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HEALTH Haslam may submit Medicaid expansion plan in fallTom Wilemon, twilemon@tennessean.com and The Associated Press 1 day ago
Larry McCormack / File / The Tennessean Gov. Bill Haslam said Thursday that the state may soon submit a proposal to Washington to expand Tennessee’s Medicaid program but did not release any new details on how it might work. 
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 The death of the Murphy Bill: On being the national spokesman
Larry Drain The Murphy Bill as we know is dead. The Republican leadership in the House announced a change in strategy. They basically decided to toss in the towel on the more controversial parts of the plan and try to see if they can move forward on elements that seem to have a greater consensus behind them. There may be CPR efforts yet but it appears done. It was a bill in trouble from the start despite the massive pr campaign that tried so hard to say it wasnt so. It managed to unify groups that might not agree on what kind of reforms they wanted, but were absolutely sure what they didnt want and that was the Murphy Bill. Part of the problem was Murphy himself. He assumed that as "the only psychologist in Congress" he was the obvious and deserved national spokesman for mental health reform. He wasnt. Being a psychologist certainly didnt qualify for the role. Neither did being a member of the House of Representatives. It seemed that Dr. Torrey annointed him and for some reason they both thought that mattered. In the end it was hard to know where he started and Dr. Torrey ended and that was perhaps a fatal flaw. He didnt understand that leadership was built or that it was a two way street. He alienated people who had lived mental health reform their entire adult lives. He thought it was about them joining him and never seemed to know it was the other way around. And he never realized that trust was everything and that when he snuck AOT into the medicare bill he destroyed his chances of trust with people whose support he needed. He was naive. The only people who believe federal laws change everything are federal lawmakers and most of them know better. To say that his law was going to prevent the next shooting was simply ego. He believed his own press clippings and his posturing before the dead were even buried just seemed like rank opportunism. Mental health reform is an ongoing effort by many, many people with different values and priorities. Sometimes it is its own worst enemy. People who cant stand each other have a hard time standing together for anything. Murphy I hope has to some degree taught people they can find unity despite their differences. And maybe the fragile unity borne of him will be the biggest take-away from the entire thing. He may indeed try again. He probably will. Dr. Torrey most surely will. He has won many, many short term victories and will doubtless win more, but the big prize has eluded him again. He is not the national spokesman he has annointed himself to be either. 
Larry Drain, Legislative Liaison for DBSA Tennessee, offers this blog with its many references that provides points for and against the Murphy bill. Please take time to self educate. Larry gives us a good start.[Children's Mental Health NetworkThe Morning Zen]Congressman Tim Murphy introduces controversial Helping Families in Mental Health Crisis Act of 20132 Comments | Posted December 15, 2013 On Friday, one day before the anniversary of the Newtown school shooting tragedy and on the same day of yet another tragic shooting at a school in Colorado, Congressman Tim Murphy introduced the Helping Families in Mental Health Crisis Act of 2013, a bill that would effectively rewrite how the Substance Abuse and Mental Health Services Administration (SAMHSA) operates and significantly narrow the focus of the types of mental health services and supports it helps promote through its grant programs. While the bill is at this point just a proposal, it is an important read for Network faithful as it sheds a light on the thinking of many individuals across the country about how to improve mental health services in America. Unfortunately, with the continued tragedies occurring at schools across the nation the tendency to equate guns and violence with mental illness leads to recommended solutions in this bill that are narrow in focus and could potentially set back the advances in the field of mental health 20 to 30 years. What makes writing this Morning Zen piece difficult for me is that I have the utmost respect for Congressman Murphy. A child psychologist by training, co-author of two books ("The Angry Child: Regaining Control When Your Child Is Out of Control" and "Overcoming Passive-Aggression), it is obvious that Congressman Murphy cares deeply about improving mental health services. For that he is to be applauded. But what is in this proposed bill for the most part is either mystifying or antithetical to what the research tells us works best for young people with emotional challenges and their families. In fairness, at the end of this post I have included links to position statements on the proposed bill from national organizations and thought leaders both for and against the bill. As always, we pride ourselves on providing as many perspectives as possible so that our educated readers can make up their own minds and respond to their elected officials accordingly. The response from mental health advocates and provider groups both for and against the bill was swift. As is the general approach of the Children's Mental Health Network we took the weekend to read and digest the 135-page bill