Update on Mental Health Policy Issues

1
Update on Mental Health Policy Issues

• June 2007 Presentation by Rusty Selix
• Executive Director
• California Council of Community Mental Health
  Agencies (CCCMHA)

2
Congress Mental Health Parity

• Chance to pass Mental Health Parity
• Impacts large employers exempt from state laws
• Full Mental Health Parity
• Substance Abuse Parity
• Senate Bill Pre-empts State Laws
• No adverse impacts in California
• House bill is more certain but unacceptable to
  interests needed to get 60 votes in Senate

3
CMS/Rehab Option

• Restrictive Medicaid Philosophy
• Rehabilitation Option Definitions
• Telephone advice to states
• Rehab limited to improvement to a former state of
  being
• Cant be maintenance
• Cant be a skill you never had
• Proposed Regs expected soon
• Home and Community Based Services Option Iowa
  example gives hope!

4
Home and Community Based Services Option -HCBS

• Authorized in deficit reduction act (DRA)
• Available January 1, 2007
• No guidance regs yet
• Iowa just approved
• Broader benefits for defined pop - SMI/SED
• States can cap eligible
• Not a waiver need not be cost neutral
• Permanent state plan amendment
• DMH-CMHDA Interested

5
Services to Veterans?

• Iraq war returnees with PTSD overwhelming VA
  capacity
• Funding and authority to refer to other providers
• CMHCs doing this in other states
• Contract or fee for service
• CCCMHA north and south committees

6
California Healthcare Reform

• Six million uninsured
• Schwarzenegger, Kuehl, Perata, Nunez
• All have legal and political problems
• Pressure to do something
• Mental Health benefits protected
• Guaranteed right to coverage pre-existing
  condition limit overcome

7
Prison Overcrowding

• 170,000 in system double capacity
• and of California prisoners with serious
  mental illnesses growing faster
• 80 Recidivism Rate
• 1998 16,000 11
• 2003 25,000 16
• 2006 34,000 20

8
Prison MH Reform SB 851

• Prop 63 will eventually serve everyone in harms
  way
• Provide AB 34 Recovery Services
• Homeless Outreach to Prevent Crime
• MH Courts - Diversion to reduce incarceration
• In Prison Rehabilitation,
• AB 2034 for parolees phased in
• State pays for parolees counties fearful

9
Co-Occurring Disorders?

• Alcohol and drug with mental illness
• Expectation not an exception
• Fully cover in public and private plans?
• Bill A/D under EPSDT?
• Train professionals to be able to do both
• Require integrated services
• Co-locate with Primary Care?
• Report to MHSOAC in July

10
2007- 08 Budget

• Estimated permanent 5 Billion Deficit
• Prop 63 Revenues Exceed Projections
• 55 million AB 2034 - Restored?
• SSI/SSP COLAs?
• AB 3632 fully funded not discussed
• EPSDT back payments over 3 years
• EPSDT up -
• Realignment up?

11
AB 3632- What is funded?

• 69 million formula via Dept of Education for
  06-07
• Addl Funds to fully pay claims for 06-07
• Addl Funds to pay most 07-08 claims
• Total wont be known until several months into
  07-08 and not due until 08-09
• No new Funds for 00-01, 01-02, and 02-03 claims
  to be repaid over 15 years

12
EPSDT Audits

• Extrapolation limited to error rate over 5
• Retroactive to 04 and 05 audits
• 75 of audits no extrapolation
• New appeals to address clerical errors and other
  adjustments not yet settled
• Cases kept open
• Each audit only one service function
  Extrapolation to 90 confidence-
• Final guidance manual nearly done

13
Proposition 63 Revenues Up!!!
14
Future Resources to spend

• Three year plans 09-10 to 11-12
• Estimated average - 2.4 Billion
• More than double original projections
• Assumes 10 annual revenue growth
• Conservative compared to current trends
• Original Projection was 7 annual growth
• Cuts in other funding and programs
• Supplantation??

