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The deep persistent problems in Medicaid Managed care

5/15/2018

First, the Mental Health Crisis has A LOT of causes. When trying to identify significant causes -- Medicaid Managed Care is right up there.

Not only is Medicaid complicated, but how this actually plays out is sometimes pretty complicated as well. In other respects, it's pretty obvious.

Let's start with the obvious, essential community intensive services that people need to avoid institutionalization or life on the Streets --tend to be more expensive than less intensive services.

The people who would be getting all this "government largesse " have historically not been favored by the public in general, and governments. That's changing --mainly because it is becoming painfully obvious the disastrous costs of NOT providing for people with intensive mental health needs. AND we have a long way to go.

So in this instance, the failure largely rests with the States in failing to adequately designate and fund ESSENTIAL SERVICES such as Adult Residential Services, Assertive Community Treatment, and Intensive Case Management as a Medicaid Entitlement Service.

But it is not just Medicaid mandatory services that States need to be concerned about-- it's Parity, Olmstead, and Medicaid Network Adequacy.

That's a HUGE problem -- but there's also the problem that Medicaid doesn't cover housing or some other "Social Determinants of Health." Under Olmstead, States should be providing housing for people with disabilities -- and they do -- just not near enough.

So legally, morally, ethically and practically we need BOTH Essential Intensive Community Mental Health Services available to all Medicaid recipients where reasonably medically necessary as well as housing.

Thursday we'll be looking @ CO Medicaid Mental Health "Alternative" Services under the lens of Parity.

"Alternative" in that CO Medicaid considers them "additional" services so that the "entitlement" allegedly does not attach.

The problem is Adult Residential, Assertive Community Treatment, & Intensive Case Management are ESSENTIAL SERVICES that should be offered as a matter of right.

This is a unconscionable systematic failure --that can be fixed and there are a lot of ways to do it. Also, not surprisingly we believe it violates the Law.

What Are Medicaid Behavioral Health Services?

"States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines.

Federal law requires states to provide certain “mandatory” benefits and allows states the choice of covering other “optional” benefits.

Mandatory benefits include services like inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others.

Optional benefits include services like prescription drugs, case management, physical therapy, and occupational therapy. "

https://www.medicaid.gov/medicaid/benefits/index.html

1915 (b) Waiver Basics

States can also implement a managed care delivery system using waiver authority under 1915(b). There are four (4) 1915(b) waivers:

(b)(1) Freedom of Choice - restricts Medicaid enrollees from receiving services within the managed care network

(b)(2) Enrollment Broker - utilizes a "central broker"

(b)(3) Non-Medicaid Services Waiver - uses cost savings to provide additional services to beneficiaries.

(b)(4) Selective Contracting Waiver - restricts the provider from whom the Medicaid eligible may obtain services

The Centers for Medicare & Medicaid Services (CMS) has started the process of "modularizing" its current 1915(b) waiver application to separate the various statutory authorities.

First in this process is a streamlined application for States to selectively contract with providers under their fee-for-service delivery system. It simplifies the process for documenting the cost-effectiveness of the waiver but requires that States demonstrate maintenance of beneficiary access.

https://www.medicaid.gov/medicaid/managed-care/authorities/index.html

Medicaid is the single largest payer for mental health services in the United States and is increasingly playing a larger role in the reimbursement of substance use disorder services.

Individuals with a behavioral health disorder also utilize significant health care services—nearly 12 million visits made to U.S. hospital emergency departments in 2007 involved individuals with a mental disorder, substance abuse problem, or both.

Congress enacted several laws designed to improve access to mental health and substance use disorder services under health insurance or benefit plans that provide medical/surgical benefits.

The most recent law, the Mental Health Parity and Addiction Equity Act (MHPAEA), impacts the millions of Medicaid beneficiaries participating in Managed Care Organizations, State alternative benefit plans (as described in Section 1937 of the Social Security Act) and the Children’s Health Insurance Program.

This is Colorado's Waiver thru June 2017--p.10

c.  1915(b)(3) - (Applies to the Community Behavioral Health Services Program and the Special Connections Substance Abuse Treatment Program)

The State will share cost savings resulting from the use of more cost-effective medical care with enrollees by providing them with additional services.

The savings must be expended for the benefit of the Medicaid beneficiary enrolled in the waiver. Note: this can only be requested in conjunction with section 1915(b)(1) or (b)(4) authority.

https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/CO_Community-Mental-Health-Services-Program_CO-03.pdf

List of Medicaid Benefits

The list below outlines mandatory Medicaid benefits, which states are required to provide under federal law, and optional benefits that states may cover if they choose.

