MHW Highlights Some of the Field's 2018 Priorities
Mental Health Weekly January 1,8, 2018
Editor’s note: For our 2018 Special Preview Issue, we asked readers to tell us what their most pressing challenges and opportunities will be this year. (NYAPRS has combined comments from the January 1 and 8 issues).
Richard S. Edley, Ph.D., president and CEO of the Rehabilitation and Community Providers Association:
As we enter 2018, one of the most pressing issues for behavioral health providers is the movement, or rush, toward “value-based purchasing” (VBP). Indeed, this is the catchphrase of the year. But what is value-based purchasing when it comes to behavioral health?
When implemented properly, it represents an alternative reimbursement strategy that moves away from traditional fee-for-service and then adds mechanisms by which providers can earn more for meeting quality-, performance- and outcomes- based targets. Costs can be reduced, reimbursement is more predictable for providers and quality is enhanced. Isn’t that what we all want in health care?
In reality, VBP has become more like the “Wild West” of health care. Without proven models, each managed care organization, each contract and/or each state develops its own strategy and approach. For example, it may begin with withholding on fee-for-service payments, which can then be earned back (and more) if targets are met. If the targets are unachievable, then the value-based payment methodology becomes no more than a reduction in fee-for-service reimbursement.
Providers need to educate themselves and be active participants in this development. Value-based purchasing is coming to your area soon. It can be a tremendous opportunity — if you are ready.
Ron Manderscheid, Ph.D., executive director of the National Association of County Behavioral Health and Developmental Disability Directors and the National Association for Rural Mental Health:
The “Sturm und Drang” of 2017 will reverberate down the months of 2018. This maelstrom affects all of health care, not just behavioral health. It is an unvarnished and unremitting attack on those who are poor, disabled, or very old or very young.
In 2018, it again will take the form of attacks on Medicaid and Medicare, and on Supplemental Security Income and Social Security Disability Insurance. Federal budgets will not be immune. Expect attacks on the budgets and staffs of the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration and the Centers for Disease Control and Prevention.
Guideposts in this storm will be essential. We must call upon our human values that seek social justice: all people have a right to good health, and we value all people equally. We also must continue to promote our core vision of person- centered care directed toward recovery and self-determination.
In the long run, the truth and human values will win if we persist. Don’t give up.
Harvey Rosenthal, executive director, New York Association of Psychiatric Rehabilitation Services, Inc. (NYAPRS):
NYAPRS greatly welcomes and lauds the leadership role that Assistant Secretary for Mental Illness and Substance Use Dr. Elinore McCance- Katz and the new federal ISMICC [Interdepartmental Serious Mental Illness Coordinating Committee] will play in focusing public policy and provider practices to vastly improve outcomes for those with the most daunting challenges and their families.
Toward these ends:
• Advancing the integration of medical, behavioral health and social services is essential, as is a resolute commitment to assuring full integration into local communities over a re- building of hospital and other institutional settings.
• Evidence-based quality care is a must. Accordingly, we must greatly expand investments into research on the effectiveness of peer support and rehabilitation models.
• Dr. McCance-Katz’s leadership in bringing together medical and recovery models will be critical, as will be major in- vestments in approaches that address the social determinants of health (e.g., housing, employment and culturally relevant social supports).
• Reforming systems of care can lead to historic advances, but it won’t matter if people in the greatest need don’t trust or access them: hence, we must provide more funding and time for the critical process of outreach and engagement, often delivered best by peer specialists.
• Money is the ultimate driver of care and so, getting CMS [Centers for Medicare & Medicaid Services] to tie financial incentives to services that best succeed with individuals with the greatest challenges is essential.
• Expanding the Certified Community Behavioral Health Clinic (CCBHC) program and its inclusion of peer services component is greatly warranted: yet, CCBHCs can and should contract with peer-run agencies to deliver fidelity- level evidence-based services.
