MENTAL HEALTH Group D Trey Perez Heather Rawls DJ Reid

MENTAL HEALTHMENTAL HEALTH

Group DGroup DTrey PerezTrey Perez

Heather RawlsHeather RawlsDJ ReidDJ Reid

AgendaAgenda

Mental health overviewMental health overview

Previous LegislationPrevious Legislation

Current LegislationCurrent Legislation

Republican and Democratic viewsRepublican and Democratic views

Policy and Fiscal ImplicationsPolicy and Fiscal Implications

Proposed LegislationProposed Legislation

What is Mental HealthWhat is Mental Health

The meaning of being mentally healthy is subject The meaning of being mentally healthy is subject to many interpretations rooted in value to many interpretations rooted in value judgments, which may vary across cultures. judgments, which may vary across cultures.

Mental health should not be seen as the Mental health should not be seen as the absence of illness, but more to do with a form of absence of illness, but more to do with a form of subjective well being, when individuals feel that subjective well being, when individuals feel that they are coping, fairly in control of their lives, they are coping, fairly in control of their lives, able to face challenges, and take on able to face challenges, and take on responsibility.responsibility.

Defined by WHODefined by WHO

Mental health is a state of successful Mental health is a state of successful performance of mental function, performance of mental function, resulting in productive activities, resulting in productive activities, fulfilling relationships with other fulfilling relationships with other people, and the ability to adapt to people, and the ability to adapt to change and to cope with adversity change and to cope with adversity specific to the individual’s culturespecific to the individual’s culture (WHO).(WHO).

What is Mental Illness?What is Mental Illness?

Mental illness refers collectively to all Mental illness refers collectively to all diagnosable mental health problems that diagnosable mental health problems that become “clinical,” that is where a degree become “clinical,” that is where a degree of professional intervention and treatment of professional intervention and treatment is required. Generally, the term refers to is required. Generally, the term refers to more serious problems, rather than, for more serious problems, rather than, for example, a mild episode of depression or example, a mild episode of depression or anxiety requiring temporary help (WHO).anxiety requiring temporary help (WHO).

History of Mental Health PolicyHistory of Mental Health Policy

Mental health has been shaped by cultural Mental health has been shaped by cultural changes and major social policies changes and major social policies designed with other populations in mind as designed with other populations in mind as well as by the efforts of persons working in well as by the efforts of persons working in the mental health field itself. the mental health field itself. (Center For Mental (Center For Mental Health Services)Health Services)


There have been significant improvements in There have been significant improvements in treatment, public attitudes, and services treatment, public attitudes, and services organization, and enormous growth in mental organization, and enormous growth in mental health insurance coverage, treatment resources, health insurance coverage, treatment resources, episodes of care, and research of all kinds in the episodes of care, and research of all kinds in the past 50 years.past 50 years.– Systems have transitioned from largely Systems have transitioned from largely

psychotherapy for the affluent and custodial psychotherapy for the affluent and custodial institutional care for all others, to a range of outpatient institutional care for all others, to a range of outpatient services, inpatient care in various settings, residential services, inpatient care in various settings, residential care, and housing alternatives care, and housing alternatives


The change that is currently transforming The change that is currently transforming mental health care mental health care – The introduction and growth of managed The introduction and growth of managed

behavioral health care behavioral health care – The work of mental health professionals.The work of mental health professionals.

Mental Health Economy: Mental Health Economy: Past and PresentPast and Present

Resource allocation of mental health care Resource allocation of mental health care has been decentralized over the past 35 has been decentralized over the past 35 years.years.– 1950’s: 75 percent of episodes of treatment 1950’s: 75 percent of episodes of treatment

were provided by public mental hospitals were provided by public mental hospitals – 1990’s: less than a quarter of treatment 1990’s: less than a quarter of treatment

episodes are provided by publicly owned episodes are provided by publicly owned mental hospitals mental hospitals

Mental Health Economy: Mental Health Economy: Past and PresentPast and Present

1950’s through the 1970’s the mental 1950’s through the 1970’s the mental health system operated as a planned health system operated as a planned economy.economy.

Today, there is a market for insurance, Today, there is a market for insurance, services, and management of mental services, and management of mental health systems.health systems.– The majority of individuals in the United The majority of individuals in the United

States acquire their mental healthcare from States acquire their mental healthcare from private providers who compete for customers.private providers who compete for customers.

Disparity of Mental Health ServicesDisparity of Mental Health Services

With the emergence of dramatic structural With the emergence of dramatic structural changes in mental health services over the changes in mental health services over the past 50 years, disparities have been past 50 years, disparities have been created, with the biggest disproportion of created, with the biggest disproportion of services being available to children and services being available to children and seniors located in rural settings.seniors located in rural settings.

Child and Adolescent Mental Child and Adolescent Mental HealthHealth

The MECA Study (Methodology for The MECA Study (Methodology for Epidemiology of Mental Disorders in Epidemiology of Mental Disorders in Children and Adolescents) estimated that Children and Adolescents) estimated that almost 21 percent of U.S. children ages 9 almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or to 17 had a diagnosable mental or addictive disorder associated with at least addictive disorder associated with at least minimum impairment. minimum impairment.

Children and adolescents age 9–17 with Children and adolescents age 9–17 with mental or addictive disorders, mental or addictive disorders,

combined MECA sample, 6-month combined MECA sample, 6-month (current) prevalence*(current) prevalence*

* Disorders include diagnosis-specific impairment and CGAS < or * Disorders include diagnosis-specific impairment and CGAS < or = 70 (mild global impairment)= 70 (mild global impairment)

Child and Adolescent Mental Child and Adolescent Mental Health Health

The mental disorders affecting children and adolescents The mental disorders affecting children and adolescents include the following include the following (NIMH)(NIMH)::– Attention Deficit Hyperactivity Disorder (ADHD, ADD)Attention Deficit Hyperactivity Disorder (ADHD, ADD)::

ADHD/ADD, is one of the most common mental disorders that ADHD/ADD, is one of the most common mental disorders that develop in children. Characterized by impulsiveness, hyperactivity, develop in children. Characterized by impulsiveness, hyperactivity, and inattention. and inattention.