Mandatory Benefits

Inpatient hospital services
Outpatient hospital services
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
Nursing Facility Services
Home health services
Physician services
Rural health clinic services
Federally qualified health center services
Laboratory and X-ray services
Family planning services
Nurse Midwife services
Certified Pediatric and Family Nurse Practitioner services
Freestanding Birth Center services (when licensed or otherwise recognized by the state)
Transportation to medical care
Tobacco cessation counseling for pregnant women

Optional Benefits

Prescription Drugs
Clinic services
Physical therapy
Occupational therapy
Speech, hearing and language disorder services
Respiratory care services
Other diagnostic, screening, preventive and rehabilitative services
Podiatry services
Optometry services
Dental Services
Dentures
Prosthetics
Eyeglasses
Chiropractic services
Other practitioner services

Private duty nursing services

Personal Care
Hospice
Case management
Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
Services in an intermediate care facility for Individuals with Intellectual Disability
State Plan Home and Community Based Services- 1915(i)
Self-Directed Personal Assistance Services- 1915(j)
Community First Choice Option- 1915(k)
TB Related Services
Inpatient psychiatric services for individuals under age 21

Other services approved by the Secretary*
Health Homes for Enrollees with Chronic Conditions – Section 1945

*This includes services furnished in a religious nonmedical health care institution, emergency hospital services by a non-Medicare certified hospital, and critical access hospital (CAH).

https://www.medicaid.gov/medicaid/benefits/list-of-benefits/index.html

Mother's Day, Mental Health, Stigma & Hope

5/13/2018

I chose Rosemary Clooney's rendition of "I'll Be Seeing You" as the Musical Selection for Mother's Day for a lot of reasons:

Rosemary Clooney had a reputation of being "the girl next door" with enormous talent;
She also became famous in some respects for an unfaithful husband she married twice;
She was the mother of 5 children
She's also well known for having mental health and substance use issues

My mother passed away 11 years ago -- and I am seeing her in all the familiar and not so familiar places -- not just today but all the time.
Like a lot of mother and daughters, we definitely had our conflicts.
My mother bore the brunt of caring for our Father who had Lewy Body Dementia for 11 years.
She died a year after my father.
I had my psychotic break two months before my father's death--- due to many, many emotional & physical factors -- but definitely the stress of my father's illness played a big role in my physical & mental health.
After the death of my father and my potentially dangerous psychotic break, I now had the stigma of mental illness and was a Mom with two elementary age children.
When people talk about the pain of STIGMA it can be seemingly overwhelming and unbearable. For me, it was the stigma of being a Mother with mental illness. I never considered suicide before or since-- but I did after this psychotic episode.
When one's mind fails one so seriously --it's a terrifying experience -- at least it was for me.
I could NOT let this ever happen again
Maybe people would be better off without me? How could I ever be authenticate again? Would I always be living a secret life?
I'm happy I had a chance to have the Mother I had [& the Father] and the chance to have a loving Stay-the-Course Husband and two sensitive and outrageously opinionated kids -- I wonder where they got that?

Findings

Families developed resilience through processes such as shared humour or regular family rituals and routines.

In some cases, open communication about mental illness enabled families to better cope when parents were unwell and to build a greater sense of family connectedness.

However, data suggest that parental mental illness potentially creates stress and confusion for families and there are multiple social and cultural barriers that make it difficult for families to acknowledge and speak openly about mental illness.

For participants, resilience tended to be about maintaining a balance between stress/distress and optimism and strength within their family.

COACT Colorado & High Fidelity wraparound services could serve as a Model for Medicaid Adult Mental Health Services

5/12/2018

We have a HUGE challenge: bringing Medicaid Intensive Mental Health Services to scale to meet the need.

CO Medicaid to our knowledge still has not changed their regulations regarding Assertive Community Treatment (ACT), Residential Services, and Intensive Case Management as Alternative Services -- not available to all where reasonably medically necessary.

We were told by HCPF that ACT would be available where reasonably medically necessary -- but it seems to still be listed as an "Alternative Service."

That "Alternative Service" designation doesn't pass Mental Health Parity Muster as far as we're concerned.

But an option available to the State is to create an array of INTENSIVE SERVICES such as High Fidelity Wraparound to reduce the need for Residential Services and ACT.

Also, I think HIGH FIDELITY WRAPAROUND is better than Intensive Case Management --because it doesn't burnout the caseworkers as quickly and the results are likely better.

The Colorado Department of Human Services (CDHS) is already using HIGH FIDELITY WRAPAROUND for youth with serious behavioral issues -- under COACT, albeit not statewide.

COACT looks like Youth Assertive Community Treatment (ACT) with some built-in protective concepts such as:

Family Voice & Choice
Use of Natural Supports
Community-based
Culturally Competent
Individualized
Strength-Based
Persistence
Outcome-Based

Words matter -- the focus on High Fidelity Wraparound as opposed to "Assertive Community Treatment" probably has a lot of advantages -- it doesn't sound coercive and it seems more description.

I think this is pretty much what the people in the Adult Arena want as well when it comes to Assertive Community Treatment--High Fidelity Wraparound with Individual Voice and Choice.

