Category: Parity

Limitations, working together & -- We're #1

12/6/2018

I remember from my days working @ The Legal Center for People with Disabilities & Older People [now Disability Law Colorado] that 90% of the calls were from people wanting services we didn't provide and we weren't very clear about what we did and didn't do.

So, of course, people assumed we didn't do anything -- and nothing could be further from the truth.

So different entities have different problems and concerns when communicating their Limitations.

For the Government, they may be concerned about communicating the true state of their limitations because they have legal obligations to meet such as Parity, Medicaid Network Adequacy, Time Frames for Competency Exams, the larger crisis and shortage not only in psych beds but Medicaid Intensive Community Mental Health Services, Olmstead Compliance, etc.

Other entities like advocacy groups or innovation centers --- like to puff themselves up [we're not immune to that ourselves] --- "We're the Best, We're Number 1." And in one respect or another -- those claims are not necessarily untrue, but they generally fall far short of the extravagant claims -- and when they do--- people can feel misled.
A lot of it really comes down to clarity.
- If you are focusing on "Technology and Mental Health" and a lot of things are going to be put on the back burner -- you probably need to say that -- especially if you are advertising yourself as a "National Mental Health Innovation Center" -- CU we mean you.

The BOTTOM LINE:

People will forgive A LOT if others are responsive to them -- when they are not -- & the CU Innovation Center has not been responsive to us -- the judgments can be pretty harsh -- even when the entity may be doing good things.

P.S. I think we just got struck by lightning . . .

CO Medicaid Mental Health Quality & Network Adequacy, Olmstead, & Contracting: Known Knowns, Known Unknowns, and Unknown Unknowns

2/13/2018

I think sometimes why Olmstead is so resisted by States is that it provides a dictate -- BUT it doesn't provide a lot in HOW.
The U.S. Supreme Court's decision was really designed to give the States flexibility. It has taken awhile since the original 1999 Olmstead Case to work some of this out.
The Minnesota Federal Olmstead Planning Case, the Georgia/DOJ MI/DD Comprehensive Settlement Agreement, the Delaware/DOJ Findings Letter re: NO Fundamental Alteration where bringing Housing & Services to Scale, DOJ Guidance on Olmstead-- at the end of the day there was a lot to be gleaned from those.
Then States like Colorado promptly ignored all that stuff -- also, known as LAW.
So it's a little bit, maybe a lot Pollyannish to say, "If the States just had the right tools, they would do the right thing."
BUT the States are doing some right things in Colorado and around the country -- they've even got some good things in their provider contracts -- although, not NEAR ENOUGH.
States spend A LOT MORE TIME on contracting with providers than they do with Olmstead Planning.

With Olmstead Planning -- often States just don't do Olmstead Planning at all or there are no MEASURABLE GOALS, etc. even though its pretty much common knowledge that the States have NOT brought Housing & Services to Scale to prevent unnecessary institutionalization of people with disabilities, including the great risk of institutionalization in homelessness.

BUT the Code of Federal Regulations & CMS have some "requirements" -- some softer than others -- regarding:

Managed Care Quality Assessment &
Improvement

One of the challenges to one's sanity is that we already have some pretty important known values::

Thousands of people with mental illness in Colorado Jails.
Thousands of people with mental illness in Colorado Prisons.
Thousands of People with mental illness who are Homeless.
Thousands of People with mental illness who are in nursing homes.
Federal Legal Duties on States to provide Housing & Services for People with Disabilities to avoid unnecessary institutionalization, or the great risk of institutionalization inherent in homelessness OR Provide a Comprehensive, Effectively Working Plan to do so with Measurable Goals, Etc..
Federal Legal Duties on States to Provide Mental Health Parity, including modifying CAPITATION RATE SETTING where necessary.
It is Medicaid Mental Health Managed Care that needs to have "NETWORK ADEQUACY" to provide for the people listed above in the Community. NEWS FLASH: COLORADO MEDICAID DOES NOT HAVE "NETWORK ADEQUACY" FOR THIS.
The State has made some improvements, BUT what it is doing is WAY NOT ENOUGH to comply with the LAW and even more importantly save Coloradans with mental illness from the Horrors of Abuse or Neglect or the Daily rights violations that have been and are occurring.

