The President's New Freedom Commission on Mental Health met on January 7-9, 2003 at the Crystal Gateway Marriott, 1700 Jefferson Davis Highway in Arlington, Virginia. In accordance with the provisions of Public Law 92-463, the meeting was open to the public on January 7th from 4:30 p.m. to 6:00, on January 8th from 1:30 p.m. to 5:30 p.m. and on January 9th from 8:30 a.m. to noon, when the meeting adjourned.
Michael F. Hogan, Chair
Staff members present:
Claire Heffernan, Executive Director
Presenters and consultants who attended portions of the meeting included:
Robert M. Kolodner, M.D., Acting Deputy Chief Information Officer
for Health, Office of Information, Veterans Health Administration,
January 7, 2003
Panel Presentation: Reducing Fragmentation and Improving Quality
in Mental Health Services: The Role of Information Technology
Chair Hogan opened the meeting at 4:30 p.m. and set the stage for the panel presentation on information technology. He cited the emerging role of information technology as a tool for integrating information across settings to improve quality of care, reduce fragmentation, and enhance accountability.
In her introduction of the panel, Commissioner Murphy underscored the themes of information and health technology, ranging from tele-medicine to computerized records, as methods to increase the system's ability to provide coordinated and integrated care across settings and disciplines.
Dr. Robert Kolodner, of the Veterans Health Administration, gave a brief overview of the development of VA's automation efforts. The current system, VistA, is a nationally integrated inpatient and outpatient information system, which also works in other care settings (e.g., nursing homes). VistA's clinical applications include mental health, medicine, surgery, nursing, and dental.
In 1996 the VA launched "point and click" software called CPRS. CPRS allows health care professionals to order medication on line, input progress notes, initiate consultation requests, and pull up pharmacy or lab information. Dr. Kolodner gave a live demonstration of the CPRS system used by every VA Medical Center, and highlighted the ease of accessing and interacting with the "patient" record.
Dr. Canon gave further explanation of the mental health software used by the VA. While all medical professionals use a common electronic record, mental health clinicians have some unique needs, particularly around assessment tools. Similar to CPRS, the Mental Health Assistant allows many psychological tests to be administered online and includes frequently used tests for substance abuse assessment.
A key system component is the interactive clinical reminders, which are based upon evidence-based clinical practice guidelines and often link professionals to the next steps in the practice guidelines. Dr. Kolodner also discussed two performance measures implemented by VA: (1) all primary care patients who do not have a diagnosis of depression or are not in treatment should be screened once a year for depression; and (2) patients who screen positively for depression should have a follow-up evaluation within 6 weeks to determine if they do have depression. Clinical reminders prompt clinicians at the point of care and support both clinical practice guidelines and performance measures. Other national clinical reminders include screening for involuntary movement and sexual trauma. Local facilities also have the option of customizing clinical reminders to fit their specific needs (e.g., alcohol dependence, PTSD).
Dr. Kolodner described the future generation of information systems as moving from facility-centered data to person-centered data. Systems are in the process of standardizing core data so that data collection and interpretation is meaningful across sites and across the lifespan. Dr. Kolodner said that the VA expects to achieve a national repository of data by 2005 and is also working with private companies like Kaiser-Permanente to move the automated system out of VA and into other systems. Currently, moving data across health information systems is very difficult given the hundreds of existing systems and lack of standardization.
Dr. Kizer, who is currently CEO of the National Forum for Healthcare Quality Measurement and Reporting and was formerly head of the VA's technology initiatives, was the next presenter. He stated that building a comprehensive information technology system does not depend solely upon software and hardware, but also on the development of performance measures and clinical prompts that promote quality care. Dr. Kizer described the National Forum as a body that aims to standardize performance measures, develop an overall national strategy for quality measurement and reporting, and otherwise lead quality improvement efforts. Since February 2000, the National Forum has brought together governmental agencies and the private sector to serve as a voluntary, consensus standard-setting body in the area of healthcare quality measurement and reporting.
The Forum has promulgated national consensus standards for diabetes, and cancer, and is working on safe practices to minimize likelihood of medical errors and performance measures for acute care hospitals. Dr. Kizer noted that, while the consensus standards are voluntary, they do have some legal standing as federal agencies are obligated to use consensus standards when they exist or justify why they do not if they are using different standards.
