Minding Houston XVII: Parity Disparity

With all the issues surrounding mental health, perhaps none has a bigger impact than parity. But parity also happens to be one of the hardest to understand and hardest to implement. In this episode, we will look at the legislative history of parity, current problems with enforcement, and a new ruling that impacts parity across the country. Insurance parity for behavioral health coverage makes providing behavioral health services possible and it is impossible to improve access without it.

This is Minding Houston, I’m Bill Kelly.

When we talk about parity, we need to talk a little political history. The Houston Chronicle’s Jenny Deam wrote about the situation regarding parity and its roots in federal legislation, and she sums it up nicely:

“President George W. Bush signed a law requiring any insurance policy that included mental health treatment to be equal in coverage to medical treatment, in an effort to stop the long-standing practice of charging higher co-pays for mental health care, limiting treatment or denying it outright. It was cheered as a triumph for the nation’s millions with mental illness.

The measure was further strengthened in 2010 with the passage of the Affordable Care Act, which extended federal parity requirements to individual and small-group plans and mandated mental health and substance abuse be covered in any plan sold on the federal marketplace or state exchanges.

But the lofty goal of equality has fallen far short of its promise, providers, patients and policy experts say.”

So with federal legislation passed, what’s the problem? Parity is the law of the land, why isn’t it the standard practice of providers? Well, as Ben Franklin once said, “”Justice will not be served until those who are unaffected are as outraged as those who are,” which I think was his way of stirring up those of us who care about behavioral health coverage. Deam’s article continues:

“In fact, certain managed care groups are well known within the Houston behavioral care community of having a “predictably higher rate of denials” and a “higher hassle factor,” says Dr. George Santos, chief medical officer and executive medical director at Houston Behavioral Hospital. “They hide behind statements like, ‘We are not telling you what to do.’ But I have had many instances where these physicians will make specific treatment recommendations regarding medications and doses. They will certainly say a patient no longer needs inpatient care and will deny approval.”

Take Dr. Richard Noel, medical director at IntraCare North, a Houston psychiatric facility. He spends hours each week on the phone arguing with doctors paid by insurance companies who have never seen his patients. He says he now has to prove that medications for inpatient children and teens are being adjusted every few days – often before the drugs have had a chance to work – or insurers will no longer cover a hospital stay. He says he has had issues with nearly all of the major insurance companies.”

What are the consequences when parity for behavioral health isn’t enforced with providers? Well, I would refer to statements made by Dr. William Streusand, an adolescent child psychiatrist at the Texas A&M Health Science center. He testified in front of the House Select Committee on Mental Health on March 22nd and answered the following question from Rep. Greg Bonnen, also a physician:

Bonnen: “You don’t take private insurance in your practice, why is that?”

Streusand: “I don’t have to.”

Bonnen: “Well, okay, could you elaborate on why you wouldn’t have to?”

Streusand: “Yeah, like I said it is a seller’s market.”

While that is true, what else is true, as followers of Minding Houston well know, is Texas has a scarcity of providers. How bad is the situation and how does it affect parity? From the Chronicle article:

“Texas ranks 47th out of 50 states and the District of Columbia in access to mental health care, and 50th in the number of mental health providers with only one for every 1,757 in the state, according to a study by Mental Health America. By contrast, Massachusetts, which ranks first, has one provider for every 248 people.

“They flat out tell me, ‘We don’t take insurance anymore because we have too much trouble getting paid,’ ” says Carrie Stowell, a single mother whose 16-year-old daughter has been diagnosed with bipolar disorder, attention deficit hyperactivity disorder and anxiety. She lives in Conroe and found 10 doctors in a 40-mile radius who treat adolescents, but only one is taking new patients or is in her plan. The wait for an appointment is six months.

Santos also feels the shortage. “It is extremely difficult to recruit a physician willing to work at an inpatient setting because of insurance,” he says.”

Because of poor parity enforcement, Texas finds itself in a situation where access to care is being limited not only to the number of providers but the number of providers that take insurance. Having a “cash only” payment model for behavioral health is a dangerous trend for Texas and can be one of the most limiting factors in the provision of care. Texas has too many people needing services to be a “seller’s market.” It is time to make some changes.

So how can this parity enforcement problem be addressed? Based on his experience as a prosecutor and his observations of the mental health needs of so many in the criminal justice system, Congressman Joe Kennedy III has a plan that he believes can help enforce the parity laws on the books. We talked with the Congressman about his Behavioral Health Coverage & Treatment Act last week:

Bill Kelly and Congressman Joe Kennedy III

Kelly: I’m here today with Congressman Kennedy. Congressman, thank you so much for joining us. In December you filed your Behavioral Health Coverage and Transparency Act and, unlike in Texas where we face large problems due to our large uninsured population, this act primarily goes after folks with insurance looking to access services. What particular aspect really raised this on your radar screen?

Kennedy: So, I’ve been diving into issues around mental health now for a while, since I came into office and, actually, really beforehand. Before I ended up running for office, my first campaign, I was a prosecutor. I cannot tell you how many cases came across my desk from the district courts, lower courts, criminal courts in Massachusetts for folks struggling with either mental illness, substance abuse, drug abuse, or alcoholism and my boss at that point, a Republican DA,  said, “Your job is to make sure that person never commits another crime.”

And some folks are bad people and you lock them up for a long time. For others suffering from mental illness or substance abuse, the way you can do that is to treat the underlying condition. It doesn’t matter if you lock them up for three months if they are not able to get treatment for their mental illness or get clean off of a heroin addiction.

So use the tools that you have in your tool kit to help address the underlying concern. As a prosecutor, there are some tools we got; there’s a lot that we don’t and from my perspective trying a bunch of drug cases and working with a lot of drug cases, I became convinced that the way to ensure that those files that were people’s lives on my desk, the way to actually address them much further upstream is to focus on prevention and treatment rather than on prosecution.

The question then becomes how do we make sure there is access to mental health care throughout our society? And as we start peeling back the layers on this, from my perspective on it, there are two main segments. There is the public side of things where folks get their healthcare from the federal government, Medicaid primarily. Medicaid is, of course, the largest payer of mental health care services in the country. Then there is, of course, the private side doing private insurance. We’ve started by looking at the private side marketplace.

What this bill’s focus is to say, look, the combination of mental health parity, which is a simple law that has helped expand coverage, but it’s the combination of mental health parity and the Affordable Care Act that actually said as an essential health benefit in order to participate in these exchanges, you have to actually cover mental health care. So we have the combination of the Mental Health Parity Act, which says we have to treat mental health care like we do physical health care, and then the Affordable Care Act, which says you have to now cover mental health care. That leads to a huge expansion in coverage for states, particularly those who took the Medicaid expansion, which not all states did.

The challenge though is that the marketplaces still are not functioning so we still hear cases all over the country that say “I don’t need to take insurance,” because there are so many people that are in need of care and so few doctors that the doctors are essentially empowered to say “I can cherry pick my clients, I can make sure to get rates that are higher that other insurance companies will reimburse me for and I’ll just be an all-cash doctor.”

The problem with this is that you can’t just create more doctors overnight. So there are systemic issues that are affecting our ability in this country to have patients that are suffering from mental illness to actually access mental health they need. One other step for you: according to one study I saw recently 55% of the counties across our country do not have a single practicing psychiatrist, psychologist or social worker, 55% of the counties across our country!

So when we start talking about trying to get access to care, insurance is an important part to this, but we have to make sure you can actually get a doctor and stay treated. So the bill that we filed is a first step in trying to basically force insurance companies to divulge information around how they are actually covering mental health care. As you know, there are many people that are suffering from mental illness who get their insurance claims denied at a much higher rate than those suffering from typical, physical maladies such as a broken leg or a broken arm. So this bill will hopefully shine a light on some of those practices and force insurance companies to actually make this transition to focus on prevention and treatment, rather than triage at the back end of mental health.

Kelly: And you mention that this bill, it doesn’t put forth any new regulations as much as it focuses on transparency the for given laws that you mentioned with parity and the ACA.

Kennedy: Absolutely. Part of the way we crafted this is to say, look we are not trying to add any additional burden to these insurance companies, but disclose the methodology at which you end up making your decisions and make sure that information is available and digestible to regulators so we can actually start to shine a light on this and ask are things actually going as they should – which case there might be something else that needs to be done – or are they not?

