Mental Health Care Coverage in Minnesota – Supplementing Federal Healthcare Reform

In 2007, the governor of Minnesota proposed a mental health initiative and the legislature passed it. One of the more important components of the initiative was legislation amending Minnesota’s two programs for the uninsured – General Assistance Medical Care and Minnesota Care – to add to the comprehensive mental health and addictions benefit.

Who Is Covered?

General Assistance Medical Care covers those with income at or below 75% of the federal poverty level who meet one or more of additional criteria known as General Assistance Medical Care qualifiers. Qualifiers include waiting or appealing disability determination by Social Security Administration or state medical review team; or being in a homeless or live in shelter, hotel, or other place of public accommodation.

Minnesota Care covers children and pregnant women, parents, and caretakers up to 275% of the federal poverty level, except that parents and caretakers gross income cannot exceed $50,000. Single adults without children increased to 200% of federal poverty level by January 1, 2008 and will rise to 215% of federal poverty level by January 1, 2009.

What Services Are Covered?

For Minnesota Care, there are limits of $10,000 on inpatient care for any condition (physical, mental health, or addictions) for parents over 175% of federal poverty level and childless adults. For General Assistance Medical Care, inpatient benefits are fully covered. Both programs cover chemical dependency outpatient services. An intensive array of outpatient and residential mental health services are available.

What Is The Cost?

In Minnesota, the Medicaid Temporary Assistance for Needy Families population, General Assistance Medical Care and Minnesota Care are enrolled in comprehensive nonprofit health plans that are responsible to deliver and are at risk for the entire health benefit, including behavioral health. Adding mental health rehabilitative services (including adult rehabilitative mental health services individual and group rehabilitation services, assertive community treatment, intensive residential treatment and mobile and residential crisis services) to Minnesota Care was projected to cost $3.40 per person per month. For General Assistance Medical Care, which includes a homeless population, the cost was $7.01 per person per month. The additional targeted case management service was projected to cost $2.22 per person per month for Minnesota Care and $7.66 for General Assistance Medical Care.

The legislature appropriated a total of $1 million in additional state dollars in fiscal year 2008 and $ 3.5 million in fiscal year 2009 to add the adult rehabilitative services and case management in Minnesota Care. State funds previously targeted for case management were moved from the counties to the state in an amount of $4.4 million in fiscal year 2009.

What Led To Comprehensive Coverage?

The state collected data on the residents served by Minnesota Care, General Assistance Medical Care, and Medicaid managed care plans serving non-disabled populations, and discovered that an increasing number of individuals with serious mental illnesses were in these plans. Several insurance reforms – similar to those included in the national healthcare reform bill – modified the private market, including guaranteed issue in small and large group plans, broader rate bands, parity for mental health and chemical dependency services, medical loss ratios, high risk insurance pool, and others. A lawsuit by the attorney general called attention to health plan denials of payment for court-ordered treatment, for example for civil commitment or out of home placement for adolescents.

Health plans settled with an agreement that behavioral and mental health benefits would be covered by a health plan if the court based its decision on a diagnostic evaluation and plan of care developed by a qualified professional. In addition to the court-ordered services provision, the state contracts and capitation with prepaid health programs (Minnesota Care and General Assistance Medical Care) were amended to align risk and responsibility for services in institutions for mental illnesses, 180 days of nursing home or home health, and court-ordered treatment. There were also highly successful experiments reducing costs and improving outcomes for commercial and non-disabled Medicaid clients who were offered a more intensive community based mental health service that improved coordination with and linkages to behavioral healthcare, primary care, and other needed services.

These demonstrations produced a positive return on investment – $0.38/person/month – and gave the health plans tools to manage the increased risk that resulted from several insurance reforms, including parity, a statutory definition of medical necessity, and the court-ordered treatment provision.

The state supported comprehensive coverage because it sought to provide mental health and addiction services in Minnesota as part of mainstream healthcare. Minnesota’s mental health agency and other stakeholders desired to move mental illness from its historical treatment as a social disease requiring social services to an illness like any other. They wanted to foster earlier interventions and avoid shifting enrollees among different programs in order to access specific services. Operationalizing this change required rethinking medical necessity determinations, provider credentialing, contracting, procedure codes and other processes common to private insurance plans.

How Did It Get Through The Political Process?

Three factors significantly contributed to the political viability of a benefit expansion in the Minnesota Care and General Assistance Medical Care programs:

>> The governor of Minnesota and the administration provided strong leadership. The provisions to expand the mental health benefits in these plans were part of the governor’s mental health initiative, set forth in advance of the 2007 legislative session.

