Confused about the changes coming to publicly funded treatment in Michigan? Here’s the background.

historyI’ve gotten several questions about yesterday’s post on looming changes for publicly funded treatment in Michigan. These questions made me realize I probably needed to provide a little background. To be honest, I haven’t followed it that closely and it’s all a little confusing.

Background

Michigan is one of a shrinking number of states that “carves out” its behavior health funding. Meaning that Medicaid HMOs are not responsible for behavioral health services. (Behavioral health services refers to services for mental illness, developmental disabilities and substance use disorders.)

Instead, the state keeps about $2.4 billion dollars and distributes it to 10 regional organizations called PIHPs (Prepaid Inpatient Health Plans) that are responsible for behavioral health services in their region. The PIHPs do not deliver the services themselves, but they contract for these services and oversee them.

In February of 2016, Governor Snyder proposed that, by Sept. 2017, all behavioral health clients and money be transferred to the state Medicaid HMOs. (This is referred to as Section 298, referring to the relevant portion of the budget proposal.)

There had been no groundwork or forewarning leading up to the proposal and it caught people by surprise.

There has been a national trend away from carve-outs. There may be many reasons for this trend but the two reasons I hear are preferences for privatization and a desire to increase integration of behavioral health with physical health systems. It can also be argued that there are ways in which it seems sensible and destigmatizing to have Medicaid recipients receive services just like everyone else—through their insurer.

On the other hand, the people served by the public system often represent the most severe and complex cases. In response to this severity and complexity, public systems has developed systems of care that include things like peer support, supportive housing, employment support, and mental health club houses. They also work with local communities and first responders on things like overdose rescue, and problem solving courts. It’s hard to imagine HMOs doing this kind of work.

Providers, service recipients, families and mental health advocates organized to oppose the change. They expressed concern that this would result in cuts in services and that there would not be any financial savings for the state.

In April 2016 the outcry about the proposal resulted in the legislature creating a workgroup that is responsible for reviewing the issue and issuing a report with recommendations by February 2017. This workgroup is called the Section 298 Workgroup.

So, to this point, nothing has changed.

This brings us to yesterday’s post which was about an interim report that was released by the workgroup on Friday.

If I’m reading the report correctly, it looks like they recommend keeping the carve out and trying some pilots programs.

So, privatization looks less likely than it did a year ago, but anything could happen.

A lot depends on what the final report from the workgroup looks like and how deferent the legislature will be to the workgroup.

The new Michigan legislature is even more conservative than the last and it’s easy to imagine them deciding they want to privatize regardless of the final report’s recommendations.

 

 

Here is the statement the workgroup issued on Friday:

The Michigan Department of Health and Human Services (MDHHS) today submitted the interim report for the Section 298 Initiative to the Michigan legislature. The Section 298 Initiative is a statewide effort to improve the coordination of physical health services and behavioral health services. The interim report reflects the discussions of the 298 Facilitation Workgroup. The interim report contains a series of policy recommendations for the Michigan Legislature on improving the coordination of physical health and behavioral health services.

The MDHHS and the 298 Facilitation Workgroup also launched the next phase on the Section 298 Initiative today. The next phase of the initiative focuses on the development of recommendations on models and benchmarks for implementation.

As part of the next phase of the initiative, interested stakeholders can submit potential models for consideration by the 298 Facilitation Workgroup. MDHHS will accept model proposals submitted to MDHHS-298@michigan.gov using a standardized template from January 13, 2017 to February 3, 2017 at 5:00 p.m. The model proposal template can be found on the MDHHS webpage at www.michigan.gov/stakeholder298.

The model proposal process is not a request for proposal which will result in a direct contract or other formal engagement of the submitter(s): this process is a request for information which will contribute to the development of the Section 298 Final Report for the Michigan legislature.

For more information about the interim report and the model proposal process, visit www.michigan.gov/stakeholder298 or send an email to MDHHS-298@michigan.gov.

If you have opinions on the matter, please contact the workgroup and your legislators. (There’s still plenty of time. This has not been a fast moving process.)

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Changes coming to publicly funded treatment in Michigan

historyIf you haven’t heard, there’s been serious discussion about making major changes to publicly funded mental health and substance use disorders in Michigan. The current system carves out money for those services and give it to 10 regional entities that contract for and oversee Community Mental Health services and substance use disorder services. The question is whether that should continue or whether the money and responsibility should be given to the HMOs serving Michigan Medicaid recipients.

