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:

Chronicle

“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:

BK & Kennedy

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:

CMS

” . . . 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.


 

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

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?

Hogg 11

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.

Code Red LogoUnfortunately, 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:

MASTHEAD-Houston-Chronicle

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.


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

       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.

CroppedSide2_400x400avatars-000071167573-llcflk-t200x200

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.

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.


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 MediaTo 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.”

Meadows

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.

Meadows

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.Click for larger photo

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.


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 84th 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]Cap Dome Lighter

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.

State and Federal Updates

In this post, surprisingly NO budget updates, but a little on Medicaid and federal and state behavioral health legislation.

Medicaid Expansion Being Debated Today

This morning, the House Appropriations Subcommittee on Budget Transparency and Reform heard testimony on HB 3376 by Rep. Sylvester Turner, which would expand Medicaid to all individuals eligible under the ACA.  As previously mentioned, it is estimated that 90% of individuals currently receiving public mental health and substance abuse services would be eligible for Medicaid under such an expansion.

Dozens of advocates were out in full force to express their support for this important legislation.  NAMI Policy Director Greg Hansch and Hogg Foundation for Mental Health Fellow Peter McGraw gave testimony about the positive impact Medicaid expansion would have on people with mental illness.  The hearing recessed for House proceedings but will resume after the House adjourns for the day.

Other legislation the subcommittee will consider include HB 3791, Rep. Zerwas’ “Texas solution” Medicaid expansion bill, and HB 3339 by Rep. Martinez-Fisher, which would allow the use of Rainy Day Funds to restore the $5.4 billion cut from public schools last session.

Comprehensive Federal Behavioral Health Legislation Moving Forward

Last week I shared a little about S. 689, the Mental Health Awareness and Improvement Act, which is being sponsored by Health, Education, Labor and Pensions (HELP) Committee Chairman Tom Harkins. The bipartisan bill was introduced after the HELP Committee’s January hearing to assess the state of the country’s mental health system. The bill was voted unanimously out of the HELP Committee last Wednesday and is now awaiting action by the full Senate.

The bill takes a number of positive steps to promote prevention and early intervention and improve the delivery of mental health and substance abuse services. From the Section-by-Section analysis (with a few minor revisions), key provisions of the bill include:

• Encouraging the development of school-wide prevention programs, such as positive behavioral interventions and supports.

• Encouraging states to provide technical assistance to school districts and school personnel on the implementation of school-based mental health programs.

• Reauthorizing the Youth Suicide Early Intervention and Prevention Strategies grants to states and tribes.

• Reauthorizing the Mental Health and Substance Use Disorder Services on Campuses grant program and updates the use of funds to allow for the education of students, families, faculty, and staff to increase awareness and training to respond effectively to students with mental health and substance use disorders, to provide outreach to administer voluntary screenings and assessments to students, and to enhance networks with health care providers who treat mental health and substance use disorders. Incorporates consideration of the needs of veterans enrolled as students on campus.

• Reauthorizing grants to states, political subdivisions of states, Indian tribes, tribal organizations, and nonprofit private entities to train teachers, appropriate school personnel, emergency services personnel, and others, as appropriate, to recognize the signs and symptoms of mental illness, to become familiar with resources in the community for individuals with mental illnesses, and for the purpose of the safe de-escalation of crisis situations involving individuals with mental illness.

• Reauthorizing the National Child Traumatic Stress Initiative.

• Requiring a Government Accountability Office (GAO) report on the federal requirements affecting access to mental health and substance use disorder treatment related to integration with primary care, administrative and regulatory issues, quality measurement and accountability, and data sharing.

• Directing the Substance Abuse and Mental Health Services Administration to advance the education and awareness of providers, patients, and other stakeholders regarding FDA-approved products to treat opioid use disorders; calls for a report on such activities, including the role of adherence in the treatment of opioid use disorders, and recommendations on priorities and strategies to address co-occurring substance use disorders and mental illness.

• Requiring a GAO report on the utilization of mental health services for children, including information about how children access care and referrals; the tools and assessments available for children; and the usage of psychotropic medications.

