plan that I had
been used to signing in years past when I received public mental health
services in the community." "Consumers need to be proactive,"
stated Ms. Van Tosh, "and learn what kinds of providers will best fit our
needs. Underlying all of this proposed change is an urgent need for
technical assistance (TA). In an effort to address the TA needs, the
Consumer Managed Care Network was formed in April 1995, and it has
now grown to over 100 members representing 35 States in the country,
including Alaska and Hawaii. That group is developing training
modules for managed care companies. The Managed Care Network is
working with the Institute for Behavioral Health Care to help develop a
workshop on TA for consumers in four regional conferences in 1996. In
addition, the NASMHPD group is setting up a meeting between
consumers and managed care representatives.
Ms. Veech elected to address a number of consumer questions from the
areas of education, discrimination, and options.
"Consumers are concerned about providers. Managed care companies
will reconcile their treatment philosophy differences up front, or use
them as a divisive tool with their patients."
"Consumers, as we have heard, must be involved in treatment decisions.
There is some activity on advance directives, and that could be tested to
see how effective they are. You have heard this--consumers must have
choice in providers and alternative services. You need consumers and
families on your advisory boards."
In terms of education, Ms. Veech emphasized, Awe need opportunities
to learn together from each other. Providers in managed care do not
have the market cornered on what is needed. Consumers and families
really are the experts. We have to bring some of the providers in the
public system up to speed."
AI think that the history of managed care is a little confusing,"
continued Ms. Veech. AI have heard managed care companies in
particular try to give their historical account of why we are having
managed care." Managed care companies talk about current trends of
high technology and the ability to track patients. They talk about
economy integration and social change as the impetus. "But my
historical perspective on it is a little different. And my perspective is
that the private psychiatric hospitals and many of the mental health
professionals two decades ago in particular compromised their ethics.
They compromised their ethics for the bottom line. And as a result,
corporations and other companies started looking at how they could
manage costs, especially when companies started self-insuring."
Dr. Forstein commented that the public sector has not always provided
comprehensive care. AI think we have managed to provide reasonable
care in some places for some people. I think there has been a proportion
of the population with severe illness that has never been adequately
treated, and whole categories of individuals have been without access to
care, so we don't know how many people are out there who need care,
and who just haven't had it in a while."
"Managed care," according to Dr. Forstein, "is more than one beast. The
standards by which one group operates because, perhaps, of moral fiber
and some dedication to training and education and learning, is very
different from the bottom line of some other companies whom I work
with. And so in many cases we're talking about managed costs, and not
at all talking about managed care."
Dr. Forstein also noted the lack of integration of medical and psychiatric
care. "Most of our patients are given a choice between good medical
care or good psychiatric care, and finding them in the same place is too
often the exception." "I would like to see, frankly, that the Council try
to work with you around the issue of some parallel standards of care that
really speak to what does it take to provide what people need who have
mental illness? And when they are not suffering from the acute
exacerbations of the illness, what are the resources that need to be put in
place so that they can rejoin the work force?"
Many Council members remarked on the potential danger in the long-
term quest for quality medical care, quality integration of social
services, psychiatric services, financial services, training, and
rehabilitation. "The next generation of mental health providers really
needs to learn much more than just traditional psychiatric medicine."
Councilmember Slack remarked that, during his hospital stays, he
received many evaluations and apparently participated in research
protocols. However, "Since I recovered, no one has ever asked me how
I did it or what worked. And there is all sorts of information available
that is still being generated on things about the illness, but very little as
to what recovery means. And I think that kind of information would be
extremely helpful for people to reference when they look at designing
continua of services and so forth."
Dr. Martinez remarked that the public sector as we know it is quickly
disappearing. "Very quickly I think we will not have either a private or
a public sector. Instead, an interesting blend of a number of different
forces is coming together, including public interest kinds of issues and
entrepreneurial interests, and there really are no established or set
models."
"One concern," according to Dr. Martinez, "Is financial."
Six years ago, the initial Arizona Medicaid waiver demonstration program had
a cap of $735 per month for persons with serious mental illness. The current
cap is $306, and that is an impossible budget."
SAMHSA Administrator's Report
The SAMHSA Administrator's Report was offered by Frank Sullivan,
Ph.D., SAMHSA Associate Administrator, for Nelba Chavez, Ph.D.,
SAMHSA Administrator.
