Confronting the Mental Health Effects of COVID-19 in America

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

0:05

Good afternoon, everybody. I’m Jill O’Brien, Senior Health Policy Analyst at the Alliance for Health Policy. For those who are not familiar with the Alliance, welcome, we are a non partisan resource for the policy community dedicated to advancing knowledge and understanding of health policy issues.

0:23

Welcome to this afternoon’s webinar about Confronting the Mental Health Effects of Covert 19 in America.

0:30

The Alliance for Health Policy, gratefully acknowledges the Commonwealth Fund for supporting today’s webinar.

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You can join today’s conversation on Twitter using the hashtag #AllHealthLive and follow us @AllHealthPolicy.

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0:49

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1:05

Check out our website at all health policy dot org for background materials, and a recording of today’s webinar which will be made available there soon.

1:13

Now I am so pleased to introduce Reggie Williams to moderate today’s discussion. Reggie is Vice President of International Health Policy and Practice Innovations at the Commonwealth Fund. He also serves on the Board of Mental Health America, a non-profit dedicated to helping people live mentally healthier lives.

1:32

Reggie, thank you so much for joining us. Now I’ll turn it over to you to introduce our panelists.

1:38

Thank you, Joe.

1:40

It’s no secret.

1:42

At a time when the countries around the world are re-opening, ours is still struggling to return to work in daily life.

1:49

As the number of confirmed coven cases and deaths in the US continues to climb.

1:54

We need to start implementing public health measures that we know work, like mask wearing social distancing, robust testing and tracing helps stop the spread of probate as so many others around the world effectively accomplished.

2:09

We have an opportunity to look abroad for innovative solutions.

2:13

There are valuable lessons we can learn, particularly improving access to mental health services in addressing the social and economic needs of people that have been exacerbated by this pandemic.

2:24

Mental health and solutions to improve. Mental wellness are the focus of today’s webinar.

2:30

Today, I’m so pleased to be joined by an esteemed group experts.

2:36

First we have Paul John Frieda who’s the president and CEO of Mental Health America.

2:42

Previously, he served a four year term on the National Advisory Council to the SAMHSA Center for Mental Health Services earlier in this career.

2:52

You serve in the Connecticut House of Representatives and was the mayor of Middletown, Connecticut.

2:59

Next, I’m pleased to introduce Beth Mcguinty, who is an Associate Professor, the Associate Chair for Research and Practice in the Department of Health, Policy and Management at the Johns Hopkins Bloomberg School of Public Health.

3:15

She is also the Deputy Director at the Center for Mental Health and Addiction Policy Research and Associate Director of a L a C R I T Y Center for Health longevity.

3:31

Finally, I’m pleased to introduce evermore tone. Evan is the Executive Director of the Technical Assistance Collaborative.

3:38

Prior to joining tech, he was the President of the National Association of State Mental Health Program Directors, serve as the Deputy Commissioner of the New Jersey Department of Human Services.

3:51

So excited to have this wonderful panel of experts here today.

3:56

But before we get started with the panel, I just wanted to mention a few opening comments.

4:02

We, at the Commonwealth Fund, released a report last week, do Americans face greater mental health and economic consequences from COVID 19, Comparing the US With other high income countries, it’s the latest of the Fund’s cross National healthcare comparisons, provides country specific data on people’s experiences during the early months of Cove in 19, March to May in the United States, Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, and the United Kingdom.

4:39

From our research, it’s clear that mental health and economic impacts of the …

4:44

pandemic, taking a substantial toll on people across the globe.

4:48

Data from our research demonstrates that US adults when compared to people on other high income countries, face greater mental health and financial consequences from the ….

4:59

We found that 33% of people in the US report experiencing stress, anxiety, in great sadness that was difficult to cope with alone since the outbreak started.

5:11

This is followed by the UK and Canada at 26%.

5:15

Also alarming, we found that less than a third of the people in the United States who wanted to get care, were able to get mental health care, a similar rate in the UK. But people in Canada and Australia are better able to access the care they want.

5:33

The survey findings clearly demonstrate that people in the United States face greater mental health and economic challenges.

5:39

19, have relatively low levels of trust in their national leadership compared to residents and other high income countries.

5:48

As the number of confirmed Kobe, one thousand cases and deaths in the US continues to swell.

5:54

National, state and local policy makers can look abroad. Early lessons learn, innovative strategies for dealing with the virus.

6:03

Today, in our discussion, we’ll be able to speak and hear from experts that are focused on US policy and how we can make some changes.

6:13

Thank you. Now, I’m going to turn it over to Paul to make his own.

6:24

Thank you Reggie. I really appreciate the opportunity to be part of this and also just to thank you for the information that you shared to start this off. I know we’re going to be talking the three of us and throughout this hour about the levers and policy levers that people are able to use to address some of what we’re seeing. But at Mental Health America, we’re seeing a lot of what you’ve seen in your your report. We have an online screening program that about three quarters of, a million people have used over the course of the last three months. And they are telling us the very same things that in real time that your study has a demonstrated.