42 CFR § 438.330 Quality assessment and performance improvement program.

(a) General rules.

(1) The State must require, through its contracts, that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees that includes the elements identified in paragraph (b) of this section.

(2) After consulting with States and other stakeholders and providing public notice and opportunity to comment, CMS may specify performance measures and PIPs, which must be included in the standard measures identified and PIPs required by the State in accordance with paragraphs (c) and (d) of this section. A State may request an exemption from including the performance measures or PIPs established under paragraph (a)(2) of this section, by submitting a written request to CMS explaining the basis for such request.

(3) The State must require, through its contracts, that each PCCM entity described in § 438.310(c)(2) establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees which incorporates, at a minimum, paragraphs (b)(2) and (3) of this section and the performance measures identified by the State per paragraph (c) of this section.

(b) Basic elements of quality assessment and performance improvement programs. The comprehensive quality assessment and performance improvement program described in paragraph (a) of this section must include at least the following elements:

(1) Performance improvement projects in accordance with paragraph (d) of this section.

(2) Collection and submission of performance measurement data in accordance with paragraph (c) of this section.

(3) Mechanisms to detect both underutilization and overutilization of services.

(4) Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under § 438.340.

(5) For MCOs, PIHPs, or PAHPs providing long-term services and supports:

(i) Mechanisms to assess the quality and appropriateness of care furnished to enrollees using long-term services and supports, including assessment of care between care settings and a comparison of services and supports received with those set forth in the enrollee's treatment/service plan, if applicable; and

(ii) Participate in efforts by the State to prevent, detect, and remediate critical incidents (consistent with assuring beneficiary health and welfare per §§ 441.302 and 441.730(a) of this chapter) that are based, at a minimum, on the requirements on the State for home and community-based waiver programs per § 441.302(h) of this chapter.

(c) Performance measurement. The State must -
(1)

(i) Identify standard performance measures, including those performance measures that may be specified by CMS under paragraph (a)(2) of this section, relating to the performance of MCOs, PIHPs, and PAHPs; and

(ii) In addition to the measures specified in paragraph (c)(1)(i) of this section, in the case of an MCO,PIHP, or PAHP providing long-term services and supports, identify standard performance measures relating to quality of life, rebalancing, and community integration activities for individuals receiving long-term services and supports.

(2) Require that each MCO, PIHP, and PAHP annually -
(i) Measure and report to the State on its performance, using the standard measures required by theState in paragraph (c)(1) of this section;

(ii) Submit to the State data, specified by the State, which enables the State to calculate the MCO's,PIHP's, or PAHP's performance using the standard measures identified by the State under paragraph (c)(1) of this section; or

(iii) Perform a combination of the activities described in paragraphs (c)(2)(i) and (ii) of this section.

(d)Performance improvement projects.

(1) The State must require that MCOs, PIHPs, and PAHPs conduct performance improvement projects, including any performance improvement projects required by CMS in accordance with paragraph (a)(2) of this section, that focus on both clinical and nonclinical areas.

(2) Each performance improvement project must be designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction, and must include the following elements:

(i) Measurement of performance using objective quality indicators.

(ii) Implementation of interventions to achieve improvement in the access to and quality of care.

(iii) Evaluation of the effectiveness of the interventions based on the performance measures inparagraph (d)(2)(i) of this section.

(iv) Planning and initiation of activities for increasing or sustaining improvement.

(3) The State must require each MCO, PIHP, and PAHP to report the status and results of each project conducted per paragraph (d)(1) of this section to the State as requested, but not less than once per year.

(4) The State may permit an MCO, PIHP, or PAHP exclusively serving dual eligibles to substitute an MA Organization quality improvement project conducted under § 422.152(d) of this chapter for one or more of the performance improvement projects otherwise required under this section.

(e) Program review by the State.

(1) The State must review, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP, and PCCM entity described in § 438.310(c)(2). The review must include -

(i) The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report.

(ii) The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects.

(iii) The results of any efforts by the MCO, PIHP, or PAHP to support community integration for enrolleesusing long-term services and supports.

(2) The State may require that an MCO, PIHP, PAHP, or PCCM entity described in § 438.310(c)(2) develop a process to evaluate the impact and effectiveness of its own quality assessment and performance improvement program.