Dr. Sullivan emphasized the Clinton Administration's continuing efforts
to "streamline, downsize -- do more with less, do less with less, and just
do less." He reported that the Office of the Assistant Secretary for
Health is being eliminated. Its 1,400 employees are being transferred to
other agencies, and the various functions of the OASH are being
dispersed to such offices as the Assistant Secretary for Planning and
Evaluation. The support functions are being shifted to a Program
Support Center that will be run and directed by a Board of Directors
made up of the agencies served. "There is heightened attention to the
issue of a field presence and a regional presence for the Department."
According to Dr. Sullivan, AHRSA and CDC have employees in the
field. SAMHSA has been asked to consider the most efficient way to
have our staff in the regions to attend to mental health and substance
abuse issues." Dr. Sullivan emphasized that it is of continuing
importance to have mental health and substance abuse become part of
the larger concept of "health".
Dr. Sullivan remarked that "one of the key features of the
reauthorization process is that in neither the Administration's proposal
nor in Senator Kassebaum's proposal to reauthorize SAMHSA programs
is there any proposal being made to change the legislatively mandated
structure of SAMHSA. The current legislation provides for three
centers."
Dr. Sullivan reiterated the budget scenario for CMHS, which "has some
pretty draconian cuts included in the House mark, including a 75 percent
cut in our demonstration programs, which is a significant reduction and
a significant threat to the Center's ability to develop the knowledge and
disseminate the knowledge that helps keep the system constantly
improving itself."
ASAMHSA realizes," Dr. Sullivan stated, "that it needs to emphasize
managed care and the resulting revolution in systems delivery. In
addition, SAMHSA intends to focus on early intervention for children
and for families and work hard on the issue of persons with multiple
problems, persons with co-occurring mental health and substance abuse
disorders."
Councilmember Forstein remarked that "The real challenge is going to
be how to maintain an identity to advocate for mental health and
substance abuse in the health field."
Mental Health Provisions in State 1115 Waiver Demonstrations
Dr. Arons reported that a number of states have sought Medicaid
Section 1115 waivers in an effort to reform their Medicaid or large
health insurance systems. These waivers can have a significant impact
on Medicaid-funded mental health and substance abuse services and on
those individuals who need those services.
Leslie Scallet, Executive Director of the Mental Health Policy Resource
Center, and Cynthia Folcarelli, Policy Associate for State Affairs, also
from the Mental Health Policy Resource Center, reported on a research
project investigating the impact of Section 1115 waivers.
"While there is a lot of information about Section 1115 waivers,"
reported Ms. Folcarelli, "very little of it addresses mental health and
substance abuse services. The Mental Health and Policy Resource
Center's project took a representative sample of States in order to get an
indepth look at what mental health and substance abuse services are
covered and how they are implemented. The project also permitted
some cross-State comparisons by looking at five States with approved
Section 1115 waiver demonstrations: Florida, Hawaii, Oregon, Rhode
Island, and Tennessee."
According to Ms. Folcarelli, the study looked at the general approach
and the purpose of the waiver, the eligible groups, how the delivery
system is structured, the cost-sharing requirements, and what mental
health and substance abuse services are covered.
In terms of eligibility, the study found that all five of the State waivers
included the Aid to Families with Dependent Children population. In
two States, Hawaii and Rhode Island, the Supplemental Security Income
population (aged and disabled population) were excluded from the
waivers. That population would continue to be served through the
traditional Medicaid program. The result is that in a State under a
waiver program, two parallel programs may be operating. "However,
many are hoping to integrate all of their populations into these waiver
demonstrations, but they are kind of doing it in bits and pieces. All five
of the States expand eligibility to previously uninsured populations.
The stated major goal of all of these waivers was to try to expand
eligibility. However, it is important to note that in Florida, the
medically needy category of Medicaid is eliminated. The medically
needy category of Medicaid underwent some revisions as well in
Tennessee, and it was also eliminated in Hawaii, although the
discussions I had stated that they felt the medically needy population
would still be covered under the expanded eligibility on the uninsured
side." Ms. Folcarelli emphasized the importance of the change in the
"medically needy" criteria for the mental health community.
According to Ms. Folcarelli, each waiver was quite unique "Each State
has its own way of doing things, and each of them are their own unique
creation...but patterns did emerge, which included a focus on primary
care, particularly for pregnant women and children and other
populations that had not had health insurance before." The initial thrust
of the waiver came out of efforts to increase access to primary care, and
mental health and substance abuse fit around that emphasis. "Once that
larger framework was established, then States tried to figure out how to
fit in mental health and substance abuse. Obviously, there have been
some pretty dramatic examples of that, such as Tennessee, where
initially they were not going to include mental health or substance abuse
at all, and sort of in the eleventh hour they had to try to figure out how
to fit it into the system that they had created."
