April 2007 NACBHDD Newsletter
The Newsletter of the National Association of County Behavioral Health and Developmental Disability Directors
In this Issue...
The Board agreed at its latest meeting to officially change the acronym for the organization to NACBHDD in order to better and more accurately represent the Developmental Disability membership and mission of the organization.
Search for a New President and CEO Advances to the Interview Stage
As previously reported, NACBHDD President and CEO Melissa Staats resigned her position in the organization effective December 31 to become the Director of Mental Health in Westchester County, New York. (Staats continues to be a member of NACBHDD.) In the meantime, Tom Joseph, Senior Associate, Waterman & Associates, is working to ensure that NACBHDD is represented on all policy issues. For more information about Joseph and his experience, see the February newsletter.
The search committee, chaired by Leon Evans, Executive Director, the Center for Health Care Services, San Antonio, Texas, has been busy reviewing applications over the past few months, and has narrowed the field to several candidates, who will be interviewed in Washington May 7.
Member Testifies at Hearing on Mentally Ill Offender Treatment and Crime Reduction Act
NACBHDD Vice Chair Leon Evans, Executive Director, the Center for Health Care Services, San Antonio, Texas, recently testified at a hearing regarding the "Mentally Ill Offender Treatment and Crime Reduction Act." In his testimony, Evans described the local collaboration in Bexar County, Texas which created a very successful community initiative known as "The Bexar County Jail Diversion Program." In the last two years, this collaboration has been nationally recognized for its excellence in service, focusing on first line contact within the jail diversion continuum, including the American Psychiatric Association's 2006 national "Gold Award" recognizing their program.
As Evans noted in his testimony, "In Fiscal Year 2004, our first economic study revealed that in Bexar County, with the diversion of over 1,700 people an estimated $3.8 million to $5.0 million dollars in avoided costs was actualized within the Bexar County Criminal Justice System.
"Economically, it makes sense to divert from incarceration and treat non-violent persons with serious mental illness in different venues and make available crisis services and other treatment modalities outside the criminal justice system. This protects the dignity of persons with a severe mental illness while making sure our county, state and federal dollars are spent in the most effective and efficient way possible. By not providing the appropriate intervention and treatment we are finding that people with mental illness are being incarcerated. This inappropriate system of incarceration could be considered cruel and unusual punishment."
To access the complete testimony, click here. Look for an interview with Evans about his testimony in the May newsletter.
NACBHDD Sends Letter to Congress on Supplemental Spending Bill
Maeghan Gilmore, Director of Government Affairs and Public Policy, sent the following communication to NACBHDD members on April 19:
The House and Senate are beginning to resolve the differences in their respective Iraq war supplemental bills, which also include domestic issues of concern to NACBHDD. Attached is one of the letters sent to the Chairmen and Ranking Minority Member of the House and Senate Appropriations Committees. To view the letter, click here.
The letter outlines NACBHDD's support for a moratorium on the CMS Medicaid rule on public providers, support for the $100 million appropriation for mental health services to returning veterans, and support for the additional funds needed by 14 states for SCHIP.
Please feel free to contact Maeghan Gilmore at mgilmore@nacbhd.org or at (202) 661-8816, or Tom Joseph at tj@wafed.com, or at (202) 898-1444, if you have questions.
Tom Joseph submitted the following update on developments related to Medicaid:
As reported in last month's newsletter, there is an effort in the Senate to institute a two-year delay in the implementation of the Medicaid rule affecting public providers. The regulation will shift an estimated $5 billion in costs to state and local governments over the next five years. The provision is in the Senate's version of the supplemental spending bill to fund war efforts in Iraq and Afghanistan. House and Senate conferees are meeting to resolve the differences in their two bills, but the overriding issue continues to be whether the bill should contain a timetable for troop withdrawal, which will draw a presidential veto of the entire package. As of this writing, the House-Senate conference agreement contains a one year moratorium. Any delay in the regulation requires a budget offset to pay for the $5 billion in federal savings over five years. At this stage, Congress only found enough offsets for one year.
This debate likely will continue into May. NACBHDD sent a letter to the Chairs and Ranking Minority members of the House and Senate Appropriations Committees supporting the moratorium. The letter also expresses support for the $100 million contained in both bills for mental health services for returning veterans and support for federal funding to ensure that states have enough federal State Children's Health Insurance Program (SCHIP) funding for the remainder of the federal fiscal year. To read a copy of the letter, click here.