Dr. Kizer commented that ultimately, information technology is a
critical enabler for quality performance. The Forum has discussed
developing standardized performance measures for behavioral health
with the Substance Abuse and Mental Health Services Administration
(SAMHSA). Regrettably, fields often develop multiple systems which
results in different and competing sets of measures and standards.
Without standardization, health care systems cannot realize the benefit
of information technology.
January 8, 2003
At 3:25 p.m. Chair Hogan opened the work session and the full Commission's discussion about policy options presented by two Subcommittees.
Report of the Subcommittee on Older Adults
Commissioner Godbole and Commissioner Murphy, co-chairs of the Subcommittee on Older Adults, provided an overview of the topic and the Subcommittee's recommended policy options. They expressed appreciation to Stephen Bartels, M.D., the consultant to the Subcommittee, other Subcommittee members, and those individuals who had testified on the mental health needs of older adults before the Commission at its October meeting.
After Dr. Godbole gave an overview of the emerging national geriatric health care crisis, Dr. Murphy outlined the policy options put forth by the Subcommittee. The overarching policy option was the development of a National Leadership Partnership to Improve the Mental Health Service Delivery System for Older Adults. The Chairs described it as a national partnership among the federal government, other public and private sector organizations, consumers, and families, with HHS as the lead agency.
In addition, the Subcommittee identified three priorities for the mental health of older adults: (1) improve access and continuity of care; (2) improve quality of care, and (3) develop workforce and caregiver capacity. For each of the priorities, the Subcommittee suggested several policy options.
Policy options which would improve access and continuity of care
To improve quality, the Subcommittee suggested:
Finally, in order to develop workforce and caregiver capacity, the
At the conclusion of the oral report, Commissioners provided comments and questions.
Commissioner Lerner-Wren questioned the scope of the definition of older Americans with mental illnesses, including the target age and whether those with brain and other neurological impairments were included. Dr. Godbole responded that, to do this topic justice, the Subcommittee felt that the definition needed to be broad for its discussions.
Commissioner Adams inquired about discussion of older adults who have substance abuse problems. Commissioner Godbole commented that they had discussed the issues of undetected misuse of alcohol and prescription medications, which will be reflected in the final issue paper. Commissioner Adams also recommended that the issues of caregiver support and workforce development be separated in the policy section. Commissioner Murphy responded that the Subcommittee had grouped them together deliberately, believing, both caregiver and professionals were equally important in that discussion.
Commissioner Stanton asked how the policy option of integrating payment mechanisms linked with the policy option promoting evidence-based practices. Commissioner Godbole suggested that the Subcommittee hoped financing would shift from being institutional-based to the evidence-supported collaborative care model, where a mental health worker works in proximity to a primary care physician.
Chair Hogan inquired about other recommended models for older persons in other settings beyond the collaborative care model. Dr. Godbole responded that home-based services, case management, outreach services also were viewed as important models for this population.
Given the importance of primary care settings for this population, Commissioner Mayberg wondered what the nexus was between the report by the Subcommittee on Older Adults and the Subcommittee on Mental Health Interface with General Medicine. Commissioner Murphy commented that this Subcommittee discussed the issue at length and recognized the need to provide increased geriatric training to mental health professionals and health care providers in both geriatric settings and mental health settings. Commissioner Godbole mentioned that the final issue paper also will include several comprehensive multi-site studies examining the service delivery models in primary care. Commissioner Lerner Wren added that there are data that indicate people who commit suicide have seen their primary care provider in the weeks prior to their death. The Commissioners agreed that there is a critical need for mental health collaboration with primary care providers.
Commissioner Fisher inquired whether the Subcommittee addressed the housing needs of older adults, particularly given the problems of isolation and need for peer support among older adults. Commissioner Murphy commented that most of the group's discussion about housing focused on the least restrictive environment.
Commissioner Stanton suggested that the Commission consider informing
the current debate about Medicare reform by promoting that the underlying
principles of mental health service need to be addressed in the debate
rather than recommending specific policy changes. Similarly, the Commission
may choose to address the parity issue by expressing principles it
can support within the President's charge.
Commissioner Mayberg expressed concern about who is included in the "older adults" population. Given the varying benefit eligibility based on diagnosis, if his State were to expand its definition to include persons with dementia and Alzheimer's, the system's costs would double. He cited the real quandary of defining the eligible population. Commissioner Murphy responded to his concern that the Subcommittee debated this issue of defining populations at length. Her belief is that the field needs to have a care system that focuses around the person, rather than rigidly defined diagnostic definitions. Chair Hogan agreed it is more helpful for the Commission to frame this discussion broadly around principles.
