Vermont Council of Developmental & Mental Health Services Legislative Update for March 20, 2012 Legislators Informally Concur on Bill to Reform Mental Health System On Friday the Conference Committee informally agreed to complete their negotiations on H.630 the bill to reform Vermont’s mental health system. On Tuesday they will review the final draft with their proposed changes and formally sign off on it. The legislation will then be voted on by the House and Senate before the Governor signs it to enact it into law. The key sticking point had been the number of beds of the state operated facility in central Vermont. The final language calls for building 25 beds, but allows for downsizing the facility to 16 beds if federal requirements impact funding. If the facility is downsized the 9 beds will be replaced, if necessary. Legislators had a strong interest in holding the department accountable to achieve the goals of the plan and called for an independent consultant to report to them. The consultant will be contracted by a special committee consisting of members of the joint fiscal committee and the chairs and vice chairs of the senate committee on health and welfare and the house committee on human services in consultation with the commissioner of mental health. The consultant will report on December 1st on whether the proposed mental health system appropriately serves the needs of individuals with mental health conditions and, if any unmet needs are identified, how they may be addressed. Additionally, they will report on the data and evaluation mechanisms necessary to manage and improve the quality of care and outcomes. The bill also calls for the Department of Mental Health to report to the senate committee on health and welfare and the house committee on human services regarding the efforts to plan for implementation, quality improvement, and innovation of the mental health system and how it recommends improving the system. The recommendations shall be based on assessment of outcome and financial measures to include: 1. development of sufficient capacity for inpatient and community psychiatric services and peer supports across the continuum of care; 2. the support of individuals in accessing the services nearest to their homes; 3. the reduction in emergency department usage and law enforcement intervention; 4. the reduction in hospital admissions and length of inpatient stays, including any impact on readmissions; 5. the implementation of quality assessment tools for evaluation of services at all levels, including those needed to measure the effectiveness of the care management system; 6. the department’s use of current financial data to conduct a fiscal analysis of the capital and annual operating costs associated with the plan; 7. Individuals’ satisfaction with provided services. The Senate wanted to assure that hospitals would receive adequate reimbursement. Representative Pugh suggested that the community providers should receive that, too. In the end they agreed that state rate setting office would review the hospital costs. House Appropriations Committee Approves Fiscal Year 2013 Budget The House Appropriations Committee completed their work on the budget bill and it will now go to the full House of Representatives for review and approval. The Council had testified in support of the Governor's proposed budget, while advocating for continued funding for the Light House public inebriate program and questioning the proposed reduction in funding for developmental services while individuals who receive waiver services are hospitalized. The committee vice chair Mitzi Johnson worked with the administration to secure ongoing funding for the Light House. The estimated savings from hospitalizations were adjusted and the new caseload funds for developmental services were reduced, leaving the net funding request for developmental services the same. Recommendations to reduce funding in mental health by the House Human Services Committee were not incorporated into the budget. Senate Appropriations Committee Hears Mental Health Budget Patrick Flood spoke about how quickly mental health services are changing. Morrisville’s temporary hospital is going to be funded with general funds and this was not in the original budget request. Patrick spoke highly about the success of the Challenges for Change pilots which will receive continued funding in the FY'13 budget. Jane expressed her interest that The Light House program receives full funding - she knows that the house has addressed it with Patrick's support. In reference to the enhanced community mental health services Committee Chair Jane Kitchel asked, “How will we know we are doing a good job? DAs will tell us they are doing a good job.” Patrick explained that the language is being developed by the conference committee. He is interested in what the customers think about whether they are getting what they need. Senator Hinda Miller asked about DAs being subject to public records law. Patrick said once DAs send information to State government, then it is public. He assured the committee that they will receive more robust data than ever. Senator Kitchel then asked about the outcomes of success beyond six. Is it overseen? Are interventions working? Are children well served? DMH Finance Director Heidi Hall spoke about outcomes