Highlight on Alabama: Class action against state alleges inadequate prison mental health care

Focus on the issue of accessibility to quality mental health care has been growing in recent years, and the state of Alabama is facing intense scrutiny for the possible failure to treat mentally ill inmates. A federal trial began on December 5, 2016, in which dozens of inmates are expected to testify.

This trial is one part of a larger suit filed by the Southern Poverty Law Center (SPLC) in 2014 alleging that overall, medical care in the state’s prisons is below constitutional standards. Claims that the Department of Corrections (DOC) failed to accommodate prisoners with physical disabilities were previously settled, with the DOC agreeing to improve its facilities.

U.S. District Judge Myron Thompson granted class action status to the mental health portion of the case in November 2016,  noting that the failure to provide funding for staff creates an Eighth Amendment violation, even if this is caused by a lack of available money.

The claims currently being heard allege that the mental health care, provided through the contractor MHM Correctional Services, fails to provide enough providers to offer care, including psychiatrists, psychologists, and nurses. Additionally, the lack of security staff causes interruptions in care. This results in failing to identify mentally ill inmates and properly diagnose the severity of illness in those who are identified. These issues have led to a failure to prescribe medication, manage side effects, offer adequate counseling, and properly monitor and treat inmates who are suicidal and self harm.

According to a local news report, the first inmate witness had been in prison for six years and is currently at the Donaldson Correctional Facility. He testified that he had physical and mental illnesses and was prone to self harm, but he only sees mental health staff approximately every two months for sessions lasting about five or 10 minutes.

SPLC stated that other expected witnesses include a Dr. Kathryn Burns, a mental health expert who has inspected nine Alabama prisons and their mental health procedures.

This suit is not the only attention Alabama’s prisons are currently receiving. In October 2016, the Department of Justice began a statewide investigation into the conditions in Alabama’s prisons. This investigation is to focus on efforts to protect prisoners from abuse and excessive force at the hands of other prisoners or correctional offers, as well as the provision of sanitary, secure, and safe living conditions.

Highlight on California: the price of privatizing psychiatric care

California may privatize a state mental health hospital as a cost saving measure. However, critics are worried that Correct Care Recovery Solutions, the selected contractor, will achieve cost savings through dangerous reductions in care quality. The California Mental Health Services Authority—the consortium of California county mental health agencies—is proposing a facility which would serve around 250 civilly-committed patients. Additional beds are needed due to a persistent and historically high need for the most dangerous and severe of the state’s mentally ill.

Backlog

The current network of state hospitals houses people who are charged with crimes but found mentally incompetent to stand trial or not guilty by reason of insanity. In June, the waiting list for hospital beds reached a five-year high of 700 individuals. The average wait time for an individual not found competent to stand trial is two months, but many are forced to wait several months.  Those patients found incompetent to stand trial who do not have access to a bed are forced to wait in county jails, typically in Los Angeles County.  In county jails, patients have access to basic mental health care but long-term psychiatric treatment is often delayed. Other patients, those who are civilly-committed, are housed in local psychiatric hospitals.

Costs

The costs are significant regardless of where patients are housed. It can cost between $600 and $1,300 a day to house civilly-committed patients in local psychiatric hospitals in Los Angeles County. When patients are eventually transferred to state hospitals, counties are still obligated to pay for the care provided to patients, and the state bills about $650 per patient, per day. In 2015, Los Angeles County, alone, spent $55 million on patient care in state mental health hospitals.

Correct Care

The contractor, Correct Care, says it can cut the state’s cost by 10 percent. However, the promise of cost savings through privatization has a complex history. The Department of Justice (DOJ) announced in August 2016 that it would end its use of private prisons noting that private facilities are both less safe and less effective than government run facilities. Soon after, the Obama Administration announced it would take steps to move away from the use of for-profit (private) immigration detention facilities. Privatization of state psychiatric facilities poses similar problems to those which led to the administration’s policy on prisons and immigration facilities.