Assertive Community Treatment: Mental Health Parity, Olmstead, Capitation, & CMS Quality of Care Requirements for States Contracting with Managed Care Organizations

2/12/2018

So here we have it: ALL kinds of reasons why people with mental illness should have access to the Mental Health Care at the the level that they need AND one of the BIG REASONS why they don't.
These challenges are NOT unique to Community Mental Health or in fact to Managed Care. We have had serious quality of healthcare problems:

in Nursing Homes,
Abuse problems in facilities for people with developmental disabilities
Serious Staffing Problems @ the Colorado Mental Health Institute @ Pueblo for DECADES -- maybe the State is finally trying to tackle that this legislative session. We would like to see more Emergency Action on this.
The Deaths and maiming of Colorado Inmates with mental illness in the shadow mental healthcare system of our prisons and jails.
This is true in public health and its true in private healthcare. It is very difficult for patients and their families to enforce quality of care standards.

We are struggling as a Society "To Do The Right Thing" and at the same time "CYAing" ourselves to the maximum extent possible.

IT IS NOT WORKING.

On paper -- in the Statute books, the US Supreme Court Reporters, Federal Reporters, Code of Federal Regulations, CMS [Centers for Medicare & Medicaid Services] Guidance, State Regulations --- WE SHOULD NOT HAVE A PROBLEM WITH ACCESS TO PERSON-CENTERED, INTENSIVE ASSERTIVE COMMUNITY TREATMENT, ETC.

BUT WE DO HAVE A PROBLEM WITH ADEQUATE ACCESS TO ASSERTIVE COMMUNITY TREATMENT & A LOT OF OTHER THINGS.

If one has low to medium needs with regard to mental health treatment -- Managed Care may work out pretty well.

BUT Colorado Medicaid Managed Care it is a FRICKIN' EPIC FAIL when it comes to people with the most intensive mental health needs and is just NOT UP TO SCALE.

The State of Colorado knows that it doesn't have adequate capacity, and it's one of many reasons they have so powerfully passively resisted Olmstead Compliance and Planning and bringing needed housing & services to scale.

They are not necessarily opposed to those things, BUT they don't want to be held ACCOUNTABLE for them either.

Which brings us back to our Society that "Wants To Do The Right Thing" and spends a whole lot of time "CYAing" itself.

People Tort Reform is NOT going to get us to the Solution to this problem, mainly because it doesn't get us to Solutions to the "Root Causes" of the original presenting problems.

A LOT of the FOUNDATION for Solutions to the Systemic Problems we find in Mental Health Managed Care has really already been LAID -- in Statute, Caselaw, Federal Agency Guidance and Requirements, State Regulations.

It's really analyzing what are the BARRIERS to realizing this in PRACTICE and NOT just THEORY.

CMS -- Overview of Quality of Care Information for Managed Care

CMS on State Responsibilties for Quality Assessment & Improvement in Managed Care

CMS on State Responsibilities to Conduct External Quality Review of Managed Care Organizations

So There Are A Lot Of Issues For CO Medicaid Assertive Community Treatment: Parity, Network Adequacy, Adequate Planning, Provider Reimbursement, Etc. [& Olmstead]

2/10/2018

Things happen for reasons. Usually a lot of complicated factors.
We don't have Thousands of Coloradans with Mental Illness:

In Prisons & Jails
On the Streets, and
In Nursing Homes

by accident.
We've made some pretty HORRIFIC policy choices as a society, here in Colorado and across the Country.
AND at one time, we thought we could get away with those short-sighted choices refusing to:

adequately fund Housing for people with disabilities; and
refusing to do the REAL PLANNING and NETWORK ADEQUACY WORK for INTENSIVE COMMUNITY MENTAL HEALTH TREATMENT that people in this State need --- NOT just LIP SERVICE to it. [Remember, this is the same Administration that refused to do Olmstead Planning with measurable goals & refused to respond when asked about a waitlist for Assertive Community Treatment]

So our point is essentially without:

some type of specific measure of "Reasonable Medical Necessity" for Assertive Community Treatment
and applying that to the relevant populations

-- How is Colorado going to know if its Network is Adequate?
Of course, the rest of us already know that Colorado Housing and Medicaid mental health services are NOT sufficient to keep people out of:

prisons & jails
homeless shelters
nursing homes, and
mental institutes

This really isn't rocket science folks -- it can just be expensive. While this is going to mean an increase in Community Mental Health Costs, it will mean a decrease in:

Corrections Costs
County Jail Costs
Nursing Home Costs

We're willing to work with people on innovative solutions and we're tired of playing games.

