This week Morning Zen features a review of the eighteenth annual Rosalynn Carter Georgia Mental Health Forum by CMHNetwork Advisory Council member Brigitte Manteuffel. To say that the forum had some wow power would be an understatement. The release of the CDC report on children's mental health and the surprise visit by Patrick Kennedy were only two of the many quality-laden occurrences at the meeting. Here is Brigitte's synopsis of events:
Stigma reduction – changing laws and policies, and hearts and minds – Watch for the national dialogue on mental health later this year. This dialogue, requested by President Obama, is led by HHS Secretary Kathleen Sebelius and Secretary of Education Arne Duncan. SAMHSA and the Department of Education are working together on launching the national dialogue. Participate in the dialogue in your communities!
Early identification, screening and intervention – catching symptoms and illnesses early is key to a better service system.
Need for data to understand need for services, and to plan, monitor outcomes and revise interventions.
ACA and parity provide opportunities for prevention, increased access to care, increased mental health care, detection and treatment.
Good mental health is essential to overall health CDC Director Dr. Thomas Frieden’s keynote and dialogue with Carter Center Mental Health Program Director, Thomas Borneman, provided context for the report and future directions. Dr. Frieden emphasized the critical need for early identification, intervention, treatment and prevention to reduce disease burden; integration of behavioral health and physical health; increased awareness and dialogue on mental health; and the importance of data.
Mental health rises to the top of disease burden, yet only half of those with mental health concerns are recognized, and only half of those recognized are adequately treated.
Bring mental illness into physical health perception. All practitioners need to address mental health; mental health providers need to be aware of physical health.
Increase awareness. Mainstream attention to mental health. Mental health problems are common and treatable and affect everyone.
National dialogue. Dialogue on mental health is needed at multiple levels, not just the policy level. Parents need to talk to their pediatricians about issues. Teens need to talk to adults and peers. Health professionals need greater awareness and understanding.
Early Intervention. Resilience can be increased by early identification and intervention.
Data are transformational. Surveillance provides for the systematic collection of information and dissemination to populations that need the information. Surveillance provides an objective measure that can be used to plan, to assess whether programs are working or not, and to defend programs that work.
3 key areas for prevention were identified:
Importance of early childhood experiences. Patterns are set early and are hard to undo. Promote healthy development in children so that all children can reach their full potential.
Reduction in alcohol use by mothers, families and teens would have a major impact.
Physical activity is the closest thing we have to a wonder drug for prevention of disease, including depression.
True to the focus on Georgia in this annual forum, a panel of experts led by CDC’s Ruth Perou, who facilitated the preparation of the report, provided comparison of the national statistics to Georgia’s and shared use of data at CDC and in Georgia to improve children’s mental health services in the community, to improve school climate (Check out the Georgia Student Health Survey II and report), and to address cultural and linguistic competence (CETPA). Congratulations, Ruth and colleagues for providing us with a useful resource to better understand child and adolescent mental health and to work to improve services. . The report provides a rich resource for asking questions about children’s mental health statistics. Questions such as, “Why is ADHD the most common diagnosis?” and “What are more mental health problems observed among boys?” and “What do these data tell us about the mental health service needs of diverse populations?” and “What else do we need to know to understand these statistics?”
Former Representative Patrick Kennedy made a “mystery guest” appearance at lunchtime. Demonstrating his commitment to stigma elimination, Kennedy introduced himself as in recovery from substance abuse and mental illness. A staunch supporter of health care reform, Kennedy urged meeting attendees to assure that providers not take the place of consumers in the debates surrounding implementation of the Mental Health Parity and Addiction Equity Act with the implementation of the Affordable Care Act (ACA). ACA provides the opportunity to rewrite the rules of health care and patients need to be number one as States implement.
Implementation of the Georgia Department of Justice Settlement Agreement is underway. Kudos to Georgia’s Behavioral Health and Developmental Disabilities Commissioner, Frank Berry, for recognizing the broader opportunity for systems change provided by the settlement agreement.
The Carter Center’s Mental Health Program is looking toward future programming in child and adolescent mental health services.
Noteworthy reports for Network faithful to check out
Note: The 29th Rosalyn Carter Symposium on Mental Health Policy on November 7 & 8, 2013 will focus on the Affordable Care Act. More details on this as they emerge.
