xxAACP Newsletter, Volume 12,
Number 3, Summer 1998
Regional Reports
HAWAII
Back in 1996 the Hawaii Psychiatric Medical Association (HPMA) set out four legislative goals:
- Attain Parity for Mental Illness
- Improve the Hawaii State Hospital Situation, Regarding Involuntary Treatment
- Curb Managed Care
- Educate Legislators on the Dangers of Psychologists' Prescribing
It has been a tough two years with good results having been attained in each of these four areas. A parity bill has been signed. This bill increases outpatient visits from 12 per year to 24 and goes into effect July 1, 1998. Another bill, providing for involuntary treatment to coincide with involuntary committment, has not yet been signed. Governor Cayetano has until July 21, 1998 to sign bills passed by this year's legislature. The Managed Care issue is currently being approached from several different angles. First, an alliance with the Hawaii Coalition for Health has been formed; second, in ongoing working discussions with HPMA, HMSA and Biodyne; and finally, through proposing our own legislation. HPMA member, Greg Yuen's wife, Keala Yuen, had legislation introduced requesting the Hawaii State Auditor to conduct a financial audit of Aloha Care. Through the Resolution was killed in its second committee hearing, it has effectively put managed care companies on notice that they will be held accountable. Finally, HPMA was effective in educating the legislators as to the dangers of the psychologists' move to attain prescribing rights. However the issue is still alive nationally and for Hawaii, regardless of our success in keeping this bill from even being heard this past legislative session and in killing the resolution. The issue will probably come up again next year.
Nationally, there are two issues of importance occurring. One are concerns over the recent Department of Veterans Affairs proposal to "update" regulations governing prescribing medications to the effect that "health care professionals" within the VA system -- other than physicians -- would be officially recognized by the VA as "capable" of prescribing medications and conducting medication reviews." The term "health care professionals" is sweeping and ill-advised. It had been going forward as exempt from any public hearing, notice and/or comment. Dr. Jeff Akaka and other HPMA members wrote Senator Daniel Akaka calling attention to the problem. Senator Akaka, in turn, has requested the VA to review this language and halt going further with its "update" of regulations governing prescribing of medications until it can be clarified. Dr. Akaka has also asked others to write similar letters in order to stress the importance of the issue.
Margaret Copi, MD
VERMONT
Vermont has legitimately assumed a reputation for providing state of the art public sector treatment of its severely and persistently mentally ill (SPMI) population. If only this standard of concern extended to the psychiatrists making the system go. The past three years have witnessed considerable change in Vermont Public Sector Psychiatry. The Governor's Office has issued a directive to further downsize the capacity of the State Hospital from 60 to 45 adult beds (state population of about 6,000). The Division of Mental Health (DMH) has released funding to 1) commit acutely psychotic or dangerous or non-compliant patients to community hospitals for 72 hour holds, with the possibllity of longer stays; 2) establish crisis residence and group homes; 3) expand services offered by emergency services to include mobile outreach and brief intensive treatment; 4) create continuous treatment teams for the SPMI population according to the PACT model; 5) set up "wraparound" service plans for state hospital discharges, requiring intensive coordination of the above programs in addition to case management and usual care. The LOCUS instrument is being used to determine the highest level of severity that various state hospital alternatives are capable of handling; the Risk of Harm Dimension has been used to distinguish between violence to self vs others and to determine placement in a community or state facility.
While considerable progress has been made in establishing alternatives to state hospital care, the state hospital census has not dropped below 50. One legitimate objection to the State's policy is that current plans will shut down one of the three psychiatric units at the State Hospital, thus increasing the census of each remaining unit, one of which is reserved for forensic patients. An alternative supported by the psychiatric community would be to reduce the census while retaining the advantgages of preserving three treatment units. This would allow the system to expand more readily to absorb an admission "overflow" and retain a high staff/patient ratio. A competing plan is favored by the Governor: the third unit would be used for housing female corrections inmates.
The nation's most ambitious Parity bill was passed in Vermont this yeawr requiring equal insurance coverage for persons with emotional and substance abuse disorders. Costs will be contained through managed care, now thought to be about 95% "penetrated" in the state. A forced medication law was also passed, requiring non-compliant patients with a history of involuntary treatment to comply with pharmacotherapy to contain dangerousness or to avoid imminent deterioration. Recognition of the important role of consumers and advocacy groups is exemplified by the State's official adoptioon of Recovery principles for the SPMI population and a new law requiring 51% membership of consumers and advocates on CMHC Boards. Vermont has obtained a HCFA Waiver to set up managed Medicaid for the working poor, persons who were previously denied Medicaid or commercial health insurance. Fee-for-service payments for these cases is considerably less than for standard Medicaid. (Web Editor's Note, June 23, 2002: The HCFA is now called the "Centers for Medicare & Medicaid Services" - CMS.)
Vermont has experienced an exodus of 50% of CMHC psychiatrists in the past year which may be due to a number of factors: 1) poor salary and benefits, 2) lack of representation in political processes and policy development, 3) lack of job descriptions and 4) minimal supervisory and administrative responsiblitites. Efforts are currently underway to develop job descriptions which will remedy some of these concerns as the state moves toward Medicaid Managed Care.
Stephan A. Cole, MD
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