Regional Policy Council 2016: A year of learning, sharing, and celebrating… setting the stage for 2017.
The Regional Policy Council (RPC) concluded its 2016 meeting season with 120 affiliate and community partner attendees at four day-long policy meetings. Speakers included policy experts, industry leaders, and experts in national, state, and local policy. Each meeting coincided with a national meeting of state legislators or elected officials, including the National Governors Association (NGA), the National Conference of State Legislatures (NCSL), the Council of State Governments (CSG), and the American Legislative Exchange Council (ALEC). (NGA, NCLS, CSG, ALEC), More than 200 legislators and guests attended each meeting or accompanying legislative receptions where three governors and eight state legislative champions were honored. Other RPC activities included monthly regional calls, monthly national calls with RPC representatives, participation in developing a white paper about managed care options in Nevada, legislative advocacy, speaking at legislative conferences (CSG, NCSL, and WIG). There were three RPC webinars; The Power of Zero: A Systems Approach to Suicide Prevention, Six Unused Medicaid Rules and How to Implement Them; and This Year’s Gains, Next Year’s Challenges. And as the final product for 2016, there is this year-end report, which provides details about each RPC meeting and a preview of 2017 activities.
Washington DC: Evolving Strategies for the Delivery and Payment of Mental Health Services
As with all RPC gatherings MHA policy and advocacy staff opened the meeting with an up-to the-minute briefing on what’s happening on Capitol Hill. This DC-based meeting also included experts from the federal government. Setting the stage for the day’s deep dive into the topic Evolving Strategizes for the Delivery and Payment for Mental Health Services, public health advisors from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Mental Health Services (CMHS) were joined by evaluators from the Health Resources and Services Administration (HRSA) Office of Planning, Analysis and Evaluation to present an overview of progress and methods for measuring outcomes for the integration for physical and behavioral health services. They reviewed with participants why this is essential for people with behavioral health conditions—one reason is that 68 percent also have one or more chronic co-occurring conditions.
MHA invited industry Partners such as Beacon Health, the nation’s largest behavioral health managed care company, who have been pioneers in the adoption of peer run services. Building on that history, MHA invited Beacon presenters Lori Szczygiel, Senior Vice President, Strategy & Development, and Dr. Lawrence Goldman, Senior Vice President of Government Relations. The topic of their presentation, Funding for Peer and Crisis Services in Managed Care, offered a brief tutorial on payment methodologies, including fee-for-service, episode bundled payment, case rate payment, and behavioral health capitation. Meeting participants learned about barriers to moving from the traditional fee-for-service models, which include inertia (“it’s how things have always been done”), lack of continuum of care, lack of integrated services, and outcomes measurements that are solely clinical. Ms. Szcygiel and Dr. Goldman presented an array of payment option combinations currently utilized in a wide variety of states, demonstrating the axiom that if you’ve seen one state’s Medicaid plan, you’ve seen one state’s Medicaid plan. They also offered examples of how various states use valued-based payments to provide Emergency Services Programs (ESP) which are recovery-oriented, crisis services. They further explained that ESP services emphasize the three R’s (resiliency, rehabilitation, and recovery) by providing 24/7 mental health and substance use crisis services that employ Certified Peer Specialists, and connect with peer run programs and family partners.
They explained that increasing the peer workforce was a key component to achieving the value in value-based payment methods. In order to grow the peer workforce, there also must be growth in wages and benefits, greater support for peers in all settings, and expansion of the payment options for peer services beyond the public sector—into private insurance.
Glenn Liebman, Executive Director of MHA in New York, and advocacy champion Harvey Rosenthal, Executive Director of the New York Association of Psychiatric Rehabilitation Services, presented on New York State’s HARP program for people who are covered jointly by Medicaid and Medicare—commonly referred to as folks who are duel eligible. These are the 20 percent of NY’s 5 million Medicaid recipients who use 80 percent of the plan dollars. Forty percent of these people have a primary behavioral health diagnosis and are affected by one or more chronic, co-occurring health conditions. The HARP plan targets the social determinants of health, provides enhanced home and community-based services, and integrates high quality physical health care with behavioral health. And it does so by moving to outcomes-based payment and away from traditional fee-for-service. The person-directed, recovery-based services provided in these plans were designed with the input of consumers and advocacy organizations.
Mental Health America presented the B4Stage4 Award to Governors Scott Walker of Wisconsin, Jay Nixon of Missouri, and Terry McAuliffe of Virginia, for their leadership in mental health. Governors Walker and Nixon accepted the award in-person.
Indianapolis, Indiana: The Economics of State-Funded Mental Health: Penny Wise or Pound Foolish?
Who better to ask the topic question than state legislators, who are members of the American Legislative Exchange Council, (ALEC), and high ranking state officials? At this meeting, RPC participants were introduced to the priorities of ALEC members. ALEC staffers were introduced to Mental Health America’s values of prevention, early intervention, integration, and recovery, as well as the attendant fiscal return on investment that is accrued when state policies embrace these values.