Brigitte Manteuffel, PhD, brings to the Children's Mental Health Network's Advisory Board extensive expertise in children's mental health services research. As the former principal investigator for the national evaluation of the Children's Mental Health Initiative (CMHI) at the Substance Abuse and Mental Health Services Administration (SAMHSA), over the past 14 years she examined the implementation and outcomes of systems of care in over 150 communities at the State, county, city, and tribal levels. Before her work with the CMHI national evaluation, Dr. Manteuffel conducted studies at Emory University's Rollins School of Public Health and Nell Hodgson Woodruff School of Nursing on HIV prevention among youth and young adults, fatigue and cancer stressors in children, epilepsy self management, and the alleviation of nausea in pregnancy. She has contributed to studies of youth suicide and violence prevention, child traumatic stress treatment, motivational interviewing to reduce risk of fetal alcohol spectrum disorders, and HIV prevention and treatment costs and outcomes. Her projects in the US and Africa have been funded by NIMH, CDC, ASPE, the World Bank, and the UK Department for International Development. Dr. Manteuffel received her doctorate from Emory University's Graduate Institute of the Liberal Arts where she focused her studies on depth psychology, anthropology and semiotics to examine the role of hypnotic states in healing. In addition to over 50 publications and over 100 presentations, she has contributed to over 150 briefs and reports, including annual reports to Congress and Children's Mental Health Awareness Day Brief Reports. In 2012, Dr. Manteuffel was one of two recipients of the Outstanding Community Partner Award given by the Department of Child and Family Studies at the University of South Florida. Dr. Manteuffel is committed to improving the access, quality, evidence base, and cost efficiency of health services, especially mental health and substance use services for children, youth and young adults.
There has been much buzz lately about an article that was recently published in the New England Journal of Medicine on the impact of the "The Oregon Experiment — Effects of Medicaid on Clinical Outcomes" study. Okay, real quick, here is the gist of the study:
In 2008 Oregon had enough funding to open up its Medicaid program to 10,000 people. But a whole lot more wanted in. What to do? Hold a lottery to determine who got in and who didn't.
The seeds for a study were born. Sad situation but a great opportunity to assess the effectiveness of the program. Medicaid expansion in Oregon based on lottery drawings from a waiting list provided an opportunity to evaluate these effects.
The study published in the New England Journal of Medicine showed that expanding Medicaid coverage to some low-income Oregon residents substantially improved their mental health and reduced financial strains on them, but it didn’t significantly boost their physical health.
And this is where opinion on what this means for Medicaid expansion diverges. Those against Medicaid expansion and the ACA in general seize on the lack of dramatic significance on changes in physical health.
New York Times economics reporter Annie Lowrey pointed out in a blog post that this latest paper is far from a comprehensive evaluation of the expansion as the study subjects had only been enrolled in Medicaid for two years at most.
However, it is important to step back a bit and look at the results of the study closely and hone in on some very significant positive findings:
People on Medicaid ended up with significantly better mental health: The rate of depression among Medicaid beneficiaries was 30 percent lower than the rate of depression among people who remained uninsured. This is huge. Depression is the number one cause of loss of work worldwide. Better mental health leads to a wide range of positive impacts, not to mention fiscal impacts. If I feel better about myself I am more likely to contribute to my community, maintain employment, be a productive citizen and reduce the costs mental health challenges impose on a community.
Medicaid significantly increased the probability of being diagnosed with diabetes (after the lottery) and use of diabetes medication. In addition, the study saw an increase in the use of preventive care. Both of these findings have significant long-term cost savings implications.
Jonathan Cohn, in The New Republic, provides the following points worthy of consideration:
The glass-half-empty version of that argument is that government will never get health care right, making the whole Medicaid exercise pointless. This is what many conservatives believe. But Medicaid clearly delivered other benefits for the enrolled Oregonians, starting with mental health. The presence of large improvements in mental health were just as surprising to the researchers as the lack of large improvements in physical health. Better mental health might be partly the result of a placebo effect, or the fact that people who don’t worry about medical bills have one less reason to be depressed. Whatever the reason, it's still "a big deal," as Adrianna McIntyre wrote at the blog Project Milennial. Not only might better mental health save some money, given the costs to society of lost productivity and activity. It should also save lives.
