MENTAL HEALTH Group D Trey Perez Heather Rawls DJ Reid

1. MENTAL HEALTH Group D Trey Perez Heather Rawls DJ Reid

2. Agenda • Mental health overview • Previous Legislation • Current Legislation • Republican and Democratic views • Policy and Fiscal Implications • Proposed Legislation

3. What is Mental Health • The meaning of being mentally healthy is subject to many interpretations rooted in value judgments, which may vary across cultures. • Mental health should not be seen as the absence of illness, but more to do with a form of subjective well being, when individuals feel that they are coping, fairly in control of their lives, able to face challenges, and take on responsibility.

4. Defined by WHO • Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity specific to the individual’s culture (WHO).

5. What is Mental Illness? • Mental illness refers collectively to all diagnosable mental health problems that become “clinical,” that is where a degree of professional intervention and treatment is required. Generally, the term refers to more serious problems, rather than, for example, a mild episode of depression or anxiety requiring temporary help (WHO).

6. History of Mental Health Policy • Mental health has been shaped by cultural changes and major social policies designed with other populations in mind as well as by the efforts of persons working in the mental health field itself. (Center For Mental Health Services)

7. History of Mental Health Policy • There have been significant improvements in treatment, public attitudes, and services organization, and enormous growth in mental health insurance coverage, treatment resources, episodes of care, and research of all kinds in the past 50 years. • Systems have transitioned from largely psychotherapy for the affluent and custodial institutional care for all others, to a range of outpatient services, inpatient care in various settings, residential care, and housing alternatives

8. History of Mental Health Policy • The change that is currently transforming mental health care • The introduction and growth of managed behavioral health care • The work of mental health professionals.

9. Mental Health Economy: Past and Present • Resource allocation of mental health care has been decentralized over the past 35 years. • 1950’s: 75 percent of episodes of treatment were provided by public mental hospitals • 1990’s: less than a quarter of treatment episodes are provided by publicly owned mental hospitals

10. Mental Health Economy: Past and Present • 1950’s through the 1970’s the mental health system operated as a planned economy. • Today, there is a market for insurance, services, and management of mental health systems. • The majority of individuals in the United States acquire their mental healthcare from private providers who compete for customers.

11. Disparity of Mental Health Services • With the emergence of dramatic structural changes in mental health services over the past 50 years, disparities have been created, with the biggest disproportion of services being available to children and seniors located in rural settings.

12. Child and Adolescent Mental Health • The MECA Study (Methodology for Epidemiology of Mental Disorders in Children and Adolescents) estimated that almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder associated with at least minimum impairment.

13. Children and adolescents age 9–17 with mental or addictive disorders, combined MECA sample, 6-month (current) prevalence* * Disorders include diagnosis-specific impairment and CGAS < or = 70 (mild global impairment)

14. Child and Adolescent Mental Health • The mental disorders affecting children and adolescents include the following (NIMH): • Attention Deficit Hyperactivity Disorder (ADHD, ADD): ADHD/ADD, is one of the most common mental disorders that develop in children. Characterized by impulsiveness, hyperactivity, and inattention. • Autism Spectrum Disorders (Pervasive Developmental Disorders) Autism Spectrum Disorders (ASD), also known as Pervasive Developmental Disorders (PDDs), cause severe and pervasive impairment in thinking, feeling, language, and the ability to relate to others. • Bipolar Disorder Bipolar Disorder, also known as manic-depressive illness, is a serious medical illness that causes shifts in a person's mood, energy, and ability to function.

15. Child and Adolescent Mental Health • Borderline Personality Disorder Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. • Depression Depression is a disorder that affects an individuals thoughts, mood, feelings, behavior, and physical health. • Eating Disorders Eating disorders involve serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating, as well as feelings of distress or extreme concern about body shape or weight. • Childhood-Onset Schizophrenia Schizophrenia is a chronic, severe, and disabling brain disorder.

16. Reported Mental Health Concerns: Gender and School Level * School Mental Health Services in the United States. 2006. http://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdf

17. The Tragedy • Most children and adolescents with psychiatric disorders do not get the help they need. If left untreated, the physical, emotional, social and intellectual development of children with mental disorders will be severely stunted, if not crippled. • These children are at a heightened risk for school failure and dropout, drug abuse, and many other difficulties - all of which can be prevented by timely evaluation and appropriate treatment.

18. Elderly Adult Mental Health • Mental health issues affect seniors differently than other age groups due to loss, physical health concerns, and economic and social changes acting either individually or in combination. • Up to 25% of people over the age of 60 experience some kind of mental illness, particularly depression.

19. Elderly Adult Mental Health • The lack of attention to the mental health problems of the elderly may be attributed to: • ageism • inadequate training of health care providers • the shortage of geriatric specialists • the need for more knowledge and research,

20. Medicaid Coverage of Mental Health Treatment • There are certain mental health services that are mandatory under federal law and must be offered to all Medicaid beneficiaries in all states. • Inpatient and residential treatment • Outpatient physician and hospital services • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) • Requires coverage of all optional services when necessary for a child.