Now one of the things that characterizes ACT is 24/7 -- 7 days a week coverage. Now not everybody probably needs that -- BUT a whole lot of people need HIGH FIDELITY WRAPAROUND.

With graduated intensive services available where reasonably medically necessary and clear screening tools, our Medicaid Intensive Mental Health Services could become much more understandable and user-friendly for everyone.

Under Medicaid Network Adequacy, we need to have an understanding of how many Coloradans need to access various levels of intensive mental health services --- and what do we need to do to plan for that.

"COACT Colorado is a system of care for children and youth with behavioral health challenges and their families.

It uses an evidence-based and effective process called high-fidelity wraparound to manage care for families with complex needs who are involved in multiple systems.

"High-fidelity wraparound implements a collaborative plan for the child and the family, as well as service providers and professionals working with the family. The process utilizes the individual strengths, needs, and culture of the family to achieve desired goals.

"High-fidelity wraparound often makes case work easier and more efficient for providers and professionals while generating positive outcomes."

https://coactcolorado.org/for-providers

1. Family Voice and Choice
Family and youth perspectives and opinions are asked for often, and prioritized during all phases of the process. Planning is built on family members’ perspectives, and the team aims to build a plan that reflects a family’s values.

2. Team-based
The wraparound team consists of individuals providing services to the family as well as the family’s natural supports.

3. Natural supports
The team actively seeks out and encourages the full participation of team members drawn from family members’ own networks of interpersonal and community relationships.

The plan reflects activities and interventions that draw on these individuals as sources of natural support.

4. Collaboration
Team members work together and share responsibility for developing, implementing, monitoring and evaluating a single high-fidelity wraparound plan. The plan is a collaboration of all team members’ ideas, opinions and resources and guides each team member toward meeting the team’s goals.

5. Community-based
The team implements a plan that offers services and supports that take place in the most inclusive, responsive and accessible settings possible; and that safely promote child and family integration into home and community life.

6. Culturally competent
The process respects and builds on the values, preferences, beliefs, culture, and identity of the family, child, and their community.

7. Individualized
The team will develop and implement a customized set of strategies, supports, and services to achieve goals laid out in its plan.

8. Strengths-based
The high-fidelity wraparound process and plan identify, build on, and enhance the capabilities, knowledge, skills, and assets of the child and family, their community, and other team members.

9. Persistence
Challenges can and will come up throughout this process. However, the team will persist in working toward the goals laid out in the plan until the team reaches an agreement that the goals have been met and the formal process is no longer needed.

10. Outcome-based
The team ties the goals and strategies of the high-fidelity wraparound plan to measurable indicators of success and monitors progress by checking in on these indicators.

If something isn’t working, the team will revise the plan.

The Deep Structural Problems In Colorado Medicaid Mental Health Inpatient and Intensive Community Services & Some Ideas to Fix them

5/10/2018

Mental Health Services are expensive. It's not like Colorado and other states aren't spending anything -- they are spending quite a lot.
But even with that States are struggling a lot to provide coherent and adequately staffed services, especially on the intensive end of the spectrum.
We really need clear screening tools for:

Inpatient
Residential Services
Assertive Community Treatment, and
Intensive Case Management

We don't have enough:

Inpatient beds
Residential Services
Assertive Community Treatment, or
Intensive Case Management

How could the CO Medicaid Community Mental Health Supports Waiver be made more relevant to the long term care needs of the vast majority of people with long term mental health care needs. [SUGGESTION: Get rid of the requirement for assistance with Activities of Daily Living [ADLs] and include on the array of services -- Residential and ACT]

Network Adequacy is a huge problem in Colorado and around the country.

A lot of the Mental Health Court Liaison program is designed to rely on existing resources in the community.

Well there are resources -- but they are NOT adequate -- that's how all those people ended up in jail.

We are going to be concentrating on the resources available under Medicaid -- because the more Medicaid can competently handle intensive mental health needs, the less need for more expensive Institute beds.

So we're working on a:

Complaint to CMS, and
A pitch for a Legislative Audit of Medicaid Intensive Mental Health Services assessing adequate quality and quantity , namely:
- Inpatient
- Residential Services
- Assertive Community Treatment, and
- Intensive Case Management
A pitch for Community Support to re-vamp the CMHS waiver, including:
- Getting Rid of the Requirement for assistance with ADLs
- Including Residential Services
- Assertive Community Treatment
- Peer-Run Services

To the State & Anyone Else:

If you believe there are important facts we should know ---please let us know.
If you think we have made any factual errors, please let us know.

Re-modelers Chip & Joanna Gaines

What are we trying to say with this video? Well our Mental Health System(s) are in the process of being remodeled -- and it is messy and necessary even as we may be trying each other's patience. Additionally, we need some "insurance" that things are being done as legally required.

