The 2010 Legislative session was an extremely active and difficult session.  While the primary goal was to pass a bonding bill for long-term projects, spending on health and human services came into sharp debate.  Looking back at everything that happened, what will be the impact on mental health services?

We see four areas of major importance.  GAMC was the big concern early and late in the session, and we expect more news to come soon.  For more detailed history on what happened, you can read our previous entries here.  Right now, letters are going out informing people that GAMC is changing and that they must select a hospital home for clinic care.  Otherwise, they will be restricted to emergency only treatment.  What we don’t know is how the proposed patient limits will affect this process, or how many previously eligible individuals will complete their paperwork.  We suspect that this will be a major barrier.  What we do know is that this is bad news for people living in outstate Minnesota.  The four hospitals that agreed to this plan are all in the Metro area.  People can still go to the ER, but only for emergency treatment.  We are working to find other resources for people who need assistance with obtaining medication or other non-emergency care, but the outlook is not great.

Guardianship law was one of the few “wins” we had this session.  You can read our summary here.  This change introduces a basic level of accountability for guardians and protects the rights of individuals to make long-term choices about their health care.  We believe that it is an important piece of working towards models of care that better involve and respect the person’s wishes.  In addition, it showed that we can still make important policy changes, as long as they do not require funding.

MA expansion was brought up several times in the session, and has an uncertain future, even though it is strongly favored by providers.  We view it as the best long-term solution to the GAMC issue and it is required to happen in 2014.  At the end of session, the final compromise budget did not include early expansion of MA, but authorizes the Governor to trigger entry at a later time.  Gov. Pawlenty has staked out a public position against federal health care reform and is unlikely to do so.  However, the next Governor may not be opposed or simply not have any choice to refuse so much federal money.  You can read about the candidates’ stances on MA expansion here.

Funding for basic mental health services came into jeopardy this session.  When the state invested an additional $34 M in spending in the mental health system in 2007, it was seen as a major move forward.  Yet, we are now seeing major cuts that will quickly dwarf that investment.  It’s hard to interpret this as anything but a step backwards.  Some of these cuts are set to expire in 2011, but we know that it will take a lot of political will in order to resist sustaining those cuts as the budget crisis deepens.  State Operated Services will be redesigned and face cuts, despite delaying the inevitable by refusing to follow legislative and community input.  MHAM is pleased to be included with other advocates and stakeholders in helping outline what SOS truly needs to deliver.  While the cuts will be significant here, we are hopeful that an intelligent redesign process will limit the impact on consumers.

As these conversations continue through the election season and into the next session, we think that the State needs to face facts about budget cuts.  We believe that many of these shifts and cuts do not really last.  Property taxes are up sharply as counties try to recover from reduced aid from the state, and cuts to low-income health care typically raise the rates for those with insurance.  Supportive housing, PCA services, drop-in centers, and other long term/lower intensity services have all been on the chopping block.  But hospitalization, crisis response, and police involvement are far more expensive.  When these services are cut, the trade-offs have both human and financial costs, and we will work hard to push back against the band-aid approach to budgeting in the state.

Working towards the next legislative session, a few things are going to be different.

• There will be many new faces.  We will have a new Governor, but we will also have many new legislators as well.  Many retirements were announced as the end of session, and many elections will be hotly contested.  We see this as an opportunity to educate and inform new lawmakers about why mental health services are important and can reduce long-term costs.
• The deficit will be larger.  The funding “shifts” for K-12 education will come due, one-time funding has been used up, and tax revenues are still lower than in previous years.  The new Governor and the Legislature will have difficult decisions to make about how to balance the budget.
• Lastly, we hope that more of you will join us in calling, writing, and staying involved.  We know that contact from constituents made a big difference in outcomes this session.  We will continue our outreach across the state to LAC groups and other communities, and we would love to hear from you about getting involved.

Mental health services in Minnesota unexpectedly lost ground today, as the House Health and Human Services Finance Division introduced their proposed budget. The bottom line is that the House is aiming to take more away from mental health services than the Governor.

We find it hard to believe that the same Legislators that worked so diligently to try to find some solution for GAMC would abandon the critical programs that help keep Minnesotans independent and prevent hospitalization or other high-cost crisis situations. This news requires our immediate and strong response. Please call your Representative immediately, and tell them what mental health services mean to you and what you think about these cuts:

