Capitol Connector Update from National Council for Behavioral Health

2015 HHS Appropriations On Hold After Subcommittee Markup Tuesday, the Senate Appropriations subcommittee with jurisdiction over healthcare released its proposed fiscal year 2015 funding levels for the Department of Health and Human Services (HHS). While program-level detail is not yet available, the top-line numbers held few surprises for the Substance Abuse and Mental Health Services Administration. Read More

Medicaid and CHIP Enrollment Climbs by 6M vs. Pre-Health Reform Era Newly released data from the Centers for Medicare & Medicaid Services (CMS) indicate that Medicaid enrollment continued to grow throughout April, beyond the March 31 end of the open enrollment period in state and federal health insurance exchanges. Because enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) can occur year-round, enrollment under the programs continues to grow. The new data show roughly six million more Medicaid and CHIP enrollees as compared to the period immediately preceding the initial open enrollment period under the Affordable Care Act (ACA). Read More National Council for Behavioral Health [communications@thenationalcouncil.org]

Medicaid Coverage of Behavioral Health Services for Children, Youth, and Young Adults with Significant Mental Health Conditions

Posted at http://gucchdtacenter.georgetown.edu/resources/TAWebinars.html Reposted at http://www.darkestcloset.blogspot.com,

June 20, 2013, 1:00 - 2:30 PM E.T.

Webinar Description: This webinar will provide a comprehensive overview of the Centers for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) Joint Informational Bulletin issued on May 7, 2013, entitled "Coverage of Behavioral Health Services for Children, Youth, and Young Adults with Significant Mental Health Conditions".

This bulletin provides important information to assist states in designing a service array to enable children with complex behavioral health needs to be served in their homes and communities. In addition to describing important services to include in a benefit design such as Intensive Care Coordination using a Wraparound approach, parent and youth peer support services, intensive in-home services, respite care, mobile crisis response and stabilization and flex funds, the document provides links to helpful resources from states who have successfully been using these services.

Comprehensive information is provided about the various Medicaid Authorities and Demonstrations that can be used to provide the kind of coverage described in this bulletin. Much of the information in the bulletin is based on the experiences of states and communities supported by two major CMS and SAMHSA initiatives - the Psychiatric Residential Treatment Facilities (PRTF) Waiver Demonstration and the Children's Mental Health Initiative. In this webinar, two states who have experience with both of these initiatives will share their lessons learned from the beginning stages of benefit design, through the successes and challenges in providing the services, and finally to their sustainability plans using several of the Medicaid Authorities and Demonstrations described in the bulletin.

Health Reform to Increase Number Receiving Medicaid Mental Health Services

The number of Medicaid beneficiaries using mental health and addiction treatment services is expected to increase from 2.1 million in 2006 to 4.4 million in 2019—the date when all health reform provisions are implemented to expand Medicaid coverage to low-income childless adults between the ages of 18 and 64. The number of 18-to-64-year-old adult behavioral health service users overall (counting those covered by Medicare, Medicaid, private insurance, and the uninsured) is expected to increase from 25.4 million in 2006 to 26.6 million by 2019.. The projected increase in behavioral health service utilization was based on research on non-elderly adults’ mental health status and insurance status by income level reported in the 2004–2006 Medical Expenditure Panel Surveys. (Open Minds, 10/10/11)