– Autism Spectrum Disorders (Pervasive Developmental DisorderAutism Spectrum Disorders (Pervasive Developmental Disorders)s)

Autism Spectrum Disorders (ASD), also known as Pervasive Autism Spectrum Disorders (ASD), also known as Pervasive Developmental Disorders (PDDs), cause severe and pervasive Developmental Disorders (PDDs), cause severe and pervasive impairment in thinking, feeling, language, and the ability to relate to impairment in thinking, feeling, language, and the ability to relate to others. others.

– Bipolar DisorderBipolar Disorder Bipolar Disorder, also known as manic-depressive illness, is a Bipolar Disorder, also known as manic-depressive illness, is a serious medical illness that causes shifts in a person's mood, serious medical illness that causes shifts in a person's mood, energy, and ability to function. energy, and ability to function.

Child and Adolescent Mental Child and Adolescent Mental HealthHealth

– Borderline Personality DisorderBorderline Personality Disorder Borderline personality disorder (BPD) is a serious mental Borderline personality disorder (BPD) is a serious mental

illness illness characterized by pervasive instability in moods, interpersonal characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. relationships, self-image, and behavior.

– DepressionDepression

Depression is a disorder that affects an individuals thoughts, Depression is a disorder that affects an individuals thoughts, mood, mood, feelings, behavior, and physical health.feelings, behavior, and physical health.

– Eating Disorders Eating Disorders

Eating disorders involve serious disturbances in eating Eating disorders involve serious disturbances in eating behavior, such as extreme and unhealthy reduction of food behavior, such as extreme and unhealthy reduction of food

intake or intake or severe overeating, as well as feelings of distress or severe overeating, as well as feelings of distress or extreme concern extreme concern about body shape or weight. about body shape or weight.

– Childhood-Onset SchizophreniaChildhood-Onset SchizophreniaSchizophrenia is a chronic, severe, and disabling brain disorder.Schizophrenia is a chronic, severe, and disabling brain disorder.

Reported Mental Health Concerns: Reported Mental Health Concerns: Gender and School LevelGender and School Level

* School Mental Health Services in the United States. 2006. http://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdfSchool Mental Health Services in the United States. 2006. http://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdf

The TragedyThe Tragedy

Most children and adolescents with psychiatric disorders Most children and adolescents with psychiatric disorders do not get the help they need. If left untreated, the do not get the help they need. If left untreated, the physical, emotional, social and intellectual development physical, emotional, social and intellectual development of children with mental disorders will be severely stunted, of children with mental disorders will be severely stunted, if not crippled.if not crippled.

These children are at a heightened risk for school failure These children are at a heightened risk for school failure and dropout, drug abuse, and many other difficulties - all and dropout, drug abuse, and many other difficulties - all of which can be prevented by timely evaluation and of which can be prevented by timely evaluation and appropriate treatment.appropriate treatment.

Elderly Adult Mental HealthElderly Adult Mental Health

Mental health issues affect seniors Mental health issues affect seniors differently than other age groups due to differently than other age groups due to loss, physical health concerns, and loss, physical health concerns, and economic and social changes acting either economic and social changes acting either individually or in combination.individually or in combination.

Up to 25% of people over the age of 60 Up to 25% of people over the age of 60 experience some kind of mental illness, experience some kind of mental illness, particularly depression.particularly depression.

Elderly Adult Mental HealthElderly Adult Mental Health

The lack of attention to the mental health The lack of attention to the mental health problems of the elderly may be attributed problems of the elderly may be attributed to:to:

– ageismageism– inadequate training of health care providersinadequate training of health care providers– the shortage of geriatric specialiststhe shortage of geriatric specialists– the need for more knowledge and research, the need for more knowledge and research,

Medicaid Coverage of Mental Medicaid Coverage of Mental Health TreatmentHealth Treatment

There are certain mental health services There are certain mental health services that are mandatory under federal law and that are mandatory under federal law and must be offered to all Medicaid must be offered to all Medicaid beneficiaries in all states.beneficiaries in all states.– Inpatient and residential treatmentInpatient and residential treatment– Outpatient physician and hospital servicesOutpatient physician and hospital services– Early and Periodic Screening, Diagnosis and Early and Periodic Screening, Diagnosis and

Treatment (EPSDT)Treatment (EPSDT)Requires coverage of all optional services when Requires coverage of all optional services when necessary for a child.necessary for a child.


Mandatory eligibility covers pregnant women Mandatory eligibility covers pregnant women and children up to age 6 in families with incomes and children up to age 6 in families with incomes up to 133 percent of the federal poverty level up to 133 percent of the federal poverty level and older children up to 100 percent of poverty.and older children up to 100 percent of poverty.

States can opt to raise these income limits to States can opt to raise these income limits to 185% or 133% of poverty respectively. States 185% or 133% of poverty respectively. States also have the option to cover children who also have the option to cover children who qualify for the State Child Health Insurance qualify for the State Child Health Insurance Program (S-CHIP), whose families can have Program (S-CHIP), whose families can have incomes as high as 250 percent of poverty incomes as high as 250 percent of poverty


A large number of individuals with mental A large number of individuals with mental disorders on Medicaid are eligible because disorders on Medicaid are eligible because they receive federal disability benefits.they receive federal disability benefits.Over a quarter of those receiving Over a quarter of those receiving Supplemental Security Income (SSI) Supplemental Security Income (SSI) disability benefits, 1.4 million, are people disability benefits, 1.4 million, are people with psychiatric disabilities. Generally, SSI with psychiatric disabilities. Generally, SSI recipients fall within the mandatory recipients fall within the mandatory eligibility category. eligibility category.