And the idea behind this bill is that if insurance companies can essentially get away with not covering people at the back end when they are in need of mental health care, then there is essentially no reason for them to make the investment they need to actually force the focus of treatment to move up that scale to prevention and treatment rather than just focusing on the back end for folks that end up in a crisis point.

So what we want to do is try to take a step back and say how are we going to address access to mental health care in the system? It needs a full-on continuum of care adjustment. We need the private sector to play a role in that and I think a critical piece to it is by getting insurance companies to not just focus on the back end, the really expensive cases of triage after you’re becoming the victim of mental illness, but to focus on treatment and prevention on the front end. How do we flesh that out? We make sure that you are actually abiding by the terms of the regulation that are already in place.

Kelly: When you talk about the regulations that are already in place, one of the things that make mental health and behavioral health a very bipartisan issue is that people in a very partisan health care landscape, have been really willing to come together. You’ve seen bills move both in the House and the Senate. Do you see your bill possibly being able to hitch onto one of these bills that seem to be making some headway down the track?

Kennedy: Absolutely hope so. This is something that I think Democrats and Republicans agree on, that our mental health system is in crisis. Whether it was folks in Congress that have had similar experiences to me as prosecutors saying this is a real problem, whether you see it in emergency rooms because you have some doctors in Congress, or you are a member in Congress involved in trying to help our access to health care period.

And if you go around even hospitals in Massachusetts it’s one of the things you will hear about in emergency departments is there are a lot of people in their EDs suffering from mental illness. So we hear about this all the time; the question is how do we go about addressing it, again in that full-on continuum of care model? I hope that this legislation will address this, either as a standalone or perhaps as an amendment to one of those other pieces of legislation that we have been working hard on. We have been working with some of our colleagues on it and they have been doing a really good job. There is also a really tricky issue on how to make these reforms across the entire system and some of my colleagues and I are trying to dive into this so hopefully we will get there.

Kelly: Well, thank you, Congressman so much for your time today and for your work on this really important issue that I hope gets the traction that it needs. Like you said, this is a critical first step to ensuring that those with private coverage get the help that they need.

Kennedy. Thank you for your time too, Bill.

As the Congressman mentioned, the largest payer of behavioral health services in the country is Medicaid. And a recent announcement by the Department of Health and Human Services is good news for increasing access.

On March 29th, the Center for Medicare & Medicaid Services (often referred to as CMS) announced the new rule in coordination with President Obama’s visit to the National Rx Drug Abuse and Heroin Summit. From the press release:

” . . . the Centers for Medicare & Medicaid Services (CMS) today finalized a rule to strengthen access to mental health and substance use services for people with Medicaid or Children’s Health Insurance Program (CHIP) coverage, aligning with protections already required of private health plans. The Mental Health Parity and Addiction Equity Act of 2008 generally requires that health insurance plans treat mental health and substance use disorder benefits on equal footing as medical and surgical benefits.

“The Affordable Care Act provided one of the largest expansions of mental health and substance use disorder coverage in a generation,” HHS Secretary Sylvia M. Burwell said. “Today’s rule eliminates a barrier to coverage for the millions of Americans who for too long faced a system that treated behavioral health as an unequal priority. It represents a critical step in our effort to ensure that everyone has access to the care they need.

“This rule will also increase access to evidence-based treatment to help more people get the help they need for their recovery and is critical in our comprehensive approach to addressing the serious opioid epidemic facing our nation.”

“The need to strengthen access to mental health and substance use disorder services is clear,” said Vikki Wachino, Deputy Administrator of CMS and Director of the Center for Medicaid and CHIP Services. “This final rule will help states strengthen care delivery and support low-income individuals in accessing the services and treatment they need to be healthy.”

The protections set forth in this final rule will benefit the over 23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP.

A link to the press release and the finalized rule can be found here

Overall, our goal at MHA of Greater Houston has been to make the provision of behavioral healthcare a successful business model. After all, if people want to access services, there needs to be providers available to treat them. Parity can help provide the basic regulatory functions under which providers can be paid in a timely manner for their services. And it is already the law . . .

Parity will continue to be a big issue at the state and national level. We look forward to continuing to work with our elected leaders in Austin and Washington to make sure parity coverage is enforced. Without this level playing field, progress in mental health care access continues to be an uphill battle.

This has been Minding Houston, I’m Bill Kelly.

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Music for this Episode: “Hotel Rodeo”, “Quisling”, and Bricolage” by Anitek and “Vacate the Premises” by Deadly Combo

Minding Houston XVI: Capacity Questions Answered

 

Whenever the topic of mental health is discussed, one of the most repeated solutions is to increase capacity, usually in the common phrase, “we need more beds.” But do people really have the facts on what the bed capacity issues are for Harris County, and how does that play into what bed capacity issues face the state? Today, we talk to a leader for Harris County’s inpatient mental health hospital to get very specific on capacity issues.

This is Minding Houston, I’m Bill Kelly

Sgt. Joe Friday should have taught public policy. His “just the facts” line is one of my favorites and carries the objective tone of trying to boil down a problem to its core. So it is in that Dragnet spirit that I hope you don’t mind if we focus on a few graphs and numbers to get the story on capacity for state psychiatric beds.

The Texas Department of State Health Services has often presented the above slide in talking about the number of publicly funded beds available in the Texas State Hospital system. The graph shows two sets of numbers: first, the state hospital psychiatric beds represented with the light blue line, and secondly state funded (or private) psych beds represented by a red line. The black line at the top shows the sum of these two numbers and the overall trend in patient capacity for the state.

What’s apparent from this graph are two things which are important to note when looking at future trends regarding capacity options:

First, the number of state-owned beds has largely flat-lined since 2006, which shows that despite recent investments at the state level, Texas has not increased inpatient capacity for state-owned beds.

Secondly, the number of state-funded, private beds has more than doubled during that same time period, moving close to 20% of the state bed capacity total.

Clearly, the preferred option to increasing state bed capacity has been to buy, rather than build.

However, one number is not included in this data set that is the most important in answering what the real situation is with regards to the capacity of inpatient beds in Texas, and that’s population. Anyone who is living in Texas knows the explosive population growth seen in the past two decades, and in order to get the whole picture, the number of Texans needs to be accounted for in this data.

In a presentation to the Senate Finance Committee on January 15th, Assistant Commissioner Lauren Lacefield Lewis presented the following slide that tracks the total number of state beds to state population, and the numbers are not encouraging:

From the graph, you can see that Texas is currently at the lowest ratio of beds to population since 1994. So in talking about what the psychiatric bed capacity for Texas is, we are starting from the lowest point based on population.

But aside from just the overall population, there’s another factor putting added pressure on the number of psych beds available for Texans: the criminal justice system. In the same presentation to Senate Finance, Mrs. Lewis showed the following slide that confirms a trend that first reached a tipping point in 2014. That trend is that more people are admitted to the Texas State Hospital system through forensic commitments than civil.

2014 marked the first year that more people entered the state hospital through the criminal justice system (a forensic commitment) than were voluntarily committed (civil commitment). And the trend has continued in 2015 and 2016.

This is a dangerous situation, as the public safety of Texans is now using up resources designed to make sure Texans have access to mental health beds. And the consequences are already showing up in real world situations right here in Harris County.

According to a March 4th Edition of the Houston Chronicle, the number of beds for forensic commitments were supposed to take up a third of the Texas State Hospital system but have instead become a majority.

The case of Shannon Miles, who stands accused of the murder of Harris County Sheriff’s Deputy Darren Goforth last August, has had more than its share of strange twists and turns. The case also has highlighted yet another problem with how the state deals with the mentally ill among us.

To review, Goforth was shot 15 times as he walked to his patrol car at a gas station. Sheriff’s deputies within a day arrested Miles, who has a history of mental illness. On Feb. 9, he was found mentally incompetent to stand trial after experts agreed he suffers from schizophrenia, and he was ordered to Vernon State Mental Hospital in North Texas. There he would receive a 120-day mental evaluation to determine whether so-called competency restoration is possible. As of this writing, he’s still in the Harris County Jail – the state’s largest de facto mental health facility, by the way – because some 60 other Harris County inmates are in line to go to Vernon ahead of him.