7:10

So I think people need to pay attention to the information that you provided. And to think about the policy opportunities that can present themselves at the federal, state, and local level. To address some of this. Now, one of the first things that I, of course mental health America will talk about is the need for widespread screening for mental health as much as we think we should be doing testing testing testing for … 19 At the same time we ought to be doing screening, screening screening for mental health issues. Since the start of the pandemic alone, about 90,000 people who have taken a mental health screen at our website have told us that they have suicidal or self harm thinking on more than half the days of the week.

7:55

And when we are seeing problems that are that big, it, across the nation, we really need to be thinking about addressing them at the earliest possible time before Stage four is, I like to say.

8:10

In addition to promoting widespread screening as the US. Preventive Services Task Force recommends for everybody over the age of 11, we need to recognize that our school kids are particularly at risk.

8:23

11 to 17 year olds are suffering the ill mental health effects of the pandemic more than any other age group, in our screening population. And yet this occurs at a time. When we have either not fully funded, the Special Education mandates are actually reduced The special education funding for people who are identified with the SCD label, which would be the label for children who are experiencing serious mental health problems. From the local level on up to the federal level, we really need to take a look at that as children of returning to school and recognize that there’s a greater need than ever before to do more for children through early identification, particularly within schools and school based populations. And, of course, that sort of points out the real issue that is out there, in terms of the way we think about mental health issues differently.

9:21

From physical health issues. You know, when the crisis is a physical health, we all rallied to do something about it when the crisis. Is it mental health? We have a tendency to separate and segregate people from the rest of society and from the healthcare delivery system. A lot of states and the federal government continue to issue to wrestle, with these issues of parity, not just through insurance …, but in general, just treating people the same no matter what condition they have. And, of course, treating people the same. No matter what racial or ethnic group they happen to be part of. And we’ve been learning that, that really hasn’t been happening for a good, long time. And I think, really, when we look at more deeply into people in need.

10:06

I think this is an opportunity also for us to think really strategically about our, our mental health block grants in our, in our both the on the substance use side, on the mental health side. Both sides of Congress, at this point have indicated they’d be willing to increase a block grant funding on the mental health side. By by at least a billion dollars in the Mental Health Block grant. Which would far more than double federal money coming into states for this. And he’s going to be critically important that we leave as much flexibility in that funding as we possibly can in addition to making certain that actually gets appropriated. So these are opportunities and in that instance, that really helps at the deep brand and it helps with all of those organizations that are providing all those services to people. Both inside and outside the healthcare delivery system.

10:57

So, we have opportunities. We have opportunities to think about whole people at this point, not just pieces of them, and have opportunities to recognize that not only is Koby 19 taking a huge toll on the mental health of the nation. But that’s a tool that has been taken even before the pandemic and will continue afterwards. And we now have some awareness of, and opportunities to make a difference here. So thank you for the opportunity to share those thoughts.

11:26

Great. Thank you, Paul.

11:29

Yeah, Now could we turn to you and hear some from your perspective around particularly what the Medicare program can focus on.

11:38

Absolutely. Thanks so much stretchy, and thanks to the Alliance for Health Policy for the opportunity to join this important conversation today. I recently had the opportunity to work with the Commonwealth Fund to consider gaps and opportunities for improving mental health coverage in Medicare, which is my role on this panel today.

12:01

Medicare is a program that covers a population with high need for mental health services about one in four Medicare beneficiaries overall have a mental illness diagnosis that prevalence is much higher. However, among Medicare beneficiaries under the age of 65 are about 60% have mental illness. So this is a population where we really need to be thinking particularly in the context of the covert pandemic where as you’ve heard from both Raji and Paul, we are seeing exacerbated needs for mental health services. This Medicare population is one where we really need to be thinking about how to enhance access to services. So I’ll highlight three places that I think are key opportunities for some policy action in this realm and we can go from there in terms of the discussion.

13:03

First, there are psychiatric inpatient day limits in Medicare that place Medicare squarely outside of parody which we as a society in my view should be aiming for. Medicare is now at parody for outpatient mental health visits, which is recent and important progress but still places a very strict 190 day lifetime limit on mental health in patient. Tells, as you can imagine, that 190 day limit, particularly for Medicare beneficiaries under age 65, can run out very quickly. And that 190 day limit on mental health inpatient days is far more stringent than Medicare’s limits on general medical inpatient days. That limit is 90 days per beneficiary per benefit period and so much more.

14:03

Yes.

14:04

The second area that I want to highlight for potential opportunity for improvement in Medicare is improving Medicare Advantage mental health networks.

14:15

We have good evidence from multiple studies that we have very narrow networks in terms of mental health providers and many medic, Medicare Advantage beneficiaries are forced to go out of network to get the care that they need. Because there are so few mental health providers within ERIT Network. And then finally, I think there is an opportunity to improve access to mental health services for Medicare beneficiaries by reimbursing licensed professional counselors, licensed professional counselors to deliver a wide range of mental health services, both group and individual services.