Medicaid also offers coverage of Medicaid also offers coverage of individuals who have high medical costs individuals who have high medical costs and who can qualify as “medically needy.”and who can qualify as “medically needy.”– These individuals must still meet the eligibility These individuals must still meet the eligibility

standards of some category of Medicaid (such standards of some category of Medicaid (such as by being disabled), but need not meet the as by being disabled), but need not meet the Medicaid income test Medicaid income test

Medicare Coverage of Mental Medicare Coverage of Mental Health TreatmentHealth Treatment

Hospitalization: Medicare covers care in specialized Hospitalization: Medicare covers care in specialized psychiatric hospitals which only treat mental illness when psychiatric hospitals which only treat mental illness when in-patient care is needed for active psychiatric treatment.in-patient care is needed for active psychiatric treatment.– pays for necessary in-patient hospitalization for up to 90 days pays for necessary in-patient hospitalization for up to 90 days

per benefit period.per benefit period.

Partial hospitalization programs offer intensive Partial hospitalization programs offer intensive psychiatric treatment on an outpatient basis to psychiatric treatment on an outpatient basis to psychiatric patients, with an expectation that the patient’s psychiatric patients, with an expectation that the patient’s psychiatric condition and level of functioning will improve psychiatric condition and level of functioning will improve and that relapse will be prevented so that and that relapse will be prevented so that re-hospitalization can be avoided re-hospitalization can be avoided


Medicare covers needed diagnostic and treatment Medicare covers needed diagnostic and treatment services provided by physicians, including psychiatrists, services provided by physicians, including psychiatrists, as well as clinical psychologists, social workers, as well as clinical psychologists, social workers, psychiatric nurse specialists, nurse practitioners and psychiatric nurse specialists, nurse practitioners and physicians assistants.physicians assistants.Medicare pays for home health services for individuals Medicare pays for home health services for individuals who require skilled care on a part-time or intermittent who require skilled care on a part-time or intermittent basis and who are confined to the home. People with basis and who are confined to the home. People with mental health needs who meet these eligibility criteria mental health needs who meet these eligibility criteria are eligible for care in their home, even if they have no are eligible for care in their home, even if they have no physical limitations physical limitations


LIMITATIONS:LIMITATIONS:– Reimbursement for certain psychiatric Reimbursement for certain psychiatric

services differs from the usual Medicare services differs from the usual Medicare reimbursement rules.reimbursement rules.

Medicare Part B generally reimburses doctors at Medicare Part B generally reimburses doctors at 80% of the approved amount; the patient pays the 80% of the approved amount; the patient pays the remaining 20% coinsurance amount. remaining 20% coinsurance amount. When a claim is for mental health services, When a claim is for mental health services, Medicare makes an initial deduction of 37½ % Medicare makes an initial deduction of 37½ % before paying 80% of the charge. As a result, the before paying 80% of the charge. As a result, the Part B reimbursement is, on average, about 50% Part B reimbursement is, on average, about 50% of the charge. of the charge.


It is recommended that individuals need to It is recommended that individuals need to consider carefully how to supplement their consider carefully how to supplement their Medicare coverageMedicare coverage– Medigap policyMedigap policy– Retiree health policyRetiree health policy– Through Medicaid Through Medicaid

Previous Legislative Efforts:Previous Legislative Efforts:Keeping Families Together Act of 2007Keeping Families Together Act of 2007

To amend the Public Health Service Act to establish a State family To amend the Public Health Service Act to establish a State family support grant program to end the practice of parents giving legal support grant program to end the practice of parents giving legal custody of their seriously emotionally disturbed children to State custody of their seriously emotionally disturbed children to State agencies for the purpose of obtaining mental health services for agencies for the purpose of obtaining mental health services for those children. those children.

Introduced by Rep. Jim Ramstad (R-MN3)Introduced by Rep. Jim Ramstad (R-MN3)

PURPOSE: To assist States in eliminating the practice of parents PURPOSE: To assist States in eliminating the practice of parents giving custody of their seriously emotionally disturbed children to giving custody of their seriously emotionally disturbed children to State agencies for the purpose of securing mental health care for State agencies for the purpose of securing mental health care for those childrenthose children

Referred to the House Committee on Energy and Commerce Referred to the House Committee on Energy and Commerce

Previous Legislative Efforts:Previous Legislative Efforts:Mental Health Parity Act of 2007Mental Health Parity Act of 2007

To amend the Public Health Service Act with respect to To amend the Public Health Service Act with respect to mental health services for elderly individuals.mental health services for elderly individuals.

Introduced by Sen. Pete V. Domenici (R-NM)Introduced by Sen. Pete V. Domenici (R-NM)

STATEMENT OF PURPOSE- To provide parity between STATEMENT OF PURPOSE- To provide parity between health insurance coverage of mental health benefits and health insurance coverage of mental health benefits and benefits for medical and surgical services.benefits for medical and surgical services.

Referred to Committee on Health, Education, Labor, and Referred to Committee on Health, Education, Labor, and PensionsPensions

Previous Legislative Efforts:Previous Legislative Efforts:Seniors Mental Health Access Improvement Seniors Mental Health Access Improvement

Act of 2007Act of 2007

To amend the Social Security Act to provide for To amend the Social Security Act to provide for the coverage of marriage and family therapist the coverage of marriage and family therapist services under part B of the Medicare Program, services under part B of the Medicare Program, and for other purposes.and for other purposes.

Introduced by Rep. Edolphus Towns (D-NY).Introduced by Rep. Edolphus Towns (D-NY).– Co-Sponsored by Rep. Charles W. Pickering (R-MS3)Co-Sponsored by Rep. Charles W. Pickering (R-MS3)

Effective: The amendments made by this Act Effective: The amendments made by this Act apply with respect to services furnished on or apply with respect to services furnished on or after January 1, 2008 . after January 1, 2008 .

Bill S. 633 of the 110Bill S. 633 of the 110thth Congress Congress

TitleTitle

““Working Together for Rural Access to Working Together for Rural Access to Mental Health and Wellness for Children Mental Health and Wellness for Children and Seniors Act” and Seniors Act” – Introduced by Sen. Norm Coleman (R-MN)Introduced by Sen. Norm Coleman (R-MN)– February 15, 2007February 15, 2007– Referred to Committee on Health, Education, Referred to Committee on Health, Education,

Labor, and PensionsLabor, and Pensions

FindingsFindings

In rural areas, where specialized mental health services In rural areas, where specialized mental health services are scarce, accessing mental health professional are scarce, accessing mental health professional services is difficult. services is difficult.