The findings on financial security were just as significant. Medicaid effectively wiped out catastrophic medical expenses among the poor—and improved financial security in other ways. Obamacare critics have ignored or dismissed this finding, saying that financial security wasn’t a primary reason for health care reform. I suggest they go back and read the speech that Harry Truman gave in 1948, or the one Lyndon Johnson gave in 1965, or the one Bill Clinton gave in 1993, or the one President Obama gave in 2009. Financial security—specifically, the need to protect Americans from crushing medical bills—is the dominant theme in each of those speeches.
And finally, “Medicaid virtually eliminated out-of-pocket catastrophic medical expenditures and reduced the probability of having to borrow money or skip paying other bills because of medical expenses by more than 50 percent,” the Oregon Health Study Group wrote on its website. “The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses."
You can read the synopsis of the NEJ article - The Oregon Experiment — Effects of Medicaid on Clinical Outcomes - here.
Visit the Oregon Health Study Group website for more information. The Oregon Health Insurance Experiment is a landmark, randomized study of the effect of expanding public health insurance on the health care use, health outcomes, financial strain, and well-being of low-income adults.
Okay Network faithful, read the articles and weigh in. It is important to look beyond the headlines and make informed decisions about Medicaid expansion. For those committed to improving mental health for children, youth and families, these preliminary results after two years of study are encouraging.
Scott Bryant-Comstock President & CEO Children's Mental Health Network
A remarkable development took place on Tuesday at the SAMHSA National Children's Mental Health Awareness Day kickoff. The Centers for Medicare and Medicaid Services (CMS), along with the Substance Abuse and Mental Health Services Administration (SAMHSA), issued a Medicaid bulletin to states regarding "their options for structuring mental health benefits as part of an agency-wide effort to draw attention to behavioral health services." The bulletin "encourages states to design benefits that allow many young patients with mental health needs to live at home and get services in the community rather than be institutionalized."
This is really important Network faithful, and here is why:
This groundbreaking document identifies the critical importance of incorporating home and community based services into benefit designs specifically to support young people with significant mental health needs and their families. Such services include:
Intensive Care Coordination (Wraparound);
Family and youth peer support services;
Intensive in-home services;
Mobile crisis response and stabilization; and
Each of these services is described in the Bulletin, along with financing strategies. The report notes that "States have significant flexibilities in the Medicaid program to cover mental health and substance use services for youth with significant mental health conditions. CMS staff are available to states to further discuss how they can use the authorities below to promote better coverage." (Our bold emphasis)
Let’s let this sink in for a moment For those of you reading this who have been involved with the Child Mental Health Initiative you know how important this document is. In the over 25 years I have been involved with this movement there has always been a brutal conundrum facing those trying to implement a system of care approach to improving services and supports for children, youth and families – how the heck do you pay for what has been shown to work once the demonstration grant ends? Sustainability of “proven” effective service delivery approaches unfortunately often falls just outside of what is considered Medicaid billable – hence the conundrum and the often predictable slide towards “usual care,” a term coined by Garland, et al. in a recent journal article titled Improving Community-Based Mental Health Care for Children: Translating Knowledge into Action (see our review here). The journal article lays out some sobering statistics regarding quality in traditional mental health services. They note that 68% of the care in the studies reviewed was clinic based. A sobering reminder of how fragile our current mental health services are is the finding that “a third of the directors with site-specific budget data indicated that their agency ran at a budget deficit.” This is so important for advocates to understand. For us, “what works” goes far beyond usual care. It involves the active participation of community groups and families and the use of services and supports like those mentioned in the joint bulletin released on Tuesday. If we allow policy makers to just fund what we do now, (i.e., usual care) then we are doomed to a mediocre at best mental health service delivery system. We need a system that evaluates and supports services beyond usual care if we are going to make significant improvements. This bulletin is a huge step in helping to make that happen.
So what should you do? We are so glad you asked!
Download the Bulletin, print it out and carry it wherever you go. You never know when you are going to be in a meeting where you might here someone say, “Well, I wish we could provide family and youth peer services, but there is no way we could ever get reimbursed for that…” This is when you pull out your now dog-eared copy of this bulletin (cuz you have been showin’ it to everyone you know) and say, “Well now wait a minute, I’ve got a joint bulletin from CMS and SAMHSA that not only says we can, but backs it up with research and state specific examples.”