before making our comments. The list is long so grab a cup of coffee for this one. The proposed bill is complex in that mixed in with proposals that are administratively bureaucratic, relying on reference resources that in some cases are twenty years old and frankly dismissive of anything outside of the realm of narrowly defined evidence based practice, are some excellent proposals such as continuing funding for the Garrett Lee Smith and National Child Traumatic Stress initiatives. However, overwhelmingly the recommended changes in the bill set the advances made in knowledge about what works for youth with mental health challenges and their families back a good twenty to thirty years. Clouding the picture of how to interpret this proposed bill was the timing of its release – on the eve of the anniversary of the Newtown tragedy and on the day of yet another shooting at a school in Colorado, where emotions were already running high and the popular press was flooded with news stories about guns, violence and mental illness. Even though research shows that those with a mental illness are significantly more likely to be a victim of violence than a perpetrator of violence, discussions in Congress about what to do tend to fall too easily into the guns + violence = mental illness equation. Okay, with all of this in mind as a backdrop for what is in the proposed bill, let’s take a walk through some of the highlights. The 135 page document is one I encourage you to read to get your own sense of its merits and drawbacks. In this post I will focus on some of the key areas that are important to highlight. Page numbers of the bill are cited so that you can read the full text in the copy of the proposed bill that you can download here. Additional layers of bureaucracy added while diminishing the decision-making role of key SAMHSA personnel (Page 4) National Mental Health Policy Laboratory (page 7)
The description of the NMHPL goes on to say that "In selecting evidence-based practices and services delivery models for evaluation and dissemination under paragraph (2)(C), the Director of the NMHPL
On page 10 the language continues with "In carrying out the duties under this section, the Director of the NMHPL shall consult with representatives of the National Institute of Mental Health on organization, hiring decisions, and operations, initially and on an ongoing basis; (B) other appropriate Federal agencies; and (C) clinical and analytical experts with expertise in medicine, psychiatric and clinical psychological care, and health care management. The Children’s Mental Health Network is troubled that there is no mention of youth and family involvement in such a consulting pool, especially with the impressive track record achieved by SAMHSA in cultivating a family-driven, youth guided approach through its system of care grants and cooperative agreements over the past 20+ years. Interagency Serious Mental Illness Coordinating Committee (page 14) The responsibilities of this Committee include:
There is a long list of required members for this committee (page 15), including the Director of NIH, the Attorney General of the United States; the Director of the Centers for Disease Control and Prevention and more. Members of the Committee serve 4-year terms and would be required to meet a minimum of two times per year. In addition, the Committee “may establish subcommittees and convene workshops and conferences "to enable the subcommittees to carry out their duties." And finally, with regard to administrative duties, on page 70 it is noted that the administration of block grants would be removed from the Director of the Center for Mental Health Services and shifted to the Assistant Secretary for Mental Health and Substance Use Disorders. Gonna be one busy Assistant Secretary if this proposal goes through! I can't help but think that if this plan were to come to fruition there would be bureaucratic gridlock. Two new significant leadership positions assuming key duties of currently existing high ranking officials within SAMHSA and a large Committee with sub-committees to "assist the Assistant Secretary in carrying out the Assistant Secretary's duties" (Page 14). In my mind, this is a huge duplication of duties already ascribed to the SAMHSA Administrator, the Director of the Center for Mental Health Services and others within SAMHSA. Let's move away from administrative duties to some of the new grant programs proposed, specifically the Assisted Outpatient Treatment Program. The proposed bill calls for up to 50 grants each year for a 4-year pilot program to focus on assisted outpatient treatment programs (Page 19). Each grant would be eligible for one million dollars per year for four years - $15,000,000 per year would be authorized totaling $60,000,000 over the four-year period. Assisted outpatient treatment is a controversial topic, with some saying it is the best option for an adult with a mental illness who "lacks capacity to fully understand or lacks judgment to make informed decisions regarding his or her need for treatment, care, or supervision." Others, including the Children's Mental Health Network, see this as a potentially dangerous road to travel in that it could have wide-ranging impact on those who might be swept up unnecessarily. You can review both sides of the argument regarding Assisted Outpatient Treatment at the end of this post. Number of seriously mentally ill who are imprisoned (page 63) Reducing the stigma of serious mental illness (page 79) Title XI-SAMHSA Reauthorization and Reforms (page 99) In addition, it would be required that "Before awarding a grant, cooperative agreement, or