14:58

But they are not currently reimbursable by Medicare, and given, that we know we already have a mental health provider shortage, is exacerbated in the context of increased needs due to the covert 19 pandemic, Increasing that group of providers to provide evidence based mental health services is an important opportunity.

15:26

OK, thank you, Beth, for the opening remarks, Kevin.

16:06

Kevin, just want to let you know we’re having a little trouble hearing you.

16:10

I’m going to start again. There we go. Sorry about that, folks. Know, I just wanted to start with by saying that, you know, we really need to continue to think about mental health as a public health issue, not a public safety issue. Our mental health system is is heavily weighted towards the correctional institutional system, and too many people with mental illness had poor to know X access to treatment and services prior to the pandemic neuropsychiatric disorders of the leading cause of disability in the United States.

16:39

Suicide attempt leading cause of death in the United States, and so, you know, like coronavirus, mental illness, and untreated mental illness is really a public health threat, and you really need to see it through that lens. And while we’ve increasingly understood these things over the past several years and the solutions that go with it, we’ve made little progress in these areas, and cobra is really going to exacerbate the problem that the individual and system level in the months and years ahead. Medicaid is the biggest funder of publicly available mental health services. And it does provide a lot of opportunity for states to meet folks needs. But we also know that Medicaid enrollment grows during economic downturns and disasters, and we’re currently experiencing both. During the pandemic, states have used different Medicaid authorities, the framework to make emergency changes in order to maintain critical services. And you may be familiar. These are not, it gets a little bit technical.

17:34

But these include Section 135 Waivers, They include changes made in Appendix K Of 1915 C Waivers: They include Emergency state plan amendment, and may include Emergency 11 and 15 waivers. And it’s a lot of Complex. Kaiser actually has a pretty good website page called the Medicaid Emergency Authority Tracker. And if you take a look at that actually provide up to date information on, on all the specific state changes that are going on under all of these Medicaid authorities.

18:08

Most of the emergency changes that we’ve seen in Medicaid are broader than just mental health, but they do impact mental health services for sure. A few of those changes are specific to mental health services, whereas we have seen, many States make some specific changes to other disability groups, who are served through home and community based service, or home and community based services, and long-term services and supports, whereas mental health hasn’t necessarily have the direct focus, and so that may be something for us to really think forward about in the Medicaid world.

18:41

In the interest of time, generally, states are responding by making changes within these three authorities in three main buckets. First, or sustaining or modifying access to services through things like telehealth flexibilities and relaxing provider requirements, such as bending prior authorizations, and location of service delivery, the second thing is, states are trying to increase flexibility and reduce costs for service recipients. Know, so that means things like I’m trying to be more flexible refills for pharmacy and pharmaceuticals, mean wave and co-pays for individuals, and from the service recipient. And it means allowing increased access to services like telehealth so people can continue to see their, their, their care providers. And the third thing is, is states are making efforts to increase funding to providers to ensure provider about availability and viability. Frankly.

19:37

You know, without the providers of the providers implode, we have a real problem. And so, states are doing things through provider rate enhancements or even making retainer payments to providers. So that they can continue to have that capacity for books. one of the biggest challenges, despite all the flexibility through the emergency Medicaid programs are, just state budget concerns inaccessible. Evidence based mental health system requires a combination of Medicaid and other funding. And we know that, but if states are put in a position to find savings due to the economic crisis, access, to Medicaid coverage of services for people with mental illness can, can significantly be impacted in a negative basis. So emergency Medicaid authorities are good, but only at funding there to ensure accessible services and just the final piece on, on some solutions.

20:26

In addition to basic treatment services that we fund to the Medicaid program, we can’t forget about the social determinants of health. For many, folks with mental with mental illness, mental health problems are exacerbated or caused by stressors such as poverty, lack of affordable housing, homelessness, sub standard housing conditions, poor nutrition. And Medicaid and Managed Care have taken an increasing role in the social determinants of health and recent years. In addressing these through Medicaid or other avenues can go a long way in helping people through the crisis and manning, and managing Medicaid budgets. Just a quick snippet we do report attacked every couple of years called priced out. And the input glaring statistic. and basically what it does is it says that no one on SSI, which is predominantly the population that we’re talking about here with serious mental illness, folks who are on the Medicaid program. No one on SSI can afford housing, rental housing at the fair market rent in any housing market in the country, nowhere, and that that’s a real tragedy, and that has an impact on health and mental health.

21:26

Other solutions that we need to keep in mind, obviously, are integrated, co located care. We see a lot of good strategies there. We also need to emphasize the need for outreach type work, from things like case management, sort of community treatment, supportive housing. And that means often through Medicaid, let me to continue to find ways to support our workforce, to be able to deliver these services. Also, including the availability of PPE, and the last point I wanna make is we also need to ensure that people are not being placed in or getting stuck in institutional settings. This is really a civil rights issue in addition to a public health issue. Discharges in transition slowed down significantly in many states.

22:05

As workers couldn’t go out because they lack PPE or they were sick themselves in the original believe that that sort of existed was that people would be safer and hospitals or nursing homes And we know this turned out not to be true and was deadly for many people. And so, we need to make sure, you know that, from a medical perspective, as well as other state funding, revenue and resources. You know, that we’re that we’re trying to provide the right types of services in the right settings, where people, and really not putting sort of heading in the wrong direction. So, I’ll pause there and look forward to any questions.