Schedule a meeting with your state Medicaid Director for the sole purpose of discussing the recommendations within this bulletin and how your state can move forward with implementing tangible change.
Send a copy of this bulletin to any and all community and state level collaboratives you may be involved with. Knowledge is power folks, and we need to spread the word about this important document.
Schedule a meeting with your local health and mental health provider agencies to discuss the bulletin. The Feds have made a big step on their part, now we need street-level advocacy to get these services recognized as mainstream, productive, cost-effective and billable services.
Push for continued training and evaluation of the effectiveness of the services identified in the bulletin. The Garland article points out a troubling finding that indicates big gaps between identified evidence-based practice and common usual care practice. All 50 states in the U.S. reportedly “promote, require, or support” the use of EB practices in children’s mental health service delivery in some way, but only eight states have explicitly mandated their mental health care systems to “promote, support, or require” specific EB practices (Cooper et al., 2008). The article cites that in one study they “found that approximately half of the patients’ charts did not meet basic treatment quality indicators based primarily on EB “best practices.” If the services and supports mentioned in this bulletin are to become mainstream we must advocate for rigorous and continued evaluation of their effectiveness.
Okay, that’s a start. Let us know what your ideas are for promoting services that work and enable children with complex mental health needs – many of whom have traditionally been served in restrictive settings like residential treatment centers, group homes and psychiatric hospitals – to live in community settings and participate fully in family and community life.
Scott Bryant-Comstock President & CEO Children’s Mental Health Network
How appropriate for this very special week in May when we intensify our focus on children's mental health that we share with you two great organizations (with two great websites) that speak to the commitment of both youth and family run organizations partnering and supporting mutual growth. Youth M.O.V.E Oregon and the Oregon Family Support Network are definitely two organizations you will want to learn more about if you are interested in doing the same.
On a personal note it has been a joy to watch each of them grow and develop. I have known various leaders from the Oregon Family Support Network since its early stages of development with Judy Rinkin at the helm many years ago. For Youth M.O.V.E. Oregon, watching them grow along with the youth movement within system of care communities has been a great deal of fun for this old rebel as they consistently push for a stronger youth voice in decision-making arenas - and they have been quite successful in doing so.
It is no secret that creating and sustaining a viable family organization is not easy. Family organizations are consistently at the low end of the funding spectrum and consistently do the most meaningful work when it comes to meeting the needs of families who have children and youth with emotional challenges. The Oregon Family Support Network has been moving forward through good funding times and bad and appear to only be getting stronger.
Double the degree of difficulty when it comes to establishing and sustaining a youth led organization. And yet, here is Youth M.O.V.E. Oregon, recently recognized as a 501 (c)(3) non-profit organization, doing great things for young people throughout the state of Oregon.
Quite possibly the most significant thing for me is that these two organizations appear to be on the right track when it comes to both collaborating together and, especially for the family organization, supporting the growth and development of the youth organization. Far too often we see unfortunate examples where the youth voice is stifled and not allowed to flourish. That doesn't seem to be the case here. We need to see more examples of family and community organizations who do all they can to support the true independence of youth led organizations.
So 'good on ya' Youth M.O.V.E. Oregon and Oregon Family Support Network. May you continue to flourish, celebrate and support the mutual independence that makes you a strong collective voice for youth and families.
Okay Network faithful, check out their websites and show them some Network love...
The Network is quickly becoming a fan of Thomas Insel, head of the National Institute of Mental Health. To say that he is shaking things up is an understatement. His recent decision to reorient NIMH research away from DSM categories and support "research projects that look across current categories – or sub-divide current categories – to begin to develop a better system" is a breath of fresh air. In his announcement of this change he says, "What does this mean for applicants? Clinical trials might study all patients in a mood clinic rather than those meeting strict major depressive disorder criteria. Studies of biomarkers for “depression” might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms. What does this mean for patients?We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system... and seek better outcomes"
The decision does not come without controversy within the psychiatric community but good for you Thomas Insel for shaking things up in this new era of health care reform and trying to improve the bottom line - clear validity for treatment decisions made. Here is the announcement from the Director's Blog on the NIMH website (website includes references):
In a few weeks, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This volume will tweak several current diagnostic categories, from autism spectrum disorders to mood disorders. While many of these changes have been contentious, the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published. Sometimes this research recommended new categories (e.g., mood dysregulation disorder) or that previous categories could be dropped (e.g., Asperger’s syndrome).1
The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.
Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. Through a series of workshops over the past 18 months, we have tried to define several major categories for a new nosology (see below). This approach began with several assumptions:
A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
Each level of analysis needs to be understood across a dimension of function,
Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.
It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data. In this sense, RDoC is a framework for collecting the data needed for a new nosology. But it is critical to realize that we cannot succeed if we use DSM categories as the “gold standard.”2 The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories. Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes. That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category. We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response.
That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system. What does this mean for applicants? Clinical trials might study all patients in a mood clinic rather than those meeting strict major depressive disorder criteria. Studies of biomarkers for “depression” might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms. What does this mean for patients? We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system. The best reason to develop RDoC is to seek better outcomes.
RDoC, for now, is a research framework, not a clinical tool. This is a decade-long project that is just beginning. Many NIMH researchers, already stressed by budget cuts and tough competition for research funding, will not welcome this change. Some will see RDoC as an academic exercise divorced from clinical practice. But patients and families should welcome this change as a first step towards "precision medicine,” the movement that has transformed cancer diagnosis and treatment. RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders. As two eminent psychiatric geneticists recently concluded, “At the end of the 19th century, it was logical to use a simple diagnostic approach that offered reasonable prognostic validity. At the beginning of the 21st century, we must set our sights higher."
The major RDoC research domains:
Negative Valence Systems
Positive Valence Systems
Systems for Social Processes
Okay Network faithful, what do you think? Here are a couple of articles that weigh in on the controversy:
The Congressional Budget Office is out with a cost estimate analysis of S. 689 Mental Health Awareness and Improvement Act of 2013. [Note that gross funding levels for fiscal year 2013 are provided, but those amounts do not reflect the 5.0 percent reductions from the recently ordered sequestration of 2013 funding.] The good news is that the Senate agreed today to include the bipartisan mental health measure onto gun control legislation — but what does it really mean? Let's set aside for the moment whether the Bill ever fully comes to fruition and focus on the mental health amendment. The amendment offered by Sens. Tom Harkin (D-Iowa) and Lamar Alexander (R-Tenn.) was 95-2, with Sens. Rand Paul (R-Ky.) and Mike Lee (R-Utah) opposing. So that's great, right? Well, yes and no. Many mental health advocates are rejoicing that we are getting some attention (better some than nothing) but that leaves a bitter taste in our mouths. Props to Harkin and Alexander for pushing hard on this but when you read what's in it you find that at best, it treads water by offering, for the most part, what already is being funded, and even increasing scope and responsibilities for some (i.e., suicide prevention, trauma) while keeping funding at the same level as last year.
“I hope that regardless of how we might agree or disagree with this gun bill, we would agree that we … need to do a better job of mental health support services for children in our country,” Harkin said.
To achieve broad Republican support, the senators had to keep the bill budget-neutral, which is why it doesn’t actually create new programs — it just gives Congress the go-ahead to renew existing ones.
Are we pleased here at the CMHNetwork? Well, no, we are not. While appreciative of the effort by the Senators who pushed for this amendment, voting yes on something that is not a game changer in any way imaginable, especially in light of the heightened conversation around mental health the past few months is more of an appeasement to public outcry and not something to even remotely celebrate. Although the issue has risen to national legislative action, we need a commitment for following years to do far more than a budget neutral effort. If we want to improve mental health resources for our children we have to pay for it, plain and simple. Let's up the ante for the next five years and agree to fund the full need for children's mental health, not apply a Band-Aid.
Hey, remember way back in 2010 when the GAO announced appointments to a new National Health Care Commission? Here is an excerpt from the announcement about the purpose of the Commission:
The Patient Protection and Affordable Care Act created the Commission to serve as a national resource for Congress, the President, and states and localities; to communicate and coordinate with federal departments; to develop and commission evaluations of education and training activities; to identify barriers to improved coordination at the federal, state, and local levels and recommend ways to address them; and to encourage innovations that address population needs, changing technology, and other environmental factors.
The Act requires the Comptroller General to appoint the Commission members and the members are required to be appointed for three-year terms, but staggered terms are mandated for the first 15 members appointed in September 2010. Those first group of appointments are set at one, two, or three years.