Home & Intensive Services: There are A LOT of Conflicting Policies & De Facto Realities in Colorado Medicaid:

Can't access assisted living under the Community Mental Health Supports waiver unless need help with activities of daily living [really just blatantly violates mental health parity]
Mental Health Residential Services have traditionally been an "alternative service" -- meaning there is NO ENTITLEMENT to them. We are unclear as to how CO Medicaid intends to handle Residential Services under Network Adequacy.
Assertive Community Treatment (ACT) has traditionally been an "alternative service" under CO Medicaid -- meaning there is NO ENTITLEMENT. HCPF says they will make ACT available where reasonably medically necessary --- which is great --- but it is unclear that the State has determined Network Adequacy for the service. Further, historically neither the State nor the Mental Health Centers have not been really hip on providing intensive mental health services because of the cost --- how do you think we got into this mental health crisis?

First up, we've sent a request to the Colorado Department of Health Care Policy & Financing for data and analysis on how has Colorado measured Network Adequacy for Intensive Mental Health Treatment like Residential Services, Assertive Community Treatment, Intensive Case Management?, etc.

Further If there is no data and analysis by service, we've requested whatever data and analysis the State does have to demonstrate "network adequacy" for intensive mental health needs.

42 CFR 438.88(c) Development of Medicaid Network Adequacy Standards

(c) Development of network adequacy standards.

(1) States developing network adequacy standards consistent with paragraph (b)(1) of this section must consider, at a minimum, the following elements:

(i) The anticipated Medicaid enrollment.

(ii) The expected utilization of services.

iii) The characteristics and health care needs of specific Medicaid populations covered in the MCO, PIHP, and PAHP contract.

(iv) The numbers and types (in terms of training, experience, and specialization) of network providers required to furnish the contracted Medicaid services.

(v) The numbers of network providers who are not accepting new Medicaid patients.

(vi) The geographic location of network providers and Medicaid enrollees, considering distance, travel time, the means of transportation ordinarily used by Medicaid enrollees.

(vii) The ability of network providers to communicate with limited English proficient enrollees in their preferred language.

(viii) The ability of network providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medicaid enrollees with physical or mental disabilities.

(ix) The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions.

psychiatric Medication is pretty darn controversial for a lot of reasons: failure to provide Genetic Testing and high Level Neuro-pharmacology are 2 of the reasons

5/5/2018

I always get concerned when clinicians go off on "Medication Adherence."
The reality is -- if you have great medications -- people are either going:

to want to take them, or
in the alternative be glad they did afterwards.

In fact, there are a number of people who fit in one or both of those categories.
But there is a significant group that don't fall into either of those categories.
So "Medication Adherence" comes off as an abusive and even brutal practice.
   With the "Anna Karenina Principle" regarding animal microbiomes -- essentially good microbiomes are more alike, while bad microbiomes are more erratic and varied from individual to individual --- we are once again faced with the importance of individualized medicine.
Medication can affect the microbiome.
So when we talk about psychiatric medication we need access to genetic testing and the ability to consult a neuropharmacologist
-- because the variability among people with mental health concerns is so great.
It is probably not going to be too long before treatment for mental health issues includes individualized probiota.

We are not Alone in Our Body:

Insights into the Involvement of Microbiota in the Etiopathogenesis and Pharmacology of Mental Illness

Current Drug Metabolism (Dec. 2017)
https://www.ncbi.nlm.nih.gov/pubmed/?term=We+are+not+Alone+in+Our+Body%3A++Insights+into+the+Involvement+of+Microbiota+in+the+Etiopathogenesis+and+Pharmacology+of+Mental+Illness%E2%80%8B

Abstract:

Background: The etiopathogenesis of psychiatric disorders is still not completely understood.

Growing evidence supports the hypothesis that mental illness and related disturbances in the brain neurobiology do not necessarily originate in the brain.

Inflammation has been suggested to play a central role in psychiatric disorders, and altered levels of peripheral cytokines have been reported in several studies.

Objective and methods: In this review, we present and discuss studies exploring the role of dysbiosis and products of the gut-microbiota in the pathogenesis of psychiatric disorders, as well as its potential involvement in mediating the effect of antidepressants, mood stabilizers, and antipsychotics.

Results: Recently, it has emerged that bacteria populating the human gut could modulate low-grade inflammation, as well as high-order brain functions, including mood and behavior.

These bacteria constitute the microbiota, a large population comprising 40,000 bacterial species and 1,800 phila involved in key processes important to maintain body homeostasis.

Conclusion: Altered composition and functioning of gut microbiota have been reported in psychiatric disorders, and recent findings suggest that gut bacteria could be involved in modulating the efficacy of psychotropic medications.