Commissioner Townsend moved to accept the report by the Subcommittees on Older Adults, which Commissioner Mayberg seconded. The Commission voted unanimously to accept the report
Copy of the outline for the Draft Report of the Subcommittee on Older Adults is available on the web site, www.MentalHealthCommission.gov.
Report by the Subcommittee on Mental Health Interface with General Medicine
Commissioner Harbin, Chair of the Subcommittee on Mental Health Interface with General Medicine, was joined by consultant, Jurgen Unutzer, M.D. In his overview of interface between mental health and general medicine issues, Dr. Unutzer outlined the two primary problems: (1) while people with mental disorders commonly are seen in primary care settings, many people are not diagnosed, not properly diagnosed, do not receive the appropriate treatment, or do not receive treatment follow-through, and (2) individuals with severe mental illness usually do not receive care in primary health care settings. The consequences of this are
problematic because treatable disorders are not diagnosed appropriately, or not cared for effectively, particularly for more vulnerable members of society (e.g., children, older adults, and minorities).
Dr. Unutzer also addressed research findings on strategies to improve the interface. While screening in primary care settings, particularly for depression is good, screening alone does not necessarily produce better treatment or outcomes. Even when referrals are provided, there are linkage problems between mental health and primary care providers. And, while guidelines for treating depression in primary care have been developed, availability of knowledge alone does not improve mental health care. There has been more promising research on the collaborative care model, where primary care professionals provide the majority of care but a mental health provider is located close by, ideally in the primary care setting.
Finally, Dr. Unutzer discussed what was needed to enhance the interface between mental health and general medicine: education of consumers and providers; effective and efficient models for screening, adequate diagnosis and tracking of persons in treatment; information and communication systems to help with this tracking; evidence-based treatment protocols that use principles of collaborative care; well-established performance criteria that address the mental health/primary care interface; training that encourages mental health and primary care providers to work together and mechanisms to pay for collaborative care.
Commissioner Harbin outlined the policy options developed by the Subcommittee:
Commissioner Knight-Richardson suggested that since most psychiatric prescriptions are written by non-mental health professionals, the Subcommittee should address that topic specifically. He commented that the prevalence of general physicians who are treating people with mental disorders without mental health training may have a disproportionate impact on minority populations, including migrant and Native American populations.
Commissioner Speck underscored the importance of the primary/mental health care interface by referencing a recently released IOM report that indicated 65-80 percent of people with mental illness present first in primary care settings.
Commissioner Knight-Richardson observed that the stigma associated with mental illness may contribute to health care professionals missing diagnoses of mental disorders. Both patients and providers need to be comfortable discussing mental health concerns.
Commissioner Lerner-Wren confirmed that the interface-related research findings and policy options also included the pediatric population. Commissioner Huang noted it would be helpful to address interface issues along the developmental life span explicitly. Currently, the Subcommittee on Children and Families does not have specific recommendations around this interface.
Commissioner Huang inquired to what extent screening should be incorporated in pediatric offices. Commissioner Harbin responded that effective screening should be used routinely in pediatric offices but needs to be packaged with other services including case management. Screening is necessary but not sufficient. Dr. Unutzer commented that other groups have debated this issue around screening; some have suggested that repeated screening for depression is helpful only if coupled with treatment.
Commissioner Godbole underscored the importance of collaborative care, a flexible model which allows for different methods of collaboration. While the cost-offset research may not be as robust as yet, there are offsets in medical costs and work force productivity.
Commissioner Insel highlighted Dr. Unutzer's comment about the need for educated consumers. He noted that the effort of pharmaceutical companies to reach consumers and create a demand for their product provides an important lesson. The Commission may want to address how to educate and empower individuals about the type of health care services they are seeking/receiving.
Commissioner Fisher stated that consumers are also looking for complementary medicine (e.g., interventions around stress and exercise to affect heart disease). He wondered if the Subcommittee could address the need for expanded professional education and reimbursement issues to encompass the interest in complementary medicine. Commissioner Harbin responded that the Subcommittee had discussed complementary medicine and behavioral interventions for people with chronic medical problems (e.g., psychosocial interventions for people with diabetes). Chair Hogan added that the strategy may be to use a wellness and recovery model which begins with the individual's needs. Chair Hogan suggested that the Subcommittee on Consumer Issues might help move this concept forward in a broad context.