In 2012, a Travis County judge ruled that defendants requiring a forensic bed at a state mental hospital couldn’t be made to wait in jail for more than three weeks. Forensic beds are the spaces set aside for defendants, like Miles, who need psychiatric treatment to get well enough to stand trial. As Emily DePrang reported in the Texas Observer in 2014, they’ve had to wait in recent years for an average of six months.

Long waits are still the rule, despite the judge’s ruling, because Texas has less than 2,500 beds at its 10 state mental hospitals; less than a third of those are designated for forensic commitments. The cruel irony is that every bed used by someone from a jail is one less bed available for people who have committed no crime.

The wait list for the state hospital is another example of the lack of access for mental health owing to a capacity for treatment. The bottleneck for violent offenders at the Vernon State Hospital is just one example.

Another example is the overall number of people who are dependent on the public mental health system. Recently, our favorite radio program Houston Matters had me on to talk about the need for crisis clinics while highlighting a new walk-in clinic opened in Meyerland by Memorial Hermann. Houston Public Media has done an extraordinary job when it comes to highlighting mental health, which I think is evident from the questions asked by Houston Public Media’s Craig Cohen. Here’s the part of our interview focusing on the need for services:

Craig Cohen: Bill Kelly, we do tend to think of the need for 24/7 physical health emergency care. Is it something that we tend to forget or not take seriously that there is a need for 24/7 – particularly in the overnight hours – emergency mental health care?

Bill Kelly: Well, I would just point to the overall numbers and then when you look at the gap in coverage and access it really emphasizes the need to invest in them. And according to our State Health and Human Services Commission, we have about half a million Texas adults that suffer from a severe and persistent mental illness. Now severe mental illness results in a serious functional impairment which substantially interferes or limits one or more major life activities. When you add the “persistent” that means that those symptoms have lasted over a year. So if you have half a million adults that breaks down in Harris County to right at 150,000 adults. Now, we know from our Mental Health Needs Council assessment that about 90,000 of that 150,000 have no access to public or private insurance. So the very systems that Memorial Hermann and other partners with the 1115 waiver are trying to build out are badly needed for this group. Like Theresa said, if people do not get the medical services that they need and the mental health care that they need, their safety net all too often is emergency rooms that are already crowded and a system that has a coverage gap or, unfortunately, our criminal justice system.

The capacity question here in Harris County is one that should draw attention. Having such a scarcity of access will place an inordinate demand on existing resources. The relief provided by the expanded footprint of behavioral health from the 1115 Waiver’s DSRIP projects, such as this crisis clinic, should be viewed as vital. We cannot afford to lose these new programs when the waiver expires later in 2016.

Fortunately, we have a resource locally that helps with the inpatient capacity that makes Harris County the envy of other places in Texas. I sat down with Stephen Glazier, Chief Operating Officer of the Harris County Psychiatric Center, or HCPC, to talk about the role his facility plays in helping provide capacity right here in Harris County:

Bill Kelly: I’m here at the Harris County Psychiatric Center (HCPC) with Steve Glazier. Thank you so much for taking the time to meet with us today. I wanted to first go through and describe the mission and capacity here at HCPC and how it really fits into the behavioral health network of providers here in Houston.

Steve Glazier: So HCPC is primarily a short-term acute care psychiatric hospital. We do have a few units that are designed for patients that stay a little bit longer, three or four or five weeks, but the majority of beds are short term acute care which means the patients stay roughly seven to eight days. We are a 276 bed hospital. Currently, we are renovating units; we are going to have our 30th birthday in the fall and 30 years of 8,000 admissions a year. It’s time to do some renovations. So not only are we making the units nicer, we’ve been able to redesign them in a way that also makes them safer, it makes them more therapeutic. So we are keeping one unit closed, we will renovate it and move units in and then we go to renovate the next one so we are operating 250 beds right now. We are the second largest academic psychiatric hospital in the country and we stay functionally full all the time. What I mean by functionally full is if we have an empty bed, it only means that the patient that has been assigned to that bed hasn’t arrived here yet. Every morning we start the day with a list of anywhere from 30 to 45 patients waiting to come in. Most days we are able to find everyone a bed the same day. We get the same number of discharges in a day, but we stay very busy and functionally full all the time. Houston-Harris County has very, very few civil commitments to the state hospitals anymore, so HCPC essentially fills that role for this area as well.

Kelly: And you mentioned being one of the second largest in the nation with regards to academics so to be clear, who funds HCPC?

Glazier: The majority of the beds and the patient days are funded by the state, out of state general revenue. A smaller portion is funded by the county and then also a small portion are funded – we have a few beds that are available for patients with third-party funding, so another small portion is third-party funding. Most of our funding comes from the Harris Center, through our contract with the Harris Center. We do have one contract that is direct with the county with the juvenile probation department so we have one unit that is set aside specifically for adolescents from the juvenile detention center, but the majority of our funding comes from state general revenue.

Kelly: And with that, what’s probably the biggest challenge that you face here at HCPC in order to really carry out your mission?

Glazier: One of the biggest challenges is trying to do our very best with the beds we have to accommodate all the demand for admissions that we have. We take very seriously our role to try to make sure that patients that are in emergency rooms and in hospitals around the medical center, patients that have been court ordered into treatment, patients that are coming in from the neuropsychiatric center that the Harris Center runs, that when we get requests that we are able to get those patients transported here and admitted as quickly as possible. But trying to balance that with trying to manage the patients and treat the patients that are here as thoroughly as possible is a real challenge; it’s a balancing act. We don’t want to push patients out early just to make a bed for someone else who is waiting. On the same token, I don’t want patients to be waiting inordinately long times in an emergency room or a psychiatric center. So trying to manage that queue, that waiting list, can be a real challenge.

Kelly: And on that exact challenge, taking it to the state-wide level, you’re in a position to be able to look at the way the state of Texas delivers a lot of that care. Do you want to talk a little bit about that position, some of the thoughts you bring with your experience at HCPC to that council?

Glazier: One of the difficulties that we have right now, and it’s worse in certain parts of the state, is there are some patients that need longer term care than just short-term acute care, than just a week. And it’s very difficult sometimes to get a civil commitment to a state hospital where a patient can stay longer and get the treatment they need. That is something that we have to figure out because the lack of those types of beds, not only those but also the lack of residential treatment beds for adults which is another low level of care, the lack of supportive housing beds, the lack of a continuum of beds from longer term acute care to shorter-term acute care to residential to supportive housing is what is causing this constant recidivism of some of our patients and is also part of what is causing this huge number of psychiatric patients who are in the Harris County jail. The Harris County jail is commonly said to be the largest psychiatric institute in the state. In fact, the Harris County jail on any given day has more psychiatric patients that it is housing than in all of the state hospitals combined in the state of Texas. Part of the reason for that is that there are some gaps in our treatment system that if we could fill those, if we had better places that had some treatment of care to discharge someone from HCPC into, and also had sufficient case management services to surround them with, we could eliminate a lot of those recidivists and a lot of those patients who end up in jail.

Kelly: Well, thank you for your time. I know all of you are busy doing so many things so thank you so much for taking some time to be with us.

The Harris County Psychiatric Center has helped thousands of Harris County residents, and yet we know thousands more needs services. Capacity, especially for inpatient mental health services, is a challenge for all of Texans.

There are many issues to be brought up during the interim, and we look forward to hearing more from Chairman Four Price’s Select Committee on Mental Health. We hope this look at capacity has shown how statewide policy must address the ability for those seeking inpatient care to find it, and the consequences of a lack of investment in access.

This is Minding Houston, I’m Bill Kelly.

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Music: “Clear Your Head” by Cory Gray and back beats by Frank Nora

Minding Houston XV: Workforce Shortage? We have an app for that!

Welcome to the first Episode of Minding Houston for 2016. While it has been a while since we last spoke, we’ve been holding off as this episode isn’t just about policy discussions, it’s about results. And we need your help to get the word out about a program critical to the future workforce of Texas.

This is Minding Houston, I’m Bill Kelly

Astute listeners to this blog know that we have talked a lot about the mental health workforce being a big obstacle to access. In fact, we devoted a whole episode to it last February (See: Minding Houston IV), and almost a year to the day later, we are happy to announce the state of Texas is taking applications.

