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10/2/2014 12:00 AM

Despite financial investments in its behavioral health system, New Mexico lacks a “comprehensive grasp” of its finances and has done a poor job of providing services for consumers with mental health and substance abuse issues, according to a scathing report released Sept. 24 by the state’s Legislative Finance Committee.

Despite financial investments in its behavioral health system, New Mexico lacks a “comprehensive grasp” of its finances and has done a poor job of providing services for consumers with mental health and substance abuse issues, according to a scathing report released Sept. 24 by the state’s Legislative Finance Committee.

The state does not know how it spends an estimated $209 million on adult behavioral health, whether it’s funding effective services, whether services are located in high-need areas or whether services are producing expected results, according to the new report. Estimates are that the state only spends 11 percent of its limited funding on proven and effective programs for adults, even though past studies have recommended greater spending on these services.

According to the report, “LFC Results First: Evidence-Based Behavioral Health Programs to Improve Outcomes for Adults,” New Mexico has been plagued with a number of problems regarding its behavioral health system.

Last June, state officials released an audit alleging that 15 of the state’s largest behavioral health organizations had engaged in mismanagement and widespread overbilling of federal and state government money (see MHW, July 15, Sept. 16, 2013). Five Arizona agencies were subsequently brought in to manage services for consumers with serious mental illness.

For adults, New Mexico leads the nation in alcohol-related death rates and is ranked among the worst in the nation in drug overdose–related death rates, suicide rates and serious mental illness rates. These persistent challenges in behavioral health outcomes, along with gaps in services, have substantial consequences in costs to consumers and taxpayers, including increased criminal activity, increased use of the health care system, property loss, decreased labor market earnings and preventable deaths, the report stated.

Behavioral health outcomes

Behavioral health outcomes in New Mexico continue to rank among the worst in the nation, the report stated. About two in 10 New Mexico adults suffer from mental illness and one in 10 suffers from mental illness. Serious negative outcomes include:

  • The percentage of New Mexicans with a mental illness is higher than most states, and the percentage with a serious mental illness is among the highest in the nation.
  • From 2008–2012, about 63,000 adults, or 4.3 percent of the adult population in New Mexico, had serious thoughts of suicide in the previous year.
  • The suicide rate has consistently been among the highest in the nation.
  • The alcohol-related death rate has been the highest in the country since 1997.

Adult mental health issues range from stress, anxiety and depression to more serious functional impairment and life-threatening situations such as serious mental illness and suicide, the report stated. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) reports 19.6 percent (300,000) of New Mexicans 18 or older have a mental illness.

This figure is above the national percentage of 18.2 percent. SAMHSA also reports 4.72 percent (72,000) of New Mexicans 18 or older have had a serious mental illness in the past year, up from 3.4 percent in 2008. This figure is well above the national percentage of 3.97 percent and ranks among the highest in the nation, according to the report.

Limited EBPs

The report noted that evidence-based practices (EBPs) for the treatment of mental illness and substance abuse disorder are limited and oversight of program fidelity is lax for many programs. Such programs as assertive community treatment, cognitive behavioral therapy and illness management and recovery are available.

Other EBPs, including collaborative care management for depression and depression with comorbid medical conditions, and primary care behavioral health co-located in community-based and integrated care settings, may be buried in generic individual therapy codes and specific treatment interventions and cannot be identified, the report stated.

The analysis also emphasized “the need for a system of care which is planned and designed coherently, managed and led effectively, and owned and guided by those who benefit from and contribute to the system’s existence and success.”

Additionally, the report recommended that the state:

  • Develop and use common reporting system requirements;
  • Develop a common set of core services across funding streams;
  • Require or provide incentives for adherence to evidence-based practices; and
  • Create statewide behavioral health research and development capacity.

