By Brett Dumke, MHAM Education Coordinator

Who will develop the next generation of medications for mental illness? That was the question posed by the Director of the National Institute of Mental Health (NIMH), Dr. Thomas Insel, on a recent NIMH blog posting. Dr. Insel commented on the recent decision of two major pharmaceutical companies to terminate their psychiatric medication development programs and the likelihood of others to do so as well. If new drug innovation comes to a screeching halt, it will have a profound impact for individuals who have not responded well to medications that are currently available. In order to fill this void, the National Institutes of Health (NIH) and NIMH may have to play a key part in all phases of drug development in the coming years.  MHAM will continue to monitor this alarming trend and will provide updates when they develop.

We’ve all heard about health care reform passing in Congress and being signed into law.  We’ve also heard a lot of conflicting reports on what will happen.  The reality is going to be somewhere in the middle of the rhetoric. At MHAM, we see the following as the key impacts on mental health services in Minnesota:

• Expanded funding and eligibility for Medicare and Medicaid.  Right now, this may be one of the big impacts: as federal money comes into Minnesota, we need to make a strong case for why some of those dollars should stay in health care and human services, and help ease the cuts we have seen in the past biennium.  As we’ve noted, DFL leaders in Minnesota are very optimistic about the state’s ability to conform to new standards for treatment of chronic illnesses, including mental health and concurrent conditions.  This may also help ease the continuing GAMC crisis, by moving more of that population onto federal programs.

• Moving towards more parity for mental health.  While the authors  clearly intended to end specific exclusions of illnesses and expand coverage of pre-existing conditions, insurance companies announced attempts to find alternate ways of denying coverage. The Administration pushed back, and the insurance companies have retreated on these claims.  We will be alert to future conflicts over the intent of the legislation: fighting enhanced coverage for children with serious conditions is widely unpopular, but other provisions may not attract such immediate condemnation.

• Broadens requirements for coverage of preventive health care.  Insurance companies will be required to fully cover (with no co-pay or deductible) services that are shown to be effective in improving public health. Currently, this would include screening for depression in many circumstances.

• Extends coverage under group plans to age 26.  Children can stay on their parent’s health plans until age 26.  For many young people, especially in a slow job market, it has been difficult to maintain health insurance.  While these are relatively healthy years for most people, it is also an age when mental health conditions may emerge or require treatment.

• Prohibits rescission.  Rescission is the practice of ending a health care policy retroactively when large claims are made on the basis that the person did not correctly apply for the policy, even if it has been a long time since coverage started.  If a person gets very sick, some insurance companies will review their application, searching for any mistakes.  While it is important that people are honest and pay in fairly for their coverage, this practice exemplified the lack of power individuals had when seeking health care.  This is also a critical reform for anyone who may encounter a period of higher claims, such as inpatient hospitalization or intensive services for mental illnesses.

These bills are quite complex, and as we’re already seeing, may have effects different than President Obama intended.  The debate has been extremely contentious, and companies with their profits at risk are not going to simply back down.  It is important for mental health advocates to continue to be visible in the ongoing debate about how health care reform is going to work. For instance, Medicaid is being expanded, but it will take action by the state to make sure that there are workers available for the program that assesses applicants for eligibility. MHAM will work to make sure the promise of these changes is not lost for Minnesotans with mental illnesses.

For more information, you may want to attend (or listen to the online audio) of the Minnesota Senate Health and Human Services Budget Division on April 8th.  Sen. Linda Berglin is holding a meeting focused on the effects of these bills on the state.

As we’ve talked about previously, General Assistance Medical Care (GAMC) is changing dramatically this year.  This Friday, Governor Pawlenty signed SF 460 into law.  The state will pay hospitals, beginning in June, through block grant payments, for services to their GAMC patients.  The largest providers of services to GAMC patients, 17 hospitals, will become Coordinated Care Organizations (CCO).   Hospitals that served fewer GAMC patients will be able to receive funding, for six months, from an uncompensated care pool and will be able to later become a CCO.  They will be responsible for the entire health of the patients and some care will be delivered through clinics not the emergency department.

These payments to hospitals will be significantly less than they have been in the past, but do alleviate some of the uncompensated care costs they would have suffered under the Governor’s plan to auto-enroll GAMC patients into MNCare.  This bill also keeps the Health Care Access Fund intact.  Drug coverage will also be maintained for recipients, the majority of whom are mentally ill or suffer from chronic diseases and depend upon prescriptions to manage their illnesses.

While this solution is better than nothing, we are going to be working hard to identify opportunities in the recently passed federal health care reform bills for better models of care.