Privatized State Hospitals: South Florida State Hospital

If California moves forward with its plan, the state will not be the first to privatize a state mental health hospital. The South Florida State Hospital was one of the first in the U.S. to be privatized.  The Florida hospital was managed by a division of GEO Group—a private prison contractor—until 2014, when Correct Care Solutions bought the unit. Following three deaths in the facility, in 2011, Florida’s Department of Children and Families investigated the hospital. In one of the deaths, a heavily medicated patient was found dead in a bathtub with water so hot the patient’s skin sloughed off his body. Investigators determined that Correct Care was addressing the problems. However, between 2011 and 2015, investigators verified 19 more claims that staff abused, neglected, or failed to properly supervise those in their care. Some of those instances of abuse and neglect included a technician throwing a patient to the ground and a patient jumping to his death from the eighth floor of a parking garage. Those opposed to privately run mental health institutions cite understaffing as a key cause of such abuse and neglect.

State-run hospitals

The state-run hospitals are not immune from criticism and instances of patient harm. In 2014, 3,500 patient-against-patient assaults were recorded in California. Metropolitan State Hospital in Norwalk admits the type of civil-commitments which would be transferred to the hypothetical Correct Care facility. Between 2011 and 2015, the California Department of Public Health investigators found at least 55 deficiencies at Metropolitan related to a patient’s harm, abuse, neglect, and restraint.

Access

There is no dispute that California requires additional mental health hospital beds. However, regardless of who will operate additional mental health facilities, lawmakers and stakeholders in California must be careful that the wellbeing of patients is not exchanged in a bargain for a lower rate.

Access to behavioral health care is improving, but more work is needed

“The landscape for access to mental health and substance use services has markedly improve in recent years” and “it is highly likely that these trends will continue,” according to the Final Report of the White House Mental Health and Substance Use Disorder Parity Task Force. President Obama created the Task Force with the goal of developing a set of tools, guidelines, and mechanism to ensure that mental health parity is actually enforced. The Task Force’s Final Report summarizes its work including reviewing progress to date, identifying and taking immediate steps as needed, and outlining recommendations.

Task Force participants and directives

The President directed the Task Force, which included the White House Domestic Council, the Departments of Treasury, Defense, Justice, Labor, HHS, and Veteran’s Affairs as well as the Offices of Personnel Management and National Drug Control Policy, to review parity implementation; increase awareness of the protections that parity provides; and improve understanding of the requirements of parity and its protections among key stakeholders, including consumers, providers, employers, insurance issuers, and state regulations. The task force also was directed to increase the transparency of the compliance process and the support, resources, and tools available to ensure that coverage is in compliance with party and improve the monitoring and enforcement process.

Gathering information

Among the information gathered from March through October 2016, the Task Force looked at barriers to implementation and enforcement, party compliance and documenting parity violations, identifying behavioral workforce issues, documenting treatment limitations, and clarifying the role of states and the federal government in bringing about parity.

The role of mental health laws

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (P.L. 110-343) generally prohibits employment-based group health plans and health insurance issuers that provide group health coverage for mental health and substance use disorders from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. This includes restrictions related to financial requirements and quantitative treatment limitations, and nonquantitative treatment limitations. It also expands mental health parity requirements to substance use disorders, such imposing less favorable lifetime or annual dollar amount limits than the lifetime and annual dollar amount limits imposed on medical and surgical benefits.

The Patient Protection and Affordable Care Act (ACA) (P.L. 110-148) prohibits group health coverage and nongrandfathered individual market insurance from imposing lifetime and annual dollar limits on Essential Health Benefits (EHB), including mental health and substance use disorder services, and prohibits grandfathered individual markets from imposing lifetime dollar limits. The ACA increased access to mental health and substance abuse disorder coverage and parity by requiring coverage offered through Health Insurance Marketplaces and nongrandfathered health plans to cover EHBs including mental health and substance use disorder benefits. The ACA extended the application of the MHPAEA to the individual insurance market and qualified health plans and expanded Medicaid requirements to be in compliance with mental health parity.

Task Force actions

As directed by President Obama, the Task Force identified immediate actions that it could take in three main areas: education and awareness, clarification of parity requirements, and improving compliance, monitoring, and enforcement. In June 2016, the HHS and the Department of Labor jointly released a pamphlet for consumers that outlines the basic protections guaranteed by the MHPAEA and consumer rights to transparency and appeals, entitled, “Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits.” In March 2016, CMS published a Final rule to align the mental health and substance use disorder coverage benefits offered by managed care organizations, Medicaid, and the Children’s Health Insurance Program (CHIP) with parity protections required of the commercial market as well as releasing Frequently asked questions and hosting a webinar to explain the parity protections in the Final Rule.