Noting the inclusion of all payers in the policy options, Commissioner Stanton commented that the Commission may look at all financing methods which can support a comprehensive system. Federal agencies such as the Center for Medicaid and Medicare, SAMHSA, NIH, and the Veterans Administration may provide national leadership on this issue and perhaps serve as a repository for evidence-based practices and successful models. Thus, national leadership may entail encouraging all funding agencies to pay for promising models (e.g., collaborative care).
Commissioner Insel cautioned that the science may not be available to back up all claims. For example, while mental illness is a risk factor for cardiovascular diseases, the science has not demonstrated that treating the mental illness will impact the cardiovascular disease.
Commissioner Adams recommended putting information about evidence-based practices into the hands of consumers, families, and their support and advocacy organizations. The field will adopt evidence-based practices more quickly once consumers have the information and can advocate for themselves.
Commissioner Curie suggested that the policy options around mental health and general health interface could have significant impact if implemented. Linkage with primary care also is critical in SAMHSA's efforts to operationalize the science-service cycle.
Commissioner Murphy noted that the VA also supports collaborative
care through financing such models and providing collaborative care
at VA medical centers.
Commissioner Townsend emphasized the need for a public health campaign to create a cultural sense that one should seek out mental health care or support, akin to the campaign that encouraged the wide practice of visiting the dentist every six months.
Commissioner Mayberg moved to accept the Mental Health Interface with General Medicine Subcommittee's Report. The motion was seconded by Commissioner Townsend. The Commission voted unanimously to accept the Subcommittee's report.
Copy of the Outline for the Draft Report of the Subcommittee on Mental
Chair Hogan opened the period for public comment at 4:00 p.m. The Commission heard from the following individuals:
Presentation by Senator Pete Domenici (R-NM)
Commissioner Pasternack introduced Senator Pete Domenici, who was accompanied by his wife, Nancy Domenici. A fellow New Mexican, Commissioner Pasternack described the Domenicis as strong and tireless advocates on behalf of youth and adults with mental illness and their families at both the State and Federal levels.
Senator Domenici called on Commissioners to address the mental health system crisis with "broad, bold, and brave action". He noted that many still do not understand that mental illness is an illness that can be aided with appropriate medication, treatment, and support. Referencing a moving letter he had received from a Navajo woman whose son had schizophrenia and finally improved when he received the appropriate medication, Senator Domenici urged the Commission to advise the President that additional rigorous research is needed to ensure that people with mental illnesses have the best possible medication at the best possible price.
After noting the lack of effective delivery systems cited in the Commission's Interim Report, Senator Domenici suggested that the Commission address the critical insurance issues that impact the availability and delivery of effective treatment. He commented on stigmatizing insurance policies and practices, particularly the disparate insurance coverage for heart-related versus brain-related disorders. Finally, Senator Domenici encouraged the Commission to support parity legislation, such as the bill to be introduced by himself and Senator Kennedy.
At the conclusion of his remarks, Commissioner Lerner-Wren expressed appreciation for Senator Domenici's previous support of legislation that created the Broward County Mental Health Court, over which she presides in Florida. She mentioned that the Court successfully moved 5,000 people with mental illness out of jails to date.
Commissioner Fisher also was grateful to Senator Domenici for his advocacy of additional resources and support for persons with mental illnesses. Senator Domenici noted that multiple Senators have family members and friends who have a mental illness, although only a few have spoken publicly. The Senator stressed the importance of effective advocacy organizations to educate and encourage Congress, as well as the public at-large about these important issues.
Commissioner Pasternack requested Senator Domenici's thoughts about
the eventual implementation stage for the Commission's Final Report.
In addition, Commissioner Godbole asked for input about strategies
to increase resources. Senator Domenici suggested that members of
Congress would be receptive if future legislation were needed to implement
January 9, 2003
Chair Hogan began the work session at 8:40 a.m. and turned it over to Commissioner Speck for a presentation on rural issues and the Subcommittee's report.
Report of the Subcommittee on Rural Issues
Commissioner Speck, chair of the Subcommittee on Rural Issues, introduced Dennis Mohatt, Director of the Mental Health Program, Western Interstate Commission in Higher Education (WICHE), who served as the consultant to the Subcommittee. Stating that twenty-five percent of the U.S. population resides in rural America, Mr. Mohatt addressed the key differences around mental health care for rural Americans: availability, accessibility, and acceptability.