>> An extremely strong coalition of stakeholders formed a mental health action group. This group is co-chaired by a representative from the department of human services and included representation from the private insurance industry and organized and knowledgeable advocacy and provider communities.

>> There was strong support in the legislature for the expansion of benefits in Minnesota Care and General Assistance Medical Care, including from a member of the finance committee in the house, who has a son with schizophrenia. The creation of a mental health division in the health and human services policy committee also helped move the policy discussion forward.

Why Does This Approach to Healthcare Reform Work?

A recent survey of community behavioral health organizations found that on average, 42% of reimbursement for services came from private insurers. While this represents the average, the survey found that there was quite a range in reimbursement sources. For community behavioral health organizations that specialize in services such as Assertive Community Treatment or case management, Medicaid is the predominant reimbursement source, either through fee-for-service or managed care.

Reimbursement from private insurance and Medicaid managed care is uniformly better than Medicaid fee-for-service. In addition to higher rates, the private insurers and Medicaid managed care organizations have been willing to offer special contracts for packages of services for crisis care and hospital discharge plus aftercare.

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Reclaiming Good Mental Health

What is good mental health? We are all more or less mentally healthy, and this usually varies through our lives especially as we deal with difficult life events, change and so on. Whether we call this psychological wellbeing, happiness, contentment, positive mindset, all these terms relate to good mental health.

With our physical health, it’s part of our everyday discourse to be aspirational. We want to feel physically fit, energetic, strong, balanced in our weight, eating a healthy diet, supple, resilient and not prone to minor ailments. Sure we complain about our problems, and talk about how we can’t do all the things we know we ought to do. We know it’s not easy to stay physically healthy without working at it, especially if we’ve experienced health problems. We know that even if we reach the peak of physical fitness, we can’t maintain this for the rest of our lives without paying attention to it.

Research tells us that good mental health is even more beneficial than good physical health. A positive mental outlook increases the rate and speed of recovery from serious, even life threatening, illness. Psychological resilience and wellbeing gives people the strength to turn problems into challenges into triumphs.

Yet whenever I ask a group of people to tell me what words come into mind in relation to ‘mental health’, their responses are about mental ill-health! It’s as if the term has been hi-jacked to become totally problem-focused.

In the meantime, we’re experiencing an epidemic of mental ill-health. About 1 in 4 people are experiencing some form of common mental health problem such as depression, anxiety and various stress related symptoms. GP surgeries are overwhelmed with such problems, mental health services are only able to provide support for the 1% of the population with much more severe mental health difficulties, and there’s a plethora of largely unregulated services, treatments and remedies out on the private market. A recent research study showed that the majority of long term sickness absence from work resulted from stress related conditions.

The trouble with focusing on the problems and the pain, is that that’s what we become experts in. We’re looking for cures and treatments to fix the problem, instead of focusing on what makes for good mental health. We know that physical health is multi-dimensional – no-one imagines that pumping iron to build your muscles is a recipe for overall physical health, although it will certainly make you stronger for certain activities.

So what are the essentials of good mental health?

Connection is certainly one of the best known. Having positive close relationships is good for our mental health, as is having a wider network of friends, colleagues and acquaintances which will vary over time. Giving to others is another really important aspect of connection, improving our sense of self worth and wellbeing.

Challenge is about learning and development, it’s how we grow. For children, everyday brings new challenges, yet as adults we often become increasingly fearful of change, unwilling to learn new skills or put ourselves in unfamiliar situations. So expanding our comfort zone, sometimes in small ways if we’re feeling particularly vulnerable, will help develop our self-confidence and sense of personal achievement.

Composure means a sense of balance, and ability to distance ourselves from our thoughts and emotions. It means our ability to respond rather than react. This could be described as our sense of spiritual connection, which may come through a particular belief or faith, or may be found through connection with nature. A mentally healthy person will feel an inner strength of spirit, and find ways to support that.

Character relates to the way in which we interpret our experiences and our responses to them. We all have our own personal story, or stories, which we may or may not tell others. We may cast ourselves as the hero, the victim or the villain, and however we do this will impact generally on our mental health. Someone who has experienced severe life trauma may have great difficulty piecing together their story at all, leaving them feeling literally fragmented. Good mental health means having a strong sense of personal values, awareness of our own strengths, skills and resources, and personal stories of learning from mistakes, survival, success and appreciation.