• We greatly appreciate Dr. McCance-Katz’s passion to advance criminal justice diversion and re-entry innovations: they will be as critical as replacing the emphasis on inhumane solitary confinements and torturous punitive measures with rehabilitative practices in our prisons and jails.
We look forward to making historic advances together in 2018 to provide the best care possible to help those who need it the most.
Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness (ABHW):
In 2018, we expect that mental health and addiction issues will continue to be a focus of both Congress and the federal agencies. At the beginning of the year, we see opportunity in the potential advancement of an opioid package. The challenge for this particular piece of legislation will be making sure that it doesn’t get so loaded down that it stalls before it gains traction. ABHW and many other organizations that it works with hope that revisions to 42 CFR Part 2, substance use privacy legislation, are added to this bill.
The explosion of digital technology/mobile applications to help identify and treat behavioral health conditions will make for an exciting 2018. Many of these apps bring potential for better health outcomes, higher consumer engagement, and lower overall treatment costs. The challenge will be assessing which apps can deliver on their promises.
We also will see health plans continue to focus on integrating behavioral and physical health, implementing parity, moving toward some type of value-based purchasing, and using data to identify individuals who are at risk and may need additional services.
Susan Rogers, director, National Mental Health Consumers’ Self-Help Clearinghouse:
The political climate over the past year, which may not change for the foreseeable future, poses enormous challenges to people with disabilities — who are woke! The shocking images of courageous disability rights activists in wheelchairs being hauled off by men in uniforms are seared into our memories.
So our task is to educate policy- makers and legislators about the human rights of individuals with mental health conditions. Education — in person and via social media, email and USPS mail, phone calls, and nonviolent direct action — is more important now than ever. And we must continue to build coalitions with like-minded organizations, working together toward this goal!
For example, although some of the recommendations of the recent report of the Interdepartmental Serious Mental Illness Coordinating Committee were good — such as (quoting a Medpage Today summary: https://tinyurl.com/yadqxt8h) to “demand that ‘trauma-informed, whole person healthcare’ be delivered in all of the systems that engage people with serious mental health issues” — others raise a red flag. One of the latter is to “reevaluate ‘civil commitment standards and processes,’” which, if it resulted in loosening commitment standards, would be disastrous (https://tinyurl. com/ya8qc8pe). But we must prove that — and other such truths — to policymakers! •
Jim Probert, Ph.D., clinical associate professor and co-coordinator of the peer support program at the University of Florida Counseling and Wellness Center; and Sara Nash, Ph.D., LMHC, clinical assistant professor, CERC assistant coordinator and co-coordinator of the peer support program at the University of FloridaCounseling and Wellness Center:
A 2017 UN Human Rights Council report (https://tinyurl.com/y7rdt 2hw) calls for a “revolution” in mental health care—to “enable a long overdue shift to a rights-based approach.” As the Special Rapporteur (https://tinyurl.com/k4h7g8n) explains, “Mental health policies and services are in crisis—not a crisis of chemical imbalances, but of power imbalances. We need bold political commitments, urgent policy responses and immediate remedial action.” This appears beyond the grasp of policymakers within the United States (https://tinyurl.com/ycl2svjm), where Judi Chamberlin (https:// tinyurl.com/yzb6ytc) — an early leader of social justice movement organizing among individuals identified with mental health challenges— has been called a “civil rights hero from a civil rights movement you may have never heard of.”
While we see opportunities for more progress in 2018, at the University of Florida Counseling and Wellness Center, we have been working for years toward goals consistent with the UN human rights mandate. This includes providing workshops for trainees and staff in mental health recovery and trauma- informed, rights-based approaches to suicide prevention (https://tiny url.com/y9xax9gr, https://tinyurl.com/y77eerq8, and https://tinyurl.com/ yapn6p68
We also offer several forms of peer support (https://tinyurl.com/ ybfpch8f and https://tinyurl.com/ yb7ntpkk) developed through open participation in the peer/lived experience movement(s), and named as “critical indicators for measuring overall progress towards compliance” within the UN report. •
Joel E. Miller, executive director and CEO, American Mental Health Counselors Association:
If 2018 is anything like 2017 (the Year of the Roller Coaster), get that Pepto-Bismol ready — and keep it near your desk.