Mr. Mohatt also discussed the failed work force strategy to attract and train professionals to work competently in rural places, as well as the questionable assumption that evidence-based models tested in urban environments work as effectively in rural areas.
He showcased innovative programs and partnerships that worked well for the rural population, including initiatives in Nebraska, Wyoming, Illinois, Wyoming, and Alaska, Colorado, and Michigan. Finally, Mr. Mohatt suggested that critical ingredients to address this pressing issue include creating leadership, treating people close to where they live, and communities "growing" their own professionals by providing higher level training close to home.
Commissioner Speck reviewed the policy options put forth by the Subcommittee. Most importantly, the Subcommittee recommended that:
Additional policy options included:
Commissioner Lerner-Wren requested that the Subcommittee consider including the school system in efforts to enhance coordination between funded telehealth systems and public mental health systems within policy option #8.
Commissioner Harbin posed questions about the rural population, and
the estimates of those who are uninsured and underinsured. In response
to Commissioner Harbin's question about differences between access
to specialty mental health versus physical health specialty providers
in rural areas, Mr. Mohatt
Commissioner Knight-Richardson commented on the huge diversity within rural populations, particularly the Native American population, and the need for culturally sensitive services. Noting his own personal experience with the National Health Services training for residents and important incentive of paying back loans, he suggested that the Subcommittee expand policy option #14 to include physician training as well.
Commissioner Curie agreed that a clear focus on rural mental health issues is needed and suggested that there likely will be structural changes within SAMHSA in response to the Commission's final set of recommendations. Commissioner Hogan added that Commissioners may want to talk with Federal agency leaders about a range of action steps that will respond to the Commission's recommendations, while leaving open the question as to which structural design would best implement action steps.
Commissioner Fisher noted that the National Empowerment Center developed materials on peer support that were more often requested by people in rural areas. He suggested that the Subcommittee's training policy options include people who have recovered from mental illness.
Commissioner Yates commented that while policy options #12 and #14 were aimed at attracting master's level professionals, she was unsure whether they would be any more inclined to remain in a rural area than M.D.s or Ph.D.s. She suggested that mandating that professionals stay for five years (not just one or two years), and focusing on attracting peers, paraprofessionals, and others from within the community into training may be a more promising approach.
Commissioner Adams applauded Commissioner Speck's leadership to make rural issues a priority for the Commission. Commissioner Adams also recommended that the Subcommittee consider schools as a forum for training community members.
Commissioner Lerner-Wren questioned whether there are specific rural concerns around the issue of relinquishing custody to obtain mental health treatment (policy option #10). Based on anecdotal information and the problems of insurance in rural areas, Mr. Mohatt sought out data about the rates of relinquishing custody in rural areas. He found that there were no solid data about parents relinquishing custody in urban or rural areas.
Given that research indicates that people with mental illness are at home for 18 months before first coming into treatment, Alternate Commissioner Fenton suggested that public high school students many need to learn about the symptoms of psychosis, similar to their health education on other issues such as AIDS and substance abuse.
Commissioner Godbole observed that there are highly specialized populations within rural areas, such as those who are elderly and deaf or hearing impaired, who have even greater difficulty accessing care. Even in the Chicago area, there was difficulty finding a child psychiatrist who knows American Sign Language. Thus, the Illinois Department of Mental Health began a telemental health program so that psychiatrists with specialized skills can reach more areas, including rural Illinois.
Commissioner Knight-Richardson suggested that the Subcommittee's paper mention recent HRSA grants for establishing mental health capability in general health clinics and the availability of partnerships with universities to establish satellite training programs.
Finally, Commissioner Harbin noted that given the comprehensiveness of the policy options, it would be helpful for the Subcommittee to prioritize the action steps, particularly those actions which are supported by data and can be implemented quickly.
At the conclusion of the discussion, Commissioner Godbole moved to accept the report offered by the Subcommittee on Rural Issues and Commissioner Huang seconded the motion. Commissioners voted unanimously to accept the Subcommittee's report.
Mr. Mohatt's presentation and the Outline for the Draft Report of the Subcommittee on Rural Issues is available on the web site, www.MentalHealthCommission.gov.
Report of the Subcommittee on Rights and Engagement
Commissioner Fisher, co-chair of the Subcommittee on Rights and Engagement, acknowledged the contributions of consultants Susan Stefan and John Monahan.
