More on NYS Budget: Adult Home, Prescriber Prevails, Vet Peer Program Funding

NYAPRS Note: Here’s a follow up to yesterday’s NYAPRS NYS Budget First Look including

  • A list of NYS budget legislative items including over $2 million for veteran peer support programs
  • Senate Mental Health Committee Chairman David Carlucci’s news release affirming that prescriber prevails protections have been extended to 9 drug classes including anti-psychotic, anti-depressant, anti-retroviral, anti-rejection, anti-convulsant, endocrine, hematologic, and immunologic therapeutic drugs and a listing of some of the legislative additions to community mental health funding.
  • A memo from SCAA, MHANYS, NYAPRS and CIAD that was part of our intense efforts last week to successfully convince negotiators on adult home related budget language to walk away from further delaying the long awaited transition of adult home residents with psychiatric disabilities to the community.

NYS Budget Legislative Adds

Veteran peer-to-peer pilot programs: $2,285,000

Unlimited Potential, Inc: $150,000

Warrior Salute program: $100,000

FarmNet: $300,000

Nathan S. Kline Institute for Psychiatric Research: $175,000

MHANYS Mental Health First Aid: $50,000

North Country Behavioral Healthcare Network: $100,000

NLP Research and Recognition Project: $300,000

Senator Carlucci Announces the Restoration of Prescriber Prevails Protections

to be Included in the Final 2013-2014 Health Budget

Provision Ensures that Doctors Have the Final Say in Prescribing Medications, Not Insurance Company Health Plans

ALBANY, NY– Senator David Carlucci (D-Rockland/Westchester), Chairman of the Senate Mental Health and Developmental Disabilities Committee, today announced that prescriber prevails protections have been restored for atypical antipsychotic drugs and drug classes within Medicaid fee for services in the final Health Budget.In addition, it has been restored for eight additional drug classes, including: anti-depressants, anti-retroviral, anti-rejection, seizure, epilepsy, endocrine, hematologic, and immunologic therapeutic. This is a major victory for people with mental illnesses and physicians throughout the State who have fought to reinstate this vital provision.

Prescriber prevails for atypical anti-psychotic medications requires that if a physician determines that a medicine is necessary for an individual, even after an insurance health plan denies coverage, the physician’s determination is final and the plan must cover that drug. This requirement is vital for people with mental illnesses because these illnesses are very complex and individualized. These drugs also help an individual live a more stable and productive life, and without access to clinically appropriate medication, individuals have higher rates of emergency room visits, hospitalization, and other health services.It also ensures that prescribers have the full spectrum of medications available at their disposal to effectively treat an individual.

“I am pleased that we were able to restore prescriber prevails protections in this year’s budget, and in doing so we have sent a clear message that we cannot substitute cost for care," said Senator Carlucci. "In light of a renewed emphasis focused on improving ones mental health, we recognize that mental illnesses are truly unique to each individual.In the end, we were only as successful as the people who stood behind us all the way through.This was a collaborative effort that would not have been possible without the assistance of countless advocates who believe that decisions medical decisions should be made by those with an M.D. next to their name.”

After a hard fought victory last year to get prescriber prevails protections for atypical antipsychotic drugs into the final health budget, earlier this year, the Governor proposed eliminating these protections for atypical antipsychotics in his Executive Budget.

Mental health advocates, doctors, and people with mental illnesses opposed the Governor's proposals, arguing that this would mean the most cost-effective medication would be prescribed instead of what is clinically recommended by a health professional.Had this been the case, many individuals would have to go through a lengthy try and fail process in order to show that the covered drug does not work. During this long process, critics suggested that many individuals may become unstable and may run the risk of hospitalization.

The restoration of this provision ensures will ensure that physicians, not bureaucrats, have the final say in what medications should be prescribed.

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Coalition of Institutionalized Aged & Disabled (CIAD)

Mental Health Association in New York State (MHANYS)

New York Association of Psychiatric Rehabilitation Services (NYAPRS)

Schuyler Center for Analysis & Advocacy (SCAA)

March 21, 2013

Memo of Opposition

Senate budget proposal to delay and diminish the long-awaited opportunity for adult home residents with psychiatric disabilities to choose community housing alternatives.