But I believe 2018 will be more like a “Take a Breather Year” if I am reading Senate Majority Leader Mitch McConnell’s tea leaves correctly (not Paul Ryan’s pronouncements about taking on entitlement reform). I think McConnell is a good barometer, especially in an election year. This is the year of the “WIND”— The Wall, infrastructure, net neutrality and DACA [Deferred Action for Childhood Arrivals].
Oh sure, there will be other non-health-care-related items that will be gaining lots of attention, like the “Russian thing.” However, with the midterms here before you can say “WIND,” I believe that Congress will be able to achieve only so much given that members of Congress will be back home politicking most of the year.
So that leaves us with only funding for CHIP [Children’s Health Insurance Program] and dealing with the opioid crisis as the main measures on the health care and behavioral health docket.
But beware that this could be the “Year of the Prelude to Starving the Beloved Beast” — namely, efforts to reduce spending in the Medicare, Medicaid and Social Security programs. It will be tough this year to reduce spending in these popular programs to make up for the revenue losses due to the Tax Reform Plan that just passed. The elections will give the GOP pause to reduce spending in these social pro- grams in which huge majorities of Americans have come to rely on and support. The 2018 midterms will dictate if reduced spending on these programs will be seriously considered in 2019 by our elected officials.
With all of that said, the behavioral health community will need to be on guard, as usual. The Affordable Care Act repeal-and-replace effort could raise its ugly head. And mental health care services are usually the first programs to be on the chopping block when there is discussion about controlling health care costs in Congress. So use those PACs [political action committees] and fundraisers!
Glenn Liebman, CEO, Mental Health Association in New York State, Inc. (MHANYS):
Despite a looming budget deficit in New York, the needs of community mental health must remain a priority in the coming year. Last year, for the first time in many years, there was a funding increase for the behavioral health workforce. While that was very helpful, it did not reflect the overall needs for a living wage. This year, the entire behavioral health community is banding together to advocate for additional funding for the workforce.
The other priority area for MHA- NYS is mental health education in schools. This innovative legislation that makes it mandatory to teach about mental health in school goes into effect on July 1, 2018. MHANYS has been working with the State Education Department, the Office of Mental Health and stakeholders in the education and mental health communities to help provide curriculum development and resources to help ensure a smooth transition to operationalization of the law. We will also be working with the legislature to help provide education for teachers about mental health as part of their certification process.
We will continue engagement around other priority areas, including funding increases for existing housing providers, criminal justice reform, Mental Health First Aid, suicide prevention, veterans mental health, geriatric mental health and continued engagement with New York State around implementation of Medicaid Managed Care.
Debra L. Wentz, Ph.D., president and CEO of the New Jersey Association of Mental Health and Addiction Agencies (NJAMHAA):
In 2018, clearly, the top topics to affect the field are integration of behavioral and physical health care and alternative payment methods. In New Jersey, our Division of Mental Health and Addiction Services was moved just months ago to the Department of Health (from the Department of Human Services). New Jersey is moving toward single licensure, while still in the throes of implementing a fee-for-service (FFS) reimbursement system. The move to FFS included rolling out the new Community Support Services program, the treatment component of supportive housing. Certified Community Behavioral Health Clinics (CCBHCs) were also implemented — New Jersey has seven CCBHCs, all NJAMHAA members.
All of this is within the larger environment of moving toward value-based payment and the uncertainty of federal health and tax policy impacts on the state, particularly on safety net programs. And we continue our battle with the opioid crisis, with many new initiatives begun in 2017, and many yet to be implemented.
That is a lot of change all occurring at once! These challenges also represent our greatest opportunities. While the service delivery landscape is being restructured, we hope to improve reimbursement, advance workforce development, include social determinants in models and see parity is fully enforced.