Senate Bill 239 by Senator Charles Schwertner creates the Mental Health Loan Repayment Assistance Program and is funded with almost $3 million. Details of the plan are shared below. The most encouraging aspect of the legislation (now law) is the recognition that it isn’t not just a lack of medical physicians, but the full spectrum of mental health providers are sorely needed to treat Texans.

While in Austin talking about the lead up to the February 8th application launch, I was able to sit down with one of the leading voices for health care in Texas, Stacy Wilson of the Texas Hospital Association, to talk about the importance of this program:

 

Bill Kelly: Here with Stacy Wilson of the Texas Hospital Association. Thank you so much for joining me today.
Stacy Wilson: It’s a pleasure.
Kelly: We are talking about SB 239 and the specific loan repayment mental health professions bill. Who should really be looking at taking advantage of these monies.

Wilson: There are five groups of mental health professionals that are targeted under the bill: psychiatrists, psychologists, APRNs who have specialized training in mental health, licensed professional counselors, licensed clinical social workers.

Kelly: And I know we are big fans of the inclusion of social workers, especially in Houston, on it. When we talk about the monies that are available – and I know there is some restriction on exactly how many of each group can be included on that – what do people need to watch out for if they are interested in pursuing a degree in one of these fields?

Wilson: Well the great thing is that now we have included this beyond just physicians as you mentioned, but there are requirements around serving the CHIP and/or Medicaid populations and/or working in a state prison. So there are some certification requirements that you have to do, there is an application you have to fill out and at the end of each year in order to be eligible, you have to certify that you actually served that population and that you’ve met the other requirements.

Kelly: And we are going to be posting a link to information from the college coordinating board on our website, but what are some of the deadlines for people who would be applying for this for some of their graduate education?

Wilson: So what we’ve heard from the higher education coordinating board is that the applications will be available around February [8] and that they will probably be due around April 30. So there is a specific website that links to this as you have mentioned and those dates are a little flexible but obviously beginning February [8] you should start looking for them.

Kelly: And as we talk to different advocacy groups around our area, how important is this to get the message out about our workforce for behavioral health?

Wilson: It’s imperative. We can ask for all the services we want to ask and more impatient beds and outpatient services but unless you have that dedicated workforce, it doesn’t mean anything. So it is the backbone of everything else that we do

Kelly: Staci, thank you so much for joining us.

Wilson: Thank you so much

So, now here’s our deliverable. You will find a link to the Texas Higher Education Coordinating Board’s application for this program here. Now, we need you, the loyal listeners and mental health care advocates, to help get the message out by forwarding this information on to a number of audiences that need to hear it.

Application: Loan Repayment Program for Mental Health Care Professionals

People we are targeting including undergraduate students looking to pursue a degree in one of the above-mentioned fields, current students already pursuing a graduate degree, college faculty or administrators, or anyone else who cares about access to mental health services.

Forward this message or cut and paste the URL for this blog to help us share this information. Our goal is to have as many people as possible help us spread the word about this new program. Texas deserves a workforce to help treat people suffering from a mental illness, and by getting the word out, you are doing your part to help make that happen.

Just as one of the newest mental health programs is rolling out, the Legislative focus is starting to heat up. On January 26th, the Senate Finance Committee, the budget crafting body for the upper chamber in the Texas Legislature, met to discuss two primary budget issues.

First, and what took up all of the media attention, was “Discussion on the Impact of Oil Prices and Production on State Revenue and the Budget” with Texas Comptroller Glenn Hegar testifying. Clearly, this was an important conversation to have, but for this session, it really boiled down to two numbers:

From the Texas Tribune:

Texas Comptroller Glenn Hegar on Tuesday faced some skepticism as he sought to soothe lawmakers’ fears about what plummeting oil prices mean for the state’s bottom line.
“Is the sky falling?” asked Sen. Royce West, D-Dallas, at a hearing of the Senate Committee on Finance, which helps write the state budget.

“No, sir,” Hegar replied, adding that while there are “clouds on the horizon,” he’d rather be in Texas than in any other state.

“I just don’t want to live in a state of denial,” West responded.

{…}

Though Hegar has noted that oil’s plunge means Texas will send hundreds of millions fewer dollars toward road construction and maintenance than originally expected, the drilling slowdown should not leave lawmakers with a revenue shortfall, he said.

In fact, much of the certified revenue estimate Hegar released in October has stayed accurate — even though it was based on significantly higher oil prices — because producers are pumping more oil than anyone expected, Hegar said.

“The budget you passed – it works, and it will continue to work,” Hegar said, noting that lawmakers also left a significant cushion of unallocated funds.

That wiggle room totals about $4 billion, said Ursula Parks, director of the Legislative Budget Board.

There’s the number: a current $4 billion surplus of unspent funds available for the 2016-2017 session. Hegar’s assessment that despite the fall in oil prices that “the sky is not falling” is a very insightful remark. Especially in view of the second number.
According to testimony given by Comptroller Hegar on January 26th, the state has $9.6 billion in the Economic Stabilization Fund, commonly referred to as the state’s “Rainy Day Fund.” Given that the two-year total, or biennium budget, for the state was set at $209.4 billion, having almost $10 billion in the bank is a good position to be in, but should Texas not be spending some of that on needed programs?
The Pew Charitable Trusts released a report on January 19th describing how state’s save money in rainy day accounts and takes a special notice of Texas. Here’s what Pew writes about how Texas has decided to move on this issue:

Given the state’s other pressing budgetary priorities— particularly the need for improved water and transportation infrastructure and a desire to reduce the state’s total amount of outstanding debt—Texas lawmakers have been divided over whether the current level of reserves is sufficient or excessive.
At the heart of this debate lies a basic disagreement over the intended purpose of the Economic Stabilization Fund. “It’s become a surprisingly emotional issue in the political debate,” said Dale Craymer, president of the nonprofit Texas Taxpayers and Research Association and a former legislative aide who helped House leaders draft the 1987 constitutional amendment that created the fund. “The last two sessions, the rainy day fund has taken on this sacred nature that was never really intended. It was intended as a management tool.”
As revenue and spending pressures shift along with the booms and busts of the economy, states stand to benefit from the additional flexibility provided by robust rainy day funds to smooth over unexpected bumps in the road. Despite having billions of dollars in its rainy day fund, Texas struggles to answer the question of how much is enough because the state lacks a clear consensus on why the fund exists in the first place. Absent a clear purpose for saving, other states also find it extremely difficult to set a meaningful savings target, which can confound their efforts to manage the budgetary ups and downs of economic activity.

View Report: Pew Charitable Trusts – Why States Save

 

Senator Jane Nelson

While the Legislature deals with those numbers, one thing is clear: there is no need to cut services, especially for newly expanded behavioral health access. The Comptroller was clear in his assessment, and we hope lawmakers continue their investments in better access and quality of services, no matter what the cost of a barrel of oil.

The second part of the meeting, after all the media attention on oil prices left, was on behavioral health funding. Chair Jane Nelson was distressed about inaccurate news reports about how much Texas was spending on behavioral health.
As followers of Minding Houston, you should know all of our numbers come from the Legislative Budget Board, the same body that testified before Senate Finance. A link to their presentation is below, and as someone who has worked for a member of the House Appropriations Committee, these are the numbers I use when looking at state expenditures.

View: Legislative Budget Board

To give a recap of the presentation, the most informative slide is pictured below in what was the main point of the budget conversation: Texas spends about $3.6 billion in a biennium on behavioral health services across 18 agencies in 5 separate articles of the state budget. And as Chair Nelson repeatedly (and very rightly) points out, that total does not include Medicaid expenditures. See the slide below for a good breakdown:

With everyone on the same page with regards to the numbers (again, minus Medicaid), the Finance Committee expressed concern regarding the ability to coordinate spending and break down silos among various state agencies.
This is where Sonja Gaines steps in. As the Associate Commissioner for the Office of Mental Health Coordination for the Health & Human Services Commission, not only does she have a long job title, but a long list of programs to oversee and make work together.

A good example of how programs are being integrated came from Sean Hanna, Director of the Military Veteran Peer Network. He testified that after meeting with Gaines, this agency had begun to better coordinate with existing state resources of the Texas State Guard. This has greatly expanded the network of mental health peers working with our state’s armed services by maximizing existing resources.