NACBHDD periodically speaks with Karen Sanders, Associate Director for Publicly Funded Services at the American Psychiatric Association (APA) about MentalHealthPartD, or www.mentalhealthpartd.org, regarding critical issues and developments related to the implementation of the Medicare Modernization Act Part D. (The website is sponsored by advocates, including the American Association of Community Psychiatrists, the American Association for Geriatric Psychiatry, the APA, the National Alliance on Mental Illness, the National Association for State Mental Health Directors, the National Council for Community Behavioral Healthcare, Mental Health America, Treatment Effectiveness Now, and NACBHDD.)
Look for an interview with Sanders in the May newsletter and important information on the APA's Part D study on access to drugs, which highlights critical problems with access due to plans' not following the guidance of the Centers for Medicare and Medicaid Services.
Update on the Campaign for Mental Health Reform
Bill Emmet, Director of the Campaign for Mental Health Reform, of which NACBHDD is a partner, provides an update on recent Campaign activities:
SAMHSA reauthorization
The Campaign's primary focus at this time is SAMHSA reauthorization, and it has been working very hard over the last six weeks on the areas on which it would like the Senate Health, Education, Labor, and Pensions (HELP) Committee to concentrate at its May 8 hearing for SAMHSA reauthorization. Overall, the Campaign is hoping the reauthorization reflects the priorities of the New Freedom Commission and the transformation priorities outlined there, which have taken root in the field. Emmet highlighted the following areas of emphasis for SAMHSA reauthorization:
Mental Heath is Integral to Health Act
The Campaign is still working on legislation around the broader issue of the crucial relationship between mental health and physical health. Some of the provisions of SAMHSA reauthorization fit into this proposed legislation well.
The Campaign is hoping for a way or ways to embed mental health measures in the surveillance done by the Centers for Disease Control and Prevention (CDC). The CDC has a few programs that do touch on mental health, but Emmet says, there is not the coordination that there should be. The Act would aim to expand the mission of the CDC to integrate mental health into the mission, and to develop more tools for ongoing surveillance in mental health. A unit in the CDC would be responsible for mental health programs.
Emmet notes that the issue of mortality and morbidity for individuals in the public mental health system has been looked at closely, most recently in the National Association of State Mental Health Program Directors' October 2006 Morbidity and Mortality in People with Serious Mental Illness report that revealed that individuals in the public mental health system die 25 years earlier than other individuals. The Campaign wants the Department of Health and Human Services, through SAMHSA, to identify why and make sure that there are funds for people in the system to access the appropriate medical care, and in addition, give individuals in the public mental health system programmatic priority.
Mentally Ill Offender Treatment and Crime Reduction Act of 2003
The Campaign continues to work with the Council of State Governments, the National Association of Counties (of which NACBHDD is an affiliate), and others regarding the funding for the programs authorized under this Act (which is not up for reauthorization for a couple of years); this activity may result in hearings. President Bush's budget was released with no money for these programs, and Emmet notes that this is "a great program that communities embrace."
The Campaign is finding support in both houses, and is hoping for as much as $30 million per year for the programs authorized under the Act.
The mental health of soldiers returning from the war in Iraq
In mid-April, the Senate Mental Health Caucus held a briefing on mental health care for soldiers returning from Iraq and their families. Emmet characterizes the hearing as "very powerful," and as something that "got a lot of people thinking about the issue." Many Senate staffers were in attendance, as well as NACBHDD staff.
Pennsylvania Member Testifies at Parity Hearing
Background
The Senate Health, Education, Labor and Pensions (HELP) Committee approved in February The Senator Paul Wellstone Mental Health Parity Act of 2007 (S 558) by a vote of 18-3. The bill is recognized as a compromise between businesses, the insurance industry, and the mental health community. And, the House recently introduced their parity bill, H.R.1424, sponsored by Representatives Kennedy (D-RI) and Ramstad (R-MN). Their bill has 255 co-sponsors. That bill has not been marked up in the House.