Only one problem... the Commission was never funded and has never met. Ouch. The Children's Mental Health Network has brought up the issue of workforce development in anticipation for the rollout of the ACA on several occasions. One of our favorite posts of many on the topic of expanding the workforce to meet the needs of families is from last May but still worth a re-read - check it out here.
Okay, back to the challenge at hand.
This week, The Association of Academic Health Centers made its way to Capitol Hill to call on lawmakers to quickly fund and expedite the work of a long-idle commission established by the health law to make periodic recommendations about the health care workforce (Read their issue brief here). That commission has gone unfunded for three years, even as experts suggested that the lack of access to health care professionals — especially for patients in rural, underserved areas — could reach crisis levels.
In a hearing on Tuesday convened by Sen. Bernie Sanders (I-Vt.) to discuss the problem, Sanders issued a report estimating that 57 million Americans live without ready access to primary care.
This is going to have an impact on children and youth with emotional challenges and their families, so this is one worthy of paying attention to and tracking.
“In order for the promise of expanded coverage passed into law by ACA to become a reality, the provisions designed to reach those goals must be fully funded and implemented,” Sanders said in the report. “We need to make sure that our health care system has the infrastructure in place to provide the care necessary to prevent diseases and improve the health of all Americans.”
The Affordable Care Act created the commission “to develop a fiscally sustainable integrated workforce that supports a high-quality, readily accessible health care delivery system that meets the needs of patients and populations.” The commission was supposed to explore the health workforce needs in rural and “medically underserved” settings, the capacity of the nursing workforce, graduate medical education policies, education and loan programs for health care professionals and the “mental and behavioral health care workforce capacity.”
This issue is not going away. The Commission needs to be funded and start meeting ASAP.
Holy smokes - if you live in North Carolina, it is best not to take a nap or close your eyes for a minute - cuz things are changin' much too quickly for our liking. Here is the latest...
Medicaid overhaul (no, Tar Heels ain't expandin') With much fanfare, Governor McCrory announced that North Carolina would not expand Medicaid, they would "fix" it instead. In what some consider a bold stroke (and what we consider not as well thought out as it should be) the Governor laid out a plan to create "comprehensive care entities", four to be exact, who would be responsible for helping patients navigate the health care system. Read the press release here.
Okay, so what does that really mean? Pretty simple - it means that McCrory's plan would put three to four for-profit companies or nonprofit agencies in charge of all aspects of the state's $13 billion Medicaid program - physical, behavioral and dental. The rationale is to create a system that treats the "whole person" with integrated services. On the surface, the goal sounds pretty plausible, right? But it's the "Gettin' there" that may be a bit problematic.
Read the Bill introduced into the General Assembly proposing a unified public health system that would consolidate mental health into the public health domain here.
What concerns the Children's Mental Health Network For starters, North Carolina has been through consolidation efforts before. For a trip down memory lane on previous attempts to streamline consider this excerpt from a report by In the Public Interest:
In 2001, North Carolina's General Assembly passed the "Mental Health System Reform Act," which required local jurisdictions to separate the management of mental health services from the delivery of those services. Previously, local entities such as counties and regional agencies delivered mental health services by directly employing the care providers. The 2001 law required the governmental local management entities (LMEs) to contract with private providers to serve area residents who needed mental health services. The local counties and regions no longer directly controlled the provision of services, but instead were responsible for managing provider contracts.
Shortly after the new system was put in place, numerous problems occurred. Many highly trained mental health care workers left the field as private providers took control of service delivery, decimating the professional public-sector workforce. Furthermore, the fragmented system created through privatization had a tremendous negative impact on the quality of services provided to clients. Many times, important mental health services were no longer even available to clients. Private providers engaged in "cherry-picking," offering only the most profitable services, such as "community support" services. These services include basic assistance and mentoring, and such tasks as running errands for a client or helping with a child's homework. They could be performed by low-paid, unlicensed personnel. Many providers focus on these highly profitable community support services and left seriously ill clients without the more costly care they needed.
Reports of cost overruns estimate that the state wasted at least $400 million in community support services offered by private providers that were unnecessary for the client or not even performed. As a result of the in treatment offered by the private providers, the number of North Carolinians with mental illness who ended up in emergency rooms or jails significantly increased.