The presentation notes that the statewide coordinating council should be developing a coordinated expenditure proposal for fiscal year 2017, and that as state budget writers, Chair Nelson will make sure any exceptional items match up within those plans.
The Health and Human Services Commission will submit that proposal to the Legislative Budget Board on June 1st of 2016.

Lastly, I wanted to mention that the new House Select Committee on Mental Health will be holding their first hearing on February 18th. We are looking forward to seeing what direction Chairman Four Price of Amarillo takes in the initial hearing.

 

Chairman Price, Rep. Thompson, Rep. Davis, Rep. Coleman

As a quick reminder, our Harris County members on this committee include Representatives Senfronia Thompson, Garnet Coleman, and Sarah Davis.

As the Legislature starts to dig into policy and resources, be sure to stay tuned to Minding Houston for the latest information on how mental health policy discussions translate to better access and services in Houston.

This has been Minding Houston, I’m Bill Kelly.

 

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Music in this episode: “Viper” by Ray Rude, “True Hearts” by Nick Jaina, and “Fly Drexler” by Lazlo Supreme

Minding Houston Episode VI: The Appropriate Appropriators

Last week we talked about the consequences about not investing in mental health. It makes sense to ask: So who are the investors? Or more accurately, who is making the decisions about how and how much our state spends on mental health care? It turns out, for those of us in Greater Houston, we have Legislators in positions of leadership in the Texas House and Senate. In this episode, we look at the Legislators in position to make the financial decisions we will be watching in 2015.

This is Minding Houston, I’m Bill Kelly.

There is always a lot of focus on the “Big 3” of Texas Government. The Governor, the Lt. Governor, and the Speaker of the House get most of the press when it comes to big legislative initiatives. However it is the individual legislators who make up the committees who play a very large role in determining which areas of the budget are funded and which policy are passed.

Greater Houston is very fortunate to have a number of our elected officials in well placed position to affect what the Legislature does for mental health. To start off, newly appointed House Appropriations Chair John Otto now holds one of the most powerful positions in the entire Legislature. Elected to Represent Dayton, Texas in House District 18, the heart of his district is only 35 miles from downtown Houston. Rep. Otto is the first CPA to ever head the budget writing committee and clearly wants to let the numbers do the talking. When laying out the budget to the new members of the Appropriations Committee, Chairman Otto had the Legislative Budget Board feature mental health funding during the Overview on House Bill 1.

“… moving on to page nine on mental health funding. House Bill One as introduced includes $2.6 billion in general revenue and $3.4 billion in all funds for behavioral health and substance abuse services. That goes to 17 agencies across five articles …”

Below, you can see the slides lawmakers were looking at detailing where House Bill 1, first one showing how mental health services are funded across 17 state agencies. The next slide deals specifically deals with the mental health and substance abuse funding in the Department of State Health Services.

Mental Health and Substance Abuse General Revenue Funds

Statewide Behavioral Health Funding

Chairman Otto can choose whatever portion of the budget he would like to present when it comes to these overview hearings. The fact he included mental health funding shows his own focus on the issues and will hopefully resonate with members of his committee.

Sitting beside Chairman Otto is the Vice Chair of the Appropriations Committee Sylvester Turner. Rep. Turner is a 25 year house veteran and is regarded as one of the most knowledgeable members of the Legislature when it comes to the Appropriations Process.

During the testimony from staff with the Legislative Budget Board, Rep. Turner noticed that the base funding in House Bill 1 is predicted to generate a waiting list of over 900 adults statewide for mental health services.

Rep. Turner:  “So in comparison to what we did in the last biennium to this biennium what is the increase or decrease or are the things the same?”

“Across all of the agencies, again on slide 10, you can see is a $200,000 dollar general revenue increase so approximately the same as 1415 and then the $61 million dollar decline in all funds.”

Rep. Turner: “And then there is a waiting? Because last time we eliminated the waiting list for juveniles and adults, did we not?”

“Yes sir, I believe the waiting list for adults and children were funded last time.”

Rep. Turner: “Okay and with regards to where we are today the waiting list is returning?”

“Yes sir.”

Rep. Turner: “And the necessary cost to eliminate the waiting list there would be what?”

Shannon Sabine: “The estimated amount to fund the adult waiting list would at the moment would be about $13 million.”

Remember from our previous blog entries how Harris County is very much affected when the state is unable to serve those on the waiting list, having almost 30% of the wait list before services were funded in the last session.

Turner has filed House Bill 1393 that helps counties like Harris in funding Home and Community Based Services that provide medical assistance to persons with severe and persistent mental illness who are at the greatest risk of institutionalization. I spoke with Rep. Turner about this in Austin:

Bill Kelly: “I just caught Representative Sylvester Turner, Vice Chair of the Appropriations Committee walking off the house floor. Representative Turner, thank you for talking with us. You filed a legislation that is going to help Harris County really target the number of individuals who are at the risk of institutionalization by providing more medical assistance for health services. Could you talk a little bit about that bill?”

Rep. Turner: “Yes, there is such as tremendous need. People want to stay at home. They want that independence, that independent living and it enhances their own quality of life. So what is intended by the bill is to provide the necessary resources to keep them at home, to provide them with that support that’s needed to keep them at home, so we don’t have to put them in an institutionalized setting. That really cuts against their own quality of life and also not even beneficial or advantageous for the family members as well. And what I have found in my own personal experiences is that if you can keep people at their homes, in their communities, within that environment it’s just better for everyone around, for them as well as their family members and friends. “

Last week, subcommittees were named so that the 27 member House Appropriations Committee could focus closely on specific topic areas, often called Articles, in the budget. The Subcommittee for Health and Human Services that makes up Article II of the budget contains some very familiar faces for Harris County.

Rep. Sarah Davis returns to this committee for her second straight session. Last session, she oversaw the Department of State Health Services budget that increased funding for behavioral health services by over $300 million. Rep. Davis represents the Texas Medical Center and has many constituents that work in health related fields. I spoke with her in Austin at a Subcommittee meeting on Wednesday.

Joining her is Rep. Armando Walle who will be serving on the Appropriations Committee for the 1^st time since being elected in 2008. Rep. Walle meet with MHA in our offices during the interim to discuss state mental health policy and understands the needs of his district in getting access to services.

Kelly: “I’m here with Representative Armando Walle before the sub-appropriations committee meeting for Article II. Representative Walle, you visited with us this summer and talked about your concern with your constituents about access to services, not only for the people of your district but particularly with Veterans and your personal experiences that you have. Now that you are on the committee do you look forward to being able to address a number of those issues?”

Rep. Walle: “That is correct. Being on the committee, reviewing all the budget, PowerPoints, looking at where the money is going, item by item. Mental health is a huge issue, particularly for access in my district. Obviously, we’ve done better recently, but I think we can do a lot more to help folks access mental health because sometimes it is a taboo in a lot of our communities where they don’t want to seek out help. And we need to inform our folks, particularly low income communities, that it is okay to seek help. One example is the military, matters where military personnel come from combat, suffering from PTSD and they might not know it. Dear friends who have suffered from it, family members who come back from war and need mental health services; that is a huge issue for my district, particularly young kids that have disciplinary issues or be overrepresented in the juvenile justice system. So it runs a gambit, but we do need more access to effective treatment, diagnosis for our young kids.”

Over on the Senate side of the building, we have a number of Legislators from Harris County looking to use their experience to help shape policy as members of the Senate Finance Committee.

First, we previously mentioned Senator John Whitmire’s service as Chair of the Criminal Justice Committee. Known as “The Dean” as the longest serving State Senator, Whitmire has represented Harris County in the Senate since 1982. His experience will be key in securing the needed funding for community based programs.

Senator Joan Huffman has a background as a prosecutor and as Vice Chair of the Criminal Justice Committee and as Chair of the Senate State Affairs Committee. Last session, she authored SB 1185 with Senator Whitmire to create the Harris County Mental Health Jail Diversion Program.

During the October 2014 Texas Tribune Tribfest panel entitled “What’s Next for Mental Health?”, Senator Huffman talked about how she was able to work with her colleagues, including Finance Chair Jane Nelson, about providing more resources for mental health.

Senator Huffman: “I think it really got us thinking, what can we do in Texas to address these issues? Clearly we’ve fallen behind in treating those who are mentally ill and providing services that they desperately need. And I just think sometimes it’s an issue that everyone can understand. People want to be more informed about the issue and we had really good leadership. I served with Senator Nelson, who was the Chair of Health and Human Services. She made it a top priority and many of us followed her and made it our priority and resulted in good things happening in Texas.”