22:41

Great. Thank you, Kevin. I want to invite all the panelists to turn on their cameras, and microphones, and then really transition into a Q and A discussion.

22:54

Everyone listening, remember that you can submit questions through the interface at any time as a part of this chat, or excited to take your questions.

23:06

To start us off, I have a question.

23:10

Think all of us here are clear and understanding the impact of Kogod 19 on mental health, and what some of the impacts can be long term.

23:22

What do you think can be done to build infrastructure, to really address the existing and growing needs, that we’re seeing, for, for mental health services?

23:33

Maybe we’ll go in reverse order. So Kevin, I’ll let you have that first.

23:39

Thanks Reggie. At a very basic level, I think, from a public health approach, we need to think about prevention and early intervention. And our systems rarely have the capacity to follow that approach. It just were not built that way. So I think that’s important for us to strive as much as we can, get a very concrete level. You know, one of the things that lacking in many parts of our country are good crisis services that could be used as a way to divert people or, you know, get people access to services. And when we don’t have those in place, people tend to fall into the deeper into our system, hospitalization, emergency departments, police systems, and things like that. The challenge then on top of that is, well, when you have a crisis system in place that can divert people, what do they diverting them too if the infrastructure fragmented, you know, so we really need to think about upstream and interventions, access, outpatient services, and care, really, as the base and our system. But we, we, we don’t have, and we’re missing sorely in our system.

24:38

You know, those crisis services that can play that critical door. We hope they don’t get there. We hope people have access to begin with. But, you know, it really need that as well.

24:50

So hopefully I’m not stealing Paul’s line here. Although I might be a little bit, but I think that it’s absolutely critical that we think about scaling up a system for a universal screening and effective strategies for referring people to services, which might be clinical treatment, or might be other types of services. And we’ve made some progress on this, in recent years, I’ll stay in my Medicare lane, a bit here and that Medicare has made progress with the annual wellness visit, reimbursed at a higher rate. Depression. Screening is one of the preventive services that can be included in that visit Good progress there, but uptake is very low And so, we really need to be thinking about what kinds of technical assistance and systemwide strategies are needed to implement these types of screenings.

25:52

Yeah, and I guess I can, can jump in there and say, no, actually that they appreciate because, honestly, I mean, I’m not naive. I was a policymaker 40 years and, honestly, we’ve built this system primarily around the benefits of the provider community writ large. And, I mean, in the mental health systems to state mental health systems, for example, that was, you know, state hospitals and we close down state hospital beds. We just transition that to, you know, jails and prisons. And even though a lot of people talk a good game about redirecting funds from these kinds of non health oriented services, when it comes time to do it, it’s a question of taking money away from you, Sheriff, or, you know, taking money away from the police. In order to redirected here.

26:45

Well, you can kinda see what happened. Suddenly, we kinda can see, over the last three months that, that doesn’t go over all that well. But if we really turn it on its head, and everything Kevin said about this.

26:56

And everything that Beth has said about, this is really important. And just said, Well, what would we do if we were doing early intervention and early identification? Well, we would start with screening.

27:07

You know, with cancer, we start with screening with, you know, with, with heart disease, we start with screening, you know, hypertension, screening, blood, pressure, screening, all these kinds of things. Why aren’t we just regularly doing the mental health screening that we’re supposed to do? And if we took all that information that we got from our mental health screening, then years, before we have to deal with crisis services, we actually would be able to direct people into the appropriate medical services in long before the crisis occurred. And that would undoubtedly free up our attention and resources, for Kevin points out, is just a critical, critical need, which is getting the right crisis intervention. services in place for people when they’ve got, because, what they’ve got is a medical crisis or a health crisis, they don’t have a public safety crisis justice, He said this: This doing this is a public safety problem, as we have throughout all of our lives, and the generations come before us was exactly the wrong way to do it, and We could, and we know exactly the right way to do it, because it’s the way we’ve done it with heart disease, or cancer, with diabetes, and every other chronic condition.

28:12

Great, thank you.

28:14

Now, I’m seeing another question here.

28:17

Seems as though we know that Koval 19 has had a disproportionate impact on central workers, including health care workers, black, indigenous, and people of color.

28:33

We’re seeing special concerns that are raised by pregnant women.

28:40

So, how do we think about the mental health impact with those different vulnerable populations and, one, understanding the impact into meeting them with the types of services that would empower them to group their mental health.

28:56

Anybody want to take that question?

29:04

Paul, you’re OK. Yeah, sure. I figured, You know, I was, I was going to wait and see a Beth wanted to take this one first. But she hasn’t had a first one, but I will do, you know, part of this, because it, it flows from screening, which should be universal. And some strategies should be Universal. And access should be universal. But the reality is that when, when it comes time to plan service delivery, do, You need to do that with communities in mind, and, and, and, and there are a lot of, as you’ve mentioned, there are a lot of different communities.