He provided an overview of the policy options, noting that they addressed the promotion of legal rights with the mental health care system in three arenas: (1) rights when engaged in treatment in the community; (2) rights to remain engaged in treatment in the community and freedom from unnecessary engagement in institutional treatment; and (3) rights when engaged in institutional treatment.
Commissioner Lerner-Wren clarified some details of the report: (1) people within the criminal justice system fall within the scope of persons who are institutionalized (not just those in hospital settings) and commented that the language needed to include the criminal justice population explicitly; (2) policy option #3 should have SAMHSA as the lead (not DOJ); and (3) policy option #12, within the discussion section of oversight and expansion of PAMII, the language should include the enforcement of PAMII Act as well as CRIPA.
Commissioner Harbin commented on the process of the Rights and Engagement Subcommittee, observing that they engaged in healthy debate. While members were in agreement on the end point for the ideal system- a system where clients were engaged, rights were protected, and there was an absence of coercion, subcommittee members disagreed about how to reach that end point. The report out reflected the middle ground they forged and a list of prioritized options that could improve the system and increase compliance and engagement. He stated that, if the Subcommittee's top priority (policy option #1) was implemented for the most vulnerable population of people with serious mental illness, there would be less need for discussions about coercive treatment.
Commissioner Yates questioned whether the policy options applied only to private institutions. Commissioner Lerner-Wren responded that all of the policy options applied to both public and private sector institutions, as outlined in statute. Chair Hogan echoed this question, wondering whether CRIPA applied to acute care in general hospitals. He also queried whether there are national standards around adequate discharge from acute care. He commented that the legal infrastructure (e.g., CRIPA) is a holdover from an era when legal remedies were aimed solely at state hospitals and no other institutions. He stressed the importance of the first policy option, focusing on ways to engage people in a collaborative and voluntary way. He stated that the law is a relatively blunt instrument and that DOJ is a distant wielder of that law. Leadership and commitment may be other ways to promote alternatives and engagement.
Commissioner Lerner-Wren commented that the Subcommittee focused on legal and human rights and protections given the historical abuses of this population. In addition, she agreed with the importance of promoting leadership and collaboration at the Federal level (e.g., around discharge standards).
Commissioner Fisher added that funding mechanisms are powerful tools for ensuring some rights and encouraging engagement. For example, Massachusetts' Medicaid contracts include bonuses for providers when they meet standards for discharge planning.
Commissioner Carlile commented that Federal homelessness programs require grantees to show their discharge planning strategies and will increase expectations for outcomes.
Commissioner Stanton observed that financial underpinnings are the force that drive practice. He stressed that many opportunities for creativity and flexibility do exist at the federal level - the issue may be more the underutilization of those structures and opportunities.
Chair Hogan agreed that the need is to promote best practices that facilitate utilization of such current funding opportunities.
Commissioner Mayberg stated that while he also agreed with the desired end point, he had significant issues with some of the means suggested by the Subcommittee. He expressed concern that once litigation is begun, the result is confrontational and needed treatment money is spent on defense costs. State systems become risk-adverse and end up putting their energies into CRIPA compliance. The unintended consequence is diminished community services. In his involvement with this type of litigation, Commissioner Mayberg has observed that systems end up putting more money into institutions and not into community services. There is a paradox in the policy options which initially promote mediation and then policy options #8, 9, 10 and 12 which he believes advocate litigation. He sited the Olmstead waiting list as the "epitome of a Trojan Horse" and said that as soon as States have a waiting list, they will find themselves in court for non-compliance. Commissioner Mayberg concluded that he could not support the paper as written.
Commissioner Lerner-Wren clarified that the policy options do not advocate litigation, but they do advocate the protection of human rights. She stated that one cannot talk about this particular topic without addressing the topic of human rights, and that "it should be threatening!"
Commissioner Yates requested that the Subcommittee explicitly include private sector facilities within policy option #1, particularly given the importance of flexible funding mechanism. She gave the example that patients in crisis could be kept from going to the hospital if there were less rigid funding rules (e.g., third party payers' prohibition of different providers seeing the person on the same day).
Chair Hogan articulated there seemed to be group agreement with the intent of the first major policy option, but suggested it might be framed more broadly to promote treatment or support alternatives that engage people into care.