Use of Pharmacogenetic
Testing in Routine Clinical Practice Improves Outcomes for Psychiatry Patients

Journal of Psychiatry (2016)
https://www.omicsonline.org/open-access/use-of-pharmacogenetic-testing-in-routine-clinical-practice-improves-outcomes-for-psychiatry-patients-2378-5756-1000377.php?aid=76391

Genetic testing for CYP2D6 and CYP2C19 suggests improved outcome for antidepressant and antipsychotic medication.
----Psychiatry Research (March 2018)
https://www.ncbi.nlm.nih.gov/pubmed/29699889

TedMed Talk

John Cryan, a neuropharmacologist and microbiome expert from the University College Cork, shares surprising facts and insights about how our thoughts and emotions are connected to our guts.

Long Video:

"Toward Precision Medicine in Psychiatry:
Current implementation strategies for antidepressant and antipsychotic medications"

Daniel Mueller, MD, PhD
Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Canada

The Precision Medicine Conference 2016
Pharmacogenomics: Research To Implementation
Institute of Personalized Medicine (PUMA - IPM)
University of Minnesota

The Microbiome: Stress, Trauma, the Anna Karenina Principle, & Justice

5/3/2018

Personalized medicine is a big deal now -- recognizing the importance of individual differences to health outcomes.
We've argued for some time how critical personalized medicine is to mental health treatment, especially given how idiosyncratic the biological systems are for people with mental illness.
There are many, many reasons for differences -- but it turns out that one of them or trillions of them are the microbiota that make up our individual microbiomes.
Well what can our microbiomes affect:

Mood
Anxiety
Sleep
Personality
Etc.

When we have our Knowledge- Challenged Clinical Profession handing out "Personality Disorder" Diagnoses in the Justice System, how much longer can we ignore that they just don't have the knowledge available to make the determinations they are asked to make and that they are in fact making.

Good Bacteria, Mental Health Policy, & CU Research involving the Microbiome & PTSD

Nova Wonders: What's Living in You? Preview

Psychology Today

Chronic Stress Discombobulates Gut Microbiome Communities
Gut microbiome communities become unpredictable when someone is in distress.

When people are feeling healthy, relaxed, and safe, their gut microbiome communities generally work together harmoniously in a predictable symbiotic manner, according to a new study.

However, the Oregon State University researchers found that when someone is under stress, his or her gut microbiome communities become discombobulated and behave erratically, in ways that are unpredictable and vary from person to person.

This study, “Stress and Stability: Applying the Anna Karenina Principle to Animal Microbiomes (,” was published online August 24 [2017 in Nature Microbiology.]

Leo Tolstoy famously said: "All happy families are alike; each unhappy family is unhappy in its own way."

After realizing how unpredictably each individual's gut microbiome communities responded during "unhappy" stressful situations, the research team coined their discovery the "Anna Karenina principle" in honor of Tolstoy's dictum. In the study abstract, the authors write:

"The result is an ‘Anna Karenina principle’ for animal microbiomes, in which dysbiotic individuals vary more in microbial community composition than healthy individuals—paralleling Leo Tolstoy's dictum that “all happy families look alike; each unhappy family is unhappy in its own way."

We argue that Anna Karenina effects are a common and important response of animal microbiomes to stressors that reduce the ability of the host or its microbiome to regulate community composition."

https://www.psychologytoday.com/us/blog/the-athletes-way/201708/chronic-stress-discombobulates-gut-microbiome-communities

Multiple complex Interests & Involuntary Treatment -- Safety, Bed Space, Medicaid Network Adequacy, Parity & Olmstead -- We Need A LOT of DATA & Education

5/1/2018

I've maintained for a long time that the problem here in Colorado and around the Country is NOT our Civil Commitment Laws -- but lack of adequate treatment & housing.
But what about those people who present a danger? Well, law enforcement, mental professionals, and local media commentators don't seem to recognize that the "imminent danger" limitation just applies to emergency 72-hour holds.
There is a Colorado statutory provision to
seek a court-ordered evaluation based on "danger." Nobody seems to know about it, or if they do they don't want to use it because maybe it's more cumbersome.

[See CRS 27-65-106. Court-ordered evaluation for persons with mental health disorders]

I don't have a problem with getting rid of "imminent" before danger regarding emergency 72-hour holds or Red Flag Laws.
I'm changing my tune and saying there needs to be an INCLUSIVE stakeholder group made up of:

State Officials
Providers
Individuals with lived experience of mental illness and certification, homelessness, or incarceration.
Family Members, and
Advocates
Racially & Ethnically Diverse

To address:

Civil Commitment --Concerns some of the failure to seek a mental health evaluation on an emergency or non-emergency basis. Some of these decisions not to seek evaluation strike us as very questionable even given the problems with current law,
What is it going to take to address the practical problems of Safety & Humane Treatment and balance Constitutional & other Legal Concerns -- "Gravely Disabled" was meant in large measure to deal with the issue of people with mental illness who are homeless -- but it hasn't worked so far -- not because of the law -- because of lack of housing and intensive treatment [think Olmstead among other legal requirements].
Our apparent gross negligence involved with ignoring some homeless people who satisfy the criteria for "Gravely Disabled" -- there are many, not all, who would accept and want appropriate & person-centered, strength-based treatment and housing -- Is their openness to treatment working against them?
Greater Clarity, training and one on one Support for law enforcement, mental health professionals, and all Coloradans when it comes to emergency and non-emergency evaluations.
What about people with Brain Injury?
Are there sufficient inpatient beds?
What about Medicaid Network Adequacy and Housing?
Data Collection

Most Coloradans want Safety and sufficient inpatient beds, Medicaid Network Adequacy, & Housing for people with mental illness or brain injury.

This really goes to Mental Health America's -- B4Stage4 Campaign & the Mental Health Parity & Addiction Equity Act which bans Medicaid and other Health Insurance Providers from requiring a "FAIL FIRST" practice to access sufficiently intensive treatment.

That ban on "Fail First" policies includes not just the written policies, but the actual practices.

CRS 27-65-102.
Definitions

(4.5) "Danger to self or others" means:
(a) With respect to an individual, that the individual poses a substantial risk of physical harm to himself or herself as manifested by evidence of recent threats of or attempts at suicide or serious bodily harm to himself or herself; or
(b) With respect to other persons, that the individual poses a substantial risk of physical harm to another person or persons, as manifested by evidence of recent homicidal or other violent behavior by the person in question, or by evidence that others are placed in reasonable fear of violent behavior and serious physical harm to them, as evidenced by a recent overt act, attempt, or threat to do serious physical harm by the person in question.

Medicaid Network Adequacy: Watered Down Some for Fee For Service -- Is CMS Going to enforce Access requirements for Managed Care?

5/1/2018

So the proposed CMS Rule to give some states a break on Network Adequacy for Fee For Service if they have large Managed Care Programs isn't wholly irrational.

BUT is CMS going to be willing to provide the Systems & Framework for REAL Network Adequacy in Medicaid Managed Care?

If you look at the Code of Federal Regulations and the new Rules on Network Adequacy -- it is pretty clear the Feds thought they were providing a Framework.

BUT it is really not enough, especially since states just haven't been providing this kind of data or analysis -- and it can be powerful evidence of non-compliance with various federal requirements, including Network Adequacy.

That is NOT escaping the States.

So the goal is NOT to bankrupt the States -- it's to bring REAL HONESTY to these processes and ultimately a reasonable plan to get into compliance if there is an issue.

We NEED REAL DATA AND THAT NEEDS TO BE POSTED ON THE HCPF Website.

Medicaid Network Adequacy --CMS

"We are still interested in developing and adopting meaningful access measures that could apply consistently regardless of the service delivery approach used by the state.

:Our ultimate goal is to better measure, monitor and ensure Medicaid access across state programs and delivery systems.

"While there is a longstanding requirement in 42 CFR 431.16 that states are obligated to provide all reports required by the Secretary and must follow the Secretary's instructions regarding the form and content of such reports, we are using this opportunity to state that, in the future and informed by stakeholder feedback, we may look to adopt a more standardized form and content for the states' AMRP submissions."

Excerpts

Medicaid Program: Methods for Assuring Access to Cover Medicaid Services- Exceptions for States With High Managed Care Penetration Rates and Rate Reduction

SUMMARY:
This proposed rule would amend the process for states to document whether Medicaid payments in fee-for-service systems are sufficient to enlist providers to assure beneficiary access to covered care and services consistent with the statute. States have raised concerns over the administrative burden associated with the current requirements, particularly for states with high rates of Medicaid managed care enrollment. T

This proposed rule would provide burden relief and address those concerns.

DATES:
To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on May 22, 2018.

FOR FURTHER INFORMATION CONTACT:
Jeremy Silanskis, (410) 786-1592, [email protected].

I. Executive Summary and Background
A. Executive Summary
1. PURPOSE
Current regulations at 42 CFR 447.203(b) require states to develop and submit to CMS an access monitoring review plan (AMRP) for Medicaid services provided through a fee-for-service (FFS) delivery system.

The AMRP must be updated at least every 3 years and address the following categories of Medicaid services:

Primary care services (including those provided by a physician, federally qualified health center (FQHC), clinic or dental care); physician specialist services (for example, cardiology, radiology, urology); behavioral health services (including mental health and substance use disorder); pre- and post-natal obstetric services (including labor and delivery); and home health.

The AMRP must identify a data-driven process to review access to care and address: The extent to which beneficiary needs are fully met; the availability of care through enrolled providers; and changes in beneficiary service utilization.

Additionally, when states reduce rates for other Medicaid services, they must add those services to the AMRP and monitor the effects of the rate reductions for 3 years.

