MEETING SUMMARY
National Coalition on Mental Health and Aging
Monday, January 23, 2006

Deborah DiGilio, Chair of the National Coalition on Mental Health and Aging (NCMHA), called the meeting to order. She welcomed the 30 members in attendance.

Update on Medicare Part D

Leslie Fried of the American Bar Association/Alzheimer's Association Medicare Advocacy Project began her presentation by highlighting areas that are problematic in the transitioning process of dual eligibles from Medicaid to Medicare Part D.

Leslie reported she was part of an interorganizational effort to develop a FAX sheet, Prescription Information or Change to facilitate communication between the pharmacy and physician. This form is available to download from the CMS website at: http://new.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartDPharmacyFaxForm.pdf.

A question was raised regarding what is occurring with individuals with mental health disorders. One issue that has arisen is Medicare Part B vs. D coverage (i.e. for injectibles being paid apart from office visit). The Part D program allows coverage of the drugs but does not pay for the medical supplies and the nursing help needed for the home infusion treatments. This policy effectively shuts down such treatment for some patients, even though it is substantially cheaper than the alternative. Essentially, if it was paid by Part B, it should still be paid by Part B but there is some wiggle room, such as in this case. Other issues are authorization requirements, step therapy, transition therapy, and lack of coverage for benzodiazepines. (It was noted that all states but Tennessee have said they will cover benzodiazepines under Medicaid.) Another problem is that pharmaceutical assistance programs are being shut down. The pharmaceutical industry is saying that Part D makes such programs unnecessary. Leslie stated that a special call will be held at 1:00 p.m. Tuesday, January 24th regarding the Part B/D drug issue

Another outstanding issue is how do dual eligibles get reimbursed for money they spent for medications that should have been covered? Many were told they should go to CMS regional offices. Leslie also noted that CMS is aware of the issues for persons without decision making capacity. Specifically, who can enroll persons without capacity? The Alzheimer's Association, ABA and others are working with CMS on this issue.

CMS wants to know if providers are having problems with prior authorization. They want to identify systemic problems with Part D plans as it is difficult to change the system case by case. It is critical that providers contact CMS at prt@cms.hhs.gov to report problems with Part D plans.

Another issue Leslie discussed was the draft USP Model Guidelines for 2007 that were published on December 9. There was a short period during which stakeholders submitted written comments. For 2006, 74% of Medicare drug plans used the USP guidelines in the development of their formularies. Of particular relevance to Coalition members are the categories and classes for mental health drugs. This year, CMS is requiring Medicare drug plans to cover "all or substantially all" anti-depressants, anti-psychotics, anti-convulsants and several other classes of drugs. There is no guarantee that CMS will require plans to provide this coverage in 2007. Therefore, many stakeholders submitted comments to USP to urge the incorporation of these classes in its 2007. Members are urged to continue to remain vigilant on this issue.

Update on Current Legislative and Regulatory Issues

Jim Finley, Senior Associate with the National Association of Social Workers Government Relations section provided the update. He reported that since our last meeting not much has happened except budget reconciliation. On February 1st the House of Representatives will vote on reconciliation. Large numbers of health and religious groups are opposed to the reconciliation bill as it exists. The problematic issues in the bill are increased cost sharing in Medicaid, extending the period for transfer of assets for Medicaid coverage of LTC, waiver of state coverage mandates, EPSDT, and ambiguous changes in case management. Just six votes are needed, so it is real close. If it fails to pass, House of Representative leadership could pull the bill from the calendar. There is a great deal of pressure to finish the bill.

In terms of Medicare Part B updates, there is a scheduled 4.4% provider payment cut on January CMS is hoping that it is a short term reduction that will in turn be increased during reconciliation. The worry is that provider willingness to take on Medicare patients will decrease. It is a six year cut, so the absolute cut is 27%. A long-term fix to this problem is very costly.