HSD responds

“The Legislative Finance Committee report adds to the conversation about ways to improve behavioral health outcomes in New Mexico,” Matt Kennicott, spokesperson for the New Mexico Human Services Department, told MHW. “As has been the case over the past several years, we will continue to support the use of evidence-based practices in behavioral health. But this is only one part of the conversation.”

Kennicott added, “We also need to improve access to behavioral health services broadly by focusing on individuals in a holistic manner through integrated care in Centennial Care (our new Medicaid program), addressing behavioral health workforce shortages and streamlining the regulatory structure.”

He noted that HSD has taken important steps to improving access. “This is evident by the increase in the number of behavioral health consumers that were seen in FY14 — an increase of 30.8 percent over last fiscal year to more than 114,000 individuals served,” Kennicott said.

Meanwhile, HSD officials announced Oct. 1 that the department’s Behavioral Health Services Division has been awarded a suicide prevention grant from SAMHSA to help prevent suicide and suicide attempts among working-age adults from 25 to 64 years old, and to reduce the overall suicide rate and number of suicides in New Mexico. The grant totals $1.4 million over three years, with the state receiving $470,000 each year.

System issues

The state’s behavioral health system "has never been top notch," especially in light of the Medicaid fraud allegations in 2013, Rep. Elizabeth “Liz” Thomson (D), chair of the Behavioral Health Subcommittee, told MHW.

“It’s really disturbing and disheartening that only 11 percent of our behavioral dollars is being used on evidence-based treatment,” said Thomson. “We can’t say with one-hundred percent certainty that more funding isn’t being used [for these treatments]. We want to see better traction and more [emphasis] on evidence-based practices.”

Additionally, the way the state conducts its Medicaid billing, it’s impossible, she said, to determine whether evidence-based treatments are being used. “The billing codes need to be changed in order to dig down and see what therapies are being used,” she said.

The subcommittee, meanwhile, is working on recommendations for addressing challenges in the behavioral health system, including the lack of providers and homelessness, Thomson said. “The legislative council charged us with coming up with a plan,” Thomson said. “The problem is New Mexico is a poor state and a very rural state.” The subcommittee will take their recommendations to the full legislative subcommittee in late November or early December, she added. “We recognize that what we come up with will not [necessarily] fix the system,” said Thomson.

Bottom Line…

The state legislature’s Behavioral Health Subcommittee is preparing recommendations to release in another month on repairing New Mexico’s behavioral health system.

5/29/2014 12:00 AM

It’s been nearly two weeks since the tragedy in Isla Vista, Calif., that resulted in the killing of six students and injuries to 13 others, and once again the mental health field is confronted about what to do in order to avert future tragedies.

It’s been nearly two weeks since the tragedy in Isla Vista, Calif., that resulted in the killing of six students and injuries to 13 others, and once again the mental health field is confronted about what to do in order to avert future tragedies.

While more details are emerging, news reports indicate that Elliot Rodger,a 22-year-old student, had been seeing therapists since he was a child. In the weeks before the tragedy, his concerned parents had called the police to check on him. Officers, however, saw no cause for alarm, according to news reports.

Meanwhile Democratic Assembly members Das Williams of Santa Barbara and Nancy Skinner of Berkeley announced they will introduce a bill that would allow concerned family members or friends to notify authorities when a loved one is at risk of committing violence. That would allow law enforcement to investigate the person and potentially prevent him from buying firearms, the Sacramento Bee reported.

Members of the mental health community are advocating for research, education and expansion of crisis-related services. The National Alliance on Mental Illness (NAMI) released a statement about the steps needed to prevent future tragedies:

  • Fill the gaps in our community mental health care systems. That includes the creation and promotion of crisis services and partnerships between mental health professionals and all first responders.
  • Improve communications between mental health professionals, individuals receiving care and their families. Mental health privacy is important, but privacy laws should not stand in the way of coordinated information and action in a crisis.
  • Talk about it — within families as well as with teachers, clergy, students and community leaders. Encourage conversation about mental health, about what we are experiencing and what we can do to help. By doing so, we create and promote the space for open and honest dialogue that saves lives.