National Association of Peer Specialists

By Steve Harrington, J.D., Executive Director

Peer specialists1 are persons with a lived history of mental illness and recovery journey who help others on their recovery journeys. Because the peer specialist profession is a relatively new phenomenon in mental health services, it is often unknown or misunderstood by other mental health professionals, medical health professionals, and the general public. Confusion and misunderstandings also exist with regard to the roles peer specialists can or should play in mental health services. Although peer support can be traced to the beginning of humanity, it emerged as a powerful force in mental health in the early 1980s. At this time, mental health institutions were closing across the United States in favor of community-based treatment, where persons with psychiatric conditions could live and obtain support in the communities in which they lived. Peer support outcomes, the popularity of Alcoholics Anonymous, and the reality of recovery from serious and persistent mental health problems combined to create an atmosphere ripe for the creation of a peer support movement in mental health. Change agents. Peer providers are now commonplace in some mental health systems. Factors driving this trend included The growing recognition of the reality of recovery from even severe and persistent psychiatric conditions A political climate that expected cost-effectiveness for public funds Positive outcomes associated with peer support A ready labor force The establishment of formal peer training and certification of peer specialists In 2001, Georgia became the first State to obtain Medicaid reimbursement for peer support services (Salzer, Schwenk, & Brusilovskiy, 2010). Since then, 13 other States have followed. In addition to providing direct services to their peers, peer specialists were providing services in a variety of ways (one-on-one support, facilitating support groups, community resource connecting, education, and more)—they were acting as change agents. As employees of mental health providers, peer specialists found themselves in positions to influence organizational policies and practices to enhance service effectiveness (Fukul, Davidson, et al., 2010). In 2004, the National Association of Peer Specialists (NAPS) was formed to promote the use of peer support in mental health settings. NAPS soon became involved in advising policy makers about peer workforce issues. The organization quickly grew from a handful of dedicated peer specialists to more than 1,000 members representing every State, as well as Australia, the United Kingdom, Japan, Guam, Canada, and several other countries. NAPS acts as a peer support information clearinghouse and frequently responds to inquiries from throughout the United States. Need for national guidelines, certifications. Our Situational Analysis research has found that the number of States creating peer specialist initiatives has grown dramatically in the past 5 years. The number of States with employed peer specialists is somewhat greater than the number receiving Medicaid reimbursement (an estimate of 25 is not unreasonable), but the exact number is often difficult to determine, as programs are sometimes small and/or isolated. At least two States, North Carolina and Texas, are working toward Medicaid reimbursement for peer support and have made much progress in that regard. One of the main findings we have come across is the lack of national guidelines or certification for the profession. Each State with a formal peer specialist program exercises control over that program as it relates to certification, training, professional discipline, and other operational issues. Until recently, training was generally offered as 1-week courses to satisfy State certification requirements. A common feature among virtually all training programs is heavy reliance on peers as advisors in basic curriculum development and as instructors. Training courses do appear to be increasing in length and the topics covered, but findings have indicated a great desire among peer specialists for greater emphasis or education on cultural competency, the role of trauma in mental health, and ethics issues. Meanwhile, certification requirements vary across the States. Some States only require training, while others require training, work experience, successful completion of a comprehensive exam, character references, reference from a psychiatrist, an interview, and background investigations. Despite efforts to foster training and certification reciprocity between States, those efforts have generally resulted in rejections to “outside” assistance or suggestions. Although Kansas, Missouri, and Georgia permit a measure of reciprocity, most States do not and, at this time, appear unwilling to consider doing so. The number of States with formal certification programs is, at least, growing. In August 2007, the Centers for Medicare and Medicaid Services (CMS) issued guidelines to States wishing to use Medicaid funding for peer support services (Smith, 2007). The guidelines addressed supervision, care coordination, and training and certification. But with the issuing of these guidelines and overall growth in the peer specialist workforce, the demand for continuing education opportunities has grown as well. While many States have spent considerable time and effort to develop the basic certification procedure and requirements, many have yet to reach beyond that to develop continuing education programs. Role of peer specialists. Another finding in our assessment is just how diverse the peer specialist workforce is. This can prove both a challenge and a reward for our field as a whole. Each peer specialist brings a unique skill set to the mental health workplace. And because the profession is relatively new, there is often great flexibility in how and where those skills are used. Peer specialists work in such settings as general hospital emergency rooms, psychiatric hospitals, jails and prisons, and nursing homes. They also work as educators in communities, drop-in centers, clubhouses, and vocational placement agencies. The diversity of peer specialists is reflected by more than work setting. Tasks are also variable and include—but are not limited to—individual support, facilitating support groups, educating a variety of individuals and groups about recovery and the true nature of mental illnesses, helping people make the transition from hospital to community, housing and educational support, engagement, wellness coaching, resource connecting, advocacy, supervision, administration, teaching of formal recovery courses, and transportation.2 In recent years, the Department of Veterans Affairs (VA) has made great strides in the training, certification, and hiring of peer specialists for its healthcare facilities. In some ways, the VA’s efforts have encouraged States that once considered peer support meaningless or marginally meaningful to reconsider their positions and, ultimately, create peer specialist programs. Today, the VA has a significant peer workforce that is well-trained and professional and contributes a wealth of positive outcomes (Salzer, 2011; Salzer, Schwenk, & Brusilovskiy, 2010). Lack