Rural primary care providers have experienced an Rural primary care providers have experienced an increase in mental health issues recentlyincrease in mental health issues recently

Surgeon General estimates 21% of children experience Surgeon General estimates 21% of children experience mental health systems, which left untreated can lead to mental health systems, which left untreated can lead to school failure, drug abuse, and often incarcerationschool failure, drug abuse, and often incarceration

The Department of Health and Human Services The Department of Health and Human Services estimates 1 in 5 children and adolescents have estimates 1 in 5 children and adolescents have diagnosable disorders, yet close to 80% receive no helpdiagnosable disorders, yet close to 80% receive no help

Findings continued…Findings continued…

Few schools have the resources and funding available to Few schools have the resources and funding available to implement a full range of mental health interventionsimplement a full range of mental health interventionsMental health is a fundamental cornerstone to ensure Mental health is a fundamental cornerstone to ensure children have the opportunity to be successful in schoolchildren have the opportunity to be successful in schoolPromoting and expanding telemental health Promoting and expanding telemental health collaborations to strengthen delivery of mental health collaborations to strengthen delivery of mental health services in remote and underserved areas is needed services in remote and underserved areas is needed Telemental health is effective at diagnosing and treating Telemental health is effective at diagnosing and treating mental health disorders and can provide better access mental health disorders and can provide better access and care to rural areasand care to rural areas– Telemental health is the use of videoconferencing or similar Telemental health is the use of videoconferencing or similar

means of electronic communication to provide mental health means of electronic communication to provide mental health servicesservices

Grant Program Continued…Grant Program Continued…

Amount of Funding:Amount of Funding:

The Secretary shall award a grant to a State under this The Secretary shall award a grant to a State under this section in an amount that is based on the respective section in an amount that is based on the respective number of critical access hospitals (as defined in section number of critical access hospitals (as defined in section 1861 (mm)(1) of the Social Security Act (42 U.S.C. 1861 (mm)(1) of the Social Security Act (42 U.S.C. 1395x(mm)(1)) in the State as such compares to the 1395x(mm)(1)) in the State as such compares to the total number of critical access hospitals in all States that total number of critical access hospitals in all States that are awarded grants under this sectionare awarded grants under this section

PurposePurpose

Provide assistance to rural schools, hospitals, and Provide assistance to rural schools, hospitals, and communities through collaborative efforts to secure communities through collaborative efforts to secure progressive and innovative systems to provide mental progressive and innovative systems to provide mental healthcare access and treatment for youth, seniors, and healthcare access and treatment for youth, seniors, and familiesfamilies

Increase access to elementary and secondary schools to Increase access to elementary and secondary schools to mental health services in rural areas through the use of a mental health services in rural areas through the use of a mobile health services van programmobile health services van program

Increase access to individuals of all ages to mental Increase access to individuals of all ages to mental health services in rural areas by utilization of telemental health services in rural areas by utilization of telemental health services established in the areashealth services established in the areas

Grant programGrant programState grants shall be awarded by the State grants shall be awarded by the Secretary of Health and Human Services Secretary of Health and Human Services for the purpose of issuing subgrants to for the purpose of issuing subgrants to carry out the purposes of this actcarry out the purposes of this act

Eligibility:Eligibility:States shall be deemed eligible by submitting an States shall be deemed eligible by submitting an application with all pertinent information required, application with all pertinent information required, establishing a establishing a lead agencylead agency, and submitting a , and submitting a state planstate plan

State Lead AgencyState Lead Agency

The governor of each state shall be responsible The governor of each state shall be responsible for selecting a Lead agency (other than the State for selecting a Lead agency (other than the State Office of Rural Health) to administer the State Office of Rural Health) to administer the State programsprogramsThe lead agency shall administer directly or The lead agency shall administer directly or through other agencies the awarded fundingthrough other agencies the awarded fundingThe lead agency will also be responsible for The lead agency will also be responsible for forming the state plan which will coordinate the forming the state plan which will coordinate the expenditures in consultation with state and local expenditures in consultation with state and local representatives of educational agencies, rural representatives of educational agencies, rural mental health providers, and the state hospital mental health providers, and the state hospital associationassociation

The State PlanThe State Plan

1.1. Establish lead agencyEstablish lead agency2.2. Assure that the state will use funding in the following Assure that the state will use funding in the following

areas:areas:1.1. Provide mobile van services for elementary and secondary Provide mobile van services for elementary and secondary

education studentseducation students2.2. Provide telemental health services to individuals of all ages in Provide telemental health services to individuals of all ages in

rural areas, and cover all administrative costs associated with rural areas, and cover all administrative costs associated with these grant recipientsthese grant recipients

3.3. Assure that the grant benefits will be available Assure that the grant benefits will be available throughout the entire statethroughout the entire state

4.4. Assure the lead agency will consult mental health Assure the lead agency will consult mental health providers and state hospital associations to assess providers and state hospital associations to assess appropriate fund utilizationappropriate fund utilization

EligibilityEligibility

Located in or serving a rural areaLocated in or serving a rural areaGovernment owned or non-profit hospitalGovernment owned or non-profit hospitalCommunity mental health facilityCommunity mental health facilityPrimary care clinicPrimary care clinicOther non-profit agency providing mental health servicesOther non-profit agency providing mental health services

Selection will be based on an applicants need to improve Selection will be based on an applicants need to improve mental health care access within a community and the mental health care access within a community and the extent to which it will serve rural low-income populations. extent to which it will serve rural low-income populations. All applicants must submit a comprehensive outline of All applicants must submit a comprehensive outline of all procedures, evaluations, measurements, and must all procedures, evaluations, measurements, and must keep a record and reports available to the Secretary at keep a record and reports available to the Secretary at all times for oversight.all times for oversight.