“There are simple things that can also be looked at to improve the system to make sure this doesn’t happen again,” Katrina Gay, director of communications for NAMI, told MHW. “There’s a big gap in our community around crisis services, such as mobile crisis services, crisis intervention specialists who are trained to de-escalate [a situation].”

Gay explained that at one time such services were robustly available but that was before huge mental health budget cuts began during the recession. “Most communities only have a ‘patchwork’ of crisis mental health services at best,” she said. Crisis Intervention Team (CIT) programs are a part of that, she noted. However, there needs to be an array of assessment, crisis stabilization services and hotlines available, Gay said.

CITs know how to de-escalate in a crisis, but intervening in a crisis to provide care is another situation, she noted.

Partnerships encouraged

When Rodger’s parents contacted police, a mental health professional should have accompanied them to provide an evaluation and/or intervention, noted Gay. “Clearly someone in the family recognized a concern,” she said. “It’s not reasonable to send a police officer in those situations as a first responder.” CIT programs do help, but in this particular case somebody should have accompanied the police, she said.

In her discussion with NAMI leaders last week, Gay said the consensus was on the need for mental health providers to be a part of the crisis service array. A trained mental health provider can ask questions and has more skills about engaging an individual, she said. “Only a mental health crisis team member can determine whether a person can qualify for an intervention,” she said.

Gay added, “The system is broken. In this case, there’s very little the police could have done that would have resulted in a different outcome. We can always say ‘what if.’”

Events like this tragedy are unpredictable, said Gay. If the family knew there was a crisis and they were worried and concerned, they should be taken seriously, she added.

“There’s a huge gap in our very broken system,” said Gay. “We need to fill those gaps. Partnerships between mental health providers and law enforcement are vital to the outcome for individuals who are in crisis and struggling. It’s vital to ensure the health and safety of individuals in crisis and our community — they go hand in hand.”

More bipartisan action and agreement are needed to address the pending mental health reform bills, said Gay. “There are different pieces of legislation being discussed that have components of what we’d like to see,” she said.

Minimizing the risk

“We cannot prevent all tragedies but we can do some things that can minimize the risk,” Linda Rosenberg, president and CEO of the National Council for Behavioral Health, told MHW. “We need to get down to working on education, treatment and research.”

Like NAMI, the National Council is also promoting and supporting the need for more crisis services, which was a key area of focus during the organization’s annual conference in early May in Washington, D.C., said Rosenberg.

Rosenberg explained that for the first time during its national conference, the National Council offered a crisis track for attendees. “There’s a need to ensure that crisis services are available,” said Rosenberg. Mobile teams, crisis stabilization units, peer support, respite beds and a crisis track are all critical, she said.

The National Council is planning a series of webinars on crisis services, she said. “Our members are bringing more attention to the need for crisis services,” Rosenberg said.

Regarding treatment, Rosenberg pointed to the Excellence in Mental Health Act, which recently became a law. The Excellence Act will increase Americans’ access to community mental health and substance use treatment services while improving Medicaid reimbursement for these services. “It’s a down payment on increasing treatment capacity for individuals with both mental health and substance use disorders,” she said. “We need to make sure we have capacity.”

Nearly a billion dollars has been added to this bill, she said. The legislation calls for an eight-state demonstration program that would allow states to expand services 24/7 to support families. “It’s something we can build on,” said Rosenberg, who added that the National Council is pushing for this in all states. “We want a full payment. We will work on that.”

Research in the field is another priority. “The brain is uncharted territory in many ways,” she said. “We need a better understanding of these mental illnesses and the support of institutions like the National Institute on Mental Health [NIMH].”

“What do we know about violence and how the brain functions?” Rosenberg noted. “What goes on in the brain that motivates violence? Is it a mental illness or some other process that we’re unaware of?”

