MEETING SUMMARY
National Coalition on Mental Health and Aging
February 10, 2003

Sanford Finkel, Chair of the National Coalition on Mental Health and Aging called the meeting to order and welcomed the 29 members and 4 guests in attendance.

New Members

Two requests for membership in the National Coalition on Mental Health and Aging were considered and approved by members. The Coalition welcomed the two organizations, the American Mental Health Counselors Association (AMHCA) and Psychologists In Long Term Care (PLTC). Beth Powell will represent AMHCA and David Powers will represent PLTC. These representatives will make brief presentations about their organizations at the next Coalition meeting on June 9th.

Legislative and Regulatory Update

Nicholas Meyers, Deputy Director, Congressional Relations, American Psychiatric Association began the update with a brief recap of the 107th Congress. Little movement was made on issues of interest to the Coalition, such as parity and the Medicare Provider Payback. Failure to address these and other issues will have a negative impact on access to care for older Americans. The 108th Congress is expected to address issues such as the reintroduction of parity, Medicare restructuring (although prospects are difficult because of finances), liability reform, and prescription drug coverage (which will probably be limited and tied to Medicare restructuring).

In the President's 2003 budget, domestic discretionary funding is increased by 4% (including items such as homeland security, AIDS, substance abuse). Non-bioterrorism research will decline for the first time since 1989. The Center for Mental Health Services' PATH Program for community-based services for people who are homeless and have serious mental illnesses will increase $3 million to $50 million, and a $10 million increase is proposed for children's mental health. All other CMHS programs are frozen. Also included is the largest ever increase for Department of Veteran Affairs' health services. No Medicaid increases are in the budget for facility-based mental health services. The President has also announced plans for Medicaid reform that would include providing states with more control and increased use of managed care. This will be a very politicized debate in Congress. It was noted that mental health services are very vulnerable to state cuts.

It was also noted that CMS sent a memo to its Insurance Commissioners and Issuers in December 2002 clarifying Medigap issuer's coinsurance obligation with Medicare Part B out patient mental heath services. It stated Medigap policies must cover Part B co-payments for Medicare beneficiaries. This memo codifies what has been in the regulations for 13 years but often ignored. The memo can be found at: http://cms.hhs.gov/medigap/mdgp0202.pdf. Related to Medicare issues, Leslie Fried, ABA/Alzheimer's Association Project, mentioned that a change in the Medicare appeal process has been proposed. It would allow hearing officers ("qualified independent contractors") other than Administrative Law Judges to review Medicare appeals. This is not a positive change - currently ALJs overturn 80% of the denials brought to them for review.

It appears that The President's New Freedom Commission on Mental Health is putting the emphasis for system reform on community-based action. There is concern in a number of quarters about whether the emphasis on community based care and structural change can happen without significant new and increased resources. Bob Bernstein, Bazelon Center for Mental Health Law made note of two Commission statements: that the mental health system is in shambles, and that recovery from mental illness is a desired outcome - this is a much different and broader goal than illness management and reduced hospitalization. Bob also mentioned that of the thousands of public comments submitted to the Commission in regards to its work, only 18 were specific to aging issues.

SAMHSA Update on Older Adult Activities

Gail Hutchings, Acting Director, Center for Mental Health Services visited with the Coalition to review current and planned SAMHSA activities. A major SAMHSA priority is to facilitate the transfer of scientific knowledge related to effective, evidence based practices into practice. SAMHSA is working closely with NIH and NIMH in this regard. A number of planned and current strategies were discussed. A national registry of effective strategies was one idea raised to facilitate the science to service cycle. In terms of integration initiatives, they are exploring a technical assistance model that would be a state system-wide approach to bringing all state level decision makers to the table for discussion and planning. Instituting Policy Academies was another strategy mentioned. The critical need for workforce development and training efforts was also discussed.

The National Technical Assistance Center on Mental Health for Older Adults at Harvard Medical School was discussed. Betsy McDonell Herr is the Project Officer and Sue Levkoff is its Director. Its focus is on fostering the integration of high quality evidence based mental health services into primary care settings and strengthening the mental health/primary care interface. Two overarching project concepts are moving from an illness management model to one of recovery, and consumer participation.

Implementation of Olmstead: State Efforts Related to Older Adults

Jennifer Mathis and Robert Bernstein of the Bazelon Center for Mental Health Law discussed the findings of their project to analyze the barriers that have led to the neglect of older adults in states' efforts to shift mental health services to the community. With support from the Retirement Research Foundation, five states (Pennsylvania, Alabama, Illinois, Michigan and Nevada) were surveyed and visited to: 1) to identify the state policies and practices that create barriers to community integration for older adults with mental illnesses and the efforts that have been successful in overcoming some of these barriers, and 2) to formulate recommendations for change to reduce the number of older adults with mental illnesses needlessly segregated in institutions of various types and facilitate better (and, often, less costly) service models in community-integrating settings.