Senator Larry Taylor serves not only on the Senate Finance Committee but chairs the Senate Public Education Committee. Senator Taylor will be a key player in seeing mental health funding, such as Mental Health First Aide, is distributed to educators across the state. Last session, $5 million was allocated to train educators in Mental Health First Aide, and 8 hour program that teaches how to help people developing a mental illness or in crisis. In Harris County alone, that means 400 teachers trained in Mental Health First Aide.

Freshman Senator Paul Bettencourt is serving his first term in the Texas Senate, taking over the seat previously held by Lt. Governor Dan Patrick. Senator Bettencourt has meet with our office and from his seats on the Senate Public Education and Higher Education Committees has a very unique position to help with mental health initiatives, especially the mental health loan assistant repayment program in SB 239.

This impressive lineup has a difficult task in front of it in securing the needed resources for mental health. They will need to hear from people across Texas to make sure that mental health isn’t ignored or pushed to the side. So when and how are people reaching out to thank, educate, and persuade legislators? More on that, next time.

This is Minding Houston. I’m Bill Kelly.

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Music from this episode: “Badass” and Funky Suspense” by Bensound, “Motown ton” by Ton, “Einsame Verfolger” by Melophon and Premium Music

Thank you to the Texas Tribune. To listen to the complete “What’s Next for Mental Health?” panel, visit their Soundcloud.

Minding Houston Episode V – Criminal Justice & Mental Health: Connected Because of Failure

We’ve talked about funding and workforce needs for mental health services. So why is it so important that Texas lawmakers prioritize mental health services in view of all the other needs in the state? Well, my argument would be we are already paying for these mental health services, in a much more costly and difficult way: the criminal justice system.

This is Minding Houston, I’m Bill Kelly.

Before we start this, I have a caveat I’d like to place on the connection between mental health and criminal justice. Way too often, we closely associate the two and it sometimes seems that having a mental health condition makes you a criminal or a risk to society.

The Hogg Foundation for Mental Health recently hosted a forum about violence prevention and mental health at the State Capitol. Some interesting stats that Dr. Joel Dvoskin the University of Arizona brought up included:

• People suffering from a Severe and Persistent Mental Illness are 11 to 12 times more likely to be victims of a violent crime
• If all violence related to mental illness were to go away, the overall reduction in violent crime would be only 4%
• The odds of someone with schizophrenia killing someone is approximately 1 in 140,000

Let me be very clear: the only thing criminal about mental illness is the way we have failed to invest in access for treatment.

With that, let’s get back to how mental health and criminal justice are connected. Far too often, this failure to invest in access has lead to individuals entering the criminal justice system, instead of the public health programs. This leaves jails and prisons becoming the safety net for Texans suffering from a mental illness. The statistics clearly bear this out.

The Meadows Mental Health Public Policy Institute list “Smart Justice” as a priority for their work. The statistics they offer show exactly why:

• Individuals with untreated mental health and substance use disorders at 8 times more likely to be incarcerated, often due to the lack of access to appropriate crisis services and ongoing care.
• 34% of Texas inmates have a mental health need and most have substance use disorders
• 17% of adults entering jails and state prisons have a serious mental health illness (SMHI)

What does that mean for us here in Greater Houston? Well, just listen to Sheriff Garcia talk about how much of his work is consumed caring for inmates who are mentally ill:

Houston Matters – June 9, 2014

Sheriff: I completely agree and look, I take pride in a lot of things being Sheriff of Harris County, but the one I don’t take pride in is the fact that the Harris County jail system is often referred to as the largest psychiatric facility in the state of Texas. And look, we don’t want people in the county jail for being sick. We want them there for having committed some terrible crime, but we don’t want them there because they are sick and that it is there illness that principally drives them to come to the attention of local law enforcement. And so we need the state to be responsible about this issue, responsible about the care that these individuals need and provide the citizens of Texas a better way to respond to those challenges that some families inadvertently are confronting.

Craig Cohen: Roughly speaking, what percentage of the jail population falls under the category of ‘these are people who are mentally ill and need in patient care and by default you have to provide it?’

Sheriff: Approximately 30%. I mean, just as Bill mentioned that number is very accurate. It’s about 30% of my population at any given time and you have to recognize the significance of the fact that it’s been 30% regardless of when I was overcrowded and at 12,000 – nearly 12,000 capacity or right now when I’m not overcrowded it’s still 30%. And again, they’re there principally because they are sick, not because they are bad people.

Now, Sheriff Garcia sees the consequences of a lack of access. Another elected leader who has dealt with the state’s criminal justice system is long time Texas Senate Criminal Justice Chair Senator John Whitmire. He clearly draws the line between the lack of access for the population to mental health care and prison.

Houston Public Media – Pilot Jail Diversion Program For Mentally Ill – August 21, 2014

According to the Department of Criminal Justice, roughly one third of the people in the Texas prison system have some form of mental illness.

Houston state Sen. John Whitmire chairs the Senate Criminal Justice Committee. He says those inmates end up in jail because they fell through the cracks and were not being treated for their illness.

Harris County Crisis intervention Response Team

“Thirty-two-thousand have been identified, that were in a mental health program before they ever committed a crime. But because of the lack of community mental health services in this state, because of budget cuts at 2003, they do not get assistance when they’re having an episode or crying out for help,” said Whitmire.

The re-entry program for these people doesn’t exist anywhere in the state, and Whitmire says that probably means a return to prison.

“They don’t get their counseling. They don’t get their medication. They’re bipolar; they’re schizophrenic. They have an altercation with their family or a neighbor. Law enforcement is called, then they have an altercation with law enforcement. Welcome to the criminal justice system,” said Whitmire.

With these statistics and testimonials, I think we can all agree about the problem facing those with mental illness and the unfortunate burden on the criminal justice system in providing care.

So how do we make treatment more available and accessible so jails aren’t the largest providers of mental health services?

Harris County has an idea: let’s keep patients out of jail.

Last Session, Senate Bill 1185 created the Harris County Mental Health Jail Diversion program. With bipartisan support from Senators John Whitmire and Joan Huffman, County Judge Ed Emmett pushed the Legislature to match Harris County’s investment to establish a system to address individuals suffering from a mental illness that cycled in and out of the Harris County Jail. SB 1185 looks to concentrate resources and coordinate social services so that patients get the care they need outside of jail cell.

Houston Public Media – Pilot Jail Diversion Program For Mentally Ill – August 21, 2014

The Harris County Mental Health Jail Diversion program is the product of legislation passed by Texas lawmakers last year, that provided $5-million dollars for the launch.

Director Reginia Hicks says some goals of the program include the reduction of the frequency of arrests, incarcerations and the number of days spent in jail, to increase access to housing, health and social services, and to improve the quality of life.

“We have a special mental health program within our jails. We have specialty courts with judges that are focusing on behavioral health issues,” said Hicks. “We have providers with many years of experience.

We have the opportunity of making some earlier interventions.”

After the official launch, Harris County Judge Ed Emmett said he felt confident the Mental Health Jail Diversion program will serve as the model for other cities to emulate.

“The Legislature wants us to do it for four years, and then we will present to the Legislature what works,” said Emmett. “Because if it applies in Harris County, it clearly applies in the rest of the state, and then perhaps even the nation. So, I hope that what we develop here is the model program for the whole nation.”

Emmett and other officials often describe the county lockup as the “largest mental health facility in the state of Texas.”

It seems an obvious notion that people suffering from mental illness would be better served in clinical, rather than criminal settings. It is also much less expensive to provide acute inpatient or outpatient mental health care than the constant cycling of through county jails, prisons, and courts. The Houston Chronicle lauds the local programs that try and address this problem with this from their Editorial Board:

Harris County has adopted some strong programs. Teams of police officers and mental health professionals partner on targeted calls to help ensure that people with mental illness are not arrested unnecessarily. Through its pilot jail-diversion program, judges work with these professionals to keep those with mental illness from cycling through the criminal justice system.