Education about mental illness as part of the National Council’s public education program, Mental Health First Aid, continues to be critical, Rosenberg said. “We’re having these conversations in communities,” she said. Teachers, aunts, neighbors and others need to know how to help people who are having a tough time, she said. “Bad things will always happen,” said Rosenberg. The field can work together to help minimize or even avert future tragedies, she noted.

5/15/2014 12:00 AM

Mental health advocates are encouraged about a mental health bill that makes new investments in prevention and early intervention, advances mental illness research and proposes a White House Office of Mental Health Policy. Despite competition from another proposal introduced five months earlier, advocates remain hopeful that Democrats and Republicans will compromise on comprehensive legislation.

Mental health advocates are encouraged about a mental health bill that makes new investments in prevention and early intervention, advances mental illness research and proposes a White House Office of Mental Health Policy. Despite competition from another proposal introduced five months earlier, advocates remain hopeful that Democrats and Republicans will compromise on comprehensive legislation.

The Strengthening Mental Health in Our Communities Act of 2014 was introduced by Rep. Ron Barber (D-Ariz.) during the National Council for Behavioral Health conference on May 5 in Washington, D.C. (see MHW, May 12). H.R. 4574 is sponsored by Barber along with Reps. Diana DeGette (D-Colo.), Doris Matsui (D-Calif.), Grace Napolitano (D-Calif.) and Paul Tonko (D-N.Y.).

Provisions in the new bill include the reauthorization of important services and programs under the Substance Abuse and Mental Health Services Administration (SAMHSA) and a White House Office of Mental Health Policy that is responsible for developing and implementing a national strategy for mental health. The proposal would ensure collaboration between mental health programs and services across federal, state and local agencies.

Rep. Tim Murphy (R-Pa.) introduced mental health legislation aimed at reforming the mental health system last December. Although those in the field were pleased that the bill includes the reauthorization of suicide prevention programs and Mental Health First Aid, they were not pleased about the bill’s proposal to cut back on the Protection and Advocacy (P&A) program for individuals with mental illness by 85 percent.

Some advocacy groups noted that Murphy’s bill would also expand the use of involuntary treatment and ignore the rights of persons with mental health conditions to make their own decisions concerning treatment. Assisted outpatient treatment (AOT) should be used as a last resort, they said (see MHW, Dec. 23, 2013).

Bill provisions

Barber’s legislation, which aims to fill significant gaps in the mental health care system, includes the following provisions:

  • Reauthorizes the Garrett Lee Smith Memorial Act for suicide prevention;
  • Emphasizes evidence-based practices that have been proven effective through empirical evidence;
  • Authorizes mental health awareness training grants to improve mental health awareness;
  • Creates a national media campaign to reduce the stigma associated with mental illness; and
  • Requires a report on evidence-based mental health practices to better serve older Americans.

Barber said that he received letters from a number of organizations, including the American Psychological Association, about issues the groups felt were important in a mental health reform bill. “That was an important factor in designing the bill,” Barber told MHW.

Barber was wounded along with then-Congresswoman Gabrielle Giffords in the shooting in Tucson in 2011 that left 13 wounded and six people dead. “At least two years prior to the shooting, the gunman, Jared Lee Loughner, displayed symptoms that we now know [revealed] deteriorating problems,” said Barber.

“The police and school saw and no one ever put it together,” he said. “If they had, this might not have happened.” That’s why Mental Health First Aid is so critical, said Barber. The legislation provides $20 million for the public education program.

Barber said he is continuing to seek sponsors for the bill. “We’re hoping the Republicans will join us,” he said. “Any attempt to make this a partisan issue is a mistake.”

Advocates weigh in

“I know that there are some folks who [view] Barber’s bill as an alternative to Murphy’s bill,” Ron Honberg, national director of policy and legal affairs for the National Alliance on Mental Illness (NAMI), told MHW. “We see it a little bit differently. Hopefully, the legislation could be viewed as a potential framework for a compromise or a 'meeting of the minds' among lawmakers," he said.