contract, the Secretary shall provide a list of the members of the peer review group responsible for reviewing the award to the Committee on Energy and Commerce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate." This is yet another opportunity for delay and bureaucratic red tape. Transfer of all functions and responsibilities of the Center for Behavioral Health Statistics and Quality to the National Mental Health Policy Laboratory (page 102) Establish a clearinghouse of evidence-based practices (page 106) Unfortunately there is no mention of consumers, families or youth involved in this review. Limitations on Authority (page 133) No financial assistance to any program without evidence-based practices (page 133) If you have made it this far in this lengthy post you know that this leads back to the question "What is an evidence-based practice and who is involved in deciding that?" From reading the full text of the proposed bill the decision makers are definitely skewed toward the medical community with a strong focus on a narrow slice of the overall population of individuals needing mental health services. Elimination of unauthorized SAMHSA programs without explicit statutory authorization (page 134) The proposed bill goes on to say "The Assistant Secretary for Mental Health and Substance Use Disorders shall seek to enter into an arrangement with the Institute of Medicine under which the Institute (or, if the Institute declines to enter into such arrangement, another appropriate entity) agrees to submit a report to the Congress not later than July 31, 2014, identifying each program, project, or activity to be terminated under subsection (a). So, there you have it. Quite a bit to chew on and I cut this post down significantly. Please take the time to read the proposed bill. Whether it gains traction in the House or not it is important to remember that this proposed bill reflects the thinking of many. If you are concerned about this, as we are, then you might want to consider an education campaign. Next week we will share our collaborative efforts with Maryland-based mental health providers, adult and youth representatives with experience receiving mental health services, and family advocates and other agency representatives to put together a site visit for Senate and House Appropriations Committee staff to not only show them what a coordinated system of care approach looks like in the effective provision of services and supports for young adults with mental health challenges, but also to provide them the opportunity for one on one dialogue with youth and adults who utilize mental health services, families and the amazingly dedicated professionals who work side by side with them. We began organizing this effort for Senate Appropriations staff as a result of our inquiry into the Healthy Transitions Initiative in August of this year. Senate Appropriations Committee staff have agreed to come and we will be extending an invitation to House Appropriations Committee staff this week. I will give you full details in the Morning Zen post this coming Friday. What is so important about our education campaign is that it is not focused on one grant or particular service. We are not bringing staffers to a visit to ask for money. We are bringing staffers to a visit to let them experience firsthand the importance of a comprehensive approach to meeting (in this case) the needs of young adults with mental health challenges. Sounds like a systems of care approach to me! And finally, here is a sampling of different individual and organizational analyses and reactions to the proposed bill, both pro and con. Remember, an educated voice is a powerful voice. For the proposed bill
Against the proposed bill
Scott Bryant-Comstock Submitted by Jennifer Dochod, Legislative Liasion for DBSA Tennessee. The brief summary by Mr. Murphy's office highlights the points in the proposed Bill he drafted. Tim Murphy U.S. Congressman for the 18th District of Pennsylvania Short Summary of The Helping Families In Mental Health Crisis Act (H.R. 3717) Ensuring Psychiatric Care for Those in Need of Help the Most Rep. Tim Murphy, PhD Mental illness does not discriminate based on age, class or ethnicity. It affects all segments of society. More than 11 million Americans have severe schizophrenia, bipolar disorder, and major depression yet millions are going without treatment as families struggle to find care for loved ones. To understand why so many go without treatment, the Energy and Commerce Subcommittee on Oversight and Investigations launched a top-to-bottom review of the country’s mental health system beginning in January 2013. The investigation revealed that the approach by the federal government to mental health is a chaotic patchwork of antiquated programs and ineffective policies across numerous agencies. Not only is this frustrating for families in need of medical care, but when left untreated, those with mental illness often end up in the criminal justice system or on the streets. The mentally ill are no more violent than anyone else, and in fact are more likely to be the victims of violence than the perpetrators, but individuals with untreated serious mental illness are at an increased risk of violent behavior. Tragically, undertreated mental illness has been linked to homicides, assaults, and suicides. The Helping Families In Mental Health Crisis Act (H.R. 3717) fixes the nation’s broken mental health system by focusing programs and resources on psychiatric care for patients and families most in need of services. The legislation: EMPOWERS PARENTS AND CAREGIVERS What the investigation found: Physicians are often unwilling to share or receive information with loved ones about an individual who has a serious mental illness and is experiencing a psychotic break because of complicated federal rules on communicating with immediate family members and caregivers. This scenario is especially problematic for parents of young adults with mental illness because psychosis begins to manifest between ages 14 and 25. Clarifies Health Information Portability and Accountability Act (HIPAA) privacy rule and the Family Educational Rights and Privacy Act so physicians and mental health professionals can provide crucial information to parents and caregivers about a loved one who is in an acute mental health crisis to protect their health, safety, and well-being. 2332 Rayburn House Office Building | Washington, DC 20515