21. Medicaid Coverage of Mental Health Treatment • Mandatory eligibility covers pregnant women and children up to age 6 in families with incomes up to 133 percent of the federal poverty level and older children up to 100 percent of poverty. • States can opt to raise these income limits to 185% or 133% of poverty respectively. States also have the option to cover children who qualify for the State Child Health Insurance Program (S-CHIP), whose families can have incomes as high as 250 percent of poverty

22. Medicaid Coverage of Mental Health Treatment • A large number of individuals with mental disorders on Medicaid are eligible because they receive federal disability benefits. • Over a quarter of those receiving Supplemental Security Income (SSI) disability benefits, 1.4 million, are people with psychiatric disabilities. Generally, SSI recipients fall within the mandatory eligibility category.

23. Medicaid Coverage of Mental Health Treatment • Medicaid also offers coverage of individuals who have high medical costs and who can qualify as “medically needy.” • These individuals must still meet the eligibility standards of some category of Medicaid (such as by being disabled), but need not meet the Medicaid income test  

24. Medicare Coverage of Mental Health Treatment • Hospitalization: Medicare covers care in specialized psychiatric hospitals which only treat mental illness when in-patient care is needed for active psychiatric treatment. • pays for necessary in-patient hospitalization for up to 90 days per benefit period. • Partial hospitalization programs offer intensive psychiatric treatment on an outpatient basis to psychiatric patients, with an expectation that the patient’s psychiatric condition and level of functioning will improve and that relapse will be prevented so that re-hospitalization can be avoided

25. Medicare Coverage of Mental Health Treatment • Medicare covers needed diagnostic and treatment services provided by physicians, including psychiatrists, as well as clinical psychologists, social workers, psychiatric nurse specialists, nurse practitioners and physicians assistants. • Medicare pays for home health services for individuals who require skilled care on a part-time or intermittent basis and who are confined to the home. People with mental health needs who meet these eligibility criteria are eligible for care in their home, even if they have no physical limitations

26. Medicare Coverage of Mental Health Treatment • LIMITATIONS: • Reimbursement for certain psychiatric services differs from the usual Medicare reimbursement rules. • Medicare Part B generally reimburses doctors at 80% of the approved amount; the patient pays the remaining 20% coinsurance amount. • When a claim is for mental health services, Medicare makes an initial deduction of 37½ % before paying 80% of the charge. As a result, the Part B reimbursement is, on average, about 50% of the charge.

27. Medicare Coverage of Mental Health Treatment • It is recommended that individuals need to consider carefully how to supplement their Medicare coverage • Medigap policy • Retiree health policy • Through Medicaid

28. Previous Legislative Efforts:Keeping Families Together Act of 2007 • To amend the Public Health Service Act to establish a State family support grant program to end the practice of parents giving legal custody of their seriously emotionally disturbed children to State agencies for the purpose of obtaining mental health services for those children. • Introduced by Rep. Jim Ramstad (R-MN3) • PURPOSE: To assist States in eliminating the practice of parents giving custody of their seriously emotionally disturbed children to State agencies for the purpose of securing mental health care for those children • Referred to the House Committee on Energy and Commerce

29. Previous Legislative Efforts:Mental Health Parity Act of 2007 • To amend the Public Health Service Act with respect to mental health services for elderly individuals. • Introduced by Sen. Pete V. Domenici (R-NM) • STATEMENT OF PURPOSE- To provide parity between health insurance coverage of mental health benefits and benefits for medical and surgical services. • Referred to Committee on Health, Education, Labor, and Pensions

30. Previous Legislative Efforts:Seniors Mental Health Access Improvement Act of 2007 • To amend the Social Security Act to provide for the coverage of marriage and family therapist services under part B of the Medicare Program, and for other purposes. • Introduced by Rep. Edolphus Towns (D-NY). • Co-Sponsored by Rep. Charles W. Pickering (R-MS3) • Effective: The amendments made by this Act apply with respect to services furnished on or after January 1, 2008 .