It’s complicated.

There are ways in which it seems sensible and de-stigmatizing to have Medicaid recipients receive services just like everyone else—through their insurer.

On the other hand, the people served by the public system often represent the most severe and complex cases. In response to this severity and complexity, public systems has developed systems of care that include things like peer support, supportive housing, employment support, and mental health club houses. They also work with local communities and first responders on things like overdose rescue, and problem solving courts. It’s hard to imagine HMOs doing this kind of work.

There is a 298 workgroup and they just issued the following statement:

The Michigan Department of Health and Human Services (MDHHS) today submitted the interim report for the Section 298 Initiative to the Michigan legislature. The Section 298 Initiative is a statewide effort to improve the coordination of physical health services and behavioral health services. The interim report reflects the discussions of the 298 Facilitation Workgroup. The interim report contains a series of policy recommendations for the Michigan Legislature on improving the coordination of physical health and behavioral health services.

The MDHHS and the 298 Facilitation Workgroup also launched the next phase on the Section 298 Initiative today. The next phase of the initiative focuses on the development of recommendations on models and benchmarks for implementation.

As part of the next phase of the initiative, interested stakeholders can submit potential models for consideration by the 298 Facilitation Workgroup. MDHHS will accept model proposals submitted to MDHHS-298@michigan.gov using a standardized template from January 13, 2017 to February 3, 2017 at 5:00 p.m. The model proposal template can be found on the MDHHS webpage at www.michigan.gov/stakeholder298.

The model proposal process is not a request for proposal which will result in a direct contract or other formal engagement of the submitter(s): this process is a request for information which will contribute to the development of the Section 298 Final Report for the Michigan legislature.

For more information about the interim report and the model proposal process, visit www.michigan.gov/stakeholder298 or send an email to MDHHS-298@michigan.gov.

If you have opinions on the matter, please contact the workgroup and your legislators. (There’s still plenty of time. This has not been a fast moving process.)

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Updates to 42 CFR part 2

confidentialityNew rules have been released for 42 CFR part 2, the law that provides for confidentiality of addiction treatment records.

The changes are intended to make information sharing between providers easier, though it’s not clear how much this will actually help.

The new rules can be found here.

The federal press release can be found here.

The proposed and final rules are not loved by all:

In response to the proposed rule, Kaiser Permanente had written: “SAMHSA appears to have gone out of its way to make sharing clinical information for treatment purposes more difficult, other than nominal easing of consent form requirements for a very limited type of HIE. SAMHSA has not created a treatment exception, has not permitted patients to consent to disclosure of information to “all of my treating providers ….and has made consent forms more complicated and confusing.”

In response to the final rule, Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness, noted that while the final rule is an improvement over current regulations and over the proposed rule, it continues to limit communication among providers, and in some cases, the ability to use existing medical information to identify members at risk for substance, such as opioid, misuse or diversion,

“ABHW applauds SAMHSA for addressing this important matter. Our hope was that the final rule would align substance use privacy protections with the Health Insurance Portability and Accountability Act (HIPAA). Unfortunately, it does not,” Greenberg said in a prepared statement. “Separation of substance use from the rest of medicine creates several problems: primary care lacks the ability to coordinate a patient’s medical and substance use treatment; substance use treatment programs lack the capability to coordinate a patient’s medical and substance use care; and patients are put at risk of unsafe, uncoordinated, and uninformed care.”

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Book review – Sex in Recovery: A Meeting Between the Covers

9895zoomI’m taking some time off for the holidays and using it as an opportunity to catch up on a long neglected item on my to-do list. (It was a busy semester.) I’ve just now had a chance to seriously dig in to Jennifer Matesa’s most recent book, Sex in Recovery: A Meeting Between the Covers.

Sex can be such a complicated topic. Fortunately, Matesa seems fearless.

She declares the truth (often unspoken but self-evident) that sex and intimacy are fundamental to the human experience and reassuringly grabs us by the hand to lead us into an exploration and conversation about our experience, strength and hope as they relate to sex and intimacy in recovery.

Matesa says her goal is to convene “a special meeting to help us begin to talk about sex” and she is successful. It feels a little like the AA Grapevine (AA’s “meeting in print”) but skillfully facilitated to go beyond the boundaries of what’s discussed in 12 step meetings.