• Encouraging the Secretary of HHS to disseminate information and provide technical assistance on evidence-based practices for mental health and substance use disorders in older adults.

• Requiring a GAO study on the status of implementation of recommendations developed after the Virginia Tech tragedy, as well as identification of any barriers to implementation and identification of additional actions the Federal government can take to support states and local communities to ensure the Federal government and laws are not obstacles at the community level.

We will continue to monitor and share updates on this bill as it makes its way through the legislative process.

Behavioral Health Legislation

Many pieces of legislation MHA is tracking continue to be on the move. In the last week, the following bills have passed out of committee or their respective chambers:

VOTED OUT OF COMMITTEE

HB 592
Relating to the definition of serious mental illness for purposes of certain group health benefit plans. 

HB 1947
Relating to the criteria for commitment of a person with mental illness.

HB 1952
Relating to professional development training for certain public school personnel regarding student disciplinary procedures.

HB 2392
Relating to the mental health program for veterans.

HB 2812
Relating to an annual report by the reentry and integration division and the parole division of the Texas Department of Criminal Justice.

SB 34
Relating to the administration of psychoactive medications to persons receiving services in certain facilities.

SB 861
Relating to requiring certain notices to be posted on the premises of certain alcoholic beverage retailers. 

SB 913
Relating to the reexamination of an applicant for a professional counselor license. 

SB 914
Relating to a behavior improvement plan adopted for certain students with an individualized education program.

SB 1356
Relating to requiring trauma-informed care training for certain staff of county and state juvenile facilities.

VOTED OUT OF CHAMBER

HB 232
Relating to allowing certain minors convicted of certain alcohol offenses to perform community service instead of attending an alcohol awareness program.

HB 807
Relating to the practice of psychology; authorizing a fee.

HB 1738
Relating to a standard form of notification for the detention of a person with mental illness.

SB 718
Relating to voluntary and involuntary mental health services.

SB 831
Relating to a list of mental health, substance abuse, and suicide prevention programs that may be selected for implementation by public schools.

SB 898
Relating to the mental health program for veterans.

SB 1057
Relating to information about private health care insurance coverage and the health insurance exchange for individuals applying for certain Department of State Health Services health or mental health benefits, services, and assistance.

SB 1114
Relating to the prosecution of certain misdemeanor offenses committed by children and to school district law enforcement.

SB 1178
Relating to training for public school educators in identifying mental health and suicide risks among students.

SB 1352
Relating to inclusion of mental health concerns in existing state and local coordinated school health efforts.

For a more in-depth view of behavioral health legislation and MHA’s position on these bills, check out our bill tracker here.

More next week!

All About the Budget…and a Little More

In this issue, get more detailed information on the mental health and substance abuse services funded by the House and Senate budget bills, information on how sequestration will affect behavioral health, and as always, a bill update.

Senate Budget On Its Way to the Floor

Last Wednesday, the Senate Finance Committee voted out its budget bill, CSSB 1, which includes over $200 million more for behavioral health services.  Since I’ve previously outlined the approved Senate mental health and substance abuse initiatives, I won’t repeat all of that information. However, there are a few budget riders–“footnotes” that designate funding for certain purposes–worth mentioning:

  • Requirement that DSHS withhold 10% of appropriated funds to each Local Mental Health Authority (LMHA) for ongoing community and crisis mental health services and distribute the funds based upon a performance-based incentive plan
  • Requirement that DSHS develop a 10-year plan for the provision of psychiatric services at state hospitals (with the inclusion of public input)
  • Designation of children’s mental health prevention and early intervention funds for  evidence-based curricula that train school personnel and community members about the signs and risks of mental health issues
  • $8 million of appropriated funds designated for the veterans mental health program
  • $8 million of appropriated crisis funds designated for outpatient competency restoration programs

House Makes Amends

As I mentioned in my last post, also on Wednesday, the House Appropriations Committee approved over $200 million more for mental health and substance abuse services as well. This was a reversal from earlier Article II Subcommittee decisions that amounted to just $33 million more for behavioral health. The House budget bill, which will be substituted in place of the Senate bill when it makes its way over to the House, funds the following services:

Mental Health

  • $54.2 million to eliminate the ~6,500 person waiting list for mental health services
  • $24.8 million to expand housing support options for people with mental illness
  • $32.5 million to expand the YES waiver
  • $25 million for Haven for Hope-like community parterships
  • $25 million to expand crisis services
  • $20 million to expand community mental health services for children and adults
  • $17 million to increase service package offerings for underserved children and adults
  • $6 million to expand NorthSTAR services
  • $4 million for veterans mental health
  • $2.4 million for 6 long-term treatment beds (up to 90 days) at the Harris County Psychiatric Center

Substance Abuse

  • $6 million to increase substance abuse provider rates by 3.9%
  • $5 million for substance abuse services for individuals referred by DFPS
  • $4.9 million to eliminate the 946-person substance abuse service waiting list
  • $1.1 million to expand the Oxford House model across Texas

Additionally, Representatives Sylvester Turner and Ruth Jones McClendon submitted a rider to the budget that would ensure that increased mental health funding would address inequities among LMHAs. If maintained in the final version of the bill, this would mean that Harris County MHMRA, which has one of the lowest per capita funding rates among the LMHAs, would receive a disproportionate amount of the additional monies. The House Appropriations Committee also adopted the performance-based incentive plan rider adopted by Senate Finance.

Regarding funding for behavioral health services, so far, so good! If you didn’t get a chance to respond to the MHA alert sent out yesterday, how about take a moment to call your favorite members of House Appropriations and Senate Finance to thank them for their good work?

Federal Behavioral Health Funding Cut

While the budget is looking good at the state level, things are shaky at the federal level. As a result of sequestration–the automatic federal budget cuts that are kicking in due to lack of Congressional action on deficit reduction–the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) is set to lose $168 million, or about 5%, of its total funding by September 30th of this year. This will include across-the-board cuts to all programs, including the mental health block grant (funded at a level of $460 million) and the substance abuse block grant (funded at a level of $1.8 billion). As a result, funding will be reduced accordingly at the state level.

According to DSHS, funding for substance abuse services will need to be reduced by $6.7 million and funding for mental health services by $1.7 million. DSHS has asked stakeholders to complete a survey to give input on how DSHS should implement these cuts.

Obviously, substance abuse programs will take a bigger hit, so it’s important to try and minimize the impact to the most important programs. For whatever my 2 cents is worth, I probably would recommend that funding for children’s substance abuse prevention, intervention and treatment services remain unharmed. If the adults take cuts, it may be better to target those to prevention and intervention, rather than treatment, since we still have a substance abuse treatment waiting list (at least in the current fiscal year). Again, that’s just what I think.  If the substance abuse community has any thoughts, please share!

That being said, please take a moment to complete this survey. It is due this Friday, March 22nd.

Behavioral Health Legislation

As you know, MHA is tracking over 200 mental health- and substance abuse-related bills. You can view them all here. Many of the bills have been progressing quickly through the process.The following legislation has been voted out of committee:

HB 908
Relating to the assessment of an elderly or disabled person’s psychological status for purposes of an emergency order authorizing protective services.

SB 36
Relating to the detention and transportation of a person with a mental illness.

SB 58
Relating to integrating behavioral health and physical health services provided under the Medicaid program using managed care organizations.

SB 152
Relating to the protection and care of persons who are elderly or disabled or who are children.

SB 256
Relating to tracking career information for graduates of Texas medical schools.

SB 401
Relating to a notification requirement if a school counselor is not assigned to a public school campus.

SB 462
Relating to specialty court programs in this state.

SB 944
Relating to criminal history record checks for certain employees of facilities licensed by the Department of State Health Services.

In addition, the Senate already has voted a few bills out of its chamber, which are now awaiting action in the House. These include:

SB 50
Relating to the Children’s Policy Council, including the composition of the council.

SB 109
Relating to a housing plan developed and certain housing information collected and reported by the Texas Department of Housing and Community Affairs.

SB 126
Relating to the creation of a mental health and substance abuse public reporting system.

SB 426
Relating to a home visiting program for at-risk families.

Again, check out summaries of these bills, MHA’s positions, and more by viewing our bill tracker.

Catcha next week!