The 1996 federal parity law established annual and lifetime dollar limits. The current bills prohibit unequal co-payments and deductibles for mental health and addictions. Additionally, day and visit limits are pre-empted. While the Senate bill pre-empts state parity standards regarding financial and treatment limitations as well as other components of state law, the House bill will not pre-empt state laws that provide consumer protections.
Representatives Kennedy and Ramstad conducted a number of mental health parity hearings nationwide. To learn more, see www.equitycampaign.net/.
NACBHDD member's testimony emphasizes federal parity law should not pre-empt states
NACBHDD member Patricia Valentine, Deputy Director of the Alleghany, Pennsylvania Office of Behavioral Health, testified at a congressional field hearing on parity March 12 in Pittsburgh. Valentine's focus was on explaining that any federal parity legislation should not supplant Act 106, Pennsylvania's drug and alcohol insurance law.
Valentine says the main concern with the Senate bill is that under the bill, federal legislation would preempt state legislation. Pennsylvania Act 106 has been in place since 1997, and is for substance abuse disorders only. There is no similar law for minimum requirements for mental health coverage in Pennsylvania.
The Act says that 1) group health plans have to provide a minimum level of care for substance abuse disorders, and 2) The medication needed is determined by the treating psychiatrist. Therefore, insurers cannot say that a medication is not medically necessary. The Senate bill does not provide for any minimum visits. For example, if an insurer only provides for 10 outpatient visits for physical reasons, only 10 outpatient visits are allowed for mental health reasons. This would be fewer than stipulated under Act 106, and there is concern in Pennsylvania that under the Senate version consumers would get less than they do under the state Act 106. On the other hand, Valentine says the House bill does note supersede Act 106.
While insurers in the state often try not to abide by Act 106, the system as a whole tries to make sure it is followed. For example, if an insurer tries to impose less than what is stipulated in Act 106, providers are supposed to notify the insurer about the requirements in the Act and that they are not following those requirements.
To address the issue of noncompliance, the Pennsylvania Department of Insurance issued clarification about three years ago because so many insurance companies were fighting Act 106. To view the clarification, click here.
Pennsylvania's perspective
Pennsylvania has a relatively generous funding system relative to other states; Medicare Part D is an example of this. Therefore, says Valentine, some proposed federal initiatives harm Pennsylvania's delivery systems while helping other states with less comprehensive approaches.
Next steps
The next step is to get something passed in the House. Then, that legislation will attempt to be merged with the Senate bill into legislation that both houses can support. Valentine hopes that whatever passes protects state laws, and she says that even if the hearings are over, it is important for people to communicate with the House Energy and Commerce Committee about it.
To read Valentine's testimony, click here. To access an article on Valentine's testimony, click here.
Update on Autism Services Bill
Maeghan Gilmore, Director of Government Affairs and Public Policy, provided the following update on the Expanding the Promise for Individuals with Autism Act of 2007:
Senators Hillary Clinton (D-NY) and Wayne Allard (R-CO) introduced the legislation, (S. 937) "Expanding the Promise for Individuals with Autism" (S.937) in late March, and it was later followed in the House of Representatives in mid April with HR 1881 by Reps. Mike Doyle (D-PA) and Chris Smith (R-NJ). The legislation would provide approximately $83 million in FY 2008 to improve access to treatments and services for individuals with autism spectrum disorders.
The Senate Appropriations Subcommittee on Labor, Health and Human Services held a hearing addressing autism spectrum disorders on Tuesday, April 17. Chairman Harkin said autism is "out of control" in the U.S., adding, "We've got to do something." Ranking Minority member Sen. Arlen Specter (R-PA) indicated that NIH has not funded autism research at the same level as other conditions. To view the hearing and/or obtain copies of the testimonies check the subcommittee page at www.appropriations.senate.gov/labor.cfm.
Individuals who testified include
Studies Show Benefits Outweigh Risks of Antidepressants in Children and Adolescents
From an April 17 National Alliance on Mental Illness (NAMI) press release
Studies Support Monitored Use of Antidepressants for Children and Adolescents
Statement of Ken Duckworth, M.D.,
Medical Director, NAMI
Today, the Journal of the American Medical Association (JAMA) published a review of all major studies involving anti-depressants in children and adolescents by a team of researchers from Western Psychiatric Institute in Pittsburgh.