Fund UtilizationFund Utilization

Mobile vansMobile vans– Offset all costs incurred after Dec. 31, 2007Offset all costs incurred after Dec. 31, 2007– Purchase or lease of vehiclePurchase or lease of vehicle– Repairs and maintenanceRepairs and maintenance– Purchase or lease of communication Purchase or lease of communication

equipmentequipment– Education and training of staff using the vanEducation and training of staff using the van– Professional staff employmentProfessional staff employment

Fund Utilization Continued…Fund Utilization Continued…

Telemental health servicesTelemental health services– Offset all costs incurred after Dec. 31, 2007Offset all costs incurred after Dec. 31, 2007– Purchasing, leasing, maintaining, and Purchasing, leasing, maintaining, and

repairing all telemental health equipmentrepairing all telemental health equipment– Telecommunications, utility, and software Telecommunications, utility, and software

upkeep and purchaseupkeep and purchase– Education and training to telemental health Education and training to telemental health

service staffservice staff– Professional staff employmentProfessional staff employment

LimitationsLimitations

$10,000,000 in appropriations for the program $10,000,000 in appropriations for the program for each fiscal years 2008 to 2010for each fiscal years 2008 to 2010

Each subgrant shall not exceed $300,000 for Each subgrant shall not exceed $300,000 for one fiscal yearone fiscal year

The Secretary shall review and monitor State The Secretary shall review and monitor State compliance with the requirements of this section compliance with the requirements of this section and the State plan and will be able to suspend and the State plan and will be able to suspend payments to states if compliance is not payments to states if compliance is not satisfactorily metsatisfactorily met

Republicans vs. DemocratsRepublicans vs. Democrats

Issues with mental healthcareIssues with mental healthcare

Parity of mental health careParity of mental health careMajor issue is that mental health is not cost Major issue is that mental health is not cost beneficialbeneficial

Mental health problems cost too much since they are chronicMental health problems cost too much since they are chronicMyth?Myth?What about heart disease, diabetes, asthma? Chronic What about heart disease, diabetes, asthma? Chronic physical diseases.physical diseases.

Substance abuse and rehabilitationSubstance abuse and rehabilitationShould treatment medications be covered by Should treatment medications be covered by Medicare/Medicaid?Medicare/Medicaid?

DemocratsDemocrats

Democratic Party view on Democratic Party view on mental healthmental health

Want healthcare to be available and Want healthcare to be available and affordable to everyone and provided by affordable to everyone and provided by the statethe state

Democrats believe that mental healthcare Democrats believe that mental healthcare is needed for veterans. is needed for veterans.

War costs are not just bullets and guns, but taking War costs are not just bullets and guns, but taking care of returning veterans both physically and care of returning veterans both physically and mentally.mentally.

RepublicansRepublicans

Republican view on mental Republican view on mental healthcarehealthcare

Increase the number of citizens with health Increase the number of citizens with health insuranceinsurance

Make private insurance more affordableMake private insurance more affordable

Move away from government fundingMove away from government funding

Limit mental healthcare by providers, Limit mental healthcare by providers, especially Medicare and Medicaidespecially Medicare and Medicaid

Republicans (cont.)Republicans (cont.)

““senior House Republicans and business groups senior House Republicans and business groups are staunchly opposed to the deal”are staunchly opposed to the deal”

-Deal was to include coverage of mental -Deal was to include coverage of mental healthcare in insurancehealthcare in insurance

““The compromise would outlaw disparities in The compromise would outlaw disparities in coverage between mental and physical illness coverage between mental and physical illness under group health plans sponsored by under group health plans sponsored by employers with more than 50 workers”employers with more than 50 workers”

SimilaritiesSimilarities

Both consider mental health as an important part Both consider mental health as an important part of a healthy lifeof a healthy lifeBoth parties want to end discrimination in the Both parties want to end discrimination in the work place (insurance discrimination)work place (insurance discrimination)Both want equitable mental healthcareBoth want equitable mental healthcare98% of Americans think mental health should be 98% of Americans think mental health should be covered by insurancecovered by insurance

83% of Republicans and 92% of Democrats want equitable 83% of Republicans and 92% of Democrats want equitable health insurancehealth insurance89% of both employees AND employers want mental health 89% of both employees AND employers want mental health care coveragecare coverage

Similarities (cont.)Similarities (cont.)

““That movement has galvanized Congress. That movement has galvanized Congress. Senators Pete V. Domenici, Republican of Senators Pete V. Domenici, Republican of New Mexico, and Paul Wellstone, New Mexico, and Paul Wellstone, Democrat of Minnesota, have, for more Democrat of Minnesota, have, for more than five years, led a campaign to than five years, led a campaign to translate the idea of parity into law.”translate the idea of parity into law.”

-- Robert Pear, New York Times Dec. 2001-- Robert Pear, New York Times Dec. 2001

Similarities (cont.)Similarities (cont.)

''It's a real battle,'' Mr. Specter said''It's a real battle,'' Mr. Specter saidBush says people should have the access to the Bush says people should have the access to the care they need.care they need.

But is concerned with increasing costs of But is concerned with increasing costs of healthcarehealthcare

DilemmaDilemma

Policy and Fiscal Policy and Fiscal ImplicationsImplications

The Presidents New Freedom Commission on The Presidents New Freedom Commission on Mental Health: Achieving the Promise, Mental Health: Achieving the Promise,

Transforming Mental Health Care in America Transforming Mental Health Care in America (2003)(2003)

Final report by President Bush’s Freedom Final report by President Bush’s Freedom Commission on Mental Health Commission on Mental Health Recognizes the critical role schools can Recognizes the critical role schools can play in the continuum of mental health play in the continuum of mental health services services Emphasizes building a mental health Emphasizes building a mental health system that is evidence-based, recovery-system that is evidence-based, recovery-focused and consumer- and family-drivenfocused and consumer- and family-driven

Freedom Commission on Mental HealthFreedom Commission on Mental Health

15 member commission appointed by Bush in 15 member commission appointed by Bush in 2003 to examine the Mental Health System in 2003 to examine the Mental Health System in the U.S.the U.S.Over the course of a year through public Over the course of a year through public hearings, site visits, written and oral testimony hearings, site visits, written and oral testimony from experts, and comments and concerns from experts, and comments and concerns received through the Internet the committee received through the Internet the committee concluded “concluded “the system was in shamblesthe system was in shambles.” .” Analysis of all the reports and findings Analysis of all the reports and findings suggested that the only way to create an suggested that the only way to create an effective and efficient mental health system was effective and efficient mental health system was to fundamentally to fundamentally transformtransform the system. the system.