The overarching finding is that virtually no attention is given to older adults with mental health needs in state planning to implement Olmstead. The mental health system often sees the problems of older adults as no different than the general population, and aging advocates don't perceive mental health problems as a major issue for older adults. Specific barriers mentioned included that: services are fragmented as they are funded from separate funding streams (Medicaid, AOA money, Mental Health); provider licensure requirements deter care; and that rights under PASSAR are unenforceable. The principal barriers found across all five states (and described in the report) were:

The Project's report, Last in Line Barriers to Community Integration of Older Adult with Mental Illnesses and Recommendations for Change was shared with Coalition members. View the executive summary at http://www.bazelon.org/issues/elders/publications/index.htm. Ordering information is also available at this site.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Beth Fuchs of Health Policy Alternatives, Inc., a health policy firm based in Washington DC, gave a very detailed overview of HIPPA beginning with its history and purpose. Enacted in 1996, its objectives are to: (1) provide for health insurance portability standards, (2) improve efficiency and effectiveness of health care system and (3) increase the protection and confidentiality of individually identifiable health information -- privacy standards. Under the Act, Congress was given until August 1999 to enact a privacy law or the Secretary would be required to issue regulations. Congress failed to meet this deadline and in November 1999, HHS published a proposed rule. Over 50,000 comments were received. A final rule was published but the White House postponed its implementation. HHS then provided a new 30-day comment period ending March 30, 2001. This time, 24,000 comments were received. Various postponements and modifications to the privacy rules occurred in thee past two years until the final modified rule was published in August 2002 with a set compliance date of April 14, 2003.

The rationale for the privacy rules is that there is an increased vulnerability as use of electronic information systems increase, more disclosure is possible in less time to more people, and to protect the privacy of individually identifiable health information. Covered entities include health plans, health care clearinghouses and certain health care providers (those who transmit electronically any claims, enrollment, remittances, etc). If a billing service does this on provider's behalf, the privacy standards apply to provider. It applies to oral and paper as well as to electronically transmitted protected health information. If a provider still operates entirely with paper records they are exempt, but many provider groups are encouraging their members to comply anyway.

The privacy rules cover: (1) protected health information - individually identifiable health information that has been transmitted or maintained in any form- electronic, paper, oral (2) individually identifiable health information - created or received by a provider, plan, employer, or clearinghouse; or relating to physical or mental health condition at any time, to the provision of health care or to the past, present, or future payment for the provision of health care (3) information that identifies an individual or could be used to do so.

The presentation continued with information on: limitations of the rule, permitted uses and disclosures of PHI, basic requirements on providers, giving privacy notice, psychotherapy notes, authorization and consent, a provider "To Do" list, state privacy laws, enforcement and compliance, electronic transaction standards, and sources of additional information. To learn more about privacy issues, visit the HHS Office of Civil Rights at: http://www.hhs.gov/ocr/hipaa/ or http://aspe.hhs.gov/admnsimp/. For information on administrative simplification go to: http://aspe.hhs.gov/admnsimp/ or http://www.cms.hhs.gov/hipaa/.

Well Into Your Future - A National Health Promotion Campaign on Mental Health and Aging

Grady Watts, Principal Investigator and Producer, State of the Art, Inc. spoke with the Coalition about their health promotion campaign designed to educate older adults and their caregivers on mental health issues. This three-hour documentary series funded by NIMH will be broadcast on PBS in May 2003. The three episodes are: Maintaining Mental Health, Alzheimer's and Dementia, and Depression, Not a Normal Part of Aging. Each episode highlights the stories of real people and seeks to counter they myths and stigma surrounding older adult mental health issues. The programs give real life examples of successful diagnosis, treatment, and coping strategies for individuals, families and caregivers dealing with these issues. Discussion followed on potential ways for Coalition members to become involved in the outreach and publicity campaign surrounding the May broadcast schedule.

NCOA/ASA Joint Conference Update

The 2003 Joint Conference of the National Council on the Aging and the American Society on Aging will take place March 13-16, 2003 in Chicago. The conference theme is Making Our World A Good Place to Grow Old. On March 15th, the ASA Mental Health and Aging Network and the Integration Project Planning Committee will convene a national discussion on the integration of Primary Care and Community-Based Services for Older Adults. This daylong session will explore ways to affect policy and develop funding sources to sustain viable proven programs. The emphasis will be on identifying lessons learned from evidenced based strategies and transforming research into real community applications and changes in public funding policy.

Election of Officers

The Coalition's current Executive Committee consists of the Chair (Sandy Finkle, American Association of Geriatric Psychiatry), Vice Chair (Anita Rosen, Council on Social Work Education), Immediate Past Chair (Willard Mays, National Association of State Mental Health Program Directors and American Society on Aging), and two additional members elected by the Coalition (Bob Bernstein, Bazelon Center for Mental Health Law; and Alixe McNeil, National Council on the Aging).

The officers are elected by the Coalition and serve a term of two years, with the right to be elected for a consecutive term. The initial two-year terms of office have come to an end.

According to the bylaws, the Executive Committee shall appoint a Nominating Committee of three members to establish a slate of candidates for the various offices. If you would be interested in serving on Nominating Committee, please contact Debbie DiGilio as soon as possible at ddigilio@apa.org.

Next Meeting

The next Coalition meeting will be held on Monday, June 9th 2003 from 9:30 am - 12:30 pm at the offices of the American Psychological Association. Hope to see you then.

Deborah DiGilio
Office on Aging
American Psychological Association