CODE OF FEDERAL REGULATION SECTIONS ON: MEDICAID MANAGED CARE NETWORK ADEQUACY STANDARDS, ETC.

Does Colorado Medicaid NOT know that there are thousands of Coloradans with mental illness in Colorado Prisons, Jails, Homeless Shelters, Nursing Homes, & Mental Institutes, Etc. Okay -- not all of them need ACT -- but don't we need to figure out who does. [Amy Poehler on SNL]

Our Understanding of Medicaid Network Adequacy is:

Expected Utilization of Services
Based on Member Characteristics
& Health Care Needs

(at least that is the way Wisconsin is defining it)

So you can see why refusing to do Olmstead Planning is such a BIG DEAL -- IT ALSO IMPLICATES THE ADEQUACY OF THE STATE'S MEDICAID NETWORK.

Honesty & Creativity in Complying with Mental Health Parity

2/8/2018

Coloradans with Mental Illness DON'T HAVE TO FAIL FIRST in:

incarceration
homelessness
placement in nursing homes, or
mental institutes

without adequate resource to ASSERTIVE COMMUNITY TREATMENT or FLEXIBLE ASSERTIVE COMMUNITY TREATMENT where reasonably medically necessary.

Assertive Community Treatment & Flexible Assertive Community Treatment in Norway and the Need for Colorado to Comply with Parity and Ultimately Olmstead

2/7/2018

Assertive Community Treatment is often a component of US Department of Justice Olmstead Settlement Agreements addressing Mental Health.

Colorado has some Assertive Community Treatment and they've been working to increase it.

Despite these efforts, Assertive Community Treatment is STILL not available to all where "reasonably medically necessary."

Well Colorado's failure to provide ACT where "reasonably medically necessary" is a BIG PROBLEM for A LOT of reasons:

It violates mental health parity under the Mental Health Parity & Addiction Equity Act of 2008 and subsequent CMS (Centers for Medicare & Medicaid Services) Guidance;
Failure to provide or plan to provide adequate Community Mental Health Services for those at great risk of institutionalization or homeless violates the 1999 US Supreme Court Olmstead decision, subsequent caselaw, and US Department of Justice Guidance on Olmstead and Title II of the Americans with Disabilities Act.
Failure to provide adequate intensive Community Mental Health Services including ACT is HORRIBLE Policy and Short-Sighted, leading to more homelessness and incarceration of people with mental illness. The World Health Organization has specifically called out such short-sightedness when it comes to mental health policy.

NOT EVERYBODY NEEDS ASSERTIVE COMMUNITY TREATMENT, BUT ACCESS TO THAT TREATMENT HAS TO BE BASED ON "REASONABLE MEDICAL NECESSITY."

Both the US and Europe have suffered under what Europeans have termed "incompetent" mental health policy after de-institutionalization.

Well, we are decades out from de-institutionalization @ this point. Further, the US went WAY FURTHER than most European Countries in criminalizing mental illness.

The West has had incompetent mental health policies and that includes the US and the State of Colorado.

The Hickenlooper Administration, MIXED BAG that it is, has done great work so long as its their idea --- BUT ask them to comply with the LAW -- say PARITY or OLMSTEAD, and there is PASSIVE RESISTANCE like nobody's business.

Maybe we could just say it's the Hickenlooper Administration's idea to offer Assertive Community Treatment where "reasonably medically necessary" -- AND they might do it.

We certainly wouldn't have a problem giving them a lot of credit for it, AND they would DESERVE IT.

Congressional Research Service: Jan. 19, 2018: Prevalence of Mental Illness in the US

Additional analyses of NSC-R data were conducted to determine the 12-month prevalence of mental illness at three levels of severity: serious,19 moderate,20 or mild.21

Among the 26.2% of adults identified with a mental disorder in the analysis, serious disorders (22.3% among adults with a disorder) were less common than moderate disorders (37.3%) or mild disorders (40.4%).