Findings of the CommissionFindings of the Commission

The principle findings emphasized the mental health systems need The principle findings emphasized the mental health systems need to be equivalent to the public health systemto be equivalent to the public health system– better access for all, equity in treatment and funding, and a reduction of better access for all, equity in treatment and funding, and a reduction of

stigma. stigma. MHS was built around a delivery and payment system instead of the MHS was built around a delivery and payment system instead of the needs of MHS recipients and their families, frequently resulting in needs of MHS recipients and their families, frequently resulting in unsatisfactory outcomes. unsatisfactory outcomes. The public mental health system failed to employ evidence-based The public mental health system failed to employ evidence-based practices or the newest technologies and the commission confirmed practices or the newest technologies and the commission confirmed that a person’s race, ethnicity, or geographical location could that a person’s race, ethnicity, or geographical location could compromise his or her access to services. compromise his or her access to services. The Commission recommended the creation of a comprehensive The Commission recommended the creation of a comprehensive mental health plan in each state.mental health plan in each state.

New Freedom Commission on New Freedom Commission on Mental Health (NFCMental Health (NFC))

Focusing on State Focusing on State activities related to six activities related to six goals for transforming goals for transforming mental health mental health systems from the systems from the President’s New President’s New Freedom Commission Freedom Commission Report. Report.

1) 1) Organization and Structure Component:Organization and Structure Component: to to whom the SMHA commissioner/director is whom the SMHA commissioner/director is accountable; responsibility for a variety of mental accountable; responsibility for a variety of mental health services, including State mental hospitals, health services, including State mental hospitals, community mental health programs, and forensic community mental health programs, and forensic programs; ways in which community-based mental programs; ways in which community-based mental health services are fundedhealth services are funded

2) 2) Policy Component:Policy Component: Contains information on Contains information on priority clients and mandates for core services; other priority clients and mandates for core services; other service system requirements, standards, and future service system requirements, standards, and future directions; activities relating to downsizing, closing, directions; activities relating to downsizing, closing, or consolidating State mental hospitals; privatizing or consolidating State mental hospitals; privatizing components of the public mental health system; and components of the public mental health system; and major legal issues involving the SMHA major legal issues involving the SMHA

3) 3) Client Component:Client Component: Contains aggregated data Contains aggregated data characterizing individuals served by the SMHA in State characterizing individuals served by the SMHA in State mental hospitals and community-based programs. mental hospitals and community-based programs.

4) 4) Services Component:Services Component: Describes the nature of the Describes the nature of the service system supported by each SMHA in three broad service system supported by each SMHA in three broad areas. (1) SMHA service system issues include the types areas. (1) SMHA service system issues include the types of services offered by the SMHA in State hospitals and of services offered by the SMHA in State hospitals and community programs, the definitions of these services, community programs, the definitions of these services, linkages of services among institutions and communities, linkages of services among institutions and communities, and the role of different services within the SMHA’s and the role of different services within the SMHA’s desired service system. (2) Linkages to other State desired service system. (2) Linkages to other State services systems include information about the linkages services systems include information about the linkages between the SMHA mental health system and other between the SMHA mental health system and other State agencies that provide services for individuals with State agencies that provide services for individuals with mental illness. (3) Information on the implementation of mental illness. (3) Information on the implementation of various evidence-based practices by SMHAs is a new various evidence-based practices by SMHAs is a new focus in this component.focus in this component.

5) 5) Forensic Component:Forensic Component: Contains information Contains information about the organization and delivery of services about the organization and delivery of services to forensic clients by the SMHA and the to forensic clients by the SMHA and the relationship of the SMHA to the criminal justice relationship of the SMHA to the criminal justice systems in each State.systems in each State.

6) 6) Workforce Component:Workforce Component: Staffing levels of Staffing levels of State-operated and State-funded mental health State-operated and State-funded mental health services provider organizations; minority services provider organizations; minority workforce issues; client to staff ratios; workforce issues; client to staff ratios; recruitment, training, and retention of staff; recruitment, training, and retention of staff; salary levels; and workers’ compensation.salary levels; and workers’ compensation.

7) Financial Component:7) Financial Component: Includes the forms Includes the forms and information necessary to complete the and information necessary to complete the annual SMHA-controlled Revenues and annual SMHA-controlled Revenues and Expenditures Study plus information about the Expenditures Study plus information about the resources available to the SMHAs and the resources available to the SMHAs and the States to fund the delivery of mental health States to fund the delivery of mental health services.services.

8) Managed Behavioral Health Care:8) Managed Behavioral Health Care: The use The use of managed care to deliver public mental health of managed care to deliver public mental health services, the roles of Medicaid waivers, and how services, the roles of Medicaid waivers, and how traditional SMHA-funded providers interact with traditional SMHA-funded providers interact with managed care organizations.managed care organizations.

9) Research and Evaluation Component:9) Research and Evaluation Component: Organizational locus of the research and Organizational locus of the research and evaluation functions and their funding and evaluation functions and their funding and staffing levels.staffing levels.

10) Information Management Component:10) Information Management Component: Current status of the information management Current status of the information management function and its development over time. The function and its development over time. The component provides for a systematic compilation component provides for a systematic compilation of the organizational placement of information of the organizational placement of information management functions, the level of integration of management functions, the level of integration of these functions, and their funding and staffing.these functions, and their funding and staffing.

The Need for Early InterventionThe Need for Early Intervention

3-5% of school age children diagnosed with 3-5% of school age children diagnosed with ADHDADHD

13% of kids 9-17 diagnosed with variety of 13% of kids 9-17 diagnosed with variety of anxiety disordersanxiety disorders

Most Frequent Reported Barriers to Most Frequent Reported Barriers to Mental Health ServicesMental Health Services

Financial Constraints of FamiliesFinancial Constraints of Families– Lack of InsuranceLack of Insurance– Inability to afford private pay servicesInability to afford private pay services

Limited school and community-based Limited school and community-based resources resources

““No Child is Left Behind.” No Child is Left Behind.”