The review concludes that the benefits of antidepressant medications appear to be much greater than the risks. Specifically the review concludes, "Relative to placebo, antidepressants are efficacious for pediatric major depressive disorder (MDD), obsessive compulsive disorder (OCD), and non-OCD anxiety disorders, although the effects are strongest in non-OCD anxiety disorders, intermediate in OCD, and more modest in MDD. Benefits of antidepressants appear to be much greater than risks from suicide/suicide ideation attempts across indications."
The impact of the medicines was different depending on the child's age and their condition. It should be noted that there were no completed suicides in any study.
The newly published review surveyed all studies between 1998 and 2006, regulatory reports from the United States and Britain, and clinical trial registries.
The researchers were interested in further understanding the risks of the medicines in relation to reported suicidal thinking and attempts, as well as the possible benefits the compounds offered for anxiety disorders, obsessive compulsive disorder, and major depressive disorder.
There was no new clinical trial conducted-rather they did a meta-analysis of multiple studies already in print or unpublished but relevant with specific attention to this area of clinical import.
This review is useful to parents weighing the benefits and risks of antidepressants for a child who has active symptoms of anxiety, OCD or MDD.
The latest data states that over four million children and adolescents in this country struggle with a serious mental disorder that causes significant functional impairments at home, school, and with peers. In addition to understanding the risks and benefits of medication, there are many other factors important to child and adolescent mental health care, including a comprehensive evaluation, attention to a child's strengths, school and relationships, assessment of substance use, the role of family work and psychotherapy for the child, and monitoring needs when a child is placed on antidepressants.
Every child should have the benefit of a specifically tailored plan to address his or her needs
For a review of these relevant issues in the care of a child with adolescent depression, please see NAMI's Family Guide to Adolescent Depression available at www.nami.org/adolescentdepression.
New Associate Director of Medical Affairs Will Support SAMHSA's Center for Mental Health Services
Kenneth S. Thompson, MD, Associate Professor of Psychiatry and Public Health at the University of Pittsburgh and Western Psychiatric Institute and Clinic, recently joined the staff of the Center for Mental Health Services (CMHS) at the Substance Abuse and Mental Health Services Administration (SAMHSA) where he will serve as Associate Director of Medical Affairs.
In his new role as medical advisor to A. Kathryn Power, director of CMHS at SAMHSA, Dr. Thompson will provide comprehensive medical leadership in the diverse integrated planning, design and implementation actions that relate to CMHS programs and objectives. In addition to providing medical consultation and assistance to CMHS programs, he will monitor the application of relevant American Medical Association and American Psychiatric Association professional standards to CMHS policies and programs.
A native of Pittsburgh, Dr. Thompson has worked for the past 15 years as a community psychiatrist in a wide variety of settings, including a primary care clinic, an HIV clinic, a state hospital, several disaster response teams, a homeless outreach team, and a community mental health center. He held an assortment of administrative, clinical and teaching positions within these settings. Most recently he has worked with the Office of Mental Health and Substance Abuse Services in Pennsylvania, providing psychiatric consultation to the Harrisburg State Hospital closure process.
He has been a leader in the American Association of Community Psychiatrists and has been actively engaged in local, state and national efforts to support psychiatrists interested in public service, community mental health, and transformation of mental health services to support recovery. A community-engaged scholar and practitioner, he has served on the boards of numerous national and local professional and nonprofit organizations.
Dr. Thompson received his AB degree (Phi Beta Kappa) from Kenyon College in Gambier, Ohio, before working for a year as a mental health worker at Mclean Hospital in Belmont, Massachusetts. He then attended Boston University School of Medicine on a National Health Service Corps Scholarship, graduating in 1982.
Dr. Thompson is a recipient of the American Psychiatric Association's Bruno Lima Award for his work addressing the mental health aspects of disasters and a recipient of the Chancellor's Award for Public Service at the University of Pittsburgh. He is a fellow of the International Center for Health Leadership Development at the University of Illinois, Chicago.
From an April 5 press release
Funding Available For 16 Grants to Expand Substance Abuse Treatment Capacity in Targeted Areas of Need
SAMHSA is soliciting applications for grants to expand substance abuse treatment capacity in targeted areas of need. This program is designed to address gaps in substance abuse services for persons with alcohol and drug use disorders and help meet the demand for such services. By improving needed treatment services, this program is intended to help reduce the health and social costs of substance abuse and dependence to the public and increase the safety of America's citizens by reducing substance abuse related crime and violence.
