Mental health system at crossroads as session approaches

Advocates see chance for reform, but KDADS leadership in flux and state budget tight

By Andy Marso, December 21, 2015

A recent meeting of KMHC is shown.

The Kansas Mental Health Coalition recently discussed its top issues
for the upcoming Kansas legislative session. From left are coalition
lobbyist Amy Campbell; Susan Crain Lewis, president and CEO of
Mental Health America of the Heartland in Kansas City, Kan.; Eric
Harkness, coalition secretary; and Rick Cagan, executive director of the
National Alliance on Mental Illness Kansas office. (Photo by Andy Marso)

Editor’s note: This is one in a series of articles by the KHI News Service previewing health-related issues that the Kansas Legislature will face in its upcoming 2016 session.

Kansas mental health advocates will enter the 2016 session at a critical juncture, 25 years into the state’s effort to move away from institutionalization to community-based care.

Crowded prisons and state hospitals have helped create momentum for statewide reforms to fill the gaps in that system — to provide a “continuum of care” to keep Kansans with persistent mental illness out of crisis.

But the state’s ongoing budget problems limit the Legislature’s ability to increase funding for the state hospitals or community-based mental health resources. And last year’s long, bitter tax fight has sapped some of the energy for any major legislative debate before the 2016 elections.

“Every forum I have been to with legislators, they are dreading January,” Amy Campbell, a lobbyist for the Kansas Mental Health Coalition, told the coalition last week. “They don’t want to come back. They want a short session. They want to go home and run for office with relatively few controversial votes on their record.”

At the same time, the Cabinet agency that handles many mental health issues — the Kansas Department for Aging and Disability Services — is in flux.

KDADS Secretary Kari Bruffett has been working for months with a committee of experts on continuum of care reform.

But Bruffett will leave the agency at the end of 2015 to take a job as policy director for the Kansas Health Institute, the parent organization of the editorially independent KHI News Service.

Her interim replacement, Tim Keck, is a former Kansas Department of Health and Environment attorney who is little-known in the mental health community.

As mental health advocates discuss continuum of care, they remain wary of a legislative change that allowed state regulation of antipsychotic medications prescribed to Medicaid recipients. They also are in disagreement over a proposal allowing treatment centers to hold people involuntarily for up to 72 hours.

Meanwhile, Osawatomie State Hospital remains unable to take more patients as federally mandated renovations continue. Last week federal officials announced they were pulling Medicare reimbursements for Osawatomie patients admitted after Monday because conditions at the facility don’t comply with their regulations.

All of which adds up to an uncertain session with a lot on the line.

Continuum of care

The Adult Continuum of Care Committee met five times in May and June before issuing a 42-page report in July to Bruffett.

The report’s recommendations included expanding Medicaid eligibility, restoring bed capacity at the Osawatomie hospital, lobbying for changes to federal regulations, limiting Medicaid payments for mental health services provided in large inpatient institutions and creating more crisis intervention services throughout the state.

Rather than disbanding following the report’s release, the continuum of care committee was made part of the Governor’s Behavioral Health Planning Council to continue working with the administration on implementation.

Susan Crain Lewis, president and CEO of Mental Health America of the Heartland in Kansas City, Kan., said Bruffett had been a good partner in that effort and the timing of her departure was unfortunate.

“I’m deeply hopeful that both the interim secretary and whoever ends up in that position will see the wisdom of Secretary Bruffett and of the individuals in that group and really move forward with that,” Lewis said.

KDADS spokeswoman Angela de Rocha said via email that the agency remains committed to continuum of care reform.

“The secretary’s departure does not mean that we are dropping this initiative,” de Rocha said.

Implementing the recommendations could be a challenge if it requires any additional state funding, though.

Campbell said she has been told “a couple of times” that the KDADS budget won’t be reduced, but she advised the mental health coalition members to watch individual program budgets carefully.

“Budget is going to again be a key issue for us,” Campbell said. “For us to be able to identify where money is being moved from and to, and how that is going to affect the programs that we care about is going to be a full-time job this session.”

Campbell said she believes legislative leaders know that the mental health system is “at a crisis point,” but their first priority is balancing the larger state budget.

Ted Jester, KDADS assistant director of mental health services, told the coalition that the agency is considering asking legislators to approve a mental health checkoff on income tax forms to fund “mini-grants that could grow over time” for community-based behavioral health programs.

Details of the checkoff proposal are not yet available, but Lewis said such a measure wouldn’t help financially until 2017 at the earliest, given the legislative schedule and the income tax filing schedule.