Mental Health America presented the B4Stage4 Legislative Award to Indiana State Representative Cindy Kirchofer, RPC meeting attendees heard from important state officials, including Indiana’s Director of the Division of Mental Health and Addiction (DMHA), Kevin Moore. Mr. Moore detailed the state’s Recovery Works program, highlighting another MHA priority… lessening involvement with the criminal justice system for people with mental health conditions. Recovery Works promotes recovery through community-based services that divert people away from the criminal justice system and provides reentry supports for people leaving jails and prisons.
The Indiana Secretary of Family and Social Services (FSSA), Dr. John Wernert, put forth his answer to managing the economics of state funded mental health in his presentation on the Indiana Medicaid Expansion Program, Heathy Indiana (HIP 2.0). Dr. Wernert shared his belief that Indiana’s Medicaid expansion is “an innovative alternative” for states to follow regarding expansion. Provisions very much in keeping with Mental Health America’s priorities included prioritizing parity, building out the continuum of care by linking the public and private systems, integrating physical and behavioral health within community mental health, same-day billing, increasing the use of technology, including telepsychiatry, removing state legislative and regulatory barriers, and putting provider payment structure on par with face-to-face interactions. Other Indiana specific innovations included restructuring state operated facilities into a single system hospital system with six campuses, which will get people who need hospitalization admitted quicker, with shorter length of stays by linking them to an enhanced continuum of care.
Marianne Burdison of Centene (another of the nation’s premier behavioral health managed care organizations) presented a solid economic case that one of the best investments that a state can make is to assure that people with mental health needs, especially those who are involved in the criminal justice system, have benefits in place, both as a preventative to being incarcerated, and as a reentry tool to prevent return to incarceration. Ms. Burdison provided statistics showing that one in two people in federal and state prisons have a mental illness and/or a substance use disorder. In addition, those individuals usually have at least one other comorbid condition, putting them among the highest cost people served by state systems. Ms. Burdison made clear that what is necessary to break the cycle of incarceration and re-incarceration for people with behavioral health needs is to assure that there are no interruptions in insurance coverage.
Chicago, Illinois: Walking the MHA Talk, Finding Value in Mental Health Care
Mental Health America and the Regional Policy Council continued to strengthen its relationship with the National Conference of State Legislators (NCSL) at its August meeting in Chicago. To open the meeting, MHA presented awards to seven NCSL members from both sides of the legislative aisle, representing IL, MO, KS, and IA, at a legislative reception entitled Walking the MHA Talk, Finding Value in Mental Health Care, attended by more than 100 guests.
Each section of the Walking the MHA Talk agenda represented one of the pillars of MHA. Prevention for All began by looking at the question of how states can address mental health and the front end by highlighting the accomplishments and the advocacy agenda of the Illinois Children’s Behavioral Health Integration Initiative and the Children’s Mental Health Partnership. Chairperson Barbara Shaw outlined the partnership’s accomplishments, which included adoption of a provision that school physicals include social and emotional screening into the Illinois school code. The partnership has been advancing its advocacy agenda for over ten years, garnering support for cross-walking planning and services, building trauma informed systems, and for the provision of earliest interventions, such as perinatal screening, home visitation, and parenting education programs.
Early Identification and Intervention for Those at Risk, featured the presentation Mental Health in Schools: Because that’s where the Children Are. Penny Sitler from MHA of Licking County (OH) and Sue Whitty from MHA-Dubuque (IA) presented on a wide variety of interventions being used in schools that reduce the risk of future mental health disorders, enhance protective factors, and help address emerging concerns.
Integrated Care and Treatment for Those Who Need It, focused on Suicide Prevention: Start Anywhere, End Everywhere. MHA of Wisconsin’s Karrisa Young and RPC representative Shel Gross related the goals and outcomes of Wisconsin’s Zero Suicide Initiative. The initiative uses quality improvement in clinical settings to reach the Zero Suicide movement’s goal to reduce the number of suicides to zero for people in treatment and to provide community education about suicide and public policy that supports suicide prevention.
Recovery as the Goal was directed to individuals and for communities as both a postvention, and as prevention, to create a recovery circle for families and communities that have lost people to suicide. Penny Sitler from MHA of Licking County (OH), Martina Gollin Graves from MHA of Wisconsin, and Steve Moore from the American Foundation for Suicide Prevention spoke of how more attention needs to be focused on those who have been impacted by the death of family and friends by suicide. They examined postvention guidelines, L.O.S.S. teams, survivor and attempt survivor support groups, clergy roles, and other programs that MHAs across the county can implement to help support recovery from suicide deaths and attempts.
Treatment for those Who Need It: Redux took a look closer look at mental health and substance abuse parity legislation as a watershed for recognizing the importance of behavioral health disorders to overall health, and how its full promise of parity has yet to be realized. The speakers were Tim Clement, ParityTrack Policy Director; Kelly O’Brien from the Illinois Parity Coalition; the RPC’s Barbara Johnston from MHA in New Jersey; and parity champion Rep. Lou Lang from Illinois. They discussed the imperative to assure parity by looking at resources for tracking parity implementation, model state legislation, and the efforts of MHAs across the country to shine a light on parity implementation failures.