It was noted that funding agencies at an even level dramatically curtails funding for new initiatives. This was the case in 2005 when NIH (and NIMH) were level-funded. The 2007 budget will be released on February 6th. A real net loss, which hasn't happened in recent history, can occur. There will probably be a need for a 2007 reconciliation process. The problem is that it will come right up against elections. Probably the same programs will be cut again. Medicare and Medicaid are in great jeopardy. Anything related to health disparities, improving access, and training is really problematic. Title VII funding has been hit repeatedly in recent years (30% cuts) and has just got zeroed out. This includes programs such as medical geriatric programs and geriatric education centers. Bob Rawlings noted that these programs and the services they provide enable many older adults to stay at home. It is upsetting to see programs that have existed for 30 years going away.

2005 White House Conference on Aging Debriefing

NCMHA members present at the WHCoA reported on their experiences. Willard Mays, a WHCoA delegate, began by describing the format of the WHCoA. On the first day, delegates voted for the top 50 resolutions (from the proposed 73). The first day consisted solely of presentations which can be found at www.whcoa.gov. The second full day, Tuesday, was spent in the three implementation strategy sessions that delegates selected to attend related to the top 50 resolutions. Willard described the sessions he attended, the process by which the implementation strategies were developed by the delegates, the advocacy and negotiation regarding specific strategies that occurred during the sessions, and ways he found to infuse NCMHA's positions into the process. Willard believes that the strategy NCMHA decided to go with beginning in September 2004 - crafting comprehensive resolutions and sharing this with all of our affiliates paid off. The one-page fact sheet that we developed after the 73 WHCoA resolutions were released, in which we linked our specific implementation strategies (culled from the NCMHA resolutions) to 10 of the relevant ones from the 73 also proved useful. These were widely distributed both prior to and during the WHCoA.

Jerry Reed, a WHCoA delegate from Suicide Prevention Action Network (SPAN), reported that listening to speeches the entire first day was frustrating to delegates, but he was happy with the outcome. Laurie Young, also a WHCoA delegate from the Older Women's League felt that the orchestrated process was problematic as it limited the time the delegates could provide input to the process. She felt, however, that beginning on Tuesday when the delegates crafted implementation strategies, that their time was more productively utilized. Stephanie Reed, a WHCoA observer from the American Association of Geriatric Psychiatry noted that she believes one reason mental health was voted in the top 10 was the state level and grassroots support.

WHCoA Next Steps:

Deborah reiterated that she also believed our success with mental health receiving two-thirds of the delegate vote and a #8 placement among policy resolutions was partially due to our developing a product (i.e. NCMHA Resolutions) very early on in the WHCoA process and sharing it with our constituent groups so they could adopt it or use it in the development of their own organization's priority issues. This was a much more effective strategy than waiting to act or responding to what the WHCoA developed. This is a good model for how NCMHA should gear up now to assure that the draft WHCoA report (that will go to the governors in March) and the final report (that will go to the President and Congress in June) reflects and is true to the priorities and implementation strategies generated by the WHCoA delegates, and that action is taken to implement them. It was noted that many state delegations are conducting post-WHCoA planning sessions. "Get the Facts" documents have been developed and delegates are being encouraged to review the draft that their governors receive to assure it is a true representation of what happened at the WHCoA and to continue to advocate for the implementation of strategies identified after the release of the final report.

NCMHA members agreed that we need to keep the momentum going. Regardless of what the WHCoA report looks like, it is our job to inform policymakers and advocate with the aging and mental health network for the implementation of strategies the delegates had voted for in December. NCMHA members discussed drafting a post WHCoA document that would thank delegates for their vote for mental health, encourage them to stay in contact with the governor to provide input into the governor's review of the WHCoA Draft Final Report, and would outline key points related to implementation that they should integrate in their continued efforts with their governors and policy makers. We would also suggest that they "remain a delegate" and advocate for continued consideration of these issues for next decade, until the next WHCoA. An NCMHA subcommittee was appointed to develop such a document and flesh out a plan for next steps. Members include Stephanie Reed, Anita Rosen, Lincoln Stanley, Jerry Reed, and Bob Rawlings. (If anyone else is interested in working on this issue, contact ddigilio@apa.org.).