contract with CSAC as a model for the behavioral intervention services. They will be expanded to a few other communities. Patrick explained that the Governor's plan calls for an $8 million enhancement of community services. Individual agencies are developing plans for DMH on how to best use the resources. It is his expectation that it will take time to roll out services so DMH is planning for expenditure levels of $7 million for FY'13. Patrick explained that Hilltop will focus more on step up than step down. Crisis beds will go to Lamoille and Orange Counties. The commissioner explained that he is still discussing where the 15 intensive residential beds will be in the northwest and central parts of the state. When he spoke about the secure residential facility, he noted that DMH is still looking for community placements. The House is expected to pass a budget to the Senate this week. The total budget for DMH is $173 Million. Commissioner Wehry Presents DAIL Budget to Senate Appropriations Committee On March 14th Commissioner Wehry provided an overview of DAIL programs and shared the budget proposal for FY’13 with the Senate Appropriations Committee. The budget proposal for DS includes $4,163,857 in new caseload, which is inclusive of graduates and $1,976,292 for those who meet public safety criteria. There is a reduction of $475,000 that will be achieved though changing reimbursement practices during hospitalization. The Commissioner said that CMS does not allow to double bill; however, in 2002 or 2003 a waiver or variance was sought to bill waiver services for a period of time. DAIL revisited the interpretation of that a year ago and determined that billing should not be allowed for all services. Senator Kitchel noted that there are fixed costs and the Commissioner indicated that providers will be paid for what they are providing, but not for employment, community supports, therapies, transportation, etc. Though not shared in the written budget document or verbally with the Committee, the proposal shared with Senate Appropriations reduces new caseload funds by $350,000 from the Governor's budget proposal. This $350,000 reduction would make whole the $850,000 reduction anticipated from no longer allowing billing during hospitalization. The result of the reduction is that the proposed overall increase for DS remains the same as proposed in the Governor's budget at $4,915,149. The FY’13 budget will provide $1.55 million less in caseload funding than is available for FY’12, although half of the FY’12 new caseload funds were achieved through a reduction to existing services. House Health Committee Supports Equal Cost-sharing for Mental Health & Primary Care Representative Anne Donahue, the lead sponsor of the H.498, gave a brief history of the mental health parity discussion on whether mental health would be considered primary or specialty care. BISHCA determined that it should be considered specialty care since it is provided based on referral from primary care. The federal mental health parity, by rule, considers some mental health care as primary care in relation to co-pay requirements. However, BISHCA says small employers do not have to meet federal parity requirements. Anne would like to have state law consistent with federal parity for all employers and insurance. State law does state that there should be no greater burden on an insured for access to mental health condition than for access to treatment for other health conditions. Anne suggests that basic counseling by masters level clinicians should be considered primary care. Health Committee Chair Michael Fisher thinks the standard for health reform is being set now. So this is an important issue to resolve. Ralph Provenza, Executive Director of United Counseling Services (UCS), spoke about the impact of high co-pays. In FY'11 UCS served 2,200 people with a variety of insurance coverages in their outpatient programs. Co-pays range from $10 - 50. The average is $25. A growing number of people served have high deductible insurance and a growing number of people cannot pay their fees. This appears to correspond with a growing number of people leaving after 2 sessions. Anecdotal information indicates that clients leave service and complain about high co-pays. UCS lost $273,000 in their outpatient program in fiscal year 2011. Ralph thinks people who do specialized evaluations; neuropsychological testing, etc should be considered specialists. He suggested looking at the scope of practice to determine primary care: e.g. social work, counselors; psychologists. He was clear that community mental health is primary care. With the blueprint PCPs walk clients down the hall to receive primary mental health services. He personally sees higher co-pays for mental health services as discriminatory. Medicare will be shifting its co-pays for mental health care in the future to bring them to a more reasonable level. Julie Tessler of the Council gave a broader perspective on why mental health care should be considered primary care. If mental health conditions go unaddressed they result in very high co-morbidity with physical health problems. As many as 70% of the reasons for visits to the doctor are due to mental health and substance use disorders. Underlying and unaddressed mental health concerns negatively effects treatment outcomes for