• Supportive long-term housing is important because it provides stability and a chance to recover. It is the single most important priority we have for our community.
• Instead, State Operated Services hospital system escapes unscathed from cuts. This rewards them for ignoring the Legislature, and refusing to deliver the services that we need.
• ACT Teams help defuse crisis situations, and find treatment for those who need it most.
• Cuts to county mental health grants attack the backbone of mental health services in Minnesota, delivered in the communities where we live. They provide services such as clinics, case managers, and housing that help us recover.
• These cuts come on top of 9 million of reductions to mental health grants in the GAMC compromise bill above and beyond lost reimbursement for services. GAMC was redesigned by cannibalizing the mental health system. In total, these grants will have been cut by over a quarter.
• Mental health services stand alone in receiving additional cuts beyond what the Governor proposed. Nursing Homes and Disability services stand to retain 100 Million that would have been cut. Mental health services are valuable, too. We can’t be the only target.
• Ultimately, this is a revenue problem. The dismantling of successful programs that help save money in the long-term is not an appropriate response to a temporary and politically exacerbated revenue shortfall.
• Expanding Medical Assistance may be a positive part of extending services to those who can’t afford them, but other cuts to hospitals and providers will weaken the system at the same time we’re adding more patients.

Tom Johnson, one of our client advocates, puts it well. You can treat a disease, and that’s part of the solution. But you also have to believe in people, too.

These cuts hit the very services that help Minnesotans with mental illnesses believe in themselves again and find recovery. At the same time, this plan will overwhelm and erode the emergency safety net that is supposed to treat them when they need it most.

The House plan is unacceptable to our community. It represents more hospitalization, less management of our conditions, and more costs.

Please call today, and send this information on to anyone who wants better lives for Minnesotans with mental illnesses.

As the SOS redesign continues, we have had many opportunities to speak about what is important to mental health consumers in Minnesota. Our refrain has been: long term care and housing with supports. We believe that supportive environments, aimed at long-term stability is what consumers need from the system. This puts the focus on the client and their independence, while hopefully reducing the need for acute services. In particular, we are hoping to reverse direction, and restore funding for CADI Waivers, and other options that put Minnesotans with mental illnesses back into their communities, and provide them with the support to stay there successfully. As Executive Director Ed Eide stated in a recent Star Tribune article, the alternative has been to warehouse patients indefinitely in restrictive settings.

We strongly believe that this kind of focus is what needs to be at the heart of the redesign process. Preserving jobs and programs are important but the provision of quality services at an appropriate level is paramount. We are calling for many of the cuts to be reversed, but we’re also showing the need to get better results with that funding. We can only really talk about appropriate staffing once we know what services we need.

We have continued our conversations with policy makers in St. Paul as well as consumers and providers around the state, seeking to build consensus around what are the best options for positively transforming SOS. As the legislative process to decide what to do with SOS continues, we will continue to provide ideas and feedback.

Another recent development has been around the revised GAMC system. As you may remember, patients are being shifted towards hospital-based care organizations that would try to move care out of the Emergency Rooms and towards clinics and less intensive settings. However, recent roadblocks have come up. The House Heath Care and Human Services Finance Division heard testimony last Thursday that many rural hospitals would refuse to participate because they did not think they could set up services quickly enough or have enough of their costs covered. Now, HCMC has signaled that it will also decline to participate. As one of the largest providers of GAMC services in the state, HCMC has played a critical role in this program. It is hard to imagine a successful care plan for low income Minnesotans that does not involve them.

Under Federal Health Care Reform, the state has the option of covering single adults with up to 133% of poverty level income under Medical Assistance (Medicaid). There are some issues with this plan, namely timely implementation and fully understanding the costs until 2014 when that expansion will be required. However, as more hospitals refuse the GAMC compromise, this option may require a second look.

Sen. Linda Berglin announced a plan to slow and redirect the SOS redesign process. With a close eye to preserving some of the programs that were identified for elimination, she and other senators stated their intent to pass legislation requiring a different strategy from DHS and SOS. The group is mostly from the DFL, but some Republicans are joining in stating that the process must be slowed or changed. Jim Abeler (R-Anoka) noted that DHS has a tendency to answer to the Governor, and not sufficiently include direction from the Legislature.

Specifically, DHS failed to heed the Legislature’s requirement that they address the issues of lost federal money because of facilities not eligible for MA certification. Berglin stated: “They didn’t do it, so I’ve done it for them.” The plan would also preserve dental services within SOS, and seek to increase Federal billing in order to pay for the retention of services.

We still have concerns. The “PERTS” model of care is still being discussed, even though we have remarkably little information about how that will be different from successful models already in place.

The other concern is looking at what is driving these efforts. For SOS leadership, the primary concern seems to be in providing highly intensive and rapid services, and significant reductions in the budget. However, the truth of the matter is that most people receiving SOS services have long-term needs. For some of the legislators stepping up to slow the process, the concern is saving local jobs. We’re not unsympathetic to preserving jobs and keeping qualified providers in the mental health system. However, the primary driver here has to be the delivery of appropriate services to clients. After so many cuts in the last year, we need to get the absolute most services per dollar we can.

MHAM and other advocates are sending our counter proposal to the Legislature. We take these concerns, and try to show what a patient centered vision of SOS might look like. Please stay tuned as we move forward!

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.