Commissioner Harbin commented that the first policy option was intended to serve as a call for expansion of community outreach programs aimed at high-risk individuals. However, given the brief format of the Subcommittee's report to the full Commission, the policy option was abbreviated. In the final subcommittee report, this policy option includes all types of outreach that have been supported by research, including outreach to private facilities.
Commissioner Curie observed that it was good to have this debate and disagreement within the full Commission, as it represents the differing views on this issue. He also requested that policy option #3 address the discrimination against people with addictive disorders and/or psychiatric disorders in treatment programs.
Commissioner Stanton suggested that policy option #8 also include HHS Office of Civil Rights, which currently has an active role in training, mediation, hearing complaints, and other activities. This ultimately forestalls litigation. He suggested that the Subcommittees review The Office of Civil Rights' Report to the President on Alternatives to Community Living (May 2002), which includes specific recommendations around avoiding litigation. The Subcommittee may want to consider using this Report as guidance, particularly in tone and language.
Chair Hogan urged that the Subcommittee focus on policy options that promote leadership instead of endorsing punishment. Perhaps the Subcommittee could build upon proactive leadership activities within Federal agencies and engage in a SAMHSA-facilitated partnership with those Federal agencies. Subcommittee members indicated that they thought such a discussion with knowledgeable people in the Administration would be appropriate.
Commissioner Lerner-Wren reiterated her belief that the Subcommittee should focus on the protection of existing civil rights, in addition to the full range of alternative activities.
Given the Commissioners' comments, Commissioner Harbin suggested
that the Subcommittee may want to word its policy options differently
so as to not appear to promote litigation. Commissioner Fisher pointed
out that the current report reflected a compromise within the Subcommittee
and that consumers would have
Commissioner Godbole agreed that fear of litigation can cause institutions to enter risk management mode; however, protection of rights must be a floor that is maintained. He suggested that the policy options needed a bit more balance to emphasize collaboration and education, with litigation as the last resort.
Commissioner Adams requested that the Subcommittee clearly include consumers and parents of youth consumers in all of its policy options. She strongly endorsed policy option #1 and the insistence on community-based supports. She also highlighted the issue of parents having to relinquish custody of their children to obtain services, which the Subcommittee addressed in their summary. Commissioner Adams agreed with Commissioner Lerner-Wren's comment about the criminalization of people with mental health needs, and extended that characterization to youth who are in jails. She requested that the policy option dealing with P&A's responsibilities include helping children remain in their communities, as some State P&A's do not encourage family cohesion. In addition, she asked the Subcommittee to broaden the discussion of seclusion and restraint to include public schools in the dialogue. Finally, Commissioner Adams returned to the request that the Subcommittee address the issue of children being sent out of state for services (perhaps in policy option #1).
Chair Hogan asked Subcommittee members and the full Commission if there was any objection to the Subcommittee including the sentiments and points expressed by Commissioner Adams. There were no objections.
In an effort to bring the discussion to closure, Chair Hogan suggested an approach whereby Commissioners voted on individual policy options, due to some disagreement by some Commissioners on some policy options.
Commissioner Lerner-Wren questioned the procedure as it was not consistent with the procedures used for other Subcommittee reports.
Commissioner Fisher recommended that the Subcommittee rework its report and not vote on individual options. Commissioner Harbin concurred, suggesting it would be preferable to have a slate of options that were more acceptable. The goal should be to reach consensus, if possible.
Chair Hogan withdrew his idea of voting on individual policy options.
Commissioner Huang referenced the Commission's mandate to look at
disparities and asked if the Subcommittee discussed language access
and civil rights for people who are not English-speaking. Commissioner
Fisher responded that the group did not address those issues, but
should, and would welcome
Commissioner Townsend spoke about the reality of the implementation of the Americans with Disabilities Act (ADA), which is a fairly new statute. In order to fully define what the ADA means, litigation will inevitably occur over the next few decades. While individuals need access to the legal system to protect their rights, another reality is that plaintiff lawyers seek publicity and monetary gain, which is a negative consequence of the jurisprudence system. He concluded that while the legal system is designed to protect individuals, an unfortunate result is that some lawsuits take resources away from the goal of serving these individuals.
Commissioner Curie commented that litigation is a tool that has been used to "right the wrongs". It would be most helpful for the Commission to shine light on other pathways to assure rights and engagement and move discussion from waiting lists to unmet needs. He also commented that the Commission could accept the Subcommittee's current report and have the disagreeing view points reflected in the record. Perhaps the Subcommittee could involve more Commissioners in future discussions, as well.