of understanding. That said, there appears to be a great number of mental health provider agencies that misunderstand the valuable roles peer specialists can play. Reports from the field reveal that some peer specialists are relegated to roles in which they are unable to use their recovery experiences and knowledge for the benefit of those they serve (or should be serving). There are reports that some peer specialists are providing parking lot security, medication monitoring, office support, or other duties that do not present meaningful peer-to-peer contact. This may be because peer specialists are often supervised by non-peers who have no specific training on how to supervise peers in the workforce. In addition, peer specialists may work in an environment where coworkers lack knowledge of the recovery paradigm or feel confused or threatened by the presence of people openly in recovery in the workplace. Failure to understand the important roles peer specialists can play is detrimental to peer specialists, coworkers, persons served, and mental health systems as a whole (Townsend & Griffin, 2006). Lack of understanding often leads to workplace conflicts. And, despite the well-proven abilities of peer specialists to create positive outcomes in these many settings (Salzer, 2011; Salzer, Schwenk, & Brusilovskiy, 2010; SAMHSA, 2009; Davidson, Chinman, Kloos, et al., 1999), the profession remains underpaid. In describing our target audience for the NAPS Situational Analysis, we found that working peer specialists often live in poverty—despite being employed. Workers often feel disrespected and operate without a meaningful career ladder, even though they have a high motivation to work and succeed at employment, and to help others on their recovery journeys. Next steps for future. Based on historical information, however, it seems a certainty that the peer specialist profession will enjoy considerable (and likely rapid) growth in the next decade. One recent study has shown that peer support can reduce rehospitalization by as much as 72 percent (OptumHealth, 2011). It is also clear the need for continuing education will grow as a component of State-sanctioned peer specialist programs, in line with the profession’s growth, maturity, and CMS guidelines. It is in this environment that NAPS will develop, and ultimately implement, training on recovery-oriented practices in our field. Our vision is a peer specialist workforce proficient in all aspects of recovery—and an environment in which others in the mental health field understand not only the value of recovery-oriented practice but the value peer specialists bring to recovery-oriented practice. Work toward this vision will involve, first of all, educating the peer workforce to increase recovery knowledge and increasing recovery knowledge and practices in the long term. NAPS aims to develop a recovery-oriented curriculum that is as participatory and experiential as possible. Among other topics, the curriculum will address cultural competency, trauma-informed practices, and ethics and boundaries. As a field, we should also work to create professional peer specialist standards that can be applied nationally. Continuing education is also important—not only formal continuing education, but also access to the many useful recovery resources that already exist. Too many of these resources remain unknown or inaccessible to peer specialists. NAPS hopes to forge collaborative relationships with organizations across the country to encourage access to depositories of evaluated and organized recovery materials. We also suggest collaborating with other mental health professions to foster recovery knowledge and acceptance of recovery practices and policies. Peer specialists often observe practices and are subject to policies that inhibit their ability to move service providers toward a recovery orientation. Without a peer specialist workforce comfortable with expressing opinions and suggestions, and coworkers and supervisors willing to listen and consider them, the recovery paradigm is inhibited. Ensuring acceptance of recovery-oriented practices will mean working closely with the other disciplines on developing and implementing these practices and, where needed, helping to educate those who work alongside peer specialists on the key aspects of recovery. One basic first step we can take in marketing recovery knowledge is to develop a fact sheet that describes why, how, where, and when peer specialists perform their work. One Indiana State mental health official has already noted our distribution of the Situational Analysis will help him promote the hiring of peer specialists in that State (B. VanDusen, personal communications, Feb. 8, 2011). With hard work, we will achieve a future in which peer specialists, as well as recovery practices as a whole, will be widely respected and adopted. Footnotes: 1Peer specialists may also be referred to as: peer support specialists, peer support technicians, consumer advocates, peer recovery support specialists, recovery specialists, and a myriad of other titles. 2This list is far from exhaustive. Transportation is included here, but it is sometimes debated whether it is a “true” or “valid” peer support task. Transportation of peers can, however, present meaningful opportunities for discussion and relationship-building that supports a individual’s recovery. References: Daniels, A., Grant, E., Filson, B., Powell, I., Fricks, L., & Goodale, L. (Ed.). (2010). Pillars of peer support: transforming mental health systems of care through peer support services. Atlanta, GA: The Carter Center. Retrieved June 8, 2011, from http://r20.rs6.net/tn.jsp?llr=toyssnfab&et=1105905864022&s=2292&e=001660qLvW9O2KDTM-CBtwTPznnUmM7xVaYP7xHvKg-J0I3fq3a0rHoE_mxdyhTSjZmdmqRloqWLQdO6EjKmMNsOAh6kwNGrN1dRl-Opg0DEEPtNti-5u5UqLPjEdD6yDbXBBIJVLC-ZCnhPKHSUAeGQm0BOeSqnISLC4UlAqFJZ3s=. Davidson, L.; Chinman, M.; Kloos, B.; Weingarter, R.; Stayner, D.; & Tebes, J.K. (1999). Peer support among individuals with severe mental illness: A review of the evidence. Clinical Psychology: Science and Practice, 6(2), 165–87. Fukul, S.; Davidson, L.J.; Holter, M.C.; & Rapp, C.A. (2010). Pathways to recovery: Impact of peer-led group participation on mental health recovery outcomes. Psychiatric Rehabilitation Journal, 34(1), 42–48. OptumHealth. (2011). Poster presentation from Association for Community Mental Health Administration Summit. New Orleans, La. Salzer, M.S. (2011). Presentation from Texas USPRA Conference 2011: Present and future of certified peer specialists: A research overview. Austin, Texas. Salzer, M.S.; Schwenk, E.; & Brusilovskiy, E. (2010). Certified peer specialist roles and activities: Results from a national survey. Psychiatric Services, 61(3), 520–23. SAMHSA. (2009). What are peer recovery support services? (HHS Publication No. [SMA] 09–4454.) Rockville, Md.: U.S. Department of Health & Human Services. Smith, D.G. (2007). Letter to State Medicaid directors. Baltimore, Md.: Department of Health & Human Services, Centers for Medicare & Medicaid Services. Townsend, W., & Griffin, G. (2006). Consumers in the mental health workforce: A handbook for providers. Rockville, Md.: National Council for Community Behavioral Healthcare.