It was recommended that NCMHA invite somebody from the Administration to give us an update on the continuing process at our next meeting.

Older Americans' Mental Health Week

Laurie Young, Director of the Older Women's League and consultant, Patrick Cody discussed plans for Older Americans' Mental Health Week 2006. The observance held during the last week in May has the goal of spreading the message to the general public and policy makers that mental illness is not a normal part of aging. In 2005, activities included the development of a tool kit, and a very well-attended Congressional briefing. At that briefing, Senator Hillary Rodham Clinton offered remarks and Gregory Hinrichsen, PhD from the American Psychological Association and Lisa Yagoda, MSW from the National Association of Social Workers presented. Plans for this year include conducting two surveys regarding perceptions of older adult mental health and available interventions (one will target the public and another allied health professionals), and the development of a toolkit for allied health professionals. Laurie noted that last year, a number of NCMHA organizations signed on as partners. This year, she requested that NCMHA, as an entity, participate and endorse Older Americans' Mental Health Week. NCMHA voted to do so. Laurie will share materials as they are being developed w. NCMHA for comment. Individual NCMHA member organizations may also want to sign on as partners as in years past, as well. Information on 2006 activities will be available at: www.owl-national.org.

Member Updates

American Society on Aging - Anita Rosen reported on the upcoming ASA/NCOA joint conference to be held March 15 - March 19 in Anaheim, California. During the last three years, MHAN sponsored a Coalition track. This year NCMHA will have a day-long Critical Issues session. Typically these sessions have over 300 attendees. ASA President, Gloria Cavanaugh, has secured funding to ensure mental health issues were highlighted at the conference. The all day program, Critical Issues in Strengthening Mental Health and Aging Coalitions, will be held on March 16th sponsored by the ASA Mental Health and Aging Network. The first session, Mental Health and Aging Coalitions: The Current Status and Critical Issues will provide an update on the work of the National Coalition on Mental Health and Aging and share information on the activities of state and local coalitions across the country. The outcomes of the White House Conference on Aging will also be discussed. Anita Rosen will moderate, and Deborah DiGilio and Willard Mays will present. The second session, Federal Initiatives in Mental Health and Substance will highlight older adult initiatives including the new Older Americans Substance Abuse & Mental Health Technical Assistance Center, the Policy Academy on Rebalancing Long-Term Care Systems Toward Quality Community Living and Healthy Aging, and several Toolkits developed to assist professionals serving this population. Alixe McNeill will moderate, and Betsy McDonel Herr (CMHS), Lisa Park (SAMHSA) and Jennifer Solomon (CSAP) will present. The third session, The Olmstead Decision: Impact on Older Adults with Mental Illnesses will be moderated by Deborah DiGilio, and presenters are Bob Bernstein (Bazelon Center), Carol Bianco (Advocates for Human Potential) and Willard Mays. Details and registration information are available at www.agingconference.org.

Bazelon Center for Mental Health Law - Bob Bernstein described litigation that is ongoing in two states involving mainly older adults who are being confined in IMD facilities. States are paying for their placement and as other funds are not available, they can not be placed in other settings. This is counter to the Olmstead decision. In another suit in a northeast state, older adults with mental disorders are being kept locked up in private nursing facilities.

National Citizens Coalition on Nursing Home Reform - Julie Meashey reported that they are collating feedback on what is happening in long term care centers related to Medicare Part D implementation. They are pleased to have individuals from their network working on this issue and in disaster response planning for events such as Katrina.

Department of Veterans Affairs - Kristen Day discussed the improvement in patient outcomes resulting from their use of information technology. Physicians do not hand-write orders anymore and medications are bar-coded. Veterans are using IT in their homes, and the departments of mental health, radiology, and dermatology involved. A lot of innovation is possible building upon IT. One outcome they have documented is decreases in pressure sores in bed-ridden community-based patients.