The estimated 12-month prevalence of serious mental illness among all adults was 5.8%.

https://fas.org/sgp/crs/misc/R43047.pdf

ACT and Flexible ACT in the Netherlands . . .

The two models are outlined below.

ACT for the most severely ill patients ACT provides multi-disciplinary care with shared caseloads for the 20% group of most severely ill patients with SMI.

When a patient under the care of an ACT team stabilizes, he or she proceeds to a lighter form of care such as case management, provided by ‘step-down’ teams.

There are now 35 ACT teams in the Netherlands.

Flexible ACT for all SMI patients Flexible ACT provides multi-disciplinary care for the whole group (100%) of SMI patients in a particular region (50,000 inhabitants).

Continuity of care is provided for these patients. If necessary (in the event of an imminent crisis recurring psychosis, threat of readmission) a Flexible ACT team can provide full ACT care by switching to shared caseload and intensive outreach.

After the crisis a step-down procedure takes place within the same team, which ensures more continuity. Because the area covered is smaller, the team is better able to support social inclusion for these patients.

The teams collaborate extensively with social partners for that purpose.

There are now about 300 Flexible ACT teams in the Netherlands.

Prevalence of Severe Mental Illness & Co-Occurring Substance Abuse in Europe

A European survey estimated the annual prevalence of severe mental illness in two European catchment areas found that approximately 2 in 1000 persons suffered severe mental illness (Ruggeri, Leese et al. 2000).

The majority of people with severe mental illness have schizophrenia and many experience severely impaired functional disability. According to the World Health Organization’s (WHO) World Health Report “New understanding, new hope” from 2001, schizophrenia is the eighth leading cause of disability-adjusted life years (DALYs) worldwide for people between 15-44 years.

DALY is a measure of overall disease burden describing the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicator.

DALYs are the number of years lost due to ill health, disability or early death. Many people with severe mental illness also suffer co-occurring substance use problems. The lifetime prevalence of alcohol abuse or dependence in the general adult population ranges from 13.5% to 22.7% (Regier, Farmer et al. 1990, Kringlen, Torgersen et al. 2001) while 3.4% to 6.1% of the adult population has a lifetime prevalence of drug abuse or dependence (Regier, Farmer et al. 1990, Kringlen, Torgersen et al. 2001).

Amongst persons with schizophrenia, the reported lifetime prevalence of any substance abuse or dependence, ranges from 47% to 60% (Regier, Farmer et al. 1990, Fioritti, Ferri et al. 1997, Fowler, Carr et al. 1998). Current prevalence ranges from 27% to 41% (Fowler, Carr et al. 1998, Ecker, Aubry et al. 2012).

p. 12
https://www.duo.uio.no/bitstream/handle/10852/58886/PhD-Hanne-K-Clausen-2017.pdf?sequence=5

Indiana's Criteria for Assertive Community Treatment and Recognizing Access to ACT as an Olmstead, Parity, & Human Rights Issue

2/6/2018

The Bottom Line is: We Don't Have an Adequate Medicaid Community Mental Health System or Hospital System, if we have a BUNCH of people with mental illness who are:

Incarcerated,
Homeless,
Or in Nursing Homes

AND Colorado does have a BUNCH of people with mental illness incarcerated, homeless or in nursing homes. In fact, we have thousands of them.

Now Assertive Community Treatment and other Intensive Treatments are cheaper than HOSPITALIZATION -- BUT if we're NOT paying for the Hospitalization it can seem CHEAPER NOT to Pay for the Assertive Community Treatment and just shift the costs to non-profits serving people on the Streets and the County Jails.

Now Colorado and a lot of States have really made a lot of progress -- BUT we're in a HUGE HOLE when it comes to adequately providing for Intensive Mental Health needs -- AND that includes Intensive Services & HOUSING.

Well, Parity is going to help FIX THAT, right? Well, only if the States comply with it, and that can be a pretty BIG IF.

We've had a pretty PAINFUL experience with the State over the course of about 3 or more years with the State politely BUT FIRMLY RESISTING what they SHOULD do on Assertive Community Treatment.

When we just had the Olmstead Decision and NOT Parity -- we asked for a WAITLIST about 2 or 3 years ago, and have renewed the question sporadically --- BUT the State has REFUSED to respond.