Ms. Folcarelli noted that "All five of the States depended very heavily
on managed care as a service delivery system. While each of the States
had lists of mental health and substance abuse services that managed
care companies were required to cover, they all gave managed care
companies a tremendous amount of authority in terms of determining
such things as what 'medical necessity' means, what preauthorization
requirements can be applied, what utilization review requirements can
be applied." The managed care companies determine what gets covered
and what is or is not a medical necessity. These companies not only are
deciding who meets the criteria, but they are also the ones deciding what
the criteria are.
"In terms of cost sharing," continued Ms. Folcarelli, "all of the States
except Oregon impose some sort of cost-sharing requirements. In
Rhode Island, if you have severe and persistent mental illness or serious
emotional disturbance, you also get your physical health care through
the managed care networks and through the demonstration, but your
mental health and substance abuse services are provided through
traditional Medicaid providers through the fee-for-service system." In
Tennessee and Oregon, persons with SMI and SED receive services
through the same networks as everyone else, although in Tennessee
there is some negotiation going on between the mental health
department and the Bureau of Tenncare (which is their demonstration)
about what services are going to be provided where."
Ms. Folcarelli reported that the service list for persons with SPMI and
SED tend to be more extensive than for the general population.
"However, while it may appear that the list of services is extensive, it
may not be adequate. There is the capitation rate, gatekeepers, and the
medical necessity criteria, all of which will impact on whether people
can access these services or not." These new programs are bringing in
some uninsured populations, and many of these packages are better than
what you would get under private insurance under a State mandate.
There is a whole population of people coming in who are going to have
coverage for mental health and substance abuse services that they did
not have before.
"Managed care does have some potential benefits," reported Ms.
Folcarelli. "Managed care helps coordinate care. States are giving a lot
of deliberate thought to when to integrate and when to carve out mental
health services. This provides us with some opportunities, as the system
shifts, to influence the system at the ground floor in terms of mental
health and substance abuse issues. Many of the programs eliminate
limits, which addresses some of the concerns the mental health
community has had about artificial limits being set on services. That is
an opportunity for mental health providers."
However, the authority that managed care companies have necessitates
new types of advocacy. Ms. Scallett emphasized the impact of these
waivers on the public mental health system. "All of these managed care
companies that are taking on new responsibilities under Medicaid have
created their programs and cut their teeth and developed their cultures in
the private sector mental health world. They are now moving into a
very, very different sector with a lot of different problems, different
populations, and how that integration between public and private takes
place will be very interesting. We may now have our single system of
care."
Councilmember Forstein asked about the liability issue under managed
care. "Is there anything in the Medicaid waiver decision that then shares
the liability with managed care companies who are making those really
unilateral decisions without any Governmental oversight?"
Ms. Folcarelli responded that each State has to demonstrate to CMS
that they have some quality assurance process in place in these systems.
Councilmember Martinez noted that the Medicaid waivers reshape the
equation and the agenda for almost every stakeholder group.
Quality Assessment Issues Under Managed Care
Dr. Manderscheid then spoke about performance indicators for managed
care systems, of which clinical outcome is one type.
"The forms that performance indicators have taken thus far, as a result
of the impetus of the Health Security Act, are called report cards," stated
Dr. Manderscheid. "The essential purpose of report cards in the Health
Security Act was to give a sense of quality of what was going on in the
system. They were intended to be universal, they were intended to be
mandated, and they were intended to provide consumers with
information that would allow them to make choices among plans. We
think that one of the major purposes of report cards is to help States
monitor what is going on in the managed care systems that they are
creating through the waivers." The development of clinical protocols
and quality assurance procedures, can be facilitated by looking at these
types of performance indicators.
Dr. Manderscheid emphasized the importance of consumers in the
development of the mental health and substance abuse report cards. "we
would argue in the report card we are developing for mental health and
substance abuse that consumers are the first line of reporting that we
need to pay attention to here. It is a report card that is a report to
consumers, not a report card that essentially reports to other groups like
providers of care."
The report card that CMHS has been involved with has several
dimensions:
- Accessibility, in terms of physical and cultural dimensions;
- Appropriateness, in terms of choice (Does the consumer have a
range of choices in the process that is commensurate with
what the consumer needs in that context?);
- Does the plan promote prevention? (How do we do things to
reduce the need for future services, and are the health
care plans, in fact, engaged in these types of activities?);
and
- Consumer satisfaction.