Section 447.204 requires states to undertake a public process and submit specific information regarding access to care when proposing to reduce or restructure Medicaid provider payment rates.

This proposed rule would provide an exemption to the regulatory requirements in §§ 447.203(b)(1) through (6) and 447.204(a) through (c) for states with comprehensive, risk-based

Medicaid managed care enrollment rates above 85 percent of the total covered population under a state's Medicaid program, including managed care comprehensive risk contracts under a state's section 1115 Medicaid demonstration.

The proposed rule would also provide an exemption to the regulatory requirements in §§ 447.203(b)(6) and 447.204(a) through (c) for states that submit state plan amendments (SPAs) to reduce rates or restructure payments where the overall reduction is 4 percent or less of overall spending within the affected state plan service category for a single state fiscal year (SFY) and 6 percent or less over 2 consecutive SFYs. Additionally, the proposed rule would modify the requirements in § 447.204(b)(2) so that, for SPAs that reduce or restructure Medicaid payment rates, states would be required to submit to CMS an assurance that data indicates current access is consistent with Start Printed Page 12697 requirements of the Social Security Act (the Act) instead of an analysis anticipating the effects of a proposed change in payment rates or structure.

Modern Healthcare

17 states could get a pass on Obama-era network adequacy rule

The CMS is letting some states off the hook when it comes to complying with an Obama-era rule that's meant to ensure Medicaid beneficiaries have adequate access to care.

In 2015, the CMS finalized a rule requiring states to assess how easy it is for fee-for-service Medicaid beneficiaries to receive primary care; pre- and post-natal obstetric services; and specialty and behavioral health care, among other services.

On Thursday, the CMS issued a proposed rule that would exempt states if the majority of their Medicaid population received services through managed-care plans.

"These new policies do not mean that we aren't interested in beneficiary access but are intended to relieve unnecessary regulatory burden on states, avoid increasing administrative costs for taxpayers, and refocus time and resources on improving the health outcomes of Medicaid beneficiaries," CMS Administrator Seema Verma said in statement.

Since the finalized rule's release in 2015, states with large managed-care populations have pushed back against the rule saying it would affect only a few thousand of people in their respective states. Of the 75.2 million beneficiaries in Medicaid in 2016, 73% were in private plans, up from 55% in 2013 according to PricewaterhouseCoopers.

In the final access rule, the CMS estimated it could take states as long as 15,000 hours to develop the plans.

If the changes are finalized, states with an overall Medicaid managed-care penetration rate of 85% or greater would be exempt from most access monitoring requirements. The CMS estimates that 17 states including Arizona, the District of Columbia, Florida, Kansas and Kentucky fall into that category.

States that cut Medicaid rates by up to 4% in one year or up to 6% in two consecutive years will no longer be required to conduct an analysis to determine if access to care will be harmed by the reductions.

"We generally believe changes below the 4% threshold to be nominal and unlikely to diminish access to care," the CMS said in the rule.

In total, the proposed changes are estimated to reduce state administrative burden by 561 hours with a total savings of over $1.6 million.

http://www.modernhealthcare.com/article/20180322/NEWS/180329960

CMS State Medicaid Director Letter:
RE: Medicaid Access to Care Implementation Guidance

Proposed Rule

Getting to the "Competency" problem in psychiatry & Psychology: We Prescribe "humbleness," Integrated Care -- Especially immunology & Genetics, & higher reimbursement

4/29/2018

It is so amazing what is going on in Science & Research right now.

At the same time that the new discoveries and insights are coming fast and furious -- awareness of our current unethical systems relying on incomplete and inaccurate information-- keeps bubbling to the surface.

Nowhere is this ethical and moral challenge felt more than in the Criminal Justice System.

We're always for Safety -- punishment can be pretty horrific
without all the knowledge and insight you need -- and if that knowledge and insight isn't currently available -- preceding to punishment anyway is one of our society's great sins.

I'm thinking specifically about two Black homeless men in their fifties with mental illness that are serving long sentences in 2 separate Colorado prisons.

They had "A LOT OF CHANCES" right? No, no they didn't.

There has began to be talk of Artificial Intelligence {AI} in the Courtroom and even in diagnosing mental illness -- maybe it could control for unconscious bias.

But even then, it has to have the knowledge to apply -- if that is in the process of discovery -- would AI be honest where mental professionals fail to acknowledge HUGE GAPS in the knowledge base.

We are so far over our heads when we try to punish people we don't currently have the means to completely comprehend.

"In 2008, the National Institutes of Mental Health at the US NIH proposed a new way of categorizing mental illness—bridging genetics, neuroscience (looking at molecules, cells, neural circuits, and physiology of the brain), and behavioral science. These Research Domain Criteria (RDoC) aspire to classify illness based on observable behavioral and neurobiological measures."