The Issue

Although adult homes were originally designed for elderly New Yorkers who are no longer able or choose not to live on their own, now, nearly 40% of adult home residents have a psychiatric diagnosis. There is widespread consensus that residents of adult care facilities who have psychiatric disabilities deserve a range of housing options in the community.

For the first time in many years, there is funding and a process in place to help adult home residents with psychiatric disabilities who choose to move to community housing. Many adult home residents who have psychiatric disabilities have been waiting for a long time to transition from an adult home to their own place in the community.

Legislative action should not slow down or stop any movement in that direction among those who want and are ready to move.

Based on what we understand to be the latest Senate proposal, our concerns are below.

I. Exemptions of adult homes that have a certain percentage of assisted living program (ALP) beds

a. This would exempt several more homes. The addition of ALP beds shouldn’t be used to exempt homes from moving people out as required by the regulations.

b. Excluding facilities that have 55%+ ALP beds is not good. This seems to be simply a way to reduce the number residents who can move and the number of adult homes that are affected.

c. A June 2007 study by the Commission on Quality of Care (CQC) identified concerns about the cost effectiveness of the ALP program, the needs assessment process of the program, and substantive disparities between level of need ratings and plans of care and between plans of care and actual services provided.

d. It delays and derails the adopted regulation until after we expand the ALP program, thus allowing transitional homes to exempt themselves before we ever get to move people out.

II. Definition of mental illness and functional disability

a. This could be used as a rationale to suggest that folks are too ‘sick’ to leave, not acknowledging how a recovery focused system (not found in most homes) helps even the most disabled to thrive.

March 21, 2013

b. Including the word “prolonged” in the definitions of mental illness; is this simply another way to keep people waiting?

c. Concerns about the definitions of mental illness and an assessment process that will restrict the numbers of residents who will be able to choose to leave.

III. We don’t need another work group

a. Few populations have waited so long or been studied as much as adult home residents with psychiatric disabilities. Discussions about assisting adult home residents with psychiatric disabilities to move into alternative housing go back decades. The 2002 Adult Care Facilities Workgroup report noted that “6,000 of the residents with psychiatric disabilities could reside in a more integrated setting” (http://www.health.ny.gov/facilities/adult_care/).

b. If a workgroup is a part of the final agreement, there must be no interim delays in residents moving to community housing and the group’s recommendations should not be binding.

IV. Hospital discharges to adult homes

a. The language about permitting, rather than prohibiting discharges from inpatient psychiatric centers or Article 28 facilities is a big change. We have had a lot of discussion about making sure that we don’t simply keep replenishing the adult homes with more new people for whom this is not the best setting. Language should be tighter about exhausting all other options.

b. Need to strengthen language that insures state psychiatric centers don't discharge to adult homes. The fear is that discharge planners will continue to do so even with “least restrictive” language in place.

V. Assessments

a. Requiring that an assessment has to be by a managed long term care provider or a health home seems restrictive and potentially problematic with regard to capacity and timing. Are there enough of these people on the ground and is there capacity to do assessments? Housing providers should be considered for inclusion.

VI. Other provisions that could be applied in ways that undermine the exodus of residents to more appropriate, desired and lawful community settings

a. Unbiased presentation, an "objective" process. There is agreement that the process should be thoughtful and unbiased by the prospect of financial gain. It is essential that peers, housing providers and organizations such as Coalition of Institutionalized Aged and Disabled (CIAD) be among the potential transition agents.

b. Assurance that community housing and supports are in place.

c. The Senate proposal seems to be about operators, rather than individuals/residents. The regulations are clear that residents have an option if they want to stay in the adult home, they can do so. They are not being forced out.

d. Continued discharges from hospitals coupled with expanded ALP revenues: this community transition should not be about operators’ needs; it should be about residents’ choice.