Reposted at darkestcloset.blogspot.com. From Recovery to Practice Weekly Highlights Volume 2, Issue 21. June 9, 2011. To access the RTP Weekly Highlights and other RTP materials, please visit http://www.dsgonline.com/rtp/resources.html.

Mental Health and Medicaid Costs: Why Ignoring Mental Health Is Expensive

http://www.huffingtonpost.com/michael-friedman-lmsw/mental-health-and-medicaid-the-_b_825047.html

Cost containment is one of the major goals of health policy reform in the United States. Because spending on mental health and substance abuse services (commonly called "behavioral health services" when referring to both) is less than 8 percent of all health spending, behavioral health seems an unlikely candidate for substantial savings. But that perception is wrong!

People with behavioral health conditions are at higher risk than others for physical illness and disability, and the cost of medical care for them is, on average, much higher than the cost of medical care for people without behavioral health conditions. Better behavioral health services for this population would be likely to reduce the costs of their physical health care and produce significant overall savings in health spending.

This view received fresh support this week from a very important report from the United Hospital Fund in New York City. Entitled "Providing Care to Medicaid Beneficiaries with Behavioral Health Challenges," the report reveals that Medicaid recipients with mental health conditions are 30 percent to 60 percent more likely to have hypertension, heart disease, pulmonary disorders, diabetes, and dementia. People with substance abuse conditions are 50 percent to 300 percent more likely to have heart disease, pulmonary disorders, and HIV/AIDS.

The United Hospital Fund report also documents far higher spending for Medicaid beneficiaries with behavioral health conditions than beneficiaries without behavioral health conditions. According to the report, average health spending for people with mental health conditions in 2003, (the year studied), was $28,451; for those without mental health conditions it was $15,964. Only 25 percent of the spending for this population was for treatment of mental disorders. "Mental health beneficiaries spending on physical health services ($21,002) was 32 percent higher than comparable spending for non-mental health beneficiaries."
For people with substance abuse conditions, average Medicaid spending was $27,839; for those without substance abuse disorders it was $18,051. Only 24 percent of the spending was for substance abuse treatment. "Substance abuse beneficiaries mean Medicaid spending on physical health services ($21,053) was 17 percent higher than comparable spending for non-substance abuse beneficiaries."

