February 2006 NACBHDD Newsletter
The Newsletter of the National Association of County Behavioral Health and Developmental Disability Directors
In this Issue...
The 2006 NACBHDD Newsletter series is brought to you by:
Medicaid Update: Spending Cut Bill Approved, Including $4.8 Billion From Medicaid
On February 1, the House passed a Budget Reconciliation bill that had a wide impact on the human services community and NACBHD members and those they serve. The spending cuts affect Medicaid, targeted case management, Temporary Assistance for Needy Families (TANF), and the Medicare Modernization Act Part D. NACBHD will be working with the Centers for Medicare and Medicaid Services (CMS) and other advocacy groups, such as the National Governors Association (NGA) to determine the exact impact of these cuts and how to best protect the most vulnerable populations. For a full description of the cuts detailed in the February 6 Washington Update, click here. In addition, the President presented his proposed 2007 budget earlier this week. Melissa Staats will inform the membership of important issues in this budget in a Washington Update.
More on NACBHD Medicaid advocacy efforts
In addition to ongoing work with other advocacy organizations and hopefully, with CMS, on Medicaid, NACBHD is also putting a high priority on other Medicaid advocacy activities at this critical time, including:
NACBHD White Paper on Medicaid Reform
NACBHD's Medicaid Committee has developed a white paper on Medicaid Reform and NACBHD's formal position on Medicaid. The paper and NACBHD's position on Medicaid are organized around the following principles:
To view the paper, click here.
NACBHD SAMHSA Grant-Completed
With a grant from the Substance Abuse and Mental Health Services Agency's Center for Mental Health Services (CMHS), and with support from the National Association of State Mental Health Program Directors (NASMPHD), the National Association of County Behavioral Health and Developmental Disability Directors (NACBHD) conducted a multi-purpose survey of county/city government and local authorities with responsibility for the management of behavioral health and developmental disability services.
What are the insights suggested by this report?
As the responses to the NACBHD survey were limited in number and respondents self selected, the results obtained cannot be regarded as generally representative of the character, circumstances or practices of county behavioral health agencies in the 23 states in which they have primary responsibility for service delivery. Moreover, the background information used to provide context to this presentation was selectively gathered for the purposes of illustration; it is not is the result of systematic comparative inquiry.
However and in addition to the insights above, one conclusion that clearly arises from this effort is that systematic gathering and analysis of the structural arrangements at the local level for the delivery of behavioral health services, and of the local financial commitment supporting these services, is needed if a full understanding of the strengths and weaknesses of the national service delivery system is to be properly understood.
Medicare Update: Mental Health Part D Web Site Tracking Significant Problems in Response to CMS Request for Documentation
Important dates. CMS is now auto-enrolling approximately six million dually eligible beneficiaries (those receiving both Medicare and Medicaid) into Medicare prescription drug plans. These new Medicare drug plans have replaced Medicaid as it is currently used by the dually eligible (and others) to support their access to medications. Because of problems ensuring that dually eligible enrollees get their medications, CMS has extended the transition period for these consumers to March 31, 2006. To view an update for state and local government officials from CMS sent to NACBHD members on January 12, click here.
NACBHD recently spoke with Karen Sanders M.S., the American Psychiatric Association's (APA) Associate Director for Publicly Funded Services about Mental Health Part D (www.mentalhealthpartd.org), a new web site that provides up-to-date information and resources related to Part D of the new Medicare law. (Several mental health advocacy organizations developed the site: the American Association of Community Psychiatrists, the American Association of Geriatric Psychiatry, the American Psychiatric Association, the National Association of State Mental Health Program Directors, the National Council for Community Behavioral Healthcare, and the Treatment Effectiveness Now, as well as NAMI and NMHA.) The groups involved, as well as NACBHD (Melissa Staats participates in routine calls with the groups), are working together to assess concerns and problems and relay them to CMS. For a full description of the site and what it offers, see the Early January 2006 newsletter.
Sanders provided an update on issues and problems that have come up since the new prescription coverage for dual eligibles began on January 1. The problems are significant and have had an impact; consumers and states are feeling the brunt of the challenges in the transition. Sanders noted that most major changes in Medicare take years, and that this transition has been attempted in a matter of months.
Access to medications. Sanders reported that the biggest problem so far is that those consumers in protected classes are not getting their drugs. (Protected classes include antipsychotics, antidepressants, anticonvulsants, anticancer drugs, immunosuppressants, and HIV/AIDS drugs.) Consumers are sometimes denied their medications when they go to the pharmacies, and then physicians are asked to go through the prior authorization process. While there is not an accurate estimate of the numbers of consumers involved, Sanders says it is "a rampant problem." She estimates the numbers are in the thousands.