"Historically, we have made the argument implicitly, if not explicitly,
that if a reasonable outcome is achieved in terms of change in
symptomatology and change in functioning, then the consumer must be
satisfied."
Councilmember Slack commented that "Recently I have been
scrutinizing some of the questionnaires that are used, and it seems to me
where there is a problem is when you try to transform these dimensions
into indicators. From a consumer's perspective, what it appears to me is
happening is once it gets into the scientists' hands, that the questions
tend to be positively stated. For example, a lot of these questionnaires
ask positively stated questions and then it asked questions like, "Did the
staff talk down to you?" "Did you feel respected or did you not feel
respected?' When I was reading it, I thought, gosh, if I had a horrible
experience in a hospital setting, by the time I was reading that
questionnaire, I would have felt like I had a good one. I mean, you
know, "The doctors treated you well, didn't they?" So my concern is
that when you take these dimensions and transform them into indicators,
that there is a balance and that the language reflects the language used
when consumers make complaints.
Dr. Manderscheid responded that he believes that it is very important to
have primary consumers involved in the process of designing the items,
because they bring some of these issues out.
The SAMHSA Managed Care Initiative
Dr. Goplerud presented on the SAMHSA Managed Care Initiative.
SAMHSA has developed some cross-cutting initiatives on some high-
priority areas and now each Center has a Managed Care Coordinator. In
order to position SAMHSA and its staff to respond to this new arena,
the first order of priority was training SAMHSA staff.
"As we think about streamlining, reinventing, reengineering our
organization, our agencies are going to have to come to grips with
retraining and redeploying staff," stated Dr. Goplerud. "If we need
fewer demonstration grant Project Officers, we are going to have to
retrain those people to be useful to the States and to the communities in
a new way." Knowledge transfer is also necessary to develop materials
and disseminate them to people who need managed care information.
SAMHSA is also involved in training the States. "we recently
sponsored a risk assessment training seminar for States and now 37
States have been trained in how to do capitation and how to develop risk
sharing or risk assessment."
Dr. Goplerud reported that SAMHSA is developing a contract to
develop accreditation standards for managed behavioral health care
networks. In addition to pursuing accreditation standards, SAMHSA is
coordinating information from consumers, families, providers, State and
county officials, and knowledgeable experts about what is going on in
the field and sharing that information in a timely fashion.
Dr. Goplerud emphasized the importance of evaluation and knowledge
development. "The top priority for our demonstrations next year and in
1997 is around managed care. We need to know what are the most
effective ways for serving the populations that CMHS has been
traditionally most concerned with. We also are working with the Health
Care Financing Administration around the evaluation of the major
Medicaid waiver programs."
Report from the National Institute of Mental Health
One of the reporting requirements of the National Institute of Mental
Health that is of particular interest to the CMHS Council is the 15
percent set-aside requirement for services research. The increase in
services research is significant, up from 8.5 percent in 1991.
Dr. Regier highlighted a number of collaborative activities with CMHS,
including the National Conference on State Mental Health Agency
Services Research and Program Evaluation, and a conference designed
to improve collaboration between mental health and criminal justice
systems.
NIMH is also making an effort to link research to some of the Center's
demonstration projects. NIMH has a major multisite study of services
research, epidemiology, and developmental psychopathology. The
intent of that project is to get detailed information on a definition of
need for care that goes beyond just the definition of a syndrome of
mental or addictive disorders that is defined in DSM-IV or ICD-10. "To
do this," reported Dr. Regier, "we are adding in a very strong
component on the disability and impairment associated with these disorders
to try to
develop something more akin to a DRG, in which you can actually
define what constitutes a definition of medical necessity in the managed
care parlance or of need for services in the more public health
tradition."
In response to a request for timely dissemination of information and
outcome results, Dr. Regier responded, "we try to stimulate areas that
we think are particularly promising." NIMH offers conferences to
stimulate the field, but typically, the Institute makes its investments
based on significant review and support from the field. Dr. Regier
emphasized the area of dissemination and the collaboration provided to
CMHS to get the results out to the service community and to facilitate
that with whatever research data is available that is going to have
immediate applicability. Dr. Regier cautioned, however, that "There is a
problem of premature release of research that have not been peer
reviewed. You can rush and get things disseminated too quickly." Dr.