physical health. As in all health care, if we have sufficient mental health capacity to address psychological issues early on we can prevent the escalation of the illness or condition resulting in better outcomes and less expensive care. High numbers of individuals served in the community mental health system do not have primary care doctors. The uninsured, in particular, often don't have access to primary care. Therefore, their primary care often takes place first within services provided by mental health. Community mental health makes referrals and communicates to primary care physicians about issues that may be barriers to care. We also assist with medication compliance, and support clients in being successful with their medical treatments. For some, community mental health is their primary care; the medical care is their specialty care. The Vermont Council supports H. 498 because equal cost-sharing for mental health services with primary care services will improve access to mental health care as an important primary care service. The overall health of Vermonters will benefit from this legislation. Alexandra Forbes testified on behalf of the Vermont Psychological Association (VPA) in support of H.498 to address the financial barriers for Vermonters seeking mental health and substance abuse treatments. VPA sees high co-pays as creating enormous disincentives for seeking and completing medically necessary mental health or substance abuse treatment and sited research on this phenomenon. [Excerpted from Medicaid Co-Pays: An Impact Analysis for New Jersey, Coalition for a Moral Budget, 2009] “A substantial body of research shows that higher co- payments are likely to cause low-income people to decrease their use of necessary health care services.” This triggers the subsequent use of more expensive services including hospital emergency rooms and hospitalization. Based on this evidence, when the State of Vermont shifts Vermonters covered by VHAP to a Catamount plan, Alex expects to see a reduction in the use of preventive services like mental health and substance abuse treatments because of the co-payment requirement. MVP Health Plan opposed the plan siting increased costs to its members and because it could set a precedent for other types of health care. In the end the Committee voted unanimously for the bill and requested Banking, Insurance, Securities and Health Care Administration (BISHCA) to adopt rules clarifying “primary” and “specialty” mental health services. House General, Housing and Military Affairs Takes up Bill on Union Organizing On March 15th the House General, Housing and Military Affairs took up H.389 on use of public funds in relation to union organizing. The first witness was Judith Hayward, executive director of HCRS. She gave background information on her agency which is a comprehensive community mental health center. Representative Stevens asked about the relationship between HCRS and state government. Judith spoke about the state oversight role. Funding sources: Medicaid is 80%, while local revenue and donations and other revenues add up to approximately $1.5 million. The Committee asked about legal fees in relationship to working with the union. Representative Bouchard however, pointed out that union negotiations do not fall into the realm of the bill which is about union organizing. Judith explained that they always work to have a positive relationship with the union and that it is helpful to have expert legal counsel for grievances and negotiations. Chris Callacci, spoke for UNAP, a labor union which represents hundreds of health workers in the state including some workers at HCRS. He said the language in the bill relies on a decision by the state rate setting office which denied use of state funding to Berlin Health and Rehab for activities they were engaged in to prevent union organizing. H.389 would apply this rule to other health care settings like community mental health. He said it is upsetting that client care dollars are being diverted to legal fees. HCRS employee and union member Jeanne Dionne seconded this statement. Rep Bouchard asked, “Don’t you expect an agency to use a lawyer to defend itself regarding an unfair labor practice? Don't they need an attorney for negotiations?” Chris Callacci agreed but noted that the law firm used by HCRS is a notorious “union dampening firm”. Christine Oliver Deputy Secretary of the Agency of Human Services expressed understanding of the concerns expressed, but noted that the Agency sees the bill as written as pre-empting federal law. AHS recommended that the committee hears from the attorney general’s office. Monitoring and enforcement by AHS would be difficult and not necessary since these issues could be redressed elsewhere. Representative John Moran asked, “Don’t we deserve a way to know how state dollars are used?” Christine replied that there are many ways that monitoring the financials of the agency can take place, but not generally by each expense. Committee Chair Helen Head asked, “If we could reframe the bill to avoid preemption of federal law then would you support the bill?” Christine noted that the purpose of the bill is already supported by federal government in the prohibition against illegal activity, such as unfair labor practices. AHS expects there are legitimate legal fees. “There