29:36

But unless you go to those communities and, and plan from their perspective, the kinds of services you want to deliver, you’re going to fall short.

29:48

And, and so I think that it’s critically important, because we haven’t learned anything else over the course. Well, since May 25th, that we haven’t learned anything else, we at least should have learned that by now.

30:02

And so, you know, listening to people and, and recognizing the kinds of problems, things, whatever, where people want to use as comfortable, that we’ve built into this system, that we need to fix. At this point, it doesn’t matter where you start an essay. Try to tell people you can just start anywhere Because anything that we would do for initiative would be better than what we’re doing now. No matter what, somebody’s philosophy is the orientation is, it’s like anything, We’d be better than this, so, so just try something, and take a risk to take a chance.

30:46

I would just add, you know, we have tremendous workforce challenges in this country, and it’s not going to be fixed overnight. But a diverse workforce does not exist in most parts of this country. And the big issue that we’ve got to look down the road, you know, the fix. I’m trying to bring diversity into our workforce. It just doesn’t even exist in most parts of the country. The other thing, and not move away from the mental health treatment and access to services issue. But many of these are no, people with mental illness and serious mental illness don’t just often have that. Right. They experience all these other things that I talked about before in the structural issues that exist in our system.

31:25

And so, when we’re talking about, know, trying to improve the overall well-being of someone with mental illness, who may be also facing these challenges, we’re talking about addressing poverty, and housing and transportation, and things like that. Well, that will also have a positive impact on their mental health and well-being, But so we have to look at it at the screening building, off what Paul was talking about, access to services. But we also have to bring in these other social determinants of health that really, I think can go a long way. And those are often beyond the mental health treatment systems, or Medicaid systems, capacity in control. But nonetheless, we know that the most successful systems out there are doing co-ordination and collaboration across systems.

32:05

Absolutely Concur with the points made by both Kevin and Paul. We have well documented, inequitable access to existing mental health services. There’s not enough for anybody, but there’s even worse access among racial and ethnic minorities and other historically, disadvantaged due to structural discrimination on other issues, groups. And we have to think not just about correcting some of those differences in access to available services, but also, as other panelists alluded to, think about building a workforce and a service system that includes culturally competent services, and that I think very much needs to be community driven asphalt.

33:04

Great.

33:06

I know we didn’t really touch upon the unique needs of pregnant women, particularly in this time period. Any kind of thoughts about maternal health broadly, and what can be done from a services standpoint?

33:27

You know, one thing I’ll say, I’m certainly not an expert in this area, but you know, when you’re talking about.

33:35

No prenatal care and women who are pregnant and seeing and seeing their, their, their positions. You know, generally, you know, the, the frontline doctors in this country are seeing, you know, mental health issues as well, right? And, you know, sometimes, they’re not equipped or they don’t feel equipped to in order to address mental health needs.

33:57

You know, when they think they’re addressing, you know, pregnancy, obstetrics, gynecology or primary Care or, Whatever it is.

34:04

And, it’s, especially given the workforce challenges that we have in this country. You know, there are no telehealth telecoms with patient types of services that exist out there that can be a resource to professionals like that. So when, you know, they’re working with individuals, who are, you know, coming through the door, who may have mental health problems. They don’t necessarily have to bear the burden of working with someone, but they can reach out to these consultation types of services, to get the support that they need to either work with them, or help refer them onto the right types of services.

34:35

Well, I’m glad you brought up the issue of Telehealth because I think coven 19 has shown us the broad expansion and the opportunity to utilize Telehealth. To give people access to services.

34:49

So, as we see the enhanced access to mental and behavioral health services, utilizing telehealth and virtual care and the like, are the remaining barriers in Medicare and Medicaid or other considerations. We should have a brown, the use of telehealth, virtual care, and other technologies to get people access to services.

35:16

I can maybe start on the first one, and particularly in that Medicare context. So, I think the sort of short answer is that we are learning a lot about this very quickly right now. And so, from a research perspective, it’s like my researcher hat on. I think some of the answers to the questions you just posed about are there are still barriers. Aren’t there potentially unintended consequences of some of the changes that we’ve been made yet, which seem largely positive? I think we don’t entirely know yet, and I think that mental health services are quite well suited in many cases to telemedicine, but there’s also research out there that suggesting that suggests that for some people, you know, face-to-face engagement is really more preferred.

36:04

And so, sort of disentangling that we have bodies of literature showing that tele mental health can also be quite effective for many people. But I think there are patient preferences and unique consumer needs that we haven’t sort of totally disentangled yet. On the policy front, you know, we’ve really seen a remarkable shift in terms of accessibility here with coven.

36:35

Not only in terms of, essentially in the Medicare context, all services that used to be covered for in person are now covered virtually with very few exceptions for services that really can’t be delivered virtually. And then, in addition to that, you know, lifting policy barriers in terms of HIPAA and privacy laws that have made it so people can use technologies that are most convenient for them, including telephone, allowed, allowing people to see providers across state lines, virtually getting rid of the originating site requirement. So, you don’t have to go in and sit at your originating site with a special software. We’ve lifted all of these barriers very quickly. I think that there’s a lot of potential and a lot of interest in studying this moving forward.