15
Realignment Adult CSS/other
16
Supplantation Issues

• MHSA says only for increases - no cuts
• No exceptions
• DMH emergency regs - required
• Exempts overmatch realignment transfers
• Permanent regs pending
• Office of Administrative Law review
• Legal challenges
• MHSOAC says it could withhold

17
Adult CSS Revenues
18
Adult CSS - MHSA vs Realignment
19
Prop 63/Mental Health Services Act (MHSA)
20
Full Service Partnerships

• Not well understood by some counties
• 24-7 and include dually diagnosed
• Housing for those not clean and sober
• Outcome oriented
• Independent living and employment
• Not limited to high need clients
• Physical health and wellness
• early death, smoking, diet, exercise

21
FSP for Kids EPSDT/3632

• Most high need kids get EPSDT/3632
• Wont pay for all needs
• Respite care and other family support
• Alcohol and drug?
• 3632 Crisis care
• Case rate to supplement EPSDT/3632
• Can have risk/reserve factor

22
Education and Training

• Stipends to attract/retain
• Loan Forgiveness
• Academic program expansion and improvement of
  curriculum
• Attract high school students
• Employ consumers and family members
• Retraining staff
• Fair share for private providers!

23
Education and Training

• 500 million through 2007-08
• Some Funds remain with state
• Based upon county needs
• State prepares five year plan
• Draft state plan due in June
• Some funds available in 07-08
• Additional funding for future years

24
Capital Facilities and Technology

• 500 million through 2007-08
• Formula distribution not yet announced
• Very flexible eligibility
• Must relate to providing eligible services
• Technology likely to be web based open system
  that can be used in all counties and by all
  providers
• Additional funding through plans for future
• Fair share for private providers!!

25
Innovative Services

• 5 of what a county receives for CSS PEI
• County proposals must be approved by Oversight
  and Accountability Commission
• Commission Developing Guidelines
• Funds expected in 2008
• Ideas may be developed locally or at state
• Cant be something already widely done

26
Prevention and Early Intervention

• PEI State first draft guidelines/regs out soon
• OAC jump start Higher Ed/Schools
• Respond to Virginia Tech
• Broad competitive grants to institutions
• Develop strategic plan?
• Stigma and Discrimination
• Statewide media campaign informed by political
  consultant
• Suicide Prevention Committee and set aside

27
Prevention and Early Intervention - concepts

• Take steps to get help as soon as possible after
  someone exhibits symptoms that could be or become
  a severe mental illness or a serious emotional
  disturbance
• Make sure it happens before someone has hit rock
  bottom or been hospitalized
• Requires education and outreach to those in a
  position to recognize that someone near needs
  help

28
Changing Attitudes through Early Intervention

• Identify and treat schizophrenia in first few
  months Early Psychosis began in Australia
• Back to work or school within a year
• Save and shift to private insurance
• Educate 15-25 year olds, their families and
  primary care about symptoms and value of
  treatment and how to access it
• Outreach/education 1 per capita per year
• Expanding to Bipolar and Depression

29
Help for schools and kids

• Teachers know who SED/at risk kids are
• Need referral system/on campus help
• Early treatment costs hundreds vs thousands
• Increases attendance and graduation
• Reduce teacher burnout
• Reduce out of home placements

30
Prevention and Early Intervention

• Minimum 20 of funds starting in 2008
• 200 per year for 2 years
• 400-600m after
• Formula distribution
• State must develop new program
• State process through summer
• County planning in fall/winter
• County plans must be approved by Oversight and
  Accountability Commission

31
This is totally new

• What are the most likely programs?
• Who will be the providers?
• What other funds will be leveraged?
• What will each program cost?
• How many people can be served?
• What results are we looking for?
• How will we measure what is achieved?

32
Planning process

• (1) State establishes program and planning
  requirements statewide stigma reduction and
  suicide prevention and plans
• (2) Develop County Plans with expanded
  stakeholder participation
• Within each community each setting and age group
  may require a different set of strategies
• Not all expected to be included at first
• (3) Review and approval by Commission

33
CCCMHA Priorities?

• Early Childhood?
• Early Psychosis?
• School Based Programs?
• Suicide Prevention?
• Outreach to elderly/primary care?
• Outreach to Latino/Asian communities?
• Other??

34
www.dmh.ca.gov/mhsa

• Situation constantly changing
• Unprecedented level of stakeholder participation
• All materials posted on DMH website
• Sign up to get notice of new materials
• www.cimh.org county specific info

35
Remember how special this is

• Transformation of a large public mental health
  system wont happen overnight
• Take the time to get it right
• Dont delay the things we know should be done
• Appreciate the broad and diverse participation
• Be assertive and patient