Creativity represents the fun, childlike aspects of our mental health. As children we are naturally creative and we play. As we grow into adulthood, our creativity and playfulness is often discouraged or devalued, and this can cause great frustration, literally diminishing the capacity of our brain to function as well as it could. Exploring creative activities has often been found to have a powerful therapeutic effect, and good mental health certainly depends in part on opportunities to bring fun, playfulness and creativity into our lives.

These 5 C’s of good mental health offer a framework within which we can think about our mental health in the same way as we might our physical health. It’s pretty damned hard to be a perfect specimen of physical health,but then who needs to be perfect? Just like our physical health, our mental health is a work in progress and always will be.

In years gone by, many people with physical illnesses were treated cruelly because of ignorance and shame. I recall when cancer was spoken in hushed whispers as the Big C. Nowadays mental ill-health is the ‘elephant in the room’ which we need to be looking at long and hard, exposing to practical common sense and intelligent discussion.

World Mental Health Day on October 10 has been a timely reminder that good mental health really is something we can aspire to for everyone. Let’s make it so!

Carolyn Barber, Bsc (Hons), CQSW, is the founder of Wayfinder Associates, a social care training and consultancy business specialising in team development, independent supervision and staff wellbeing. As a serial social entrepreneur, Carolyn has developed community based programmes to promote understanding of mental wellbeing using positive solution focused approaches.

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Teen Mental Health

Parents worried about teen mental health need not look any further. Factual information can help you to make decisions that will actually help your child be happier in his or her life. Teens are at the vulnerable stage in life and, as a parent, if you search the net or talk to your friends, you will get a lot of advice on how to help improve your teen’s mental health.

Yet, facts are what matter! Facts have no vested interest or bias and may help you, the loving parent, to determine what is best for your child. First, to define mental health symptoms, disorders and diagnoses, there are these facts: No medical tests exist that can detect a mental health disorder (no brain scan, no blood test, no chemical imbalance test). Dr. Allen Frances, Editor of the psychiatric diagnostic manual, edition IV, states in an article titled, Mislabeling Medical Illness as Mental Disorder, ” that the diagnoses “will harm people who are medically ill by mislabeling their medical problems as mental disorder.” Dr. Russell Barkley, clinical professor of psychiatry, and pediatrics, in the same article, states, ” There is no lab test for any mental disorder right now in our science.”

Psychiatric disorders are listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. The disorders are voted on by workgroups comprised of psychiatrists. Dr. Thomas Insel, Director of the National Institute of Mental Health, was reported by the New Yorker as refuting the validity of mental health diagnoses. “Insel announced that the D.S.M.’s diagnostic categories lacked validity, that they were not ‘based on any objective measures,’ and that, ‘unlike our definitions of ischemic heart disease, lymphoma or AIDS,’ which are grounded in biology, they were nothing more than constructs put together by committees of experts. America’s psychiatrist-in-chief seemed to be reiterating what many had been saying all along: that psychiatry was a pseudoscience, unworthy of inclusion in the medical kingdom. According to a 2012 report from the University of Massachusetts, “Three-fourths of the work groups continue to have a majority of their members with financial ties to the pharmaceutical industry”. Per the FDA, some of the side effects of psychiatric drugs include mania, psychosis, depression, suicidal thoughts, homicidal thoughts and death. Non-psychiatric medical professionals can, and do, perform medical tests to detect any potential underlying physical cause of unwanted mental health symptoms.

Per Florida Department of Health Regulation, Florida Patient’s Bill of Rights and Responsibilities, each individual has the right to be fully informed about the proposed medical treatment or procedure. This includes the right to know the risks and alternatives. For those who live outside of Florida, Informed Consent, the right to know the risks and the alternatives to any treatment, is a legally accepted term that is used globally and ensures your right to make decisions for your health and well being.

Second, considering the, above-mentioned, facts, there becomes a vicious circle for any teen, adult or elder, who is experiencing life’s stresses, and therefore the effects of those stresses, such as anxiety, depression, mood swings, aggression, and more. The never-ending circle is that of mental health diagnoses, mental health drugs, (more drugs, whether prescribed or abused) and more mental health diagnoses, with only seeming improvement in symptoms if the drug or drugs have chemically restrained the initial and unwanted mental health symptoms, temporarily. Unfortunately, for most those restraints fail to work after time and the adverse effects take place, which of course produce more mental health symptoms, more diagnoses and more drugs.

Teen mental health is an important topic! It has to do with the welfare of your child, our future adult in society. Those that shape and direct how our culture will develop over time. To improve your teen’s mental health, consider the facts and in doing so, talk to traditional, non mental heath, medical professionals about the possibility of a thorough medical exam that will test for all possible physical causes of the teen’s depression, anxiety, aggression, etcetera.