SB18-251 -- a Statewide Behavioral Health Court Liaison Program -- This Has The Potential to Make a Huge difference

4/26/2018

SB18-251 establishes a Statewide Behavioral Health Court Liaison Program has been so desperately needed for so long -- and to our knowledge it's the first in the nation.

This has the potential to help so many Coloradans and their often desperate family members.

In some ways as human beings we're so resilient, in others so fragile.

It really takes a State/Community to provide the Systems for:

Safety and
Healing

In addition to the State, we think Disability Law Colorado and the Colorado Lawyer's Committee magnificient efforts in the Jail Wait Case deserve an enormous amount of credit for both SB18-251 as well as SB18-250 and 252.

SB18-251
Statewide Behavioral Health Court Liaison Program
Concerning establishing a statewide behavioral health court liaison program.

The bill establishes in the office of the state court administrator (office) a statewide behavioral health court liaison program (program).

The purpose of the program is to identify and dedicate local behavioral health professionals as court liaisons (court liaisons) in each state judicial district to facilitate communication and collaboration among judicial, health care, and behavioral health systems.

The office shall administer the program and establish procedures, timelines, and funding guidelines for the program.

Program funding must be allocated to judicial districts based on case volume, geographical complexity, and density of need.

Specific duties of the court liaisons are outlined, as well as reporting requirements.

(Note: This summary applies to this bill as introduced.)

Beginning on Page 8, Line 1 of SB18-215

(c) USING THE BEHAVIORAL HEALTH INFORMATION FROM THE STATEWIDE COURT DATA SYSTEM, AS UPDATED PURSUANT TO SECTION 3 16-11.9-203 (4), TO MAKE A DETERMINATION REGARDING WHETHER A

BEHAVIORAL HEALTH CONSULTATION WOULD BE BENEFICIAL IN ACHIEVING PROGRAM GOALS AND OBJECTIVES. IF THE COURT LIAISON OPERATING IN THE JUDICIAL DISTRICT DETERMINES THAT A CONSULTATION WOULD BE BENEFICIAL,

THE COURT LIAISON SHALL CONSULT WITH EACH JUDICIAL OFFICER, DEFENSE ATTORNEY, AND DISTRICT ATTORNEY WORKING ON THE CASE, AND THE PARTIES MUST IDENTIFY, AT A MINIMUM, THE FOLLOWING INFORMATION:

(I) THE NATURE OF THE INDIVIDUAL'S BEHAVIORAL HEALTH CONDITION;

(II) WHETHER THE INDIVIDUAL HAS A READILY AVAILABLE HISTORY OF BEHAVIORAL HEALTH TREATMENT;

(III) WHETHER THE INDIVIDUAL IS A CURRENT OR PAST CLIENT OF A COMMUNITY MENTAL HEALTH CENTER IN THE JUDICIAL DISTRICT;

IV) WHETHER THERE ARE OPPORTUNITIES FOR REDIRECTION INTO COMMUNITY TREATMENT AS AN ALTERNATIVE TO FILING CHARGES AGAINST THE INDIVIDUAL; AND

(V) THE LOCAL, REGIONAL, OR STATE AVAILABILITY OF RESOURCES THAT THE INDIVIDUAL MAY NEED, INCLUDING BUT NOT LIMITED TO:

(A) OUTPATIENT AND OUT-OF-CUSTODY COMPETENCY EVALUATIONS OR COMPETENCY RESTORATION SERVICES;

(B) BEHAVIORAL HEALTH SERVICES OR PSYCHIATRIC SERVICES OR 26 SUPPORTS; OR

(C) EMPLOYMENT, HOUSING, OR OTHER SOCIAL SUPPORTS.

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Val's Blog

The deep persistent problems in Medicaid Managed care

Mother's Day, Mental Health, Stigma & Hope

COACT Colorado & High Fidelity wraparound services could serve as a Model for Medicaid Adult Mental Health Services

The Deep Structural Problems In Colorado Medicaid Mental Health Inpatient and Intensive Community Services & Some Ideas to Fix them

psychiatric Medication is pretty darn controversial for a lot of reasons: failure to provide Genetic Testing and high Level Neuro-pharmacology are 2 of the reasons

The Microbiome: Stress, Trauma, the Anna Karenina Principle, & Justice

Multiple complex Interests & Involuntary Treatment -- Safety, Bed Space, Medicaid Network Adequacy, Parity & Olmstead -- We Need A LOT of DATA & Education

CRS 27-65-102.
Definitions

Medicaid Network Adequacy: Watered Down Some for Fee For Service -- Is CMS Going to enforce Access requirements for Managed Care?

Getting to the "Competency" problem in psychiatry & Psychology: We Prescribe "humbleness," Integrated Care -- Especially immunology & Genetics, & higher reimbursement

SB18-251 -- a Statewide Behavioral Health Court Liaison Program -- This Has The Potential to Make a Huge difference

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CRS 27-65-102. Definitions

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CRS 27-65-102.
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