Sanders reported that Sam Muszynski, J.D., Director, APA Office of Health Care Systems and Financing, is attending American Medical Association meetings regarding the transition. Other protected groups, such as consumers taking immunosuppressant drugs, are also having trouble getting their medication.
The organizations involved in Mental Health Part D, including NACBHD, want clarity on the transition policy, and what provisions there are to address this issue. Unless there is some safety issue, there should be no edits.
The increase in co-pays is also a concern. The co-pay used to be $1 or $3, depending on whether the medication was generic or brand. Many consumers are getting charged a lot more, in some instances as much as $400. Co-pay overcharges should be reported to CMS.
Plans are not adhering to regulations. When asked where exactly the problems may be, Sanders said that the plans are not adhering to the guidelines and rules for protected classes, and that at this point, CMS is not addressing this.
Emergency appeals processes are taking too long. Some consumers are being expedited into to the emergency appeal process, which should take place within 24 hours, but the emergency appeals processes are sometimes taking much longer.
The problem is widespread; the burden is on advocates to demonstrate a systemic problem. CMS has put the onus on advocacy groups to prove that there is a systemic problem, but the only organization that has the statistics is CMS. Sanders reports that the Mental Health Part D site is visited frequently, and that they wish they could put some sort of form on the front page to help consumers. NAMI was so swamped with calls in the first few days of the transition that they started a help line. The National Mental Health Association also has been fielding a lot of calls. If a consumer says they cannot get their medication, they should call their regional CMS or email them.
The administrative burden is significant, and can be repetitive. A case worker told Sanders that she spent five and a half hours on the phone to enroll patients, and then she had to reenroll them again because they did not show up in the system. A lot of data at the beginning of the transition was simply lost.
States are picking up costs; several states are suing CMS. About two dozen states are picking up costs incurred from the states taking emergency action to pay for medications consumers cannot get under the new plans, and there is a concern that the federal government will not reimburse them, but CMS issued a press release saying that they would. However, Sanders explained that the question of concern is, at whose rate?
California and other states are suing CMS over the flawed federal drug plan. For more information on this lawsuit, click here.
Consumer health is beginning to suffer. The impact of the problems on consumers with mental illness is now receiving attention in the media. For a recent interview with consumers and providers assisting them, see a February 6 article in The Washington Post. click here. For another overview of the impact of the new Medicare drug plan on consumers with mental illness (The New York Times, January 21), click here.
The situation is expected to get worse. Sanders noted that the situation is expected to get worse in the next few months as more people who had previously stockpiled medications need to purchase the medications under the new plan.
Next steps. Sanders noted that advocacy groups are concerned with focusing on:
Senate Special Committee on Aging Reviews Problems in Implementation. The Senate Special Committee on Aging met February 2 to discuss the problems in implementation. Consumers delivered statements at the hearing, and the American Psychiatric Association (APA) presented a statement that addressed issues of concern related to initial implementation problems, ensuring continuity of care, appeals rights, and administrative burden. Recommendations were included in the statement. To view the APA statement, click here. To view the consumer testimony, click here.
People on Medicare only may suffer setback in transition. Sanders mentioned another group of concern. There are people who are only on Medicare and do not qualify for any other help and could previously get their medications from state pharmacy assistance programs. They went from a minimal payment structure to Medicare Part D, with the deductible, the premium, and the co-pay, and many cannot afford it. This could be a huge setback for these consumers.
President's proposed 2007 budget is likely to contain cost reductions in Medicare. A February 5 article in The Washington Post reported that the President's 2007 budget proposal may contain cost-curbing measures for the Medicare program, including cutting automatic payment increases to hospitals and other providers, with $36 billion in savings by 2011 and $105 billion in savings in 10 years. (Amy Goldstein, The Washington Post, February 5, 2006). Melissa Staats will provide more information on this in the next Washington Update.
NACBHD Survey on MMA Part D Intended to Inform Congress and the Administration
On December 28, the NACBHD membership was sent an electronic notification regarding collecting information on the Medicare Modernization Act (MMA) Part D and its impact on dual eligibles. A simple six question survey is now available on the NACBHD web site, so that members may answer questions that will provide information and data helpful in promoting implementation and program changes, if and when they are needed. Other DC advocacy groups such as the National Alliance for the Mentally Ill, the National Mental Health Association, the National Association of State Mental Health Program Directors, and the American Psychiatric Association, are also gathering data about dual eligibles. The following link will direct users to the log-in page, where the MMA survey is listed: http://www.nacbhd.org/members//member_login.cfm.