37:30

In terms of if we can keep some of these in a post world, what the potential is for increasing access, I will sort of end on the point that we exist in a world of major mental health provider shortage, and these Telemedicine exp …, they sort of help at the margins right? where we haven’t actually increased the pool of providers. We might increase accessibility at the margins where if you live in a rural place, now all of a sudden you can talk to us psychiatrist who lives in a city 400 miles away, but it’s not going to solve all of our problems in terms of workforce capacity.

38:14

Hmm.

38:16

Speaker: I think we’re, you know, it’ll be really interesting to see how it plays out, right. I think there are a lot of folks that are hoping that, you know, there is some sustainability to this post, the crisis. For individuals. I mean, there’s certainly some operational challenges. I mean, when you think about sort of the the, the capacity of the behavioral health providers across the country, you have some very small mom and pop type shock to some very sophisticated behavioral health providers. And for those smaller folks know, it may be an uphill battle. There’s a lot of training that needs to go along with it. They need infrastructure to be able to support it. No, one, from the Consumer Service recipient perspective, you know, there are certain populations where it’s very hard, you know, if you’re homeless and have a serious mental illness, it very hard just to maintain access or even have access to Internet coverage. For instance. So, there’s a lot of operational barriers, but I think there is no, the systems have responded pretty rapidly.

39:11

I think there’s probably an interest from what I gather, you know, on the CMS side to see how it plays out over time. And so, I think, I think it is the potential, you know, shining light in all of this as we move forward.

39:24

I would just add to that, you know, what the perspective that we at Mental Health America understand, the best probably as the perspective of the individual has a mental health challenge with our screening population. For example, and we’ve had about 5.5 million people come, take a screen. And, you know, these are help seekers by definition, that’s how they find us, because they’re seeking help and only a minority of the population, you know, once a referral to care, or traditional care, or treatment.

39:54

So, what people are looking for are also engagement with peers and certified peer specialists, which are used in Medicaid programs throughout the country, but not broadly beyond those. And certainly, certainly not with uniform standards at this point that would make private insurers, and even Medicare wholly comfortable with them at this stage, could be a way to augment sort of the face to face person to person contact. But when people are also looking for just more information, and they’re looking for do it yourself kinds of tools, because of the nature of mental health conditions, it reminds us that there there is likely a demand, an increasing demand for the telehealth services that could be provided. The more of those that are provided. But as Beth said, they’re not going to be no, or applies to put words in your mouth. They’re not gonna be for everybody, and they’re not going to reach everybody.

40:49

But it is a way to reach an additional, I’d like to say, you know, there’s a quarter of the population that wants information. And a quarter of the population that will do a referral care. Is a quarter of the population that will engage with services, when they can do it at the comfort of their own home, and do it virtually, and have some of the boundaries, the personal space boundaries around them that they’d like to have. So, it’s a way to augment services, but it’s not going to replace the faith the face, to face a person to person. And it’s not going to solve the provider shortage problem that we, that we have and will continue to have.

41:29

That makes a lot of sense.

41:31
Um, no, we have a question here that really focuses on the topic of schools and returning the schools.

41:39

So given the pressures facing families, as children go back to school, parents struggle with work and to manage childrens’ schedules with or without their usual supports.

41:50

one would expect that people who need access to mental health services for the first time may be kind of uniquely looking for services as their they and their children are kind of going back to school.

42:06

What tools do we have to help mobilize to meet the needs of families? and children during this time.

42:16

I don’t mind starting on this one just because I brought it up earlier, too, and, and I know I have a lot to say about this, but I’ll try to say just a little bit here, response question. You know, we do have tools, you know, we can screen, and we should be screening. And, you know, when we suggest that, you know, when we released our July data or June Date, actually in July, that no school system should be re-opening without consideration of meeting the mental health needs of the children and, of course, the families as well.

42:48

It gets us a little bit into that whole issue, I think, that you brought up right to you earlier about, you know, perinatal mental health, maternal mental health, to, you know, let’s not fall into the trap of blaming the parents for being inadequate to the task of providing for the education of their children. As we give them options about whether they’re going to be in school, or whether we’re going to teach them at home. You know, we’re asking them to do a lot. So, we also have the unique opportunity to rebuild the special education system. Now, a lot of people are afraid of this, Right. And for the last 40 years, I mean, really less, certainly less, 30 years. We’ve been cutting back on the number of kids in the special ed system who are identified as a result of the CD label. And what that meant is that fewer than one child in every 30 right now is being identified. And now if you tack on the additional stressors that children are under and their families surrender, I wouldn’t be surprised. It’s one in forty or one in fifty S were going back to school. So we know what to do. You know, we know that we can develop individualized instructional programs that will benefit for the children, and that they’re going to need. It’s just going to cost us a whole lot of money.