Ironically, on the same day Governor McCrory was laying out his plan and justifying why privatizing the Medicaid system was necessary, North Carolina’s U.S. Senator Richard Burr was giving out a national award to N.C. Medicaid for significantly lowering costs while delivering extremely high-quality care. Huh?
Governor McCrory's #1 claim as to why North Carolina should pursue the privatization route is that “[NC Medicaid Community Care] does not focus on measuring and improving overall health outcomes for recipients.” Yet a look at a recent study last year of how children and others on NC Medicaid are using health services found numerous examples of better outcomes. Community Care of North Carolina has both a detailed process for measuring quality of care delivered by providers statewide and for encouraging better quality– the “Quality Measurement and Feedback” program.
So, for us at the Network, we find ourselves repeating the phrase made famous by songwriter Ian Hunter, "Once bitten, twice shy." It sure does feel like North Carolina may be headed down the same road as in 2001, only this time on a grander scale. We will be watching closely to see how they plan to overcome the debacle know as mental health reform a mere 12 years ago. Whatever steps are taken to improve access to care need to be open, transparent and include plenty of time for input from community members.
Network faithful - if you are seeing this type of rapid change in your state, let us know. We are very interested in tracking how these rapid-fire initiatives end up impacting children, youth and families and those who serve them.
Okay Network faithful, another important component of the Affordable Care Act you need to commit to memory because it will increasingly come into play is the Prevention and Public Health Fund. You may be wondering what has gotten under Senator Tom Harkin's (D-Iowa) skin about this if you have been watching the news the past few days. In the President's budget, payment for the Marketplace Navigator Grants is coming from the Prevention and Public Health Fund. As Senator Harkin stated the other day, "It's like robbing Peter to pay Paul."
For the Children's Mental Health Network, understanding the global context of how health care reform is unveiling itself is critical as we expect mental health to be integrated into public health in the near future. Given that health care reform is fully embracing a public health model, what looks good on paper in Washington needs to be good for youth and families with mental health challenges at the local level. And if we continue to chip away at the Prevention and Public Health fund to pay for other good ideas, and the health fund is designed to shore up existing public health operations (including mental health) that will be weakened if we keep digging into the fund to pay for things like Navigators, who are so important to ensuring individuals and families get what they need from a health system that... oh wait a minute... may be crumbling because we are robbing the fund set up to support it... Dang, no wonder people throw up their hands when they try to decipher all of this. Yes, an English teacher's worst nightmare run-on sentence was intentional.
So take a bromo and consider it this way:
Prevention and Public Health Fund The Affordable Care Act of 2010 created the Prevention and Public Health Fund to invest in public health and disease prevention. The health care reform legislation allocated the prevention fund with $15 billion over its first 10 years. But President Barack Obama signed legislation on February 22, 2012 that cuts the fund by $5 billion over 10 years to help pay for other initiatives, including a continuation of payroll tax breaks. Earlier, congressional Republicans had targeted the fund for cuts or complete elimination, arguing either that it was unnecessary and wasteful or that it would accomplish little on top of existing federally funded efforts for disease prevention and health promotion. Read a great analysis of the back and forth with the Prevention and Public Health Fund here.
Navigator Program Navigators are individuals and entities that will provide unbiased information to consumers about health insurance, the new Health Insurance Marketplace, qualified health plans, and public programs including Medicaid and the Children’s Health Insurance Program.
The new funding opportunity provides up to $54 million in total funding and applications are due by June 7, 2013. The funding opportunity announcement is open to eligible self-employed individuals and private and public entities applying to serve as Navigators in states with a Federally-facilitated or State Partnership Marketplace. Read the details here.
Chipping away - How the two are related On Tuesday, the administration announced that $54 million would be made available for Navigator grants to help people sign up for insurance in the new online marketplaces that open for enrollment Oct. 1. As it turned out, that money came from the ACA's prevention fund.
The Prevention and Public Health Fund has been chipped away at by both Republicans and Democrats. President Barack Obama has repeatedly endorsed cutting the Fund budget as a means to reduce the deficit, while Republicans have voted to repeal it or failing that, use the money for other purposes.
What it all means? The Obama administration requested $1.5 billion to set up and run the marketplaces (which includes Navigators) as part of its 2014 budget blueprint. It's going to be a tough road to find the money to do this and we as advocates need to be focused on the bottom line - quality services for youth and families in communities across America - not in the offices of policy wonks in Washington DC.