Please note that the deadline for completing the survey is March 15, so that members have an opportunity to assess the initial impact of the implementation, which began January 1.
Other Medicare Modernization Act Resources
Update on the Campaign for Mental Health Reform
The Campaign for Mental Health Reform continues to actively work with national advocacy partners on critical issues, and is also involved in events to focus the agenda for 2006, and to recognize efforts in the mental health arena. The current emphasis is on:
December policy retreat focuses priorities for 2006
The December 1 policy retreat, attended by Campaign member executive directors and lead policy staff, provided a time for Campaign partners, including NACBHD, to focus on priorities for 2006. About thirty-five people came, including CEOs from the Campaign Steering Committee, which is composed of the Bazelon Center for Mental Health Law, the National Mental Health Association, the National Alliance for the Mentally Ill, and the National Association of State Mental Health Program Directors. Each organization made a presentation on public policy issues related to mental health to determine which ones the Campaign would consider priorities for 2006. Melissa Staats discussed Medicaid eligibility and individuals incarcerated in county jails. The group was strategic in their consideration of topics, emphasizing issues likely to gain political support and likely to make a difference, and the range of issues was broad - and included Medicaid, veterans' benefits, criminal justice, and housing. Medicaid was chosen as a priority for 2006. The group will reconvene soon, with the time depending on Congressional action, to determine Campaign strategy. The Campaign strongly considered veterans' mental health benefits, as well as other public policy benefits.
First Annual Awards Dinner for Leadership in Mental Health
The First Annual Awards Dinner for Leadership in Mental Health, scheduled for March 29, 2006, at the Washington, DC, Grand Hyatt, will honor members of Congress and others who have made mental health a national priority. Melissa Staats is a Dinner Co-Chair, along with other directors of Campaign partner organizations.
House Elects New Majority Leader
On February 2, the U.S. House of Representatives elected John A. Boehner (R-OH), 56, as the new majority leader. Boehner is characterized as a mainstream conservative who is able to work well with Democrats, and he is known as an opponent of "pork barrel" spending. (Reuters, February 2, http://today.reuters.com). For more information on Boehner, see a compilation of articles forwarded to D.C. advocates, including Melissa Staats, by Julio C Abreu, Senior Director, Government Affairs, the National Mental Health Association click here.
Legislative Conference: Mark Your Calendars for March 1, 2, and 3
Members are urged to mark their calendars for the NACBHD Annual Legislative Conference scheduled for March 1, 2, and 3 in Washington, DC. Registration and hotel information is available on the web site, and reservations can be made directly with the hotel. NACBHD will host a special panel of (former) state Medicaid, mental health and alcohol and substance abuse programs directors to talk about the future of Medicaid. NACBHD is hoping an end result will be the beginning of the development of a business model for transformation.
Please also note that Rep Patrick Kennedy (D-RI) will be addressing our members during our legislative reception on March 1.
ADHD Update
Anti-Psychiatric Groups Challenge Validity of ADHD, Other Diagnoses
NACBHD had the opportunity to speak with Clarke Ross, CEO of CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder) about anti-psychiatry groups and about an upcoming FDA meeting regarding medication to treat ADHD and cardiovascular risks.
New Anti-Psychiatry Membership Groups
Several new membership groups are devoted to anti-psychiatry efforts, including CHAADA, or Children and Adults Against Drugging America, (www.chaada.org) established in December 2005. The site has sections on ADHD, depression, bipolar, and PTSD. A membership of 51 is noted on the site, with no reference to a funding source. Two other web sites are cited as a reference for ADHD: Dr. Fred Baughman's www.adhdfraud.org, and a Scientology-related web site, www.ritalindeath.com. Dr. Baughman is the medical advisor for the Citizens Commission on Human Rights (CCHR), a group inspired by Scientology.
Ross warned that these new membership organizations are "another example of a sustained, well-financed campaign to discredit the mental health field." Ross pointed out that one can read the rhetoric on the CCHR web site (www.cchr.org), which emphasizes that ADHD and other disorders that came to prominence in the last century were created by psychiatrists and other mental health professionals, and that these mental health issues do not actually exist. Therefore, the professionals involved are frauds and medication is unnecessary.
Ross noted that another common strategy emerging in the anti-psychiatry campaign is the attempt to confuse the public with misinformation, particularly misinformation focused on childhood disorders. This is a particularly vulnerable area for attack since there is a natural concern about diagnosing children at a young age.