The compromise has preserved benefits though May, although current enrollees should expect a letter from the state that explains a timeline for benefit changes.  Prospective patients should apply through their county, and they will be directed to programs for which they are eligible.  More information can be found on the MN DHS website.

MHAM is relieved to see signs of progress after many setbacks.  Thank you to everyone who contacted their legislators and got involved: public pressure helps make sure that things get done right.

General Assistance Medical Care (GAMC) has passed both the House and Senate.  Given the Governor’s prior support of this plan, we expect it to be signed into law shortly before the plan is set to expire at the end of the month.  While we continue to have serious concerns about the effect of cuts to county mental health grants, we are thankful that some organized system of care will be available to those who have relied on GAMC.

Federal Health Care Reform appears to be moving forward, with the main bill signed and the addendum bill on its way.  Rep. Tom Huntley, chair of the House Health Care and Human Services Finance Division has noted that Minnesota is in good shape to capture additional federal dollars for Medical Assistance patients with chronic conditions (including mental illnesses).  While details are still coming out about the exact budget impact, we hope that as the pressure on the state is eased, some of the cuts to mental health services will be reconsidered.  Health Care Reform will have many other effects on our community, especially in terms of the availability of coverage.  We will post more here in the coming days.

Finally, the debate over State Operated Services continues.  There are no clear resolutions yet, but preliminary negotiations are underway to save some facilities by transferring operation to private companies or counties.  Your voices are still needed in making sure that the final redesign will reflect the needs of consumers. Our goals remain focused on ensuring the availability of appropriate services, transparency in how SOS is run, and the minimization of the state as a direct provider.  We have heard about many challenges and difficulties in the current system.  This is all the more reason that when we redesign SOS, we get it right.

Keep calling, writing, and staying involved…

Executive Director Ed Eide has been traveling the state, talking with LAC groups about how they can be a part of improving mental health services in Minnesota.

One of the question he’s been hearing a lot is: What will happen to services in the SOS redesign? He’s taken what he’s heard from LAC meetings in Hennepin, Dakota, Watonwan and Sherburne counties and other consumers and made sure you are being heard at the Capitol.

SOS is just one part of the picture for mental health services, but it represents the challenges we face.  Cuts are being made without transparency or consumer support.  We don’t have a lot of faith that the new SOS system will function better for patients.

Listen to Ed’s testimony here: look for the meeting of the Finance Health and Human Services Budget Division on March 23rd.  He testifies first at the beginning of the meeting.

Ed will be heading to Faribault tomorrow to work with the Rice County LAC meeting.  To learn how MHAM can help your LAC group become a better place for consumers to be heard, or if you have a personal story about SOS that would help the Legislature understand what is at stake in the redesign, please call Ed at 612-331-1630.  We’ll have more updates after he appears before the Health Care and Human Services Policy and Oversight Committee in the House on Thursday.

This was the question Sen. Sheran asked yesterday at the SOS presentation on their redesign.  The Department of Human Services (DHS) released its report and presented at Tuesdays Senate hearings in regard to their redesign of State Operated Services (SOS). The following are key changes to take place over the next fifteen months:

• Level 1 psychiatric care centers in each region of the state. These centers will provide the highest level of care for individuals with the greatest acuity and complexity and will involve 24 hours of staffed psychiatric coverage such as that now provided by Hennepin County Medical Center, Regions Hospital and the University of Minnesota Medical Center-Fairview, in the metro region. Level 2 inpatient psychiatric care centers, which provide a lower level of care, and Psychiatric Extensive Recovery Treatment Services (PERTS) will also be developed.
• A new 24-hour psychiatric access service. This service will provide consultation to emergency departments, primary care clinics, mobile crisis teams, jails and other mental health providers. Comprehensive assessments, triage services and referrals to appropriate levels of care will be provided. The access service will also include a new psychiatric emergency transportation system to be developed in consultation with consumers, family members, advocates, law enforcement, providers and other stakeholders.
• A partnership process to involve service providers. Through this process, hospitals, mental health centers, primary care centers and state-operated facilities in regions of Minnesota can collaborate to respond to state requests for proposals for Level 1 and 2 psychiatric care services and PERTS appropriate to the needs of their areas.
• Permanent closure of the Community Behavioral Health Hospital-Cold Spring, which has not been operating since October 2009.
• Closure of the 10-bed Mankato Crisis Center, with those crisis services transferred to nearby Community Behavioral Health Hospital-St. Peter.
• Closure of the state-operated adult mental health residential facility in Eveleth, to be replaced by a new adult therapeutic transitional foster care facility in northeastern Minnesota.
• Replace community transition beds with a new adult therapeutic transitional foster care facility in northeastern Minnesota in order to close the state-operated adult mental health recovery facility in Eveleth.
• Transition of state-operated dental services for people with disabilities to another model of service partnered with community providers.
• Transition of one unit at Anoka-Metro Regional Treatment Center to a state-operated psychiatric nursing facility in St. Peter. A partnership process would be started for operation of the remaining units at the Anoka facility.
• Launch of the psychiatric access service to replace the current centralized admission process to State Operated Services facilities. And establish a 24 hour psychiatric access service.
• Temporary conversion of community behavioral health hospitals in Willmar and Wadena to Psychiatric Extensive Recovery Treatment Services (PERTS). Regional stakeholders would be asked to partner to respond to a request for proposals for psychiatric facilities with levels of care matching the region’s needs.
• Conversion of Minnesota Neurorehabilitation Services in Brainerd to a 16-bed neurocognitive psychiatric extensive recovery treatment facility and additional adult therapeutic transitional foster care facilities.
• Conversion of Minnesota Extended Treatment Options in Cambridge to a 16-bed neurocognitive psychiatric extensive recovery treatment facility and additional adult therapeutic transitional foster care facilities.
• Conversion of Child and Adolescent Behavioral Health Services in Willmar to two child and adolescent psychiatric extensive recovery treatment facilities in Willmar and Bemidji.

Some questions needing to be answered about this redesign:

• When the Mental Health Initiative passed in 2007, it was the largest investment of new dollars into Minnesota’s mental health system in our history – $34 million. How can we cut half of that money and not have a negative impact?
• What are Psychiatric Extensive Recovery Treatment Services (PERTS)? Who will be using them? How will they be different than IRTS?
• Where is $17million in cuts actually coming from? • Where is the actual substance of the plan and when will we see it?
• What are the consequences and outcomes of this plan? How will it be evaluated?
• Where is the money for the new level 1 hospitals, PERTS and transportation coming from?
• Where are details on the Anoka redesign?
• How will this benefit people with mental illness?
• Where are the five regions and who will decide?
• What are the impacts of layoffs?
• What was the timeline on the decision to close and reorganize facilities?
• How does this plan fit with the needs, priorities, and goals of the community?
• How can we make this massive transition in 15 months?
• Where is the actual transformation?
• How does this relate to the intensive needs report?
• How will the 24 hour psychiatric services function?

There were many questions from members of the committee and I’m sure more to come on Friday March 19th when the presentation continues in Sen. Berglin’s committee.

That appears to be the question asked this past week at the Legislature.  In order to provide health care to the poorest Minnesotan’s, hospitals will have to develop a Coordinated Care Organization (CCO) for their GAMC patients.  GAMC recipients will have to learn to go to clinics instead of the emergency room.  Their health care will be “coordinated” in order to improve their health.  Can this system of health care work well with the homeless population once the new program begins in June?

There will be two levels of hospitals in this bill.  Level one are those who currently serve a substantial number of GAMC patients (approximately 17).  These hospitals will receive a lump sum reimbursement determined by the hospital’s recent share of GAMC business.  Currently level one hospitals serve 80 % of the GAMC patients.

The second level serves the other 20%.  They would receive funding for serving GAMC patients through an uncompensated care pool of $20 million for six months (June to November 2010) and then could become a CCO.

There are some positives with this new plan:

• Current GAMC recipients will be automatically eligible with no transition.
• It preserves access and affordability of prescription drugs.
• It preserves the Health Care Access Fund (HCFA).

Here are some questions and concerns to be alert to:

• What are the type of services to be offered?
• Will they be different depending on the CCO?
• Will hospitals opt in or out?

Part of the funding is taken from the Adult Mental Health grants to counties.  What services at the county level will be cut or eliminated? MHAM’s view of the GAMC funding bill is that it maintains a level of health care for our poorest Minnesotans.  But what will be lost in other mental health services provided at the local level with the shifting of dollars throughout the system?

State Operated System (SOS) Redesign

DHS has released their SOS redesign.  Here are some brief highlights:

• There will be Level 1 psychiatric care centers in regions of the state.
• There will be a new 24 hour psychiatric access service
• There will be a partnership process to involve service providers.
• Closure of the Mankato Crisis Center and transfer to St. Peter.
• Closure of the adult mental health residential facility in Eveleth.
• The development of Psychiatric Extensive Recovery Treatment Services (PERTS).