Commissioner Lerner-Wren commented that the Subcommittee welcomes input from all Commissioners.
Commissioner Speck commented that some lawsuits bring important treatment issues to the forefront, while others are only about monetary gain and are regretful.
Commissioner Speck moved to accept the Subcommittee's presentation, allow time for a broader Subcommittee discussion involving more Commissioners at the next meeting, and request that another report be brought back to the full Commission that can be accepted, perhaps, with consensus.
Commissioner Godbole seconded the motion.
During the discussion, Commissioner Curie inquired about the motion and asked whether the motion included a need to reach eventual consensus on this report, as that may not be possible with this or other Subcommittee reports.
Commissioner Speck clarified that she had moved that the Commission accept the presentation pending a further discussion and vote on acceptance of a revised report.
Commissioner Godbole proposed an amendment that the Subcommittee reconvene, incorporate the Commissioners' feedback, reframe the policy options (e.g., language, tone and emphasis), and bring a revised report to full Commission at next month's meeting for acceptance.
Commissioner Mayberg seconded the amendment.
During the discussion of the amendment, Commissioner Murphy pointed out the current language locks the Commission into a definite time frame (i.e., next month's meeting).
Commissioner Godbole changed the wording of his amendment so that the Subcommittee would report back to the Commission at a "future meeting", to which Commissioner Mayberg, the person who seconded the amendment, agreed.
Commissioner Speck accepted the amendment to her original motion, as did Commissioner Godbole, who had seconded the original motion.
Chair Hogan called the question and Commissioners voted unanimously in favor of the motion to return the report to the Subcommittee for further discussion at a later meeting.
Chair Hogan thanked Subcommittee members for their hard work.
The Outline for the Draft Report of the Subcommittee on Rights and Engagement is available on the web site, www.MentalHealthCommission.gov.
Approval of December Meeting Minutes
Chair Hogan requested that Commissioners approve the draft minutes from the November 12-14, 2002 meeting. Chair Hogan noted that the p.13 of the minutes should reflect that there are 30,000 suicides annually in the United States, not 35, 000 as written. Commissioner Godbole moved to accept the minutes and Commissioner Mayberg seconded the motion. The minutes were adopted by a unanimous vote with the above correction.
Additional discussion about web site input
Stan Eichenauer, the Commission's Deputy Executive Director, and Garrett Moran, Project Officer, Westat, provided Commissioners with a report analyzing the public comments received from stakeholders via the Commission's web site, email and written correspondence. During the previous six months, the Commission's web site had attracted 33,347 visitors who visited the site an average of 2.5 times for a total of approximately 83,000 visits to the site. Mr. Eichenauer reported some visitors have gone to the Spanish-language area and the Commission hopes to have additional translations (Chinese, Korean, and Vietnamese) in operation in the coming weeks. The web site is able to receive public comments in these languages, as well.
Mr. Moran described the types of public comment received by the Commission's web site. As of the report, the Commission had received 1,205 comments, most of them addressing restriction/lack of services/gap in services, financing/cost of services, consumer issues, challenges of living in the community, rights and engagement, and coordination of services. Public comments have been received from all 50 states, Puerto Rico and Guam. Comments come mainly from providers, consumers, and parents.
Commissioner Godbole, who had requested such a report, thanked Commission and Westat staff. Commissioner Huang expressed her appreciation of the translations of the web site.
Commissioner Fisher requested that staff cull out comments related to rights and engagement. A compendium of comments for each Subcommittee's area of focus has been developed and will be sent to all Commissioners.
Chair Hogan recommended that Commissioners review the report and perhaps discuss it at a future meeting.
This report is available on the Commission's web site, www.MentalHealthCommission.gov.
Reports by Subcommittees
Commissioner Mayberg gave a reminder to those members of the Subcommittee on Medicaid who were not able to attend the Subcommittee meeting that they should provide him with any comments by Monday, December 15. Several Subcommittee chairs reported that their Subcommittees are proceeding with their reports and will be prepared to present summaries to the full Commission in February.
Adjournment and Next Meeting Announcement
Chair Hogan adjourned the meeting at 11:30 am. The next Commission meeting will occur February 4-6, 2003 in Arlington, Virginia.
I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete.
These minutes were considered and approved by the Commission at its February 6, 2003 meeting and any corrections or notations are incorporated into the text.
Last Modified 2/12/03