Although the anti-psychiatry campaign has now reached very public venues (the Internet, Tom Cruise's appearance on The Today Show, and congressional hearings), Ross explained that there are two reasons that national advocacy organizations such as CHADD and the Campaign for Mental Health Reform do not respond:
On the other hand, CHADD is recognized and financed by the Centers for Disease Control and Prevention (CDC) as the national resource center on ADHD, and CHADD responds to the need for information every day by providing science-based information as part of its mission.
While CHADD does not respond to the anti-psychiatry campaigns, Ross did point out that NACBHD and other advocacy organizations should be aware of and concerned that the anti-psychiatry campaign message has had an impact in Congress. In 2004 and 2005, floor amendments introduced by Rep. Ron Paul (R-TX) to prohibit mental health screening in any federally funded public health facility (including facilities with veterans, children, and adults) were defeated. However, it is important to recognize that around 90 members of Congress supported it. And, Ross mentioned the Child Medication Safety Act as another example of the anti-psychiatry movement's effectiveness in crafting legislation. Even though CHADD is not opposed to the general message of the act - that schools may not require children to be on medication to attend school - there is language in the act that is of concern. The way the language was crafted, no school staff is allowed to talk with families about their children's behavior. This, of course, can present an obstacle to critical communication between families and school staff. Mental health advocates were able to insert a clarification in the Individuals with Disabilities Education Act (IDEA) that this legislation would not interfere with parent-teacher communication.
FDA Committee Will Consider Approaches to Examining Cardiovascular Risks of ADHD Drugs
The Food and Drug Administration's (FDA) Drug Safety and Risk Management Advisory Committee met February 9 to examine ways to study whether ADHD medications increase the risk of cardiovascular events in adults and children. According to an announcement on the committee's home page (see the link below), the FDA has received reports of serious adverse events and sudden death, including hypertension, myocardial infarction, and stroke, associated with therapeutic doses of medications used to treat ADHD in adults and children. The few controlled clinical studies have yielded little information on the cardiovascular risk.
The current examination by the FDA is related to Canada's equivalent of the FDA removing Adderall from the Canadian market last year when fewer than a dozen cardiac-related deaths around the world in individuals taking Adderall occurred. None of the deaths occurred in Canada. There has been no analysis of any other medications these individuals were on, nor has there been any analysis of their physical conditions. Adderall was restored to the Canadian market within a few months.
Ross explained that although Ritalin has been on the market since 1954, there have been no long-term demographic studies on the effect of the ADHD stimulant medications. The February 9 meeting started to examine how to study the issue, and part of the FDA's examination will be to determine the statistical risk for such side effects as cardiac events, and to determine whether any cautionary designation, such as a black box warning, is warranted.
The public may attend the FDA Drug Safety and Risk Management Advisory Committee meetings. See www.fda.gov/oc/advisory/accalendar/2006/ for more information, or contact Victoria Ferretti-Aceto at (301) 827-7001 or at ferrettiV@cder.fda.gov.
Methamphetamine Update
NACo Meth Survey Yields Important Information
The National Association of Counties recently released two surveys on methamphetamine in U.S. counties, one on the effect of methamphetamine abuse on hospital emergency rooms, and one on the challenges of treating methamphetamine abuse. The survey attracted significant media attention. To view NACo's press release on the survey, click here.
Pat Fleming, Salt Lake County Division of Substance Abuse Services, NACBHD member and a member of the NACo Meth Task Force, says of the surveys and of NACo's approach to the meth crisis:
The NACo survey has really put Meth on the radar screen. I am just thrilled that Bill Hansell and Larry Naake have taken leadership on this issue and decided that this is an issue that is impacting county government and is going to impact in a big and negative way the whole country. The survey clearly points out that the medical system (as identified in the hospital portion of the survey) and the treatment systems around the country are being overwhelmed with Meth abusing patients.
NACo has proposed a multi-pronged approach (precursor drug control, international relationships with nations who produce Meth and border control, lab cleanup, prevention, child welfare and treatment) which is a sound way to deal with the Meth problem. We can't just punish our way out of this. I was especially pleased to see that NACo was supporting an increase in the Substance Abuse Prevention Treatment Block Grant (SAPT) to an even $2.0 billion for Meth treatment.
Fleming prepared a Power Point presentation for NACo's law enforcement committee and has shared it with NACBHD members. To view it, click here.
