HHS marks Prescription Opioid and Heroin Epidemic Awareness week with $44.5M grant

The Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) will award more than $44.5 million in awards to training programs aimed at increasing the number of mental health providers and substance abuse counselors in the United States.  The funding includes 144 new and continuing grants through the Behavioral Health Workforce Education and Training (BHWET) program.

Behavioral Health Workforce Education and Training Program

 The BHWET program supports clinical internships and field placement programs for professional and paraprofessional behavioral health disciplines and occupations. The initiative serves children, adolescents, and transitional-age youth at risk for developing or who have a recognized behavioral health disorder by adding to the behavioral health workforce. Recipients of grants under this program are expected to expand the behavioral health workforce by participating in internships and field placements focusing on working with these at-risk individuals. Activities under the grant emphasize prevention and clinical intervention and treatment for those at risk of developing mental and substance abuse disorders and the involvement of families in preventing and treating behavioral health conditions.

Of the $44.5 million grant, more than $7.9 million will support a total of 34 new grantees, and the other $36.6 million will fund the program’s 110 existing grantees.

Prescription Opioid and Heroin Epidemic Awareness Week

President Barack Obama designated the week of September 18 – 23, 2016, Prescription Opioid and Heroin Epidemic Awareness Week. During this time, federal agencies focused on the work being done across government entities and announced new efforts to address the epidemic of prescription opioid and heroin abuse. In his announcement, Obama stated that he continues to “call on the Congress to provide $1.1 billion to expand access to treatment services for opioid use disorder.” The investments would build on the steps already taken to expand overdose prevention strategies and increase access to the overdose reversal drug naloxone.

Highlight on Kansas: Lack of resources impacting state employee benefits, mental health patient care

Bad news for those working for the state of Kansas: health coverage is getting worse. The state will raise premiums, raise co-pays, and raise deductibles while reducing health savings account contribution. While the state works to maintain the health plan’s cash reserves, it must also find a way to fund more resources for those experiencing mental health issues – a problem many states are facing.

Employee health plans

The Kansas Health Care Commission is concerned about the level of the employee health plan’s cash reserves, and has decided to increase the cost to state employees. The cash reserve target over the next two years is $59 million.

In order to reach this level, Kansas state employees will be subject to a 9 percent premium rate increase, while employers are subject to a 7 percent increase. Secretary of Administration Sarah Shipman stated that the adjustments are intended to “maintain plan solvency into the future” to ensure the stability of the system.

The state plan involves various levels, and the changes are different for each level. Plan A workers will have their same $1,000 deductible, but those with family enrolled will be subject to a $3,000 total deductible. Co-pays for doctor visits will rise by $10, reaching $40 for a primary care visit and $60 for specialists. Plan C, the “high deductible” plan, will subject workers to 20 percent of the cost of a doctor visit after hitting $2,750 for single workers and $5,500 for those with family coverage.

All state workers will be subject to a higher out-of-pocket maximum: $5,000 for singles and $10,000 for families. The state not only implemented all of these cost increases, but also mandated reduction in employer health savings account contributions. Single employees lose $500 there, and those with dependents lose $1,000.

When did it start?

In January 2016, a consulting firm made 105 budget recommendations to the Kansas legislature that it claimed could save the state $2 billion over five years. A considerable part of the savings came from the idea of moving all state workers to a high deductible plan. The executive director of the Kansas Organization of State Employees was quite concerned about the recommendation, noting that much of the state workforce is aging and cannot obtain adequate care through high deductible plans. She also mentioned that reduced coverage would offer even less incentive for people to work for the state, especially considering low pay rates.

Kansas feeling the mental health struggle

The state held a mental health symposium at the Kansas Statehouse to discuss issues providers are facing. Last year, Newman Regional Health almost lost its federal certification after it had issues transferring a patient with thoughts of suicide. The hospital’s CEO, Robert Wright, told CMS that the state does not have a sufficient number of mental health beds, forcing hospitals to hold these patients in emergency rooms. Hospitals may face a reduced amount of compensation or none at all for this care.

Wright believes that the issues began when the community-based care movement shuttered mental institutions, reducing the number of beds. This idea might have worked if community-based programs were given the planned amount of funding. Wright is concerned about meeting these patients’ needs without sending the hospital into bankruptcy. Last year, one of the two state-run mental health infacilities in the state was banned from accepting new patients due to overcrowding, understaffing, and safety issues.

Suggestions

Symposium attendees brainstormed ideas to address the problem and better use scarce resources. A representative of the Kansas Hospital Association said she believed that expanding Medicaid eligibility would result in many Kansas residents with mental health problems gaining insurance. Part of the problem is overcrowding in emergency rooms and a difficulty finding psychiatrists, but some raises for state-run hospitals have allowed some stabilization. The president and CEO of a nonprofit offered to train school staff on suicide prevention techniques, and state legislators admitted that the allocated resources are not enough to meet patients’ needs.

DOJ sues Mississippi, says mentally ill are unnecessarily institutionalized

The federal government emphasized its stance on the importance of using home- and community-based services (HCBS) by filing a lawsuit against the state of Mississippi over its mental health program. The Department of Justice (DOJ) alleged that the state ran afoul of the integration mandate of the Americans with Disabilities Act (ADA) (P.L. 101-336) and forced thousands of people to be institutionalized when the services could be provided in a community setting.

Integration mandate and lawsuit

In Olmstead v. L.C., 527 U.S. 581 (1999), the Supreme Court found that the ADA requires public entities to provide services to the disabled in home- and community-based settings as much as possible. The ‘integration mandate’ states, “A public entity shall administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities” (28 C.F.R. section 35.130(d)). According to the Olmstead Court, unnecessary institutionalization diminishes patients’ abilities to interact socially,  pursue education and employment, and find cultural enrichment.