As we mentioned before, there is more to information to come and many more questions.  We will provide additional information on Wed. March 17^th following a presentation at Sen. Berglin’s committee Tuesday morning.

As many of you know, State Operated Services has been up for redesign.  In our 2010 Legislative report, the Mental Health Legislative Network asked that whatever plan came out of that process be judged on how well it reflected the input of consumers and advocates.  We believe that the people who are most affected by services changes and cuts are the people who are currently using those services.

Now that the report is out, we are greatly disappointed.  We were aware that with the budget cut, SOS was going to reduce services and we had made some recommendations as to what we thought could be done.  However, the deeper issue is that we have noticed community input is going unheard.  We came to the table in good faith, participating in the community listening sessions held around the state.  But we do not see that reflected in these changes.  As it stands, it appears that the proposal leads us to more restrictive settings and services  and away from community based models.  Recovery is spoken of as a goal, but the spending looks like confinement and triage.

We will be asking tough questions about how this proposal was formed, and why it looks so different from the trajectory we have been on towards more independence and crisis management, instead of bringing back a state hospital system.

Similarly, a deal for GAMC was announced last Friday.  The text of the bill was not released until Wednesday night, and many things had changed by then.  For one, Adult Mental Health grants were back in the bill as a funding source.  We strongly oppose reductions in these services as a funding mechanism for other programs, but are not optimistic.  These grants have already been reduced by unallotment and may see further reductions in the omnibus budget.

We are not pleased with many aspects of this bill.  There is significant concern that this new model of care will not be ready by June 1, and that is largely unproven for this population.

This has become the session of bad negotiation.  There appears to be a great deal of horse trading going on, but the consistent factors have been an unwillingness to consider revenue, repeated cuts to critical services, and the direction of these cuts coming from the Governor and DHS alone.

Right now, MHAM is going back out to the community, and especially to Local Advisory Councils and talking about what services are most important and how these changes may affect people.  We hope to mobilize and inform more consumers so that they can be at the table when these deals are made.  It’s critical that we start now, even against these headwinds.  Grassroots take time to grow, and we will continue working with our fellow advocates and consumers at the Capitol, trying to be heard.

Last Friday, a new proposed solution to GAMC was unveiled.  Legislators from both parties and the Governor held a joint press conference, signaling that the long standing conflict over this program may be coming to an end.

The proposed solution is a block grant to hospitals that had high GAMC patient populations.  This money would go towards what would otherwise be uncompensated care.  Details on which providers would receive funding have not been fully released.  As Sen. Berglin noted, this plan still places a high burden on the health care system, and these costs will come back to anyone who pays for medical care in the state.

There are many questions left unanswered at this point.  We are still looking at what services these hospitals will be accountable for delivering, and what the impact will be of removing the direct link between funding and individual need.  However, we are relieved to see some forward progress on this issue, and commend the legislators who worked so hard to make a solution possible.  We are also pleased to see that the funding source been shifted towards the general fund.  Previous proposals had tapped county funding that provides critical social and health services.

The Senate Health and Human Services Budget Division will hear testimony on this plan tomorrow at 9 AM.

Please check back as we get more specifics on this bill and how it will impact Minnesotans with mental illnesses.

Sadly, a vote to override the Governor’s veto of GAMC restoration has failed in the house.  While 38 Republican members joined the DFL in voting for the bill originally, none were willing to vote for override.

While we are disappointed not to see a solution for GAMC, we are hopeful that this action will send people back to the drawing board to come up with a new plan.  The important thing to remember is that while partisan issues that bogged down this particular solution, there is broad recognition that there needs to be some kind of fix.  Consumers, hospital groups, county representatives, and legislators all know that we need some mechanism to provide and pay for critical care for the poor.

In Executive Director Ed Eide’s testimony to the Health and Human Services Committee of the MN Senate, he explained how uncompensated care functions as a tax on everyone who gets medical care in the state.  Hospitals and clinics must make up the cost of uncompensated care, and will do so with patient dollars.  The question is how fairly will we distribute this cost.  There is some indication that the compromise would be a managed care proposal, not a fee-for-service model.  We believe it is important to remember that while some GAMC recipients have chronic care issues that require frequent care, many are visiting emergency rooms only when their condition has substantially deteriorated.

We know by the number of unclaimed notification of coverage letters that the state has been making payments for managed care that homeless recipients were not benefiting from.  We encourage lawmakers to carefully consider the varying needs of GAMC recipients to understand what models of care will work best to reduce costs.

Thank you to everyone who contacted their legislators on this important issue.  We will continue to watch for new proposals, and speak out for those who rely on this safety net.