American Counseling Association - Brian Altman introduced himself as a new representative to the Coalition. He is the legislative representative for the ACA.

Administration on Aging - Diana Laurie described their work on evidence based practices, including mental health. They are finishing up a three year demonstration project and will hopefully disseminate products later this year. Diane noted that AOA is a member of a workgroup of HHS agencies focusing on the transformation of the mental health system. This group is an outcome of the New Freedom Commission on Mental Health and it is coordinated by SAMHSA.

American Occupational Therapy Association - Marian Scheinholtz discussed AOTA's efforts on assessment and intervention for Alzheimer's disease patients. They are also providing input on the Commission on Accreditation and Rehabilitation Facilities (CARF) proposed standards on dementia care. A public review period will begin at the end of February.

Center for Mental Health Services - Paul Wohlford distributed the new document, Mentally Healthy Aging: A Report on Overcoming Stigma for Older Americans which resulted from a roundtable discussion held a number of years ago. They are also committed to implementation of the President's New Freedom Commission recommendations. CMHS director Kathryn Powers considers her job description to be implementation of those recommendations. Related to this, seven Mental Health Transformation State Incentive Grants were awarded to Connecticut, Maryland, New Mexico, Ohio, Oklahoma, Texas, and Washington. The plan is to expand beyond these seven states. Perhaps a presentation on these new projects can occur at our next meeting.

American Psychological Association - David Powers reported that after the WHCoA, APA put out a press release highlighting the mental health and workforce policy recommendations. A new brochure, Life Plan for the Life Span is currently being printed which offers guidance to psychologists on how to prepare a healthy, productive old age. He also reported that the ABA/APA collaboration on capacity assessment is producing a second product, Determining Capacity of Older Adults in Guardianship Proceedings: A Benchbook for Judges. Diane Elmore announced that she has returned to the APA Public Policy Office to work on aging and other issues. As mentioned earlier, she is looking toward planning a post-WHCoA event on the Hill. She noted that APA has allocated some funds for a post WHCoA event to coincide with the release of the final report in June. She asked that NCMHA members interested in becoming involved to contact her at delmore@apa.org.

American Association of Geriatric Psychiatry - Stephanie Reed discussed their recent collaborative efforts in developing a website for practitioners and consumers related to Medicare Part D. This website was created by a partnership comprised of AAGP and the American Association of Community Psychiatrists, the American Psychiatric Association, the National Alliance on Mental Illness, the National Association of State Mental Health Program Directors, the National Council for Community Behavioral Healthcare, the National Mental Health Association, and Treatment Effectiveness Now. The website is: (www.mentalhealthpartd.org). AAGP is also working with the American Geriatrics Society to restore funding for geriatric health training programs.

Suicide Prevention Action Network - Jerry Reed noted that the highest rate of suicide is within the older adult population, and that approximately 75% of the older adults who commit suicide have seen their primary care physician in the six months preceding the suicide. One of their policy priorities is to gain legislation and funding for the "senior side" of suicide such a Garrett Smith Act (for young adults) for older adults.

American Association of Marriage and Family Therapists - Melissa Stamps reported that they were happy to have participated in WHCoA and for the attention paid to family-based interventions. Lincoln Stanley noted that their current legislative agenda is focused on attaining Medicare independent provider status and mental health parity.

National Association of State Units on Aging - Sara Aravanis reported on an Adult Protective Services/State Aging meeting she attended. She described the burden and impact of Medicare Part D at the local level, in particular on the Area Agencies on Aging, and is proud of their efforts in coming through. Part D is having a negative impact on the usual AAA activities. Even AAA directors are taking calls from consumers and offering assistance in navigating Part D. Adding operators to national Medicare call lines is not solving the problems. There is a need for more local help to do the needed one-on-one counseling. They are very happy with the WHCoA #1 resolution - to reauthorize the Older Americans Act within six months. It is on the top of their agenda and they have developed a related fact sheet. They were also pleased with the community based care vs. nursing home focus of the WHCoA.. NASUA also runs the National Center on Elder Abuse. They have a new director, Diane Justice who previously was with AOA and Congressional Research Service. They are discussing what else they can do in a focused way in terms of mental health.