The difference in spending for inpatient services for people with behavioral health conditions and those without is particularly striking. "Average annual expenditure for inpatient treatment [for people with mental illness] was $7017 compared to $3629 for others." For those with substance abuse disorders, inpatient costs averaged $11,738 compared to $3,301 for others. Also striking is the fact that, "the seven-day hospital readmission rate of mental health beneficiaries was 50 percent higher than non-mental health beneficiaries. Substance abuse beneficiaries' rate was 150 percent higher than [others.]"

Prior work supported by the United Hospital Fund and the New York Community Trust sheds additional light on the link between Medicaid spending and the co-occurrence of severe behavioral and physical health conditions. A study led by John Billings showed that nearly 60 percent of all Medicaid spending in New York is for 10 percent of the beneficiaries. Two-thirds of these "high cost cases" had severe behavioral health conditions as well as physical health conditions. Most did not get adequate care until their physical conditions became critic and resulted in long stays in hospitals.

Is it possible to improve treatment for people with behavioral health conditions before they become critical and thus bring down overall spending?

Although there are disputes about how to structure a system to improve care for people with both physical and behavioral disorders, there is consensus that earlier interventions with this population could avert health crises and thus reduce health spending. And the fundamental elements of an effective system seem clear enough. Those at highest risk need to be identified before they are in crisis; history of payments by Medicaid makes this possible. Aggressive outreach is needed to locate and engage people at high risk before they are in critical need. Those not identified until they come to emergency rooms, as they frequently do, need to be linked to community-based services immediately. Physical and behavioral health services for them in the community need to be integrated. And fundamental life needs must be addressed -- particularly the need for stable housing, without which little else can be accomplished.

None of this is easy to do; but if it is not done, people with both serious behavioral health conditions and serious physical health conditions will continue to be the high cost Medicaid cases. And most Medicaid spending will continue to be for the 10 percent of Medicaid beneficiaries who have the greatest needs.
Our health care system can continue to largely neglect mental illness and substance use disorders, but at great avoidable cost. Bottom line: forget about mental health, forget about savings.

When Mental Health Meds Are Out Of Reach, Hospitalization More Likely

Too often, mental health patients have problems accessing or paying for their prescription drugs under Medicaid. The results - longer hospital stays and more emergency room visits - are hard on patients and costly for the entire health care system, a new study finds.

Lead author Joyce West, Ph.D., and colleagues analyzed Medicaid data from 10 states and found that psychiatric patients who reported access problems with their medication visited the emergency department 74 percent more often than those who had no such difficulties.

Of the 1,625 patients West and colleagues tracked, almost a third could not access the clinically indicated or preferred medication because Medicaid did not approve it. Patients with medication access issues experienced 72 percent more acute hospital stays compared to patients without access problems.

Access problems included prescribed medication being discontinued, temporarily stopped or not covered. Some patients had problems making the co-payment.

"What's particularly troubling is that it can often take several trials and many months, if not longer, to find an appropriate medication regimen that a patient responds to," said West, policy research director at the American Psychiatric Institute for Research and Education and an assistant professor of mental health at Johns Hopkins University.

The study appears in the November-December issue of the journal General Hospital Psychiatry.

"There are major clinical risks to psychiatric patients when they're stable on their medication and then switch to a different medication," West said. "Policies to facilitate medication continuity are critically important for this highly vulnerable population."

Policymakers can save money in the Medicaid program by clamping down on medication, but other areas including emergency room visits will undeniably increase, said Ken Duckworth, medical director for the National Alliance on Mental Illness and assistant professor at Harvard Medical School.

"It's another piece in a body of evidence that says what you're doing when you're restricting access to psychiatric drugs is squeezing the balloon," Duckworth said. Psychiatric hospitalization costs $800 to $1,000 a day. "So it is quite expensive for the system," Duckworth said.

Duckworth said incarceration it particularly is important for patients with conditions such as schizophrenia, bipolar disorder and borderline personality disorder to take medications consistently. TERMS OF USE: This story is protected by copyright. When reproducing any material, including interview excerpts, attribution to the Health Behavior News Service, part of the Center for Advancing Health, is required.

General Hospital Psychiatry is a peer-reviewed research journal published bimonthly by Elsevier Inc.

West JC, et al. Medicaid medication access problems and increased psychiatric hospital and emergency care. Gen Hosp Psych 32(6), 2010.

Source:
Health Behavior News Service
http://www.medicalnewstoday.com/articles/211062.php