With effective school-With effective school-wide programs, support wide programs, support and funding, many and funding, many teachers could strengthen teachers could strengthen their focus on the their focus on the academics, problem-academics, problem-solving and critical solving and critical thinking skills essential thinking skills essential for students to acquire for students to acquire and spend less time and spend less time managing difficult managing difficult behaviors. behaviors.

What are our schools doing to help?What are our schools doing to help?

87% of schools reported providing behavioral/emotional 87% of schools reported providing behavioral/emotional assessments, behavior management consults and crisis assessments, behavior management consults and crisis intervention as primary mental health services, intervention as primary mental health services, only 59% of schools reported using curriculum-based only 59% of schools reported using curriculum-based programs to enhance social and emotional functioning programs to enhance social and emotional functioning 15% reported conducting school-wide screening for 15% reported conducting school-wide screening for behavioral or emotional problems. behavioral or emotional problems. If schools placed greater focus on school-wide behavior If schools placed greater focus on school-wide behavior prevention and social-emotional early intervention prevention and social-emotional early intervention programs, perhaps there would be less need for programs, perhaps there would be less need for individually focused services of behavior assessments, individually focused services of behavior assessments, management consultations and crisis intervention. management consultations and crisis intervention.

Burden of DiseaseBurden of Disease

Data developed by the Data developed by the massive Global Burden of massive Global Burden of Disease study conducted Disease study conducted by the World Health by the World Health Organization, the World Organization, the World Bank, and Harvard Bank, and Harvard University, reveal that University, reveal that mental illness, including mental illness, including suicide, accounts for over suicide, accounts for over 15 percent of the burden 15 percent of the burden of disease in established of disease in established market economies, such market economies, such as the United States.as the United States.

Controlling costsControlling costs

Public mental hospitals have been reduced or downsized from Public mental hospitals have been reduced or downsized from 560,000 resident patients in 1955 to fewer than 60,000 clients 560,000 resident patients in 1955 to fewer than 60,000 clients today, despite sizable population growth. today, despite sizable population growth. Most acute inpatient care is now in general hospitals; and although Most acute inpatient care is now in general hospitals; and although case-mix and co-morbidity are more complex, average length of case-mix and co-morbidity are more complex, average length of stay has fallen steadily to less than 10 days, and continues to fall.stay has fallen steadily to less than 10 days, and continues to fall.In the period 1988 to 1994, some 12.5 million days were reduced in In the period 1988 to 1994, some 12.5 million days were reduced in mental hospital care with only small compensation in days of care in mental hospital care with only small compensation in days of care in the general hospital sector (Mechanic, McAlpine, & Olfson, 1998). the general hospital sector (Mechanic, McAlpine, & Olfson, 1998). The introduction of managed care in the private sector has reduced The introduction of managed care in the private sector has reduced expenditures of some large corporate purchasers by as much as expenditures of some large corporate purchasers by as much as 30–40 percent, with most of these reductions achieved by large 30–40 percent, with most of these reductions achieved by large reductions in average length of stay (Feldman, 1998; Mechanic & reductions in average length of stay (Feldman, 1998; Mechanic & McAlpine, 1999).McAlpine, 1999).

Socioeconomic status has one of the Socioeconomic status has one of the strongest associations with the prevalence strongest associations with the prevalence

of mental disordersof mental disordersSocial policies have a Social policies have a major role in making major role in making treatment available. treatment available. Persons with serious and Persons with serious and persistent mental illness persistent mental illness remain perhaps the most remain perhaps the most disadvantaged and disadvantaged and neglected group in our neglected group in our society and suffer from society and suffer from the failures of American the failures of American health care policy.health care policy.

Decision processes do Decision processes do not sufficiently sensitize not sufficiently sensitize the seriousness and the seriousness and complexity of mental complexity of mental illness, and the patients illness, and the patients with the most severe with the most severe illnesses appear to do illnesses appear to do worse under present worse under present managed care managed care arrangements as arrangements as compared to fee-for-compared to fee-for-service practice.service practice.

Out of Sight, Out of Mind, Yet ExpensiveOut of Sight, Out of Mind, Yet Expensive

A Justice Department A Justice Department study estimated that study estimated that in midyear 1998, in midyear 1998, there were more than there were more than 280,000 persons with 280,000 persons with mental illness in jails mental illness in jails and prisons, and and prisons, and more than a half more than a half million more on million more on probation (Ditton, probation (Ditton, 1999).1999).

Olmstead Olmstead vs. vs. L. C: a possible L. C: a possible solution?solution?

(ADA) and the U.S. Supreme Court (ADA) and the U.S. Supreme Court decision which required the State of decision which required the State of Georgia to provide community care to Georgia to provide community care to persons with mental illnesses and mental persons with mental illnesses and mental retardation who could function in such less retardation who could function in such less restrictive settings without placing an restrictive settings without placing an undue burden on the State or requiring undue burden on the State or requiring that the State establish a particular type of that the State establish a particular type of program.program.

Mental Healthcare Provider Mental Healthcare Provider Rural Incentive ActRural Incentive Act

Target GroupsTarget Groups

ChildrenChildren

SeniorsSeniorsMedicare recipientsMedicare recipients

Undeserved/low incomeUndeserved/low incomeThose on MedicaidThose on Medicaid

Rationale and PurposeRationale and Purpose

Improve access to mental health care in Improve access to mental health care in rural communities.rural communities.

Incentives for doctors to work in rural Incentives for doctors to work in rural settingssettings

MechanismMechanism

Mental health doctors/psychiatrists will commit Mental health doctors/psychiatrists will commit to work in a rural community for a minimum of to work in a rural community for a minimum of two years. They must commit at least 12 two years. They must commit at least 12 hours per week for 50 weeks of the year in a hours per week for 50 weeks of the year in a rural community mental health clinic or facility.rural community mental health clinic or facility.