It is expected that approximately $8 million will be available to fund up to 16 awards for up to three years. It is intended that these grants will result in the delivery of services as soon as possible after the award. The grants will be awarded by SAMHSA's Center for Substance Abuse Treatment.
WHO CAN APPLY: Eligible applicants are domestic public and private nonprofit organizations. Category 1 is restricted to federally recognized tribes, state-recognized tribes, urban Indian organizations, tribal organizations, and Asian American/Pacific Islanders, including Native Hawaiians. Category 2 (E-therapy), Category 3 (Grassroots Partnerships) and Category 4 (Other) are domestic public and private nonprofit entities, including state and local governments.
HOW TO APPLY:
Applications for No.TI-07-008 are available by calling SAMHSA's Clearinghouse at 1-877-SAMHSA7, or by downloading from www.samhsa.gov/grants/index.aspx or www.grants.gov. Applicants are encouraged to apply online using www.grants.gov.APPLICATION DUE DATE:
May 25, 2007ADDITIONAL INFORMATION:
Applicants with questions on program issues should contact Love Foster-Horton at 240-276-1653 or e-mail to love.foster-horton@samhsa.hhs.gov. For questions on grants management issues, contact Kimberly Pendleton at 240-276-1241 or e-mail kimberly.pendleton@samhsa.hhs.gov.From an April 11 SAMHSA press release.
SAMHSA to Fund 15 National Child Traumatic Stress Initiative Grants
SAMHSA is soliciting applications pending the availability of FY 2007 funds for two categories of grants under the National Child Traumatic Stress (NCTSI) Initiative. The NCTSI Initiative is composed of categories of centers designed to address child trauma issues by creating a national network of grantees who work collaboratively to develop and promote effective community practices for children and adolescents exposed to a wide array of traumatic events.
Treatment and Service Adaptation (TSA) Center grants, Category II under this initiative, will provide expertise on specific types of traumatic events, population groups and service systems as well as support the specialized adaptation of effective treatment and service approaches for communities across the country. Applicants may apply for the following TSA priority areas: Medical Trauma, Refugee Trauma, Family Treatment and Services Approaches to Trauma, Child Protective Service Settings and American Indian/Alaska Native. It is expected that approximately $3 million will be available to fund up to five awards for up to four years.
Community Treatment and Services (CTS) Center grants, Category III under the NCTS initiative, will implement and evaluate effective treatment and services in community settings and youth-serving service systems as well as collaborate with other network centers on clinical issues, service approaches, policy, financing and training issues. It is expected that approximately $4 million will be available to fund up to 10 awards for up to four years.
Both categories of grants under this initiative will be awarded by SAMHSA's Center for Mental Health Services.
WHO CAN APPLY: Eligible applicants for both categories of grants are domestic, private and public nonprofit entities.
HOW TO APPLY: Applications for No. SM -07-010 (TSA grants) and No. SM-07-011 (CTS grants) is available by calling SAMHSA's Clearinghouse at 1-877-SAMHSA7, or by downloading from www.samhsa.gov/grants/index.aspx or www.grants.gov. Applicants are encouraged to apply online using www.grants.gov
APPLICATION DUE DATE: May 15, 2007 for TSA grants and May 18, 2007 for CTS grants.
ADDITIONAL INFORMATION: Applicants with questions on program issues for the TSA grants should contact Malcolm Gordon at 240-276-1856 or malcolm.gordon@samhsa.hhs.gov. Applicants with questions on program issues for the CTS grants should contact Jean Plaschke at 240-276-1436 or jean.plaschke@samhsa.hhs.gov. For questions on grants management issues, contact Kimberly Pendleton at 240-276-1421 or kimberly.pendleton@samhsa.hhs.gov.
From an April 10 press release from the Agency for Healthcare Research and Quality
One in Four Hospital Patients Is Admitted With a Mental Health or Substance Abuse Disorder
Almost one-fourth of all stays in U.S. community hospitals for patients age 18 and older-7.6 million of nearly 32 million stays-involved depressive, bipolar, schizophrenia and other mental health disorders or substance use related disorders in 2004, according to a new report by HHS' Agency for Healthcare Research and Quality.