are not going to be line items that say bust union.” The bill asks for certification that funds will not be used for union busting. Christine explained that even if they received such certification, the state does not have the administrative ability to then go in and do an inspection. It is the breadth of the bill that creates concerns for the administration. AHS is happy to look into single instances of legislator concerns. Michal Sirotkin on behalf of UNAP testified that he heard HCRS has no problem with disclosing more about their expenditures. Acknowledging that there are many statutes not aggressively enforced, he believes that certification by the agency will go a long way to achieve the purpose of the bill. House Human Services Committee Approves Opioid Treatment Bill H.627 supports the regionalization and more uniform application of assessment protocols to more accurately determine the treatment needs of clients seeking/needing medication assisted treatment, including both methadone and buprenorphine. In its current form the bill appears to propose to expand who can provide assessment and treatment. However, it is vague about the actual addictions training and experience necessary for this broad base of added providers. This may result in uncontrolled Medicaid billings. Barbara Cimaglio in a phone conversation with House Human Services on Friday indicated she supported the expansion. Although Bob Bick was able to attend the testimony on behalf of the Council, he recommends further analysis of impact of the bill will be necessary to determine the Council’s position when the bill is considered by the Senate. Recovery Day at the State House On Friday March 16 VAMAR and NAMI-VT held Recovery Day at the State House. Individuals in recovery from mental health conditions and addictive disorders came from around the state and shared their stories and perspectives. A number of legislators spoke to the large audience and Senator Snelling received an award. A coalition of advocacy groups and individuals, including the Vermont Council circulated a flyer highlighting the importance of quality mental health services for individuals who are incarcerated. This week’s schedule House Committee on Appropriations Monday, March 19, 2012 1:00 PM FY2013 State Budget Committee Discussion/Vote Tuesday, March 20, 2012 9:00 AM TBA 2:30 PM TBA Wednesday, March 21, 2012 9:00 AM TBA 1:15 PM TBA Thursday, March 22, 2012 8:30 AM FY2013 State Budget Floor Amendments 9:00 AM House Convenes Friday, March 23, 2012 8:30 AM FY2013 State Budget Floor Amendments 9:00 AM House Convenes House Committee on Human Services Wednesday, March 21, 2012 9:00 AM Disability Awareness Day Other TBA 9:15 AM Agency of Human Services Strategic Plan Doug Racine, Secretary, Agency of Human Services Monica Hutt, Director of Operations, Department for Children & Families 10:45 AM TBA (Disability Awareness Cafeteria Supper from 5-6) Senate Committee on Health and Welfare Tuesday, March 20, 2012 9:30 AM Senate Floor After Floor H. 559 - An act relating to health care reform implementation Act 48 Overview Robin Lunge, Director of Health Care Reform, Agency of Administration Wednesday, March 21, 2012 11:30 AM Disability Awareness Kate McCarthy-Barnett, MD, Disability Integration Specialist, FEMA Region I Thursday, March 22, 2012 10:00 AM H. 559 - An act relating to health care reform implementation Waivers, Section 33-35a, 40c Mark Larson, Commissioner, Department of Vermont Health Access (DVHA) Robin Lunge, Director of Health Care Reform, Agency of Administration 11:00 AM H. 559 - An act relating to health care reform implementation Blueprint, Sections 28, 28a, 37 Mark Larson, Commissioner, Department of Vermont Health Access (DVHA) Robin Lunge, Director of Health Care Reform, Agency of Administration Georgia Maheras, Executive Director, Green Mountain Care Board Dr. Craig Jones, Director, Blueprint for Health, Department of Health Access Senate Committee on Judiciary Thursday, March 22, 2012 9:00 AM H. 765 - An act relating to the mental health needs of the corrections population Rep. Joan Lenes, Reporter of the Bill Kasey Bryan, Legislative Counsel, Office of Legislative Council Doug Racine, Secretary, Agency of Human Services Patrick Flood, Commissioner, Department of Mental Health Andy Pallito, Commissioner, Department of Corrections 10:45 AM Break For more information or to take action: Legislative home page: http://www.leg.state.vt.us Sergeant-at-Arms Office: (802) 828-2228 or (800) 322-5616 State House fax (to reach any member): (802) 828-2424 State House mailing address (to reach any member): Your Legislator State House 115 State Street, Drawer 33 Montpelier, VT 05633-5501 Email, home address and phone: Legislators' email addresses and home contacts may be found on the Legislature home page at http://www.leg.state.vt.us Governor Peter Shumlin (802) 828-3333 or http://governor.vermont.gov/ The purpose of the legislative update is to inform individuals who are interested in developmental, mental health and substance abuse services about legislative advocacy, policy development and activities that occur in the State Legislature. The Vermont Council is a non- profit trade association whose membership consists of 16 designated developmental and mental health agencies.
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