Center for Medicaid & Medicare Services - Peggy Clark reported that although she works on Medicaid/Managed Care issues and not Part D, she knows that folks are working day and night to resolve its problems. She described the Real Choice Systems Grants which in 2004 added a category for mental health grants. Annually, they bring grantees together to discuss their progress. They are currently in the planning stages of the 2006 Conference. They estimate 800 participants. There will be eight cross cutting sessions with one session on mental health services and supports (e.g. supportive housing, transfer from institution to home). She suggested that in the future that the Coalition put together a session for CMS. In addition, it was suggested that perhaps the Real Choice Grants be a topic of discussion at a future NCMHA meeting.

Older Women's League - Laurie Young noted that OWL is moving to Arlington, VA. The new address is 3300 N. Fairfax Drive, Suite 218, 22201. Their telephone number is (703) 812-7990.

At large member, Bob Rawlings described his involvement as a board member of the Oklahoma State Unit on Aging and the Department of Mental Health. He just became a State Health Insurance Plan (SHIP) Medicare Part D Counselor. He also works as a consultant to a state and local mental health and aging coalitions, most recently in Iowa. He noted that coalitions with partnerships with their State Agencies on Aging and Geriatric Education Centers are the most successful. The Medicare Rights Center's Your Guide Through the Medicare Maze was distributed. It was noted that the Medicare Rights Center wants to hear about problems with the Medicare Part D benefit. Stories can be submitted to www.medicarerights.org/partdstories.html.

Community Integration Report

Willard Mays distributed the new SAMHSA publication, "Community Integration for Older Adults with Mental Illnesses: Overcoming Barriers and Seizing Opportunities". It was noted that this is third in a series of publications focusing on community integration of individuals with mental disorders. The first focused on children, and the second on adults. It was noted that as states developed responses to the Olmstead decision, it was believed that it was very important that their mental health issues were addressed. To facilitate this SAMHSA contracted with the Advocates for Human Potential (AHP) to develop mechanisms to assure that mental health was at table. A National Coalition on Community-Based Care Under Olmstead was formed and NCMHA was appointed to membership. Through the contract the three papers were developed and each state mental health agency was offered a $20,000 annual grant to facilitate mental health involvement in state Olmstead planning. Some states formed coalitions with the funding, others hired a part-time staff person to foster mental health efforts. This publication will support these and other efforts. The Coalition will include a session on Olmstead as part of the Coalition Building track at the ASA/NCOA Conference in Anaheim.

NCMHA Affiliate Agreement

At earlier meetings, it was discussed how it would be beneficial to formalize the relationship between NCMHA and state and local coalitions. It was noted that our success at the WHCoA was partly attributable to getting the word out via our linkages with state and local groups. The coalitions are a powerful network that is not being fully utilized or supported. It is important that NCMHA receives grassroots input from across the country, and that communications from the national level be shared at the state and local level. In May 2005, an NCMHA Executive Committee slot was created for a representative of state and local coalitions. To further solicit participation of these coalitions, a standing committee was formed to focus on coalition building, nurturing, coordination, increased communication, and other issues related to state and local coalitions. At this meeting, Bob Rawlings and Willard Mays circulated a draft affiliation agreement. The NCMHA members present approved the agreement in concept. It was decided to distribute the document via e-mail to the entire NCMHA membership for comments/edits. Comments should be submitted no later than January 31st.

Adjournment

The meeting was adjourned at 12:30 pm. The next NCMHA meeting will be held on Friday, May 19th from 9:30 am -12:30 pm at the American Psychological Association in the 6th floor boardroom.