44:02

But, we’re spending trillions of dollars in stimulus, spending tens of billions of dollars right now doing this, and that’s what it would cost. I don’t think it’s too much to ask personally, but, no, it maybe too much for a number of public officials beyond that, making certain that every child has access. And, and again, Kevin and Beth, both talk about this. today and passionately in the past about this. You know, when you look at social determinants, and you look at the stressors, and you’ll get stress induced trauma induced mental health problems. So many kids coming to school with and facing, we do recognize that understand that, and understand that the concentrated in certain communities and do something about it.

44:41

And so, we have a lot of levers to push here, and it’s another one of those examples where I’m not saying everybody’s got to do every one of them. But you could do one, you just do one, pick your favorite, and it wouldn’t make a difference. because right now, we’re sending those kids in no naked without mental health supports, and we can’t be doing that.

45:05

Kevin, I guess, kind of building on that theme that was presented there, states are experiencing budget shortfalls and increased demand for services?

45:15

What strategies do you see them employing to meet the increase behavioral health and mental health services?

45:24

This is the thing that keeps me up at night, and I don’t work in state Government anymore, but it keeps me up at night. You know, you know, despite you know, some of the opportunities that are in play, through Medicaid authorities, and things like that, the reality is, state revenues are are hurting.

45:39

You know the the enhanced F map that came in through the Cares Act is helpful, but I think states are still planning for, for, you know, cuts the behavioral health related services in the Medicaid program.

45:53

For instance, you know, even though there’s some maintenance of effort required, Buda Cares Act, the reality is, they just don’t have the revenues and the potential for cut there is important. Let me just give you a quick example on that. Not to belabor the point. If you have a $10 million program, started using some round numbers.

46:08

And 50% of the Medicaid program is funded by the federal government, 50% is funded by the state government, and the state needs to make a million dollar cut, OK? Well, that means you’re also gonna lose a million dollars of federal revenue for that, for those programs, which means the state may be making a 10% cut, but it’s a 20% cut to the overall program, significant significant impact. So, you know, I think states really continue to look at their Medicaid emergency authorities and things like that, But, you know, it is easy for me to say from the outside right now. You know, managing state revenues, but, no, we really need to try to keep those revenues in place for things. You know, that cares acting through with other funding, through SAMHSA, arguably. It was a drop in the bucket, you know, given, given the level of need out there. You know, so, I think those are important things to consider. You know, at a very basic level, I think co-ordination is really important between the behavioral health system in a primary care system.

47:05

You know, again, some people may neglect or may not have access to behavioral health services, but they may still keep in touch with a primary care provider or made increased contact with the primary care provider. As we sort of come out of quarantine in some states.

47:18

Those may be opportunities to sort of get that at least basic screening in and try to engage people, but it, I don’t know that I have solutions right now. I’m really, really fearful of the economic economic impact. The State budget. You know, when I look back on the recession, that’s when I wasn’t state government. You know, 2009 to 20 11, the amount of funding that was cut from the public mental health system was very significant. You combine that with, you know, a lot of time, Medicaid expansion came in and many states, and it expanded access from coverage for many folks. But also what happened at that time was many state revenues went this sort of go into the Medicaid program to be able to cover increased services and coverage. But at the same time, many of the state revenues in the state mental health authorities went away and never came back.

48:05

So, when you sort of look at the declining revenues, and you look at sort of just the overall loss of some state revenue dollars directly directed at mental health services and state, you can sort of see, given the economic impact that we’re seeing as a result of Koby, That even going to be worse, it’s even going to be compounded as we go forward in the next several months, a couple of years. It’s, I’m really concerned about it.

48:31

So, but I thought, with expansion states, the feds are picking up like 90% of the cost, and so do you think expansion states are going to be able to, whether this time, a little bit better?

48:44

Or what perspective you have are on You know, I think, personally, my bias would be, yes, but at the same time, you know, you still have state skin in the game, for lack of a better way of describing it. Right? And so, you know, their budgets over the past several years have been shaped accordingly, and so, you know, as they move more heavily into that Medicaid environment, you know, in a Medicaid Expansion state where many of those services having to enhance F map, you know, the state. Their budgeting was basically re-established with a lower level of state dollars in the mix. Right. Nevertheless, going into the economic impact, and the crisis that ram.

49:22

They’re still, they’re still in a position where they’re gonna have to reduce state funding somewhere, and that creates the potential problem, you know, that we’re seeing, You know, we’ll see how it plays out with the maintenance of eligibility or or or effort requirements. We’ll see how it plays out with the enhanced, you know, 6% to 8% met F map. that came through the Cares Act, but I think the concern from what I hear what I’m hearing is states are still very much concerned about the predicament that they’re going in and what that means for overall services.

49:55

Sure, thank you.

49:58

Paul, I know that you, in a mental health America, have spent time focused on employers and, and looking at how employers can play a greater role in addressing the mental health and behavioral health needs of their employees. Have you seen any kind of early activities from employers, around Cove? In 19, addressing mental health needs that you would point to is promising?

50:26

Yeah, we have. And I would say, you know, one is certainly the flexibility that somebody employers have given to their employees. In many employers who never thought about that before, to be able to work remotely and to be able to adjust their schedules in order to manage the time that they have just to put get to their families. So, the flexibility in scheduling is one thing that certainly is out there.