Here is what Senator Harkin had to say about all of this the other day:
How do you recognize Third Culture Kids (TCK's), expat kids, and other mobile children in your practice? What issues do you think they struggle with that are directly tied to mobility?
We sent this question out to several hundred recipients among various networks... and to date have received very few answers. What is going on here?
For years, we’ve known that those who move frequently in childhood and adolescence are at greater risk for certain emotional and behavioral problems that may manifest early or not present till later in adulthood -- surely mobility should be a red flag, something therapists might screen for during intake sessions with new clients.
Yet how often are clients specifically asked about childhood moves? With increasing international and domestic mobility, how are therapists being trained to recognize and deal with these issues?
Some weeks ago, I attended the Families in Global Transition conference where I sat in on a presentation by marriage and family therapist Lois Bushong of Indiana. Herself an adult TCK, an American missionary kid who grew up in Central America, she cited some fascinating -- and troubling -- facts:
Global mobility is on the rise: in 1999, there were close to 4.2 million US expats living overseas. By 2015, the number is expected to exceed 9.3 million. This does not include repatriated Americans or Americans moving within US borders.
Presenting issues may include depression and anxiety disorders, unresolved grief, identity issues, problems with relationships and transitions, substance abuse, PTSD. But without understanding how mobility can exacerbate underlying conditions, or even initiate them, children of expats who come for counseling are often misdiagnosed. The most common misdiagnoses? Borderline Personality Disorder, Narcissistic Personality Disorder, Schizophrenia.
Bushong has developed a new intake form for use with her clients designed to help identify childhood mobility, which includes places to list the number of moves and countries lived in. Her soon-to-be-released book, “Belonging Everywhere and Nowhere: Insights into Counseling the Globally Mobile,” is sure to help those who work with TCKs to better understand their challenges.
Dr. Doug Ota, whose own book on setting up effective school programs to meet the needs of internationally mobile children is due out later this year, counsels many TCKs in The Hague, and finds that issues of mobility “usually arise naturally when taking a person’s history ... the issues that arise invariably have to do with identity: the question of ‘who I am’ is not only constructed by the ‘self’ (a very Western notion), but also reinforced and held in shape by a person’s environment (a very Eastern notion of where a person’s identity comes from). Westerners often get into trouble with mobility because they don’t see the last part of that equation changing when they move. They feel erased when they arrive, as all their reinforcement vanishes, and they can feel invisible -- without even knowing why!”
“There are (and always have been) mental health issues tied to childhood mobility,” writes Bruce La Brack, cultural anthropologist and researcher, whose own childhood included nine domestic moves in eighteen years. He has published extensively on intercultural experience, cultural adjustment and reentry issues. For years he directed the University of the Pacific’s Institute for Cross-Cultural Training, working closely with TCKs and international students and preparing students for intercultural exchange. “I believe that many TCKs are either misdiagnosed (or the background causes of their anxiety or stress are either unknown or unacknowledged) if they are treated by health care professionals who are clueless about the TCK Profile or the salient factors that impact their emotional life and constitute their identity.”
These specialists understand well the challenges of frequent moves for Third Culture Kids, many of whom don’t self-identify and won’t offer up their itinerant pasts unless pressed for the information. But the patterns and characteristics that develop as a response to global mobility among TCKs can be applied to other cross-cultural children as well -- to those domestic nomads who move among cultures within a nation’s borders, or the ethnic-minority or immigrant child who lives a traditional life at home but is schooled in the larger community, or the children of refugees growing up in a country not their parents’, or international adoptees, or foster kids, or even those “stationary nomads” who remain in one place but whose world continually changes around them because of others’ mobility... the list goes on. One begins to see how huge an issue mobility has become.
How might mental health practitioners be better prepared to recognize mobility as a marker, then, when people come for help? What can our training institutions do to emphasize the importance of mobility as a catalyst for some of the presenting problems? What sort of preventive measures can be taken to insure that children -- and the adults they will become -- can more successfully navigate their transitions? And, finally, how can we take the reality of increased mobility, with all the benefits and enrichment that are also part of a mobile lifestyle, and reframe it into something TCKs and others can use as a model and a marketable skill?
I am hoping to explore these and other questions with readers of this blog. Please feel free to begin the conversation -- I look forward to your responses.