Time and history are on your side, because over time, and strewn through the last 4 decades are medical research and multitudes of documented real-life cases of individuals who did avail themselves of a thorough physical examination, found the true physical cause of their problems and resolved all through the use of medical science that carried none of the FDA warnings on mental health drugs, which of course, are mental health symptoms in themselves. Such as, mania, delusions, psychosis, worsening depression, anxiety, hallucinations, suicidal and homicidal thoughts and actions.

Will Fudeman, a Licensed Mental Health Counselor, recently published an article about his work as a psychotherapist. He felt he had to do more to help his patients than listen to their woes. He decided, after his own personal experience of having horrific pain after a car accident, that he wanted to study Chinese medicine. He got his license to practice as an Acupuncturist and, after his 20 years as a therapist, he says that he had come to understand that emotional and physical are “intertwined”.

Dr. Fudeman cites Dr. Bessel van der Kolk and his research treating those who have experienced all types of trauma. Even those who have been to war, experienced natural disasters and serious accidents, etcetera. Fudeman says “Van der Kolk has found that survivors of trauma are helped most by treatments that bring them into their bodies in the present time.”

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Mental Health Stigma

Despite the increase in publicity surrounding mental health and mental health issues, there is still a lack of understanding about mental health in general. For example, a research survey published by the government “Attitudes to Mental Illness 2007” reported that 63% of those surveyed described someone who is mentally ill as suffering from schizophrenia, and more than half believed that people with mental illness should be kept in a psychiatric ward or hospital. Overall the results showed that positive attitudes to people with mental health had actually decreased since 1994 which is worrying indeed.

Amazingly, many people still don’t understand that mental health problems affect most of us in one way or another, whether we are suffering from a mental illness ourselves or not. If we bear in mind that a quarter of the population are suffering from some kind of mental health problem at any one time, then the chances are, even if we personally don’t have a mental illness, we will know someone close to us who does, so it is our responsibility to understand what mental illness is and what can be done about it.

Many people with mental health problems will often feel isolated and rejected and too afraid to share their problems with others purely because of the way they might be perceived. This lack of understanding means they are less likely to get the kind of help and support they need and are in danger of slipping even further into depression and mental illness. People need to understand that mental illness need not be a barrier to a better quality of life and that help is available and that most people with a mental health problem can regain full control over their lives if they get the support they need.

A new guide to mental health

The Royal College of Psychiatrists has produced a new guide to mental health which was published in November 2007 and is aimed at informing the general public about what mental illness is and is a big step towards tackling the stigma that is still attached to mental illness.

The guide is written in an easy to understand format and over 60 mental health experts have contributed to it. The Mind: A User’s Guide contains chapters that cover a whole range of mental illnesses and includes a section on how the brain works, how mental illness is diagnosed, and how to cope with it.

A Scottish survey

In Scotland, a national survey of public attitudes to mental health Well? What Do You Think? (2006) was published in September 2007 and highlighted that although people living in socially deprived areas have a higher incidence of mental health, the level of stigmatisation is still no lower than in other areas. This suggests that being confronted with mental illness is not enough to change the attitudes towards it.

There are also gender differences too. According to the Scottish survey, men with a mental health problem were more likely to be treated with suspicion than women and were also more inclined to avoid social contact with someone else with a mental health problem. Even out of those who displayed a positive attitude towards people with mental health problems, many said they would be reluctant to tell anyone if they had a mental health problem themselves which just goes to show that there is still fear surrounding other peoples’ perceptions of mental health.

A CIPD Survey

A recent study conducted by the Chartered Institute of Personnel and Development and KPMG consultants surveyed over 600 employers and reported that doctors are not doing enough to help people with mental health problems return to work and that this is costing the business world billions of pounds. For example, only 3% of the participants rated doctor support as “very good”.

It may be that doctors really don’t know what else to offer someone suffering from depression and anxiety other than drugs and time off work. Even more worrying was the fact that 52% of employers maintained that they never hired anyone with a history of mental illness which serves to perpetuate the stigma. On a more positive note, of those that did hire someone with a mental health problem, more than half said the experience had been “positive”.

Changing attitudes

A lot is being done by governments and organisations to try to change public attitudes towards mental health but is it enough? Until we all recognise that mental illness doesn’t discriminate, it can affect any one of us at any time regardless of our age, gender or social background, the stigma attached to mental illness is likely to persist.

Mental illness doesn’t discriminate, it can affect any one of us at any time regardless of our age, gender or social background, and yet the stigma attached to mental illness still persists. Although a number of government initiatives, awareness campaigns and organisations have been set up specifically to tackle mental health stigma and change our attitudes towards mental health in general, there is still a long way to go.