The Helping Families in Mental Health Crisis Act (H.R. 3717), Rep. Tim Murphy 2 FIXES THE SHORTAGE OF INPATIENT PSYCHIATRIC BEDS What the investigation found: There is a severe lack of inpatient and outpatient treatment options. Seventy years ago, the country had 600,000 inpatient psychiatric beds for a country half the size. Today, there are only 40,000 beds. What the legislation does: Increases access to acute care psychiatric beds for the most critical patients by making two narrowly tailored exceptions to the Institutions for Mental Disease (IMD) exclusion under Medicaid. The IMD exclusion is what originally caused the shortage of psychiatric beds. ALTERNATIVES TO INSTITUTIONALIZATION What the investigation found: Approximately forty percent of individuals with schizophrenia do not recognize they have a mental illness, making it exceedingly difficult for them to follow through on a treatment regimen. REACHING UNDESERVED AND RURAL POPULATIONS What the investigation found: The delay between a first episode of psychosis and the onset of treatment averages 110 weeks. Early diagnosis and medical intervention improves outcomes dramatically, but there is only one child psychiatrist for every 7,000 children with a mental illness or behavioral disorder. What the legislation does: Modeled on a successful state project in Massachusetts, the bill advances tele-psychiatry to link pediatricians and primary care physicians with psychiatrists and psychologists in areas where patients do not have access to mental health professionals. DRIVING EVIDENCE-BASED CARE What the investigation found: The federal government spends $125 billion annually on mental health, but there is little interagency coordination on programs, nor does the federal government collect data on how mental health dollars are spent or whether those dollars are resulting in positive health outcomes. What the legislation does: Creates Assistant Secretary for Mental Health and Substance Use Disorders within the Department of Health and Human Services to coordinate federal government programs and ensure that recipients of the community mental health services block grant apply evidence-based models of care developed by the National Institute of Mental Health. The Assistant Secretary will ensure federal programs are optimized for patient care rather than bureaucracy.
What the investigation found: STABILIZING PATIENTS BEYOND THE ER Access to physician-prescribed medication is vital for vulnerable individuals in avoid acute mental health crisis. Current policies that permit only “one drug” per therapeutic class policy ignore the clinical needs of individuals with mental illness who rely on vital, non-interchangeable prescription drug therapies. What the legislation does: Protects certain classes of drugs commonly used to treat mental illness so physicians have prescribe the right medication for those on Medicare and Medicaid similar to the protected classes for persons with epilepsy and cancer. ADVANCES CRITICAL MEDICAL RESEARCH What the investigation found: The National Institute of Mental Health measures public health outcomes to develop medical models of care. For example, the Recovery After Initial Schizophrenia Episode (RAISE) project shows earlier intervention with treatment for a person at risk of developing full-blown schizophrenia allows patients to lead functional lives. The NIMH also excels at basic medical research, but lacks the financial resources. What the legislation does: Authorizes the BRAIN research initiative at the National Institute of Mental Health and encourages the agency to undertake additional research projects on serious mental illness and self- or other-directed violence. HIGH QUALITY COMMUNITY BEHAVIORAL HEALTH SERVICES What the investigation found: Community Mental Health Centers receiving funds from the federal government receive lower reimbursements federal insurance programs than comparable care facilities. What the legislation does: Applies rigorous quality standards for a new class of Federally Qualified Community Behavioral Health Clinics (FQCBHC), requiring them to provide a range of mental health and primary care services. DEPARTMENT OF JUSTICE REFORMS What the investigation found: Between twenty and fifty percent of the incarnated system inmates have a mental illness. Mental health courts have provided a cost-effective and responsible alternative to incarcerating the mentally ill. What the legislation does: So patients are treated in healthcare system and not warehoused in the criminal justice system, the bill reauthorizes mental health courts and requires the Department of Justice to collect more data on interactions between the police and the mentally ill. The bill also authorizes Byrne Justice Assistance Grants (JAG) to be used for mental health training of law enforcement and corrections officers.