However when Texas fails to invest in the needed clinical capacity for providing mental healthcare, we pay for it in terms of tax dollars and suffering. In a separate Editorial focusing on this need, the Chronicle states, “Our current system is pennywise and pound foolish,” and concludes with the following:

Harris County is the most populous region in the state. One in 5 people, or 350,000 adults residing in Harris County, will suffer from mental illness during their lifetime, according to Harris County Psychiatric Center. The Legislature should act next session to expand the capacity of the mental health system and give us more beds for patients in Harris County, preferably in a modern facility closer to home.

Given the strong support from our local elected leaders about the need for resources to expand capacity, who are our state leaders making these decisions? As of last week, both the Texas House and Senate have named committee chairs. What do those positions mean for mental health policy in Texas? More on that, next time.

This is Minding Houston, a presentation of Mental Health America of Greater Houston. I’m Bill Kelly.

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Music from this episode: “Please Listen Carefully” by Jahzzar, “The War of the Sun Fist” by Gasc@t, “Impact Prelude” by Kevin MacLeod, “Manhattan Skyline” by DeeTunez , and “I’m Fine, Dear” by Dexter Britain. To listen to the full interviews and news sampled in this program visit Houston Matters, Houston Public Media and the Houston Chronicle. And a very special thank you to Cody McGaughey for lending your voice to this episode. 

Minding Houston Episode IV: The Mental Health Workforce

With the 1115 Waiver making investments in behavioral health services throughout the state, and especially here in Greater Houston, it’s natural to ask the question about the professionals needed to staff these new programs. And we don’t just mean psychiatrists, but the full spectrum of mental healthcare positions, just like those masters degree clinicians from MHMRA riding along with police officers for our CIRT units. In this episode, we’ll look at the best data to describe the mental health workforce shortage that should catch everyone’s attention, especially our lawmakers.

This is Minding Houston, I’m Bill Kelly.

Before jumping into legislative solutions about how to attract more mental health professionals, it makes sense to ask the question, “do we really need them?” Or, to say it another way, what are the consequences of not having an adequate mental health workforce? A 2011 report by the Hogg Foundation for Mental Health entitled “Crisis Point: Mental Health Workforce Shortages in Texas” gives a clear answer on what we face:

The cost of mental illness does not simply disappear when service providers are not available. Instead, these costs transfer to other less effective, more expensive and unprepared environments, such as prisons and hospitals. Research and experience clearly show that the lack of sufficient mental health services often results in hospitalization, incarceration or homelessness, creating far greater economic and human costs.

Supporting a strong system of mental health services isn’t just for the benefit of people with mental illness. Mental health and wellness are important to all Texans. Without a strong mental health system, communities suffer through lost productivity, unemployment, job absenteeism, increased involvement with law enforcement, and increased local hospital costs.

Now, for anyone who cares about the bottom line in budgets, the quality of life for patients, and need for a healthy Texas, these consequences are simply unacceptable. Alright, so we know there is a problem, but how bad is it?

The report sites the following:

• Compared to California, New York, Illinois and Florida – the other four most populous states – Texas has the most severe short¬age of psychiatrists, social workers and psychologists
• The pool of mental health professionals is aging. In the coming decade, many psychiatrists, social workers and other providers will leave the workforce for retirement.
• These shortages are felt most acutely in rural and under served areas of Texas, such as the border region.

Unfortunately, things haven’t improved since this report was released in 2011. One of the most respected health care groups in Texas just released a report this January that echoes many of the same concerns. In an interview with Houston Public Media, Code Red’s task force chair and former state demographer Steve Murdock discusses the situation with behavioral health:

Maggie Martin: Medicaid wasn’t the only issue or concern that was raised in this report and something maybe especially raised for Houston, being the home of the Texas Medical Center. What are some of the issues and concerns the task force found within the health care profession itself?

Steve Murdoc: Well, I think that’s one of the things that we found is of course In areas, particularly in behavioral health, we are very short in terms of personnel. We have a wonderful medical center and it does lots of things very well but when it comes to behavioral health we lag behind many other states. I gave you the earlier example of 49th in terms of psychiatry in the country and so certainly we have areas in our health care system where we need to provide more physicians. We have for years, for example, lacked enough residencies. Now the reason that is so important is that one of the best predictors of where a physician will end up practicing is where he or she does their residency and we actually export people to residencies in other states which means that they are likely or less likely to come back and practice in Texas. So a number of things about our program are such that indicate we can also do a better job of ensuring we can get as many of those excellent students that we produce from our medical schools to stay and practice in Texas …

The good news is the Legislature is paying attention. In fact, during the last legislative session in 2013, Republican Representative Cindy Burkett from North Texas, and Democratic Representative Carol Alvarado from Houston co-authored a bill calling for a study of the Texas Mental Health Workforce Shortage and possible solutions.

The final report was issued in the September of 2014, and as you would expect, it confirmed the very serious problems Texas will face without immediate investment. Out of the five themes discussed in the report, the first recommendation is the most important in addressing this problem. Quoting from the report:

At its core, the mental health workforce shortage is driven by factors that affect recruitment and retention of individual practioners. Chief among these factors, as studies and stakeholders suggest, is that the current payment system fails to provide adequate reimbursements for providers, especially in light of the extensive training necessary for practice.

Furthermore, more students may be attracted to the mental health professions by strengthening graduate medical education and by exposing them to opportunities in the mental health field earlier in their education.

Like a lot of public policy, it boils down to money. Our state has failed to invest in this area, and unless we start making a down payment for our mental health workforce, we will undoubtedly suffer the consequence that a lack of access brings.

That’s where Sen. Charles Shwertner comes in. The new Texas Senate Chair of Health and Human Services is tackling the issue of mental health workforce for the full spectrum of providers. The Texas Tribune’s Alana Rocha reports:

Bluebonnet officials say that a bill by health and human services committee chairman Charles Schwertner could elevate the prestige of the profession and help workers balance their desire to serve the mentally ill, make ends meet, and pay off their loans. Schwertner filed a bill Monday to create a grant program to repay loans for licensed professionals, social workers, psychiatrists and psychologists.

“Money spent on mental health is money that is effectively spent. It keeps people out of the emergency room, it keeps people out of the jails and also the school resources that are spent on individuals that need help. If you can catch someone early, get them the right treatment in the right setting that’s the way to handle mental health. It’s cost effective.”

“There’s a huge return on investment for this.”

Andrea Richardson knows first-hand as the executive director of Bluebonnet she worked with Senator Schwertner, himself a practicing physician on developing the bill that creates a commitment from professionals seeking loan reimbursement. The percentage of the loan repayment grows with each year they work in the field.

“It recognizes the value of mental health. It allows for mental health to become a part of the health care system. You know so often we disconnect the mind from the body when in reality it’s the mind and the body working together that keeps us healthy.”

An integrated approach to addressing a growing need.

So, how did this trained orthopedic surgeon suddenly becomes one of the leading advocates for mental health in the entire Texas Legislature? Well, as the Houston Chronicle Editorial Board writes in support of his bill, he might have just been listening to mother:

Each of our incoming legislators will bring varied life experiences to the next session and its upcoming debates over spending and priorities. That’s certainly true of state Sen. Charles Schwertner, R-Georgetown. Schwertner, one of the few doctors in the Legislature, is not only an experienced orthopedic surgeon but also has some familiarity with mental health care. Schwertner’s mother spent over 25 years as a nurse in Texas’ mental health system. The state senator has a habit of saying that he knows firsthand what impact a dedicated mental health professional can have on the life of someone suffering from mental illness.

After reviewing many of the same statistics cited in the previous studies, the Chronicle concludes:

The Legislature should make Schwertner’s mother proud and act to pass his bill, a good first step in heading off this growing crisis.

So we’ve heard from the Hogg Foundation for Mental Health, the medical experts at Code Red, a workforce shortage study of House Bill 1023, and the newly filed mental health loan repayment bills and we hope our Legislators listen to Senator Schwertner’s mom.

But what happens when we don’t listen? In this case, what happens when we fail to provide access for mental health services? Quite simply, we face the same health challenges but we face them in a criminal justice setting. More on that next time.

From Minding Houston, I’m Bill Kelly.