With Parity -- we want an END to the ARBITRARY TREATMENT Limitations to Assertive Community Treatment, especially since it is such an important treatment for people with mental illness who have Intensive Mental Health Needs --- many of the people who need these services are poor and minorities, and endured suffering that would break most of us.

The failure to provide Assertive Community Treatment where reasonably medically necessary is DISCRIMINATION in so many ways and contributes to the most BRUTAL HUMAN RIGHTS VIOLATIONS in our Country today.

The Logical Long-Term Consequences of Our Failure to Provide Sufficient Intensive Community Mental Health Treatment

Person-Centered Planning

440 IAC 11-1-13 "Person-centered planning" defined Authority: IC 12-21-2-3; IC 12-24-19-6 Affected: IC 12-24-19 Sec. 13.

"Person-centered planning" means a process-oriented approach to empower an individual with a serious mental illness to define the services and supports necessary for recovery.

(Division of Mental Health and Addiction; 440 IAC 11-1-13; filed Feb 9, 2011, 10:24 a.m.: 20110309-IR-440090875FRA)

ACT Admission & Discharge Criteria

440 IAC 11-3-4 ACT admission and discharge criteria Authority: IC 12-21-2-3; IC 12-24-19-6 Affected: IC 12-24-19

Sec. 4. (a) All individuals admitted to ACT must meet the following criteria:

(1) Be at least eighteen (18) years of age.

(2) Meet the division criteria for persons with serious mental illness as defined in 440 IAC 8-2-2.

(3) Require intensive, community based services as specified in the admission criteria for ACT, which shall include an assessment of the following:

(A) Level of need based on the adult needs and strengths assessment tool or its successor.

(B) Discharge from a state psychiatric hospital within the previous twelve (12) months.

(C) Other psychiatric hospitalizations in the previous two (2) years.

(D) Criminal justice or legal system involvement.

(E) Co-occurring substance abuse.

(F) Homelessness or imminent risk of homelessness.

(b) An individual must meet the diagnostic criteria specified in section 3(c) of this rule.

(c) When an individual is discharged from ACT to less intensive services, a discharge plan must provide for the following:

(1) A gradual transfer period.

(2) A plan to maintain continuity of treatment at appropriate levels of intensity to support the individual's continued recovery.

(3) A plan for the individual's return to the ACT team if needed.

(d) Individuals may be readmitted to ACT based on the following criteria: 2017 Edition ASSERTIVE COMMUNITY TREATMENT TEAMS Indiana Administrative Code Page 11

(1) If the individual was discharged from ACT within the past twelve (12) months, any of the following has occurred within sixty (60) days prior to readmission:

(A) A psychiatric hospitalization or emergency room visit.

(B) A hospitalization or an emergency room visit as a result of substance abuse.

(C) An arrest or other law enforcement contact.

(D) Homelessness or risk of homelessness.

(E) Admission to a subacute stabilization facility.

(2) If the individual was discharged from ACT more than twelve (12) months prior to readmission, at least one (1) of the conditions in subsection (a)(3) has been met.

(e) Each CMHC must have specific procedures for the transfer of an individual from one (1) ACT team to another, either within a CMHC or to another CMHC. These procedures must, at a minimum, specify the steps to be taken to ensure that:

(1) the individual meets with the new team; and

(2) information from the individual's clinical record information is appropriately shared with the new team.

(f) Discharges from ACT services shall be in accordance with division-approved criteria, which includes an assessment of the following:

(1) The level of need based on the current division-approved assessment tool.

(2) The criteria for admission to ACT.

(3) The stages of change.

(4) The continued medical necessity for high intensity, community-based care. (Division of Mental Health and Addiction; 440 IAC 11-3-4; filed Feb 9, 2011, 10:24 a.m.: 20110309-IR-440090875FRA)

file:///C:/Users/user/Downloads/A00110.pdf

Mental Health Parity: Finding the Line Between Prohibited "Fail First" Medicaid Provisions and Reasonable Medical Necessity

2/5/2018

The Mental Health Parity & Equity Addiction Act of 2008 prohibits so called "Fail First" provisions.
What does that mean? It means that people can't be required to "FAIL" @ a less expensive treatment, before receiving a more expensive, likely more intensive treatment.
Well, okay --- but not everyone needs the most expensive, intensive treatment.
How are we going to determine who needs which treatments?
Well, we can't do it the old crazy way that has been rife within Colorado Medicaid for years and probably many other State Medicaid Programs:
Colorado Medicaid historically only covered intensive treatments such as Assertive Community Treatment as long as the money didn't run out from the Savings of the Medicaid Managed Care Program.
Well it is these kinds of HORRIFIC policies that Mental Health Parity is designed to get rid of.
That still doesn't mean that everyone needs Assertive Community Treatment --- What we do need are coherent criteria for "reasonable medical necessity" and eligibility for various treatments across the spectrum for example Flexible ACT, etc.