The suit against Mississippi alleges that state-run hospitals are segregating mentally ill patients who could be successful in community treatment. The Justice Department believes that patients are regularly cycling through the state’s four mental health facilities because they are not able to thrive in their communities due to a lack of services. The cuts to the DOMH have limited its ability to offer HCBS services and activities, and State Attorney General Jim Hood expressed his displeasure toward the state legislature following the filing of the suit, blaming them for offering corporate tax cuts instead of serving the population. The state attempted to settle with the federal government, but negotiations failed. The DOJ wants a consent decree, but Hood objects due to expense and perpetual oversight. The state is now in the expensive position of defending itself against the DOJ.

Mississippi budget cuts

The state of Mississippi’s budget woes have turned into what some are calling a crisis, resulting in significant budget cuts. The state government admitted in June that at the close of the state fiscal year, there would be unpaid bills and a $50-60 million shortfall. Although some representatives disagreed on the impact of the amount, overcoming the shortfall would have required collections in the $725-750 million range in the month of June.

Significant budget cuts and dipping into funds failed to ward off the shortfall. Governor Phil Bryant (R) already cut $60 million from the budget and spent $50 million out of state accounts, making use of the Rainy Day Fund. The cuts impacted  state departments, such as the Department of Revenue, which was forced to dismiss temporary workers during tax season. In July, this blog covered some of these budget issues, including an editorial written by the director of the Mississippi Public Health Association that highlighted the Department of Corrections’ generous allocations, nearly nine times more than what the Health Department will be able to use (see Highlight on Mississippi: Budget crisis has health pundits grumbling, July 1, 2016).

Health impacts

Health agencies were not immune to the budget cuts, although there are arguments that they only lost a small chunk of money and, in one case, ended up on top. According to watchdog.org, in the latest round of cuts, the Department of Health (DOH) lost $5.8 million and the Department of Mental Health (DOMH) lost $7.3 million, which amounted to 1.53 percent and 1.17 percent of their budgets, respectively.

Departments heads note that these cuts are only the latest in a line of issues. The Dr. Mary Currier, head of the DOH, said the agency closed six clinics, failed to fill 89 positions, and has cut 64 employees. Diana Mikula, who directs the DOMH, said their reserves are tapped after absorbing a total of $8.39 million in cuts. The agency cut some of its workforce or transferred employees to other positions, but was still forced to eliminate a significant amount of facility space that psychiatrists used to determine if criminals were able to stand trial. Other closures include the Acute Medical Psychiatric Service unit at a state hospital,  Male Chemical Dependency Units, early intervention services, and psychiatric beds.

Advocates say Medicaid can shelter the homeless in Pennsylvania

Pennsylvania could use Medicaid to address its homelessness problem, according to advocates that believe the state’s Medicaid program should include additional supportive housing services. Those individuals assert that additional supportive housing services can be included in Medicaid as a “wrap-around support service”—a type of service that CMS endorses and described in a Center for Medicare & CHIP Services Informational Bulletin last year.

Housing services

CMS expressly does not provide Federal Financial Participation (FFP) for room and board as part of additional support services. However, states are permitted to assist individuals through coverage of certain housing-related activities and services. Some of the housing-related services and activities that Medicaid can cover include: (1) services designed to support an individual’s ability to prepare for and transition to housing; (2) services aimed at supporting an individual’s ability to sustain tenancy; and (3) services dedicated to assisting a state in identifying and securing housing options for individuals. Specific examples of each of those services are covered in the Informational Bulletin. The Open Door is an example of an organization that provides housing support services.

Pennsylvania

In Pennsylvania, advocates like The Housing as Health Campaign are asserting that, for many Medicaid enrollees with substance abuse problems, additional support is needed to keep beneficiaries in their homes. Advocates argue that without a consistent funding stream, Medicaid beneficiaries wind up homeless. The Corporation for Supportive Housing (CSH) created a blueprint, or “Crosswalk,” to serve as a map to assist the Pennsylvania Department of Health and Human Services with aligning Medicaid-eligible services with supportive housing services.

Crosswalk

The Crosswalk was designed to guide the state of Pennsylvania, managed care entities, and service providers towards resources that can improve access to substance use treatment and mental health recovery, with a focus on housing. According to the report, individuals with unmet housing needs are often particularly vulnerable due to the high occurrence of low incomes, chronic health conditions, and behavioral health challenges among the population. The report proposes several methods to improve housing and care access for at-risk individuals. CSH started its analysis by considering the services that the state already provides through several Medicaid waivers. While Pennsylvania does have mechanisms to provide some housing support services for elderly individuals, beneficiaries with traumatic brain injuries, and individuals with a physical disability, CSH noted that additional individuals could benefit from supportive housing.

Alignment

The report identified potential opportunities for alignment, where services that are already covered under the state plan could be aligned to better address housing support service needs. For example, the report suggested that, because the Pennsylvania state Medicaid plan covers Individualized Service Plans (ISPs) for the treatment of individuals with severe mental illness, an individual could, possibly, identify housing goals as part of his or her treatment plan, thereby including housing support services through an ISP. The report lists several other types of services with potential for alignment to reduce or eliminate gaps in housing service coverage.

Rethinking Medicaid

Advocates are not directly asking for a change as to the kind of services covered by the Pennsylvania Medicaid program. Instead, the CSH report and other efforts are asserting that housing problems can be best improved through a better application of existing services under the Medicaid state plan. Advocates hope that such a rethinking of Medicaid will improve health by putting a roof over the head of more individuals.