BEHAVIORAL HEALTH AWARENESS FOR CHILDREN AND TEENS What the investigation found: Despite increased medical and scientific research into the nature and source of serious mental illness, a mental illness stigma persists. What the legislation does: The Department of Education, working with mental health stakeholders, will undertake a national campaign aimed at reducing the stigma of severe mental illness in schools. The bill also reauthorizes the Garrett Lee Smith suicide prevention program. INTEGRATES PRIMARY AND BEHAVIORAL CARE What the investigation found: Low-income individuals with serious mental illness and addiction disorders have high incidences of cancer, heart disease, diabetes and asthma. Untreated depression increases the risk of chronic diseases, and can double the cost of healthcare for health disease and diabetes. Integrating mental healthcare providers into electronic medical records systems will result in better coordinated care for patients as well as cost savings. What the legislation does: Extends the health information technology incentive program to mental health providers so they can communicate and work with primary care clinicians. INCREASES PHYSICIAN VOLUNTEERISM What the investigation found: Health centers and mental health clinics are experiencing a staff shortage. Clinicians and healthcare professionals can volunteer at federal free clinics, but federal legal barriers and the high cost of medical malpractice insurance prevent them from doing so at community health centers and mental health clinics. What the legislation does: Eliminates federal legal barriers under the Federal Tort Claims Act preventing physician volunteerism at community mental health clinics and federally-qualified health centers. REFORMS THE SUBSTANCE ABUSE & MENTAL HEALTH SERVICES ADMINISTRATION What the investigation found: Unauthorized in the last decade, the Substance Abuse and Mental Health Services Administration has lacked mission focus. Grant programs are not evidence-based or guided by the best available medical science. What the legislation does: Emphasizes evidence-based treatments, sunsets unauthorized programs, and strengthens congressional oversight of all federal behavioral health grants.
A big step backward into the future: mental health “reform” Washington style
by hopeworkscommunity The new mental health reform bill introduced by Rep Murphy provides for the following according to the Treatment Advocacy Center: " Requires states to have commitment criteria broader than “dangerousness” and to authorize assisted outpatient treatment (AOT) in order to receive Community Mental Health Service Block Grant funds. Allocates $15 million for a federal AOT block grant program to fund to 50 grants per year for new local AOT programs. Carves out an exemption in HIPAA (Health Insurance Portability and Accountability Act) allowing a “caregiver” to receive protected health information when a mental health care provider reasonably believes disclosure to the caregiver is necessary to protect the health, safety or welfare of the patient or the safety of another. (The definition of “caregiver” includes immediate family members.)" TRANSLATION: What does it mean? 1. States will be substantially limited in their control over their own mental health policy. This, in and of itself, represents a radical change of immense implications. It is a wall once breached that will never be rolled back. 2. The future direction of mental health policy will basically be in the hands of the Treatment Advocacy Center. After years and years of failing to get states to follow their policy of coercion first to the degree they want their view would effectively become federal policy. What they could never win by choice they will win by force. 3. Much gains in knowledge about what really works and helps people with mental health issues would be rendered unimportant and out of fashion. The notion of recovery would be given a death blow. 4. States by federal statute would have to agree to commit more and more people. 5. Failure to do so would make you ineligible for federal block grants that are the backbone of so many state mental health budgets. 6. Privacy laws would not allow so much privacy. Confidentiality would have holes big enough to drive a hole through. And that is only the beginning. It is a step back into an era of mental health care that was a national disgrace and one in which a diagnosis of mental illness was a life sentence. |
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