The State has invited me to speak about these issues to the Regional Accountable Entities -- which I very much appreciate.

Ultimately, it's the
State's responsibility to comply with Mental Health Parity Law. Colorado isn't doing that right now.

The State indicates it will have some requirements for "network adequacy" --- Sounds good, but we don't know what it actually means.

Further it does strike us that the State is trying to side-step responsibility for Parity and put it on the Regional Accountable Entities.

The invitation from the State to speak to Regional Accountable Entities is great ---- but it is not sufficient.

We need "reasonable medical necessity" criteria for ACT or a process to get it by the end of this week, or I'm going to CMS Region 8.

The State of Colorado Could Give Lucy A Run for Her Money in Parity Bait & Switch Routines

At Bottom It's Work: Reasonable Medical Necessity "Tools" for Assertive Community Treatment AND Could Someone Please Give the State of Colorado Some More BANDWIDTH

1/28/2018

There is so, so much work to be done in Medicaid Mental Health. It is NOT likely to get done and it's NOT being done if it is left to the Medicaid Directors to get it done.
There have to be sufficient staff with sufficient knowledge to whom Medicaid Directors can delegate the vast majority of this Mountain of Work.
Maybe a grant for Mental Health Transformation for Parity and Olmstead Compliance, and that could be broader than just Mental Health.
The Advocacy Community can do a lot research for the State [which the State is probably going to want to double-check and conduct their own research --- of course, that takes time].
BUT at some point the State has to do a fair amount of work, not just summarily declaring themselves in compliance with Olmstead and Parity -- which they are NOT.
I think we pretty much get that the big issue is money when it comes to complying with Disability Civil Rights Laws, even if ultimately they would save money -- where do you get the money in the first place?
There are a lot of ideas that we have already bandied about BUT the State has to have the BANDWIDTH to pursue them.

Flexible ACT

Minnesota Eligibility for ACT

Eligible Recipients Recipients eligible to receive ACT services must meet the following criteria as assessed by an ACT team:

• 18 years old or older (Individuals ages 16 and 17 may be eligible upon approval by the commissioner)
• Have a primary diagnosis of schizophrenia, schizoaffective disorder, major depressive disorder with psychotic features, other psychotic disorders or bipolar disorder
• Have a significant functional impairment demonstrated by at least one of the following:
• No indication that other available community-based services would be equally or more effective as evidenced by consistent and extensive efforts to treat the individual [or]
• Written opinion of a licensed mental health professional that the recipient has the need for mental health services that cannot be met with other available community based services, or is likely to experience a mental health crisis or require more restrictive setting if assertive community treatment is not provided

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_058151

Minnesota Eligibility for Youth ACT

Eligible Recipients To be eligible for Youth Act, MHCP recipients must be 16 – 20 years old and have:
• Diagnosis of serious mental illness or co-occurring mental illness and substance abuse addiction
• CASII level of care determination of level 4 or above
• Functional impairment and a history of difficulty in functioning safely and successfully in the community, school, home, or job
• Probable need for services from the adult mental health system within the next two years
• Have a current diagnostic assessment indicating the need for intensive nonresidential rehabilitative mental health services
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_181612#er

Pennsylvania ACT Standards and Guidelines

Consumer Eligibility: Following are the eligibility requirements for Assertive Community Treatment Services: Adults, 18 years of age or older, who have serious and persistent mental illness.

A person shall be considered to have a serious and persistent mental illness when all of the following criteria for diagnosis, treatment history, and functioning level are met.