Regier emphasized the importance of an orderly process for the review
of scientific findings to make sure that they are rigorous. But he added
that "we are also attentive to the need to get the information out as
quickly as possible."
SAMHSA Evaluation Policy
According to Dr. Straw, the SAMHSA Evaluation Policy ensures that
evaluation be addressed as part of the program planning process, that
evaluation issues are addressed systematically before CMHS goes to the
public with a particular program. In addition to the program narrative,
all applicants must develop a separate plan which outlines the evaluation
that will be done on the individual project as well as proposes to take the
results across projects and produces real, usable knowledge that can help
guide the service field in more effective and cost-efficient practice. This
policy will force a prospective look at how evaluation will occur in the
SAMHSA demonstration agenda.
Dr. Straw then reported on the process leading to the development of the
SAMHSA demonstration agenda and noted that the number one priority
across the Centers of SAMHSA is to look at alternative models of
managed care and the relative effectiveness of alternative models of
managed care.
"we are still in the process of targeting the highest priority populations.
For example, services for severely mentally ill adults that are either
carved out of an overall managed care or integrated with primary health
care services might be one of the critical topics."
The next priority area is the homelessness initiative. AI think this is
something that the Hill has impressed upon us that they want to see.
They believe we are doing good work in this area. They would like to
see us continue work with homeless populations, and this is a logical
extension of the work that we have already done working with homeless
populations . . . getting them housed. Then how can we assure that life
events and other things don't again find them out on the street" What
kinds of things can we do to maintain that housing once it has been
acquired?"
The third major initiative would be in the criminal justice area. "Our
interest here, as we have heard from the various stakeholder groups, is
really more directed towards the diversion of individuals who find
themselves dropped, if you will, in county jails by police and other
authorities who have no other place to take them, and who end up in
jails or prisons not so much for their criminal activity but because there
is no other place available, and to look at alternative models for
diversion from jails under those kinds of circumstances."
Report on the Council's Motion on Co-Occurring Disorders
Dr. Manderscheid introduced the topic by suggesting that there were
three issues vis-à-vis comorbidity that would be of concern to Council
members. The first of these has to do with the capacity of the system to
address people who have comorbid problems that span mental health
and substance abuse. "One of the issues that would need to be
confronted organizationally is whether to mesh these organizations or
use a different approach to bring treatment to these individuals. Another
issue is the question of how to finance care for this population and how
to create appropriate risk pools so that you can develop capitation rates
for this populations. In order to do that, you have to have a differential
understanding of questions of severity, as well as a decent financial
database. At the clinical level, we need to understand how the clinical
protocols that you are developing differ for managed care for this
population than they would for other populations."
In parallel with population epidemiology, the report addresses service
epidemiology. "How many of these people are in treatment, and where
are they receiving treatment, and what types of treatment do they
receive?"
Another feature of the study is a description of the current initiatives
that are ongoing to develop the capacity to treat people who have
comorbidity problems. "What other federal entities are working on this?
What does NIMH have in the services research portfolio? What are the
States doing? What are the private sector entities doing, and so on?"
Dr. Kessler reported that the National Comorbidity Study (NCS) is the
first national study in the United States that looked at clinically
significant psychiatric disorders. The study was done in 1990. The
study found that about 3 percent of the population has what NIMH now
defines as severe and persistent mental disorder.
Dr. Kessler reported that when the study used the DSM-III-R as the
basis for defining a mental disorder, about one-fourth of the U.S.
population had a mental disorder in a given year. About 10 percent of
the population in the age range of the comorbidity survey is considered
a substance abuser in the U.S. population. There is substantial overlap
between mental disorders and substance use disorders in the data, and
that overlap gets stronger as the problems get more severe. The
comorbidity of those people with substance disorders gets increasingly
high as the disorder gets increasingly severe. "Only a bit more than 10
percent of the people with some mental disorder, broadly defined, also
have a substance use disorder, but as the mental disorder becomes more
severe, close to 30 percent of the people with the most severe mental
disorders also have a co-occurring substance problem. Severe disorders
tend to be comorbid disorders."
The prevalence of substance abuse disorders increases dramatically over
the young adult age span, but it does not start until about the age of 12.
Dr. Kessler reported that there are between 6 and 10 million people with
a co-occurring disorder.