NACo has created a Meth Action Clearinghouse of methamphetamine information and resources. The surveys are available through the clearinghouse on NACo's web site. The clearinghouse can be accessed at: http://www.naco.org/.
Recovery Community Services Program: Advocacy Succeeds in Restoring Cuts
Pat Taylor, Executive Director of Faces and Voices of Recovery, talked with NACBHD about recent challenges to the Recovery Community Services Program (RCSP) and the successful campaign to keep the program going.
Cutting the program was being discussed in internal budget conversations at SAMHSA, but while no decision had been made, a letter writing campaign by advocates saved the program. Taylor credited this significant victory to the advocacy going on around the county and locally at the community level, emphasizing that there is more and more advocacy organization around recovery.
Taylor said they were shocked when there might be no funding for the program, and they have yet to learn why. It is the only federal program that funds peer-to-peer support for these types of programs. However, there was an extremely quick turn-around once the letter-writing campaign began - within 24 hours-on having the funding restored. Taylor believes it really indicates the strength and the capacity of the recovery community to speak with one voice. Faces and Voices' action alert to the network evoked hundreds of responses. People were able to send letters to Charles Curie, SAMHSA administrator, and to members of Congress. Taylor says this is indicative of the commitment of the recovery community and how technology can impact policy. Taylor felt that a statement from Representative Jim Ramstad (R-MN), represented the importance of the program: "As a co-chair of the Addiction, Treatment and Recovery Caucus, I'm pleased SAMHSA has preserved this critical program, which provides hope to millions of individuals who are living a sober life, free from the ravages of chemical addiction." (See the 1/20/06 press release.)
The RCSP program. According to the 1/20/06 press release from Faces and Voices, "The RCSP program complements, extends, and enhances the formal treatment provided by professionals. Peer services provide the community connectedness and social support that are so necessary to sustain recovery."
The program consists of seven to eight grants for up to four years each, with total funding of $2.5 million (approximately $350,000 each).
The request for proposals for RCSP was just announced by SAMHSA February 2. The deadline for applications is April 4. See http://www.grants.gov/search/ for the request for proposals. Or, to access the press release with information, click here. Also see the Faces and Voices press release.
Taylor explained that as we look more at developing a recovery-oriented system of care it is evident that there needs to be a recovery support system. It is important for NACBHD members to think where in their communities they could link consumers in recovery with support as they get on with their lives. In a lot of states, people are putting together recovery centers with jobs and peer-to-peer mentoring, which sustains recovery over the long-term. The goal of recovery is to deal with addiction and for those in recovery to "get on with their lives." Taylor gave examples of some RCSP programs:
In addition, Taylor cited some model recovery programs that are not funded by RCSP. They include:
Other Faces and Voices developments
As part of the budget reconciliation bill, people with prior drug convictions are now eligible for federal financial aid to attend technical school, community colleges and universities. NACBHD members can download a flyer for distribution which list contacts for further information click here.
Recovery Month 2006. In the near future, Faces and Voices will be putting together Recovery Month 2006, which is a recovery community empowerment project and involves voter registration, and the concept "I'm in recovery and I vote."
Language guide. A language guide for how to talk about recovery will be released in the Spring. It can be used by the recovery community in learning how to talk with the media. Language that works and language that does not work will be covered. The guide can also aid in discussions with policymakers, colleagues, friends, and neighbors. Information about the language guide will be available on the web site.
Media training. This will done so that the recovery community can gain experience talking with the media. There will be one session in the Midwest and one session in the West. Locations and dates will be announced on the web site.
Video project. Next week, Faces and Voices will release the video project, "The Power of Our Stories: Speaking Out for Addiction Recovery." It will be available on the web site through webstreaming or by purchasing a CD. There will be a 45-minute exercise portion to learn how to advocate and a workbook.
For information on the items above and for more information on Faces and Voices of Recovery, see www.facesandvoicesofrecovery.org.
NACBHD Members Can Now Quickly Query the Membership and Gain Insight
NACBHD members can now informally and easily gain insight from one another on important issues by simply passing on their question to the NACBHD staff at mstaats@nacbhd.org. Melissa Staats will distribute the question to the membership.
Annual Conference: "Transformation, Recovery, & Self-Determination" Conference Materials and Program Information Available
The NACBHD Annual Meeting took place October 20-22 in Portland, Oregon. The theme for this year's conference was "County/City Government and County-Sponsored Authorities Leading Transformation, Recovery, & Self-Determination." Consumers, county authorities, and staff from national advocacy organizations led discussions on issues critical for transformation to a recovery-based system. Information about the conference is now posted to the NACBHD web site.