Coeur d’Alene, Idaho, Dealing Effectively with Fiscal Challenges at the State Level
This meeting began with a lively reception attended by MHA affiliates, industry partners, legislators, and staff from the Council of State Governments (CSG) where old and new legislative friends who attended the CSG Western meeting were able to share information about innovative and cost effective programs, such as how peer-run respite can benefit the citizens, and bottom lines, of Western States.
This meeting again brought together a cohesive group of MHA affiliates that have built strong mentorship relationships over the past few years. Here they took a deep dive into alternative funding methodologies that could be adapted to work in a variety of states. While some old ideas where looked at in new ways that might be used creatively across states, the meeting topics also offered a number of cautionary notes on the cyclical nature of some funding streams, and the national climate regarding increased revenue.
Dan Aune from MHA of Montana prepared slides detailing ways other states might establish a trust to fund health and social services for people with mental health conditions, as Alaska, Montana, North Carolina, Missouri, and Alabama already had. Participants learned of an array of ways that trust funding is obtained, from taxes on distilleries and whiskey (AL); to proceeds from the sale of land (VA); settlements from state lawsuits (MT) to gifts and bequests (MO). Dan challenged his colleagues to just take the first steps and find what might work for them, and best suits their state.
RPC representative Moe Keller was joined by Richard Wansley of MHA of Oklahoma to once again engage participants in an exploration of social impact bonds (additional slides here). This method for enhancing funding to public programs though private investment, is often referred to as “pay for success.” Under such programs, defined outcomes (example: youth who engage in a funded intervention become less involved with the juvenile justice system) are rigorously measured and resultant savings are shared between the public entity that provided the service, such as the county or state, and the private investors that helped to fund the program. This model, explored at previous RPC meetings, has gained traction in the last few years as states and the federal government have provided technical assistance to support states and localities in developing, implementing, and evaluating such programs. Recent legislative actions will also create new opportunities. These include the President’s 2017 Budget and the newly passed 21st Century Cures Act, both of which offer enhanced support for Pay for Success programs.
Another option discussed at this meeting were attempts to increase a state’s tobacco tax. However these efforts did not fare well at the ballot box in November. Moe Keller spoke about Colorado’s proposal for an additional $.84 per pack increase, some of which would have gone to fund homeless services and mental health and substance use prevention programs for children and adolescents. Carlotta McCleary from MHA of North Dakota spoke about her state’s proposal to increase its tax from 44 cents per pack to $2.20 per pack in order to fund a community health trust fund for a comprehensive behavioral health plan, county-level health services, and chronic illness prevention and control programs. This measure lost by more than 30 percentage points.
Also, shared by Ms. McCleary was the recent history of boom and bust mental health funding that is tied to taxes on oil and gas in North Dakota. Just a few years ago, the state’s coffers were flush with dollars that were used increase its outreach services and prevention for children’s mental health, only to have these new and expanded services severely cut, if not eliminated, this past year as gas and oil revenues dramatically dropped.
Rusty Selix, MHA Board Member and policy leader in the state of California, spoke about a funding source that may be renewable in 2-5 year increments, which is revenue neutral, but is also subject to change with each new presidential administration—Medicaid State waivers. Mr. Selix detailed some of the ways that California is using its 1115 and 1115b waivers, which run through 2020, to coordinate services for the population that is dual eligible for Medicare and Medicaid and that has the highest rate of need. Under the Whole Person Care pilot program, which California counties may elect to participate in voluntarily, the waivers can fund services not currently covered in the state plan from the future savings that will be realized by attending to people’s whole health needs. These services include care coordination and the integration of mental health, substance use and physical health services. This is another example of how offering help saves money—and is one of MHA’s major advocacy points.
Drawing the meeting to a close MHA’s Debbie Plotnick engaged the group in a discussion about the importance of messaging to elected officials how cost-effective interventions can Achieve Value by addressing Community Values. As one affiliate meeting attendee remarked, “I’m glad to attend the RPC meetings; it’s the meeting where I always know I’ll learn new things that I can use.”
The RPC wishes to thank its sponsors for the support for these meetings and webinars that help translate MHA priorities into public policy. We look forward to continuing this work in 2017.
As we move into 2017--a year that will see a new administration in Washington and increased focus on the states and local governments--the RPC is planning an exciting new advocacy campaign. 2017 will be the inaugural year for the RPC Back-Home Campaign, which will connect MHA affiliates with their respective, local, state, and federal legislative delegations. Finally, we are pleased to announce our 2017 Regional Policy Meetings:
- Washington DC, at the National Press Club, February 24, 2017, to coincide with NGA—date firm.
- Denver, CO, July 19-21, 2017, to coincide with ALEC (date range, exact date to be announced)
- Boston, MA, August 6-9, 2017, to coincide with NCS L (date range, exact date to be announced)
- Las Vegas, NV, December 14-17, 2017, to coincide with CSG (date range, exact date to be announced)