In return, doctors will be offered grantsIn return, doctors will be offered grants1.1. Categorical grant - for up to 4 years of workCategorical grant - for up to 4 years of work

- Must be spent to repay loans- Must be spent to repay loans

2.2. Block grant Block grant - Meant to provide doctor with startup capital for private - Meant to provide doctor with startup capital for private practice or clinic.practice or clinic.

MechanismMechanism

Lead Agencies will determine the Lead Agencies will determine the communities that will qualify as “rural” and communities that will qualify as “rural” and areas that qualify doctors for these areas that qualify doctors for these incentivesincentives

Lead Agency established from Bill S. 633 - Lead Agency established from Bill S. 633 - Working together for rural access to mental health Working together for rural access to mental health and wellness for children and seniors actand wellness for children and seniors act

FinancingFinancing

Up to $100,000 in Categorical GrantUp to $100,000 in Categorical Grant– Approx. $25,000 per year for first four years in Approx. $25,000 per year for first four years in

qualifying rural settingqualifying rural setting– Must be used to repay loans used for Must be used to repay loans used for

educational purposeseducational purposes

FinancingFinancing

Up to $100,000 in other grants for fulfilling rural Up to $100,000 in other grants for fulfilling rural work obligation to help with “start up” costs.work obligation to help with “start up” costs.– $20,000 block grant minimum$20,000 block grant minimum

Can be used as doctor sees fit; i.e. pay off additional debt, Can be used as doctor sees fit; i.e. pay off additional debt, start up practice, etc.start up practice, etc.

– Up to $100,000 in project-like grant for private usesUp to $100,000 in project-like grant for private usesTo be used for establishing practices in rural communitiesTo be used for establishing practices in rural communitiesLarger grants will be given on an as-needed basis (for Larger grants will be given on an as-needed basis (for example in those communities where startup costs may be example in those communities where startup costs may be higher) but will not exceed $100,000higher) but will not exceed $100,000

FinancingFinancing

Services rendered will be covered by Medicare, Services rendered will be covered by Medicare, Medicaid, and private insuranceMedicaid, and private insurance– Mental Health Parity Act of 2007 (S. 558), states that Mental Health Parity Act of 2007 (S. 558), states that

all insurance must provide equity in the care and all insurance must provide equity in the care and treatment of mental and physical illnessestreatment of mental and physical illnesses

– ““the financial requirements applicable to such mental the financial requirements applicable to such mental health benefits are no more restrictive than the health benefits are no more restrictive than the financial requirements applied to substantially all financial requirements applied to substantially all medical and surgical benefits covered by the plan”medical and surgical benefits covered by the plan”

OutcomesOutcomes

Increase access to mental health care for Increase access to mental health care for populations in rural settingspopulations in rural settingsTo eliminate healthcare (particularly To eliminate healthcare (particularly mental healthcare) disparities among rural mental healthcare) disparities among rural and urban and suburban communitiesand urban and suburban communities– Provide better care and treatment for the Provide better care and treatment for the

children, seniors and impoverished children, seniors and impoverished populationspopulations

SummarySummary

Eliminate disparities for mentally ill in rural Eliminate disparities for mentally ill in rural areas by encouraging psychiatrist and areas by encouraging psychiatrist and other mental health related physicians to other mental health related physicians to work in these settingswork in these settings

Incentives are monetary in forms of grants Incentives are monetary in forms of grants to pay off loans and to provide capital to to pay off loans and to provide capital to establish local practice in a rural establish local practice in a rural communitycommunity

ReferencesTreatment of Children with Mental Disorders. 2006.Treatment of Children with Mental Disorders. 2006.

http://www.nimh.nih.gov/publicat/adhd.cfmhttp://www.nimh.nih.gov/publicat/adhd.cfm

School Mental Health Services in the United States. 2006. School Mental Health Services in the United States. 2006. http://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdfhttp://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdf

Mental Health, United States 2000: Chapter 7. 2000.Mental Health, United States 2000: Chapter 7. 2000.http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3537/http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3537/chapter7.aspchapter7.asp

Mental Health, United States 2000: Chapter 8. 2000.Mental Health, United States 2000: Chapter 8. 2000.http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3537/http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3537/chapter8.asp.chapter8.asp.

Geriatric Mental Health Foundation.Geriatric Mental Health Foundation.http://www.gmhfonline.org/gmhf/consumer/factsheets/http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.htmldepression_latelife.html

Republican And Democratic Voters Overwhelmingly Support Fair Mental Health Republican And Democratic Voters Overwhelmingly Support Fair Mental Health Insurance Coverage. Medical News Today. Jan 16, 2007. Insurance Coverage. Medical News Today. Jan 16, 2007. http://www.medicalnewstoday.com/medicalnews.php?newsid=60847http://www.medicalnewstoday.com/medicalnews.php?newsid=60847

Democrats Working to Expand Veterans Mental Health Care. Democratic National Democrats Working to Expand Veterans Mental Health Care. Democratic National Committee. 2007. http://www.democrats.org/a/2005/06/democrats_worki.phpCommittee. 2007. http://www.democrats.org/a/2005/06/democrats_worki.php

Making Healthcare Affordable for Everyone. Republican National Committee. 2007. Making Healthcare Affordable for Everyone. Republican National Committee. 2007. http://www.gop.com/Issues/HealthCare/.http://www.gop.com/Issues/HealthCare/.

The Olmstead Decision. March 22, 2007The Olmstead Decision. March 22, 2007http://www.workworld.org/wwwebhelp/the_olmstead_decision.htm http://www.workworld.org/wwwebhelp/the_olmstead_decision.htm

The National Institue of Mental Health. 2007.NIMH.gov

Mental Health, United States 2000: Chapter 7. 2000.Mental Health, United States 2000: Chapter 7. 2000.http://mentalhealth.samhsa.gov/publications/allpubs/SMA06-4195/chapter11.asphttp://mentalhealth.samhsa.gov/publications/allpubs/SMA06-4195/chapter11.asp

References

Documents

MENTAL HEALTH Group D Trey Perez Heather Rawls DJ Reid