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This weeks episode includes “Dirty Night,” “Settling In,” and “Slow Motion Strut” by composer Dexter Britain and “Ego Grinding” by Megatroid. Hear more of Dexter Britain’s music at DexterBritain.co.uk and Soundcloud and listen to “Ego Grinding” at FreeMusicArchive.com

View the 2011 Hogg Report here and read Code Red: The Critical Condition of Health in Texas for detailed information about the Texas mental health workforce shortage. Listen to the full Houston Matters interview with Code Red’s task force chair and former state demographer Steve Murdock and hear more about Charles Schwertner’s loan reimbursement bid at the Texas Tribune website. 

Minding Houston Episode III: The 1115 Medicaid Waiver in Houston

What if I told you the State of Texas and the federal government are working together, on an $11.4 billion partnership to help increase access to care for Texans? There are no lawsuits, political posturing, or name calling. The program is praised by Republicans, Democrats, and every healthcare organization across the state. Sound impossible? Well, let me tell you: it’s all true. And when it comes to increasing behavioral health services, it’s even better.

This is Minding Houston, I’m Bill Kelly. 

Today, we wanted to talk about the biggest expansion of behavioral health services in Texas. Ever heard of the 1115 Waiver? Well, if not, maybe it’s because it hasn’t generated the, let’s call it the “heat” that other federal initiatives have here in Texas.

So first things first, what is the 1115 Waiver? Simply put, it is a 5 year agreement between the federal Center for Medicare & Medicaid Services, or CMS, and the Texas Health and Human Services Commission, or HHSC. Together, CMS and HHSC have negotiated a plan to combine state dollars spent on healthcare to draw down matching federal funds all in an effort to expand the footprint of healthcare services in Texas.

       1115 Medicaid Waiver made easy

So what does this really mean for us in Greater Houston? As it turns out, quite a lot. Over our nine county Regional Health Partnership (one of 20 organized throughout the state), we stand to gain over $2.3 billion dollars in expanded healthcare services.

So, what do these programs look like? Well, let me introduce you to two programs funded
by the 1115 Waiver. First, in a report by Houston Public Media’s Carrie Feibel, is a look at Mental Health Crisis Clinics set up by Memorial Hermann.

Now, as we’ve noted before, the lack of access to mental healthcare leaves an increasing number of cases to be handled by law enforcement. That’s where our second example, the Crisis Intervention Response Team comes in. In this story by KHOU reporter Jeff McShan, you can see first hand the difference having both a mental health professional and law enforcement training has in dealing with a mental health crisis.

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Both the Memorial Hermann mental health crisis clinics and three CIRT details are funded by the 1115 Waiver using Delivery System Reform Incentive Payments, or DSRIP funds. In our area, there are 55 projects specifically for Behavioral Health totaling $457 million dollars. Now, remember from last week, our state spends just over 1 billion a year in mental health services through DSHS for the entire state, and DSIRP dollars put almost half a billion right here in our own backyard.

This badly needed expansion of access for mental healthcare represents a huge step forward for the State of Texas. But it also brings a number of challenges. Like, do we have enough of a workforce to staff this expansion? What is the mental health workforce shortage and what we can do about it? More on that, next time.

This is Bill Kelly for Minding Houston, a presentation of Mental Health America of Greater Houston.

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Music from this episode: “Rollin at 5 – 210” by Kevin MacLeod and “Sand Castle” by Pitx.

To hear Carrie Fiebel’s full report about the Humble Crisis Center, listen here at Houston Public Media. To hear more about the HPD Crisis Intervention & Response Team (CIRT), watch here at KHOU.com.

Minding Houston Episode II: Mental Health Money

As the 84th Legislative Session begins, our lawmakers are only constitutionally required to do one thing: pass a budget. While likely to pass over 1,000 other pieces of legislation, the Legislature is legally bound to determine the funding for state services for the next biennium. And that bill, the Appropriations Bill, is where questions about the financing for mental health services are answered.

Before looking at this biennium, it is worth looking at were we started. Historically, Texas has not funded services on the level with other states. The best study of this was done by the Kaiser Family Foundation in comparing per capita spending on mental health services.

From an interview I gave with Houston Public Media’s Craig Cohen on an episode of “Houston Matters” in June of 2014,

“For the Fiscal Year 2010, Texas ranked 49th in terms of per capita spending on mental health with right at $39. Keep that 39 dollar figure in mind for comparison sake. Our neighbors to the east in Louisiana spend $62 per capita, and further down the road, Alabama spends $78. Mississippi, who we are often compared to for social services, spends $114. The national average is $120.”

So with that historical under investment in mind, what does Texas spend on mental health now? To best show the answer, our friends at the Meadows Mental Health Policy Institute produce the following slide that breaks down the figures.

The vast majority of state spending on mental health comes from the $1.16 billion spent yearly by the Department of State Health Services. Roughly $160 million a year is spent on substance abuse.

Getting your head around those big numbers helps to show just how successful the last legislative session was for funding. A chart from the House Appropriations Committee hearing this summer outlines the additional $312 million in increased spending within DSHS. A breakdown of these additional expenditures is listed on the attached chart.

While badly needed, last session’s invest won’t solve the problem of serving Texans with mental health needs. Aside from continued investment from lawmakers, Texas needs to expand the footprint of services so more people can have access. Thanks to a partnership between Texas and the federal government, and yes you heard that right, we are doing just that. More on that next time.

This is Bill Kelly for Minding Houston, a presentation of Mental Health America of Greater Houston.

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We would like to thank both Houston Matters and the Meadows Mental Health Policy Institute. To hear the rest of the interview, listen here at the Houston Matters website.

This episodes music included “Never Let it Go” by Bluesraiders, “Strange Sensations” by Anitek and “Plethora” by Anitek.

Minding Houston Episode I: Moving Forward in 2015

Welcome to the 84^th Legislative Session! My name is Bill Kelly, the Director of Public Policy & Government Affairs here at Mental Health America of Greater Houston. With the start of new year comes 140 days of governing, and that means our advocacy will be kicking into high gear.

We invite you to keep up with our work by following our new Legislative Blog, “Minding Houston” where we will share the latest on issues and bill movement. 

I’ve been a Chief of Staff for a State Legislator and worked for the Mayor’s Office at the City of Houston. I’m very proud to work for the issues and policies that Mental Health America of Greater Houston has endorsed and look forward to using this blog to keep you updated on legislative progress.

To receive your free EMAIL SUBSCRIPTION to the blog visit mhahouston.wordpress.com

Enter your email address (see top right of page) to subscribe to this blog and receive notifications of new posts by email.  Then select, SIGN ME UP.

[Transcript below]

Since the last Legislative Session ended, there have been a number of press reports about the progress made in Texas in mental health funding. The purpose of this blog is to help keep you updated with what policies Mental Health America of Greater Houston will be working on during 2015 and the stories of real people that these policies impact.

Recently, the Mental Health America of Greater Houston Board has approved series of Legislative Priorities. It is our hope to help tell the stories of how and why policy changes have dramatic impacts for the quality of life for those with loved ones suffering from a mental illness or substance abuse problems. By highlighting our priorities in press stories, we hope to raise the attention of lawmakers and hope they continue their efforts to invest in mental health.

To help set the stage, check out this article from our friends at the Houston Chronicle on July 12th.

Advocates are urging Texas lawmakers to remember the problems in the state’s mental health system after a couple of hearings in which progress on mental health has been cast as one of the Legislature’s greatest recent accomplishments.

Last session’s roughly $350 million increase in funding for mental health and drug abuse services helped reduce the number of Texans on a waiting list for psychiatric treatment from 5,515 last February to 790 this February, including from 1,750 to zero in Harris County, and 194 to 11 among children. The reductions were hailed at a state House Appropriations Subcommittee meeting last month.

“That’s an extraordinary outcome,” said Rep. John Zerwas, R-Richmond, the panel’s chairman.

{…}

Still, Zerwas said the waiting-list reductions represent a “very solid first step.”

“We have made steps forward in the past,” the lawmaker added. “But every time we would make a step forward, we would next time make a step backward. So, a real focus of mine is making sure that we take another major step forward next year.”

This is where we hope to help Rep. Zerwas and the strong bipartisan coalition that wants to reduce the expensive consequences of failing to invest in mental health services. We need to move forward, and we know that we can by showing the solid return on investment that come with funding.

This is Bill Kelly for Minding Houston, a presentation of Mental Health America of Greater Houston.

Music from this episode: “The 3rd” by Anitek and “Looping Guitar Improv in Em” by Steve Combs.