This study presents the first documentation of the full impact of mental health and substance abuse disorders on U.S. community hospitals. According to the report, about 1.9 million of the 7.6 million stays were for patients who were hospitalized primarily because of a mental health or substance abuse problem. In the other 5.7 million stays, patients were admitted for another condition but they also were diagnosed as having a mental health or substance abuse disorder.
Nearly two-thirds of costs were billed to the government: Medicare covered nearly half of the stays, and 18 percent were billed to Medicaid. Roughly 8 percent of the patients were uninsured. Private insurers were billed for the balance. The study also found that one of every three stays of uninsured patients was related to a mental health or substance abuse disorder.
"Community hospitals play an important role in the treatment of people with mental health and substance abuse disorders," said AHRQ Director Carolyn M. Clancy, M.D. "This report gives health care policymakers an in-depth look at the impact of mental health and substance abuse care on the health care system."
SAMHSA Administrator Terry Cline, Ph.D., said, "The significant number of hospital stays related to mental health and substance use disorders signals the need for an increased national effort to identify and intervene early before the conditions require a hospital stay. Too often because of social stigma or lack of understanding, individuals and health care providers don't recognize the signs or treat mental health or substance use disorders with the same urgency as other medical conditions."
AHRQ found that most patients with mental health and substance abuse disorders were older. For example, although people age 80 and older comprised only 5 percent of the U.S. population in 2004, they accounted for nearly 21 percent of all hospital stays for these conditions-principally for dementia. There were also gender differences. The most frequent admitting diagnosis for women was mood disorders, while that for men was substance abuse.
AHRQ also found that patients who have been diagnosed with both a mental health condition and a substance abuse disorder-those with "dual diagnoses"-accounted for 1 million of the nearly 8 million stays. Nearly half of these cases with dual diagnoses involved drug abuse, a third involved alcohol abuse, and one in five involved both drug and alcohol abuse.
In addition, 240,000 women hospitalized for childbirth or pregnancy also had mental health or substance abuse problems. Four of every 10 of these patients were between 18 and 24 years of age.
Suicide attempts accounted for nearly 179,000 hospital stays. Of these, 93 percent involved a mental health condition-most commonly mood disorders-and/or substance abuse. Nearly three-quarters of these patients were between ages 18 and 44 and more than half were women.
Poisoning, by overdosing prescription medicines or ingesting a toxic substance, was the most common way patients attempted suicide.
The report is based on 2004 data-the latest currently available-from AHRQ's Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a database of hospital inpatient stays that is nationally representative of all short-term, non-federal hospitals. The data are drawn from hospitals that comprise 90 percent of all discharges in the United States and include all patients, regardless of insurance type, as well as the uninsured. For details, go to Care of Adults with Mental Health and Substance Abuse Disorders in U.S. Community Hospitals, 2004 at http://www.ahrq.gov/data/hcup/factbk10/.
For more information, please contact AHRQ Public Affairs: (301) 427-1539 or (301) 427-1855.
Resources for Coping with Traumatic Events
Several behavioral health advocacy websites have posted resources that may be of use in response to traumatic events
SAMHSA resources for coping with traumatic events
SAMHSA's Coping with Traumatic Events has resources and links related to understanding mental illness, information clearinghouses, resources for responders and health professionals, and resources for students, schools, adults, and families. See www.samhsa.gov/trauma/index.aspx.
SAMHSA's Understanding Mental Illness - After the Virginia Tech Tragedy
This section of SAMHSA's website offers extensive information and resources, including information for survivors of traumatic events, information for parents and educators, tips for talking with children, an emergency response guide for public safety workers, information on alcohol and substance abuse indicators, information on dealing with grief, information about violence and mental illness, information about stigma, and information about recovery. See http://www.samhsa.gov/MentalHealth/understanding_Mentalllness.aspx.
National Alliance on Mental Illness (NAMI) Virginia Tech Tragedy: Responses and Resources
NAMI has assembled the following resources related to coping with trauma: links to NAMI on Campus, A Snapshot of College Mental Health Centers, Depression in the Dorms: What You Need to Know About Mental Health and College, and Policy Perspectives on Virginia Tech tragedy. See www.nami.org.