31. Bill S. 633 of the 110th Congress Title • “Working Together for Rural Access to Mental Health and Wellness for Children and Seniors Act” • Introduced by Sen. Norm Coleman (R-MN) • February 15, 2007 • Referred to Committee on Health, Education, Labor, and Pensions

32. Findings • In rural areas, where specialized mental health services are scarce, accessing mental health professional services is difficult. • Rural primary care providers have experienced an increase in mental health issues recently • Surgeon General estimates 21% of children experience mental health systems, which left untreated can lead to school failure, drug abuse, and often incarceration • The Department of Health and Human Services estimates 1 in 5 children and adolescents have diagnosable disorders, yet close to 80% receive no help

33. Findings continued… • Few schools have the resources and funding available to implement a full range of mental health interventions • Mental health is a fundamental cornerstone to ensure children have the opportunity to be successful in school • Promoting and expanding telemental health collaborations to strengthen delivery of mental health services in remote and underserved areas is needed • Telemental health is effective at diagnosing and treating mental health disorders and can provide better access and care to rural areas • Telemental health is the use of videoconferencing or similar means of electronic communication to provide mental health services

34. Grant Program Continued… Amount of Funding: • The Secretary shall award a grant to a State under this section in an amount that is based on the respective number of critical access hospitals (as defined in section 1861 (mm)(1) of the Social Security Act (42 U.S.C. 1395x(mm)(1)) in the State as such compares to the total number of critical access hospitals in all States that are awarded grants under this section

35. Purpose • Provide assistance to rural schools, hospitals, and communities through collaborative efforts to secure progressive and innovative systems to provide mental healthcare access and treatment for youth, seniors, and families • Increase access to elementary and secondary schools to mental health services in rural areas through the use of a mobile health services van program • Increase access to individuals of all ages to mental health services in rural areas by utilization of telemental health services established in the areas

36. Grant program • State grants shall be awarded by the Secretary of Health and Human Services for the purpose of issuing subgrants to carry out the purposes of this act Eligibility: • States shall be deemed eligible by submitting an application with all pertinent information required, establishing a lead agency, and submitting a state plan

37. State Lead Agency • The governor of each state shall be responsible for selecting a Lead agency (other than the State Office of Rural Health) to administer the State programs • The lead agency shall administer directly or through other agencies the awarded funding • The lead agency will also be responsible for forming the state plan which will coordinate the expenditures in consultation with state and local representatives of educational agencies, rural mental health providers, and the state hospital association

38. The State Plan • Establish lead agency • Assure that the state will use funding in the following areas: • Provide mobile van services for elementary and secondary education students • Provide telemental health services to individuals of all ages in rural areas, and cover all administrative costs associated with these grant recipients • Assure that the grant benefits will be available throughout the entire state • Assure the lead agency will consult mental health providers and state hospital associations to assess appropriate fund utilization

39. Eligibility • Located in or serving a rural area • Government owned or non-profit hospital • Community mental health facility • Primary care clinic • Other non-profit agency providing mental health services Selection will be based on an applicants need to improve mental health care access within a community and the extent to which it will serve rural low-income populations. All applicants must submit a comprehensive outline of all procedures, evaluations, measurements, and must keep a record and reports available to the Secretary at all times for oversight.

40. Fund Utilization • Mobile vans • Offset all costs incurred after Dec. 31, 2007 • Purchase or lease of vehicle • Repairs and maintenance • Purchase or lease of communication equipment • Education and training of staff using the van • Professional staff employment

41. Fund Utilization Continued… • Telemental health services • Offset all costs incurred after Dec. 31, 2007 • Purchasing, leasing, maintaining, and repairing all telemental health equipment • Telecommunications, utility, and software upkeep and purchase • Education and training to telemental health service staff • Professional staff employment

42. Limitations • $10,000,000 in appropriations for the program for each fiscal years 2008 to 2010 • Each subgrant shall not exceed $300,000 for one fiscal year • The Secretary shall review and monitor State compliance with the requirements of this section and the State plan and will be able to suspend payments to states if compliance is not satisfactorily met

43. Republicans vs. Democrats

44. Issues with mental healthcare • Parity of mental health care • Major issue is that mental health is not cost beneficial • Mental health problems cost too much since they are chronic • Myth? • What about heart disease, diabetes, asthma? Chronic physical diseases. • Substance abuse and rehabilitation • Should treatment medications be covered by Medicare/Medicaid?

45. Democrats

46. Democratic Party view on mental health • Want healthcare to be available and affordable to everyone and provided by the state • Democrats believe that mental healthcare is needed for veterans. • War costs are not just bullets and guns, but taking care of returning veterans both physically and mentally.

47. Republicans

48. Republican view on mental healthcare • Increase the number of citizens with health insurance • Make private insurance more affordable • Move away from government funding • Limit mental healthcare by providers, especially Medicare and Medicaid

49. Republicans (cont.) “senior House Republicans and business groups are staunchly opposed to the deal” -Deal was to include coverage of mental healthcare in insurance “The compromise would outlaw disparities in coverage between mental and physical illness under group health plans sponsored by employers with more than 50 workers”

50. Similarities • Both consider mental health as an important part of a healthy life • Both parties want to end discrimination in the work place (insurance discrimination) • Both want equitable mental healthcare • 98% of Americans think mental health should be covered by insurance • 83% of Republicans and 92% of Democrats want equitable health insurance • 89% of both employees AND employers want mental health care coverage