50:52

Other employers, though, have gone, you know, further and really done a better job of providing authority, you know, to, to the employees. So, you know, not as much, you know, kind of management oversight if you will, that’s about filing your TPS reports for people who understand that reference and more terms of giving people the, again, the ability to run projects on their own. And to do that remotely. I think others have now really begun to think also and some of step forward to trying to provide a more robust set of self-service supports.

51:33

Basically to their employees, recognizing that the old EAP as as narrowly defined, isn’t as as useful to a lot of people, never has been, you know, for a lot of people, but it’s less So. At this time and and providing, you know, even kind of remote support groups. You know, virtual support groups among employees, there are less formal and more informal to try to make certain that they are supporting their employees as best they can. Am I doing this? A lot of them have started to pay more attention to the stress that people have had. And the fact that, you know, they, they may have thought it was narrowly limited to a small number of employees. In the past. They recognize that it’s a more universal experience, and as a result, anxiety, depression, frankly, symptoms of psychosis, or more universally felt that this, these times, and they haven’t felt in the past, I think, has made people more sensitive.

52:31

And we’ve seen employers, we do recognize with a Bell Seal program that we have, you know, employers that are often beyond, and we’ve seen quite a number of employers now applying for this, and earning the seal and doing it, based on very concrete things in these areas, as they’ve been doing. In addition to just speaking out, and, you know, changing the culture and speaking out, I mean, their leaders speak out and say, you know, it’s time to say that mental health is important. So, I also like to say that some, while, they haven’t been in ours, I’ve also appreciated. Certainly, my state government, which has done an awful lot in my state. I don’t have to mention which one it is.

53:09

But I’m deeply appreciative that they’ve continued to play many employees, you know, who otherwise are not able to continue to do the charts they were hired to do, but if continue to pay them and not furlough them and move them out to, you know, to the an employment program, which is now, again, stressing out an awful lot of people who have come through that. So. So even those states are going to have to justify some some budget shortfalls. Number of them are really doing right by their employees is setting really good examples for others to follow. one that we’ve tried to follow an organization, but not furloughing anybody and committing to not doing that for at least a year.

53:54

Great, all right, I think we have time for one more question, And I have a question here.

54:00

I think that looks like it’s a, it’s targeted towards Beth, and really looking at the Medicare program.

54:07

And so, there’s been an evolution in the Medicare program around the medical, surgical, and pharmaceutical benefits over the years.

54:17

But it seems that the mental health benefits have been pretty static. one, is that a fair characterization in to what could policymakers do today to speed up the evolution in the mental health space?

54:31

Yeah. This is a great point. That’s sort of the evolution, is a nice way of framing it. And I do think it’s correct mental health benefit evolution, if you will, has lagged behind the evolution around medical and surgical benefits. So, I’ll give credit where credit is due. We have seen some progress, like I alluded, in my opening remarks to co-insurance parody for outpatient mental health assets, which was a long time coming, but it did come as of 2014.

55:10

So, you know, I think that I can re-iterate some specific recommendations here in terms of policy changes. But I also think that bigger picture we need a bit of a paradigm shift where we recognize the importance and the need for mental health services in the Medicare population.

55:31

I think that at least some decision makers, there’s been a view that oh, we sort of contact to Medicaid, Medicaid does mental health and for dual eligibles who do have high mental health needs, OK? But there is also quite high mental health services needs among people who don’t have that dual coverage and the Medicare population. Only about 1% of all Medicare spending goes to mental health services, right? It’s a teeny tiny proportion that is very disproportionate to the need to one in four of all Medicare beneficiaries that have mental illness or the 60% of those under age 65. So, I think, sort of a values shift is needed here.

56:26

And then some of those concrete recommendations that cost money, but might get us up to, what, like, 1.7% Medicare budget. Like inpatient mental health as it parity with general medical assets. Covering services delivered by licensed professional counselors. Strategies for expanding Medicare Advantage networks, as well as, you know, Medicare is often a leader in delivery and financing innovations, like accountable care organizations. And I think that there’s some real potential for innovative thinking and testing some innovative models there. In the ACO example, we know that ACOs have done a terrible job incorporating mental health professionals into their networks, and that seems like an obvious sort of low hanging fruit place to tackle. How do we do a better job of that where Medicare can play a big role?

57:32

Well, thank you for that, for, for answering that final question. I feel like we’re just getting started, And there’s so many more topics that we could dive into. But we have limited time today. So I want to thank you all for joining us in this important discussion.

57:50

Just a couple of housekeeping notes, I’d like to make: one, for all everybody participating, please take time to complete the brief evaluation survey that you’ll receive immediately after the broadcast via e-mail. In addition, a recording of this webinar and additional materials on this topic are available on that Alliance’s website.

58:11

Please join me again in thanking Paul, Beth, and Kevin for joining us.

58:17

That concludes our broadcast for today. Thank you.

58:21

Thank you.

58:23

Thank you.