“To pass a bill in Congress you need Republican and Democratic support,” Honberg said. “The goals of Murphy and Barber’s bills are very much in synch. There are sincere efforts on everybody’s part to improve mental health services in this country. Everyone agrees the mental health system is broken.”

NAMI is very pleased about the proposal to coordinate all levels of federal funding and services, said Honberg. It also expands health insurance technology (HIT) to providers, he said. The legislation extends Medicare and Medicaid reimbursement for the use of electronic health records (EHRs) to mental health professional facilities, and makes mental health and addiction treatment providers eligible for Health Information Technology for Economic and Clinical Health Act technical assistance.

Honberg said he is also pleased about the provision that would eliminate the 190-day lifetime limit on inpatient psychiatric hospital care under Medicare. “It creates an exception to the IMD [Institutions for Mental Disease] rule,” he said. Currently, the IMD exclusion prohibits Medicaid from making payments to IMDs for services rendered to Medicaid beneficiaries aged 21 to 64.

Barber’s legislation is a “very person-centered bill rather than an institutional one,” Debbie Plotnick, senior director of state policy for Mental Health America (MHA), told MHW. The bill emphasizes important provisions for individuals, families and whole communities, she said. “People need a safe place to live,” said Plotnick. “They need coordinated supports and something meaningful to do, such as supported employment, and access to community-based services in a timely manner.”

The legislation also delves further into parity, said Plotnick, citing the provision that requires a Government Accountability Office (GAO) study on mental health and substance use disorder parity enforcement efforts. Additionally, Barber’s bill requires the Secretary of Labor to coordinate with the secretary of the U.S. Department of Health and Human Services (HHS) to prepare annual detailed reports of parity compliance activities in each state.

Individuals with mental illnesses and intellectual disabilities are residing in state institutions because there is no infrastructure for community-based programs and they have to live in restrictive settings, said Plotnick. P&A programs provide a very important function for these kinds of issues, said Plotnick. “It’s very important to P&A to continue to be able to do the exemplary work things been doing,” she said.

“We’re very much in favor of a White House coordinator for all agencies and departments, such as SAMHSA, HHS, HUD [Housing and Urban Development], DOJ [U.S. Department of Justice] and the Veterans Administration, to create an overall strategic plan," said Plotnick.

Barber’s legislation, on the other hand, places an emphasis on peer support, mobile crisis services and other programs for individuals with a mental illness before they reach a point where they’re spending hours in an ER or cycle in and out of prisons and jails, Plotnick said. “Ultimately, everybody hopes that both parties can find common ground,” she said.

Opposing concerns

DJ Jaffe, founder of Mental Illness Policy Org, told MHW that Barber’s legislation “strips out provisions that help people with a serious mental illness. It’s a mental health bill, not a mental illness bill. It gives more money to the mental health industry without requiring that any of it is spent on people with a serious mental illness.”

Jaffe said families of consumers with a serious mental illness lined up in support of Murphy’s bill. The current bill is probably well intended, he said. “We advocate for people with a serious mental illness. This bill drives funding away from programs that help people with an SMI,” said Jaffe.

“Barber’s bill increases reimbursement rates for marriage counselors, but not for treating people with schizophrenia,” said Jaffe. “The legislation does little for the 4 percent of people with a serious mental illness.”

Bottom Line…

While some in the mental health field are still split over the merits of two recently introduced mental health bills, the hope is that lawmakers can negotiate one comprehensive bill.

From the Field
9/26/2013 12:00 AM
8/7/2013 12:00 AM
In Case
7/11/2013 12:00 AM

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  • Meet the Editor

    Valarie Canady
    Managing Editor

    Valerie Canady, managing editor of Mental Health Weekly, knows the mental health field inside and out. She uncovers the essential stories and gets the scoop directly from leaders and advocates in the field.
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