Dr. Kessler reported that there were gender, race, geographic and social
class differences. "There are gender differences. Men, as you know, are
much more likely to have substance [use] problems than women, and
women are much more likely to have depression and anxiety problems
than men." The race differences are interesting in that non-Hispanic
blacks and Hispanics are more likely than non-Hispanic whites to have a
comorbid condition. "Blacks and Hispanics are much less likely than
whites to ever develop these kinds of problems. But if they do, they
tend to be much, much more chronic than the whites, and in part, this
has to do with subpopulation differences that we have not gotten to the
bottom of yet, but it ends up that blacks, in particular, in this society are
much more likely than any other group to say, 'I've never had a drink in
my whole life.' But among blacks who do drink, their probability of
developing a drug problem, a drinking-drug problem, and the
probability of that snowballing into a comorbid is considerably higher
than among whites, even at the same level of education and income."
Comorbidity of substance and mental disorders tends to be a bit higher
in urban areas than in rural areas. The rural problems tend to be
drinking and depression; in the urban areas, it is using illicit drugs and
depression. There are also regional differences. The East Coast and the
West Coast have higher rates than either the Midwest or the South.
Dr. Kessler's final report should be available for the December 1995
National Advisory Council meeting.
Electronic Communication
Dr. Arons reported on inquiries on the topic of electronic
communication and exchange. While SAMHSA has an electronic
bulletin board that is accessible by computer and modem by an 800
number, consumers of mental health services have been concerned about
access to other electronic forms of communication and information
flow. The suggestion was raised by a consumer that every grant that
focuses on services should offer consumers access via computer and
Internet technology. Mr. del Vecchio, the CMHS Consumer Affairs
Specialist, noted the importance of electronic access for consumers as a
mechanism for emotional support as well as advocacy. He cited a report
which noted that the Internet has become a safety net of support for
"thousands of people in search of solace and relief from emotional and
physical pain. One gentleman who was suicidal put an extensive note
on the Net and received a lot of responses back from other members
which ultimately prevented his suicide attempt. He stated that, "I didn't
think anybody would really see it or that it would really matter if they
did. Something snapped, and I just realized there were a lot of people
out there that cared." Mr. del Vecchio emphasized the potential power
of a medium where "you can cry out for understanding and get
something back."
Mr. del Vecchio reported on the most extensive consumer e-mail listing
called "Madness." It is operated by a woman in California named
Sylvia Caras. Ms. Caras has asked CMHS to look at ways of increasing
access for consumers to electronic communication. Her resolution
states, "All public contracts shall include provisions for the awardee to
wire physical areas used by clients to provide modem and full Internet
access to clients. Even phone services that are restricted to local calls
shall allow users manually and by modem access to toll-free numbers.
Entry-level training to use computers in telecommunications shall be
provided as part of this provision." "We, the voice of Madness, move
that all CSP grants require that applicants make direct connection with
Internet communication media available to users of services either
through a dedicated hard-wired system or through a SLIP or PPP dial-up
linkage. This connection should be available at low- or no cost such as
through the FreeNet system so that everyone might have access to such
communication."
In response, CMHS has begun to look at this issue and is evaluating the
cost data associated with pursuing this request. "we are really
interested in getting the feedback from the Council on how to proceed with
this. One suggestion was raised of a work group perhaps being formed to
look more at this issue."
While there was support for increasing access, Councilmember Forstein
reported his concerns about the potential for misinformation being
shared over the Internet. AI think there is real danger in establishing a
system by which those kinds of concerns can be dealt with as you begin
to set up a system as opposed to finding out all the stuff after you have
already done it. So what I am really saying is I think that to go a little
bit slower than the electronic age would have us believe is necessary in
thinking about this from the point of view of what can CMHS sponsor
that would increase information, provide on-line support and services,
but to do it in a way that really does not make things worse for some
people would be very, very important."
Quinn Rossander, a public member, commented that he "supports the
idea of involving people in Internet communication. It will really
facilitate a whole groundswell of understanding where people whom
now you don't hear from at all can participate not only in the ongoing
operation but [in] the planning for future programs."
Dr. Arons agreed to proceed with exploring some activities in this area.
"Those activities will include the various groups that are affected --
consumers, family members, providers, and policy makers. It will
include others outside of the mental health area who may have some
knowledge that we may need, people from the [National] Library of
Medicine, from the Library of Congress, who may have done some
thinking in this area. We will also look at the issue of what are the
training needs for those --once you have access, what do you need to
know to be an effective user, an effective contributor, both ways."
In closing, Dr. Arons suggested that Council consider the many reasons
why CMHS should continue to exist which could then be used as a
forceful statement of our importance.
KEN95-0037
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