It is therefore up to each and every one of us as individuals to make sure we are well informed and understand the issues involved because only when the public are fully aware of the facts will mental health stigma become a thing of the past.

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11 Points For Mental Health Care Reform

Due to greater understanding of how many Americans live with mental illnesses and addiction disorders and how expensive the total healthcare expenditures are for this group, we have reached a critical tipping point when it comes to healthcare reform. We understand the importance of treating the healthcare needs of individuals with serious mental illnesses and responding to the behavioral healthcare needs of all Americans. This is creating a series of exciting opportunities for the behavioral health community and a series of unprecedented challenges mental-health organizations across the U.S. are determined to provide expertise and leadership that supports member organizations, federal agencies, states, health plans, and consumer groups in ensuring that the key issues facing persons with mental-health and substance use disorders are properly addressed and integrated into healthcare reform.

In anticipation of parity and mental healthcare reform legislation, the many national and community mental health organizations have been thinking, meeting and writing for well over a year. Their work continues and their outputs guide those organizations lobbying for government healthcare reform..

MENTAL HEALTH SERVICE DELIVERY

1. Mental Health/Substance Use Health Provider Capacity Building: Community mental health and substance use treatment organizations, group practices, and individual clinicians will need to improve their ability to provide measurable, high-performing, prevention, early intervention, recovery and wellness oriented services and supports.

2. Person-Centered Healthcare Homes: There will be much greater demand for integrating mental health and substance use clinicians into primary care practices and primary care providers into mental health and substance use treatment organizations, using emerging and best practice clinical models and robust linkages between primary care and specialty behavioral healthcare.

3. Peer Counselors and Consumer Operated Services: We will see expansion of consumer-operated services and integration of peers into the mental health and substance use workforce and service array, underscoring the critical role these efforts play in supporting the recovery and wellness of persons with mental health and substance use disorders.

4. Mental Health Clinic Guidelines: The pace of development and dissemination of mental health and substance use clinical guidelines and clinical tools will increase with support from the new Patient-Centered Outcomes Research Institute and other research and implementation efforts. Of course, part of this initiative includes helping mental illness patients find a mental health clinic nearby.

MENTAL HEALTH SYSTEM MANAGEMENT

5. Medicaid Expansion and Health Insurance Exchanges: States will need to undertake major change processes to improve the quality and value of mental health and substance use services at parity as they redesign their Medicaid systems to prepare for expansion and design Health Insurance Exchanges. Provider organizations will need to be able to work with new Medicaid designs and contract with and bill services through the Exchanges.

6. Employer-Sponsored Health Plans and Parity: Employers and benefits managers will need to redefine how to use behavioral health services to address absenteeism and presenteeism and develop a more resilient and productive workforce. Provider organizations will need to tailor their service offerings to meet employer needs and work with their contracting and billing systems.

7. Accountable Care Organizations and Health Plan Redesign: Payers will encourage and in some cases mandate the development of new management structures that support healthcare reform including Accountable Care Organizations and health plan redesign, providing guidance on how mental health and substance use should be included to improve quality and better manage total healthcare expenditures. Provider organizations should take part in and become owners of ACOs that develop in their communities.

MENTAL HEALTHCARE INFRASTRUCTURE

8. Quality Improvement for Mental Healthcare: Organizations including the National Quality Forum will accelerate the development of a national quality improvement strategy that contains mental-health and substance use performance measures that will be used to improve delivery of mental-health and substance use services, patient health outcomes, and population health and manage costs. Provider organizations will need to develop the infrastructure to operate within this framework.

9. Health Information Technology: Federal and state HIT initiatives need to reflect the importance of mental-health and substance use services and include mental-health and substance use providers and data requirements in funding, design work, and infrastructure development. Provider organizations will need to be able to implement electronic health records and patient registries and connect these systems to community health information networks and health information exchanges.

10. Healthcare Payment Reform: Payers and health plans will need to design and implement new payment mechanisms including case rates and capitation that contain value-based purchasing and value-based insurance design strategies that are appropriate for persons with mental health and substance use disorders. Providers will need to adapt their practice management and billing systems and work processes in order to work with these new mechanisms.

11. Workforce Development: Major efforts including work of the new Workforce Advisory Committee will be needed to develop a national workforce strategy to meet the needs of persons with mental health and substance use disorder including expansion of peer counselors. Provider organizations will need to participate in these efforts and be ready to ramp up their workforce to meet unfolding demand.

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