She and other advocates say the need to beef up community-based services is more immediate, especially given the limited capacity at Osawatomie, which is one of two state-run inpatient facilities for Kansans with severe and persistent mental illness.

The hospital is down 60 of its 206 beds during renovations, but de Rocha said construction is going well and some existing patients are being shifted into a new unit that could soon restore half the missing capacity. “At some point we'll be able to start taking new patients,” de Rocha said. “We are not there yet.”

Involuntary hold proposal

In the absence of better options for crisis management, a coalition of mental health professionals, police and court officials from four high-population counties in northeast Kansas have drafted a proposal to allow community-based treatment facilities to hold people who are having a mental health crisis against their will for up to 72 hours.

The proposal has divided the mental health community. Some argue that it’s a better alternative to the status quo, in which a mental health crisis can land a person in an emergency room or jail — sometimes for more than 72 hours — as they wait for a bed at a state hospital or other inpatient facility.

Other mental health advocates have serious reservations about the proposal’s threat to civil liberties. “I don’t want people in jail,” Lewis said. “But at least you have due process while you’re in there.”

Lewis said the draft of the proposal she has seen is too broad in terms of when and for whom the 72-hour hold can be used. It also doesn’t provide any liability protection for police officers or mental health workers, which she said gives them an incentive to invoke the involuntary hold whenever possible and then keep the person detained for the full 72 hours.

“I would love to see something that works,” Lewis said. “This one’s got some real problems.”   

Lewis and Rick Cagan, executive director of the National Alliance on Mental Illness Kansas office, both said they think some form of the proposal could pop up during the legislative session.

Cagan’s group is still evaluating it, but he said in September that some of his board members are supportive. NAMI’s Texas branch is bullish on a similar program in that state because of its potential to decriminalize mental illness.

Still, Cagan said in a recent interview that even if the involuntary hold measure works as planned, it wouldn’t close the holes in the mental health system.

“This is not a panacea, this is more on the crisis end of the system,” Cagan said. “The desire would be (that) we’re able to focus on building up less intensive, less restrictive aspects of the system.”

The mental health coalition advocates agreed it would be better if Kansans were getting the preventative mental health care they needed to manage their symptoms, so that discussion of holding them against their will was not necessary.

But Kyle Kessler, executive director of the Association of Community Mental Health Centers of Kansas, said that’s not the case. The gap is especially large for Kansans with mental health problems that have exceeded routine maintenance but don’t yet require inpatient hospitalization.

“We don’t have nearly the amount of quick and efficient connectivity to intensive outpatient services that we did before,” Kessler said. “So this is kind of coming about. This is tugging one end and expecting the other not to move.”

Mental health medication committee

Mental health advocates also are closely watching the effects of a law passed last session that allows the state to regulate mental health drugs within Medicaid by using tools like prior authorization requirements.

Medicaid in Kansas is now administered by three private insurance companies through a managed care program called KanCare. The advocates were concerned about how the for-profit companies might use prior authorizations.

But they backed off their opposition after KDHE officials changed the proposal to add an advisory committee of medical professionals to vet new regulations before they go to KDHE’s Drug Utilization Review Board, which writes the actual guidelines.

Now that the Mental Health Medication Advisory Committee has begun meeting, the advocates are again concerned about some of what they’re seeing.

“I think the jury’s still out,” Cagan said.

Lewis and others have said that the committee’s posted agendas are too vague. The committee requires those who wish to provide public comments to sign up ahead of time but doesn’t list which drugs will be discussed.

“It has been pointed out that we are not being given the information we need to provide cogent public comment,” Lewis said.

KDHE spokeswoman Sara Belfry said via email that the agendas list common drug classes like “antipsychotics” and “SNRIs,” and that getting more specific is not necessary.

“We don’t list specific drugs because the subjects listed on the agenda are self-explanatory,” Belfry said.

But Lewis said that’s not what mental health advocates agreed to last session, and if changes aren’t made the advocates might seek help from legislators.  

She had similar concerns about the role of the MCO representatives at the meetings. The MCOs have no seats on the actual committee, but Lewis said that from one meeting to the next they’ve gradually moved from the outer ring of seats with the other observers to seats at the inner tables alongside committee members.  

“This is not what people signed up for,” Lewis said. “There’s clearly the evidence of excessive influence.”

The nonprofit KHI News Service is an editorially independent initiative of the Kansas Health Institute and a partner in the Heartland Health Monitor reporting collaboration. All stories and photos may be republished at no cost with proper attribution and a link back to KHI.org when a story is reposted online.

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