In August of 2016, Substance Abuse and Mental Health Services Administration (SAMHSA) issued a report outlining promising best practices from state insurance commissioners related to implementing MHPAEA and monitoring and enforcement efforts to ensure compliance.

Recommendations

The Task Force recommendation fall into three main areas: supporting consumers, improving parity implementation, and enhancing parity compliance and enforcement. The Final Report identifies the specific recommendations for each area and provides details for developing and implementing the recommendations, and includes the initial steps it has taken. The recommendations include:

  • Supporting Consumers: Create a one-stop consumer web portal to help consumers navigate parity and provide simplified disclosure tools to provide consistent information for consumers, plans, and issuers.
  • Improving Parity Implementation: Update guidance to address the applicability of parity to opioid use disorder services, implement the Medicaid and CHIP parity final rule in a timely manner, conduct a thorough review of how parity principles apply in Medicare, and expand access to mental health and substance use disorder services in TRICARE.
  • Compliance and Enforcement: Provide federal support for state efforts to enforce parity through trainings, resources, and new implementation tools, increase federal agencies’ capacity to audit health plans for parity, allow the Department of Labor to assess civil money penalties for party violations, ensure parity compliance in state essential health benefit benchmark plans, and review substance use disorder benefits in the Federal Employees Health Benefits Program.

Highlight on Georgia: State focused on promoting access to care

Georgians have received several pieces of good health care access news lately as the state works ensure that young adults and those living in rural areas get the care they need. Despite constant financial concerns surrounding health care, the state seems to be making it a priority.

Rural Healthcare 180

Rural Healthcare 180 is an effort to promote the new donation program that gives tax credits to both individuals and corporations that make donations to rural hospitals. Kim Gilman, chief executive of Phoebe Worth Hospital and Southwest Georgia Regional Medical Center, said that the hospitals need to upgrade expensive equipment and provide raises to employees.

In total, 48 rural hospitals are eligible to receive the donations. Tax credits will be supplied for donations of up to $4 million, with caps starting at $50 million in 2017 and increasing by $10 million each year for the next two years until program expiration. The potential of additional funding will hopefully address the crisis, as many rural hospitals seem to be set for the same fate as the five that have closed in the past four years.

Mental health center expansion

A new Atlanta campus of a mental health facility will open in October, adding 32 beds for young adults aged 18 to 26. This Rollins Campus, named for a gift received from the O. Wayne Rollins Foundation, is Skyland Trail’s second Atlanta campus. The nonprofit treatment organization operates 48 beds, and 60 percent of patients treated are young adults. Older adults have found Skyland Trail to be a lifeline, including a 63-year-old physician who reported experiencing her first psychotic episode at 56 years of age. She spent five months at Skyland Trail, where she attended to more than her mental health and was able to lose weight through the organization’s nutritional program.

State could be an example for EpiPens® in schools

In the wake of the EpiPen pricing controversy and stories about children in schools denied access to their own pens, Georgia’s approach may offer solutions to ensure safety in situations where students might be unknowingly exposed to food allergens. Karen Harris, mother to three children with severe allergies, founded Food Allergy Kids of Atlanta (FAKA) in 2007 in order to unite families like her own. Her goal is to ensure that this “first-line treatment” is accessible to everyone with any type of allergies.

In 2013, Georgia Governor Nathan Deal (R) signed the Emergency Epinephrine Act, which was introduced by Senator Chuck Hufstetler (R-Rome) and backed by FAKA. The law encourages (but does not require, unlike some states’ legislation) schools to stock EpiPens for emergency use, and authorizes providers to write a prescription in the name of a school. The law also protects anyone who uses the medication in good faith through its good Samaritan provision. A second piece of state legislation allows professionals to prescribe EpiPens for many public entities, including churches, restaurants, and arenas, provided that they register with the state. According to Georgia Health News, only 12 non-school entities have registered, and the article points out that no discount programs are offered to these entities.

Although some are concerned about parents depending on school-stocked pens and failing to provide for their children’s needs, a Georgia school nurse was thankful that they were able to receive donated pens through Mylan’s school program. She noted that in rural settings, quick access to epinephrine is vital when hospitals are some distance away. She has trained 25 teachers to administer the medication in the event of anaphylaxis.