A. Diagnosis: Primary diagnosis of schizophrenia or other psychotic disorders such as schizoaffective disorder, or bipolar disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-R or any subsequent revisions thereafter). Individuals with a primary diagnosis of a substance use disorder, mental retardation, or brain injury are not the intended consumer group; AND

B. Functioning level: Global Assessment of Functioning Scale (as specified in DSM IV-R or revisions thereafter) ratings of 40 or below; AND C. Consumers who meet at least two of the following criteria:

10 a. At least two psychiatric hospitalizations in the past 12 months or lengths of stay totaling over 30 days in the past 12 months that can include admissions to the psychiatric emergency services;

b. Intractable (i.e., persistent or very recurrent) severe major symptoms (e.g., affective, psychotic, suicidal);

c. Co-occurring mental illness and substance use disorders with more than six months duration at the time of contact;

d. High risk or recent history of criminal justice involvement which may include frequent contact with law enforcement personnel, incarcerations, parole or probation;

e. Literally homeless, imminent risk of being homeless, or residing in unsafe housing; f. Residing in an inpatient or supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not available; AND

D. Difficulty effectively utilizing traditional case management or office-based outpatient services, or evidence that they require a more assertive and frequent non-office based service to meet their clinical needs [This may be problematic from a Parity Standpoint in that it may require "FAIL FIRST," which is prohibited by the Mental Health Parity and Addiction Equity Act of 2008]

An individual who needs to receive ACT services, but who does not meet the requirements identified above may be eligible for ACT services upon written prior approval by the Behavioral Health Managed Care Organization or the County MH/MR Office, as applicable. In order to meet the DACTS fidelity standard related to admission criteria, at least 90% of the consumers admitted to the program shall meet the eligibility criteria outlined in the bulletin.

Reflections on Franz Kafka, Perfection, Imperfection and the Terrifying, Arbitrariness of Power

1/27/2018

I have to say my Father was very different than Franz Kafka's Father. Dad was a very caring, compassionate person who was also both extremely self-disciplined and not particularly into changing people.
Additionally, neither my Father or Mother were Social Climbers or Political Climbers, so they were always quite free to do what they thought was right.
I don't know how I became so obsessed with Social Reform---- It's just always seemed so incredibly interesting and important, really since elementary school.
But at that time, as a Child one thinks -- the KEY is to get rid of ALL the BAD people and put in the GOOD people. Of course, everything is very BLACK and WHITE, GOOD and EVIL -- and oneself as a person has not had time to make significant mistakes. That will change.
My brother, who I sometimes refer to as the most Conservative Person in International Development working today, observes that one has to do a lot of MENTAL GYMNASTICS to retain the ILLUSION that one is PERFECT.
Unlike Franz Kafka's Father, Dad was not exactly the prime, physical specimen -- but maybe that gave him a lot of insight. Ironically, our son is a Body Builder -- life turns out different than what you think -- Dad would have thought that was HILARIOUS.
Not ONE person in my family is perfect, including me. AND some members of my family and extended family have had to struggle much more than others. Further, I've never met a perfect person. When I was a child, I thought I was a perfect person or would be, and there were a lot of perfect people.
The Greek Gods were really a reflection of the fickleness, and arbitrariness of FATE. We try to clean that up by saying: Character is Destiny. The Criminal Justice System tries to do the same thing, aided and abetted by a less than scientific mental health profession.
The Truth is that:

Social Determinants of Health:
The Negative Physical and Mental Effects of Racial Discrimination as well as other forms of Discrimination, including Discrimination against People who are Neurologically Diverse;
The Failure to Adequately Comply with Civil Rights Laws, including Disability Civil Rights Laws such as the Americans with Disabilities Act, Olmstead and Parity

greatly impact the lives of others, especially poor people with disabilities, and such Factors implicate us all.

Themes of Terrifying, Arbitrary Power

In Chinese philosophy, yin and yang (陰陽 yīnyáng, lit. "dark-bright", "negative-positive") describe how seemingly opposite or contrary forces may actually be complementary, interconnected, and interdependent in the natural world, and how they may give rise to each other as they interrelate to one another. -- Wikipedia

Mary Anne Evans, known by her pen name George Eliot, was an English novelist, poet, journalist, translator and one of the leading writers of the Victorian era. Novalis was the pseudonym and pen name of Georg Philipp Friedrich Freiherr von Hardenberg, a poet, author, mystic, and philosopher of Early German Romanticism. -- Wikipedia

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