The book is structured with chapters that contain personal stories followed by chapters exploring topics like the one year rule, virginity, trauma and shame, touch (including non-sexual touch), pleasure, honesty and vulnerability, privacy and secrecy, the sexual consequences of addiction, experiencing sexuality, and amends as they relate to sex. Each of these chapters is followed by a collection of questions for further consideration and discussion.

These “Queries for Discussion” sections get at the strength and value of the book. Matesa’s only agenda seems to be honest exploration and discussion that will allow each reader to sort through what is best for them as an individual.

There’s a real humility to this book, which is especially impressive given Matesa’s passion for the topic. She uses her own story as a point of entry into various sub-topics, but she doesn’t project her experience onto others. She takes us on an exploration of various people’s experiences, shares what she’s learned, and she leaves the reader with something that take the them much further than self-help answers—questions.

This book his highly recommended for people in recovery and professional helpers.

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Recovery is Good Business – The Lunch Room

We’ve been working on a campaign to highlight businesses that hire people in recovery. We just completed what we hope will be the first of many video profiles.

The Lunchroom is a special place. They serve great food. Really great food. They are a successful and growing business. And, 11 out of their 27 employees are in recovery from addiction. Phillis Engelbert likes to help people but she says she’s learned that hiring people in recovery is good business. “The track record we’ve had with people in recovery has been excellent. . . . We actively seek them out. It gives this place a sense of purpose that’s more than just making awesome food and being here for our customers.”

[Recovery is Good Business – The Lunch Room from Dawn Farm on Vimeo.]

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What’s in the 21st Century Cures Act?

congress-sports-betting-2I haven’t said much about the 21st Century Cures Act because I haven’t really known what to make of it.

Addiction treatment is underfunded, so I’d never argue that funding is not needed. However, recent funding proposals have very heavily emphasized maintenance treatments for opioid addiction. This approach seems likely to reinforce a tiered system where health professionals get one kind of treatment (the gold standard) and people without their status and resources get another kind of treatment (maintenance). The problem is that most people want the outcomes that the gold standard provides and maintenance delivers another set of outcomes.

It’s unclear to me exactly what the the bill’s on-the-ground impact will be. I haven’t spent a lot of time with it, but the bill itself seems pretty vague.

It looks like the incoming Secretary of Health and Human Services is going to have a lot of discretion.

The bill creates an Opioid Grant Program with $500,000,000 for FY 2017 and $500,000,000 for FY 2018. It’s worth noting that the funding model for other health issues in the bill is smaller annual amounts over longer periods of time. This means there will be a lot of money being spent in a short period of time.

The Secretary will make grants to states for the following uses:

(A) Improving State prescription drug monitoring programs.
(B) Implementing prevention activities, and evaluating such activities to identify effective strategies to prevent opioid abuse.
(C) Training for health care practitioners, such as best practices for prescribing opioids, pain management, recognizing potential cases of substance abuse, referral of patients to treatment programs, and overdose prevention.
(D) Supporting access to health care services, including those services provided by Federally certified opioid treatment programs or other appropriate health care providers to treat substance use disorders.
(E) Other public health-related activities, as the State determines appropriate, related to addressing the opioid abuse crisis within the State.

Section 11002 asks the Secretary to review and update 42 CFR part 2, the confidentiality laws regarding treatment records:

Not later than 1 year after the date on which the Secretary of Health and Human Services (in this title referred to as the ‘‘Secretary’’) first finalizes regulations updating part 2 of title 42, Code of Federal Regulations, relating to confidentiality of alcohol and drug abuse patient records, after the date of enactment of this Act, the Secretary shall convene relevant stakeholders to determine the effect of such regulations on patient care, health outcomes, and patient privacy.

Section 13001  asks the Secretary to provide guidance on what previously passed parity legislation requires of health plans.

 

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Harm reduction and recovery advocacy

kevin-mc-podcast-poto-1024x632

If you have a couple of minutes, check out Chris Budnick’s interview with Kevin McCauley.

The whole conversation is great, but 24:15 to 25:50 really leapt out at me.

Kevin shares his mom’s reaction to learning of his addiction and harm reduction as a “deeply humane response” to what is often perceived as a “set of unsolvable conditions.”

Kevin, we’re also glad you didn’t end up in Holland shooting drugs for the rest of your life.

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