Public forums on the future of Michigan's behavioral health system (a.k.a. Community Mental Health)

This is a notice from the Michigan Department of Health and Human Services (MDHHS) inviting anyone interested in the future of the behavioral health system (Community Mental Health), including Medicaid services for people with intellectual and developmental disabilities, to attend a forum to voice your opinion.

Here is the notice followed by links to background information and my personal opinion about the cluelessness of state officials regarding the problems in our system of care and services.

MDHHS PUBLIC FORUMS:

THE FUTURE OF BEHAVIORAL HEALTH IN MICHIGAN

Please join the Michigan Department of Health and Human Services (MDHHS) for a conversation about the future of behavioral health in Michigan.

In December 2019, MDHHS outlined a vision for a stronger behavioral health system that integrates specialty behavioral health and physical health services. If you are served by Michigan’s Medicaid-funded behavioral health system or are the family member of a person served, we want to hear from YOU.

MDHHS is hosting five public forums throughout the state and online in early 2020. Department leadership will be in attendance to further discuss the vision, answer your questions, and listen to your feedback. Please join us!

Detroit: January 8, 2020, from 5:00—6:30 p.m.
Cadillac Place, 3044 W. Grand Blvd
Conference Room L-150

Grand Rapids: January 9, 2020, from 5:00—6:30 p.m.
Grand Valley State University L.V. Eberhard Center, 
301 W. Fulton, Room 201

Marquette: January 22, 2020, from 5:00—6:30 p.m.
Marquette Senior High School
1203 W. Fair Ave
Little Theater

Saginaw: January 30, 2020, from 5:00—6:30 p.m
Saginaw Valley State University, Gilbertson Hall, 
7400 Bay Road
Ott Auditorium

Virtual Forum: February 6, 2020, from 5:00—6:30 p.m.

The link for this event will be shared on www.Michigan.gov/FutureOfBehavioralHealth
in late January.

To learn more about the Department’s vision, please visit www.Michigan.gov/FutureOfBehavioralHealth. 

If you cannot attend an event, we would still love to hear from you. You can email your feedback to FutureOfBH@michigan.gov.

*********************************

Speech by Robert Gordon, Director of MDHHS, to the Community Mental Health Association of Michigan

The vision MDHHS is proposing

Section 298 Initiative The 298 Initiative has been abandoned, but it looks like current proposals by the state are trying to resurrect it. 

For many years, Medicaid Health Plans, both for profit and nonprofit, have been trying to get their  hands on Medicaid funds for behavioral health services (CMH) with promises that they can do it better and for less money than the public agencies that most people rely on. For some very good reasons, people don't believe them. Medicaid Health Plans do not have experience providing the social service supports people with IDD and other disabilities need to survive (housing, case management, caregiving, family supports, health maintenance, etc.). When medical health systems are faced with limitations on funding through a managed care system, they naturally turn to denying and limiting services to the people they are supposed to serve.

Let's not kid ourselves.The community mental health system leaves much to be desired with its inability to recognize or serve the full continuum of services that are needed by this diverse population. 

The State's proposals for reforming the behavioral health system (again) do not tell us what they are trying to reform other than a system of financial management for Medicaid funds. It seems to me this is starting at the wrong place again with the wrong people.

If you want a say in the future of Behavioral Health, tell the MDHHS what you know and what they need to know to do a better job. Lead with that, and don't let the state's proposals be the only thing you respond to.

Abelone Kelley January 07, 2020 0

Michigan hearings on Community Mental Health: House Appropriations Subcommittee on Health & Human Services

Michigan State Representative Mary Whiteford, Chair of the MI House Appropriations Subcommittee on Health and Human Services, has announced a series of hearings on Behavioral Health, Community Mental Health Redesign, and Behavioral Health Integration. These are scheduled for Wednesday mornings, from October 2, 2019 through November 6, 2019: 

10:30 A.M. - 12 P.M.

Room 352

House Appropriations
State Capitol Building

Note that two hearings to receive public input will be held on October 30 and November 6, 2019. Call Mary Whiteford's office at (517) 373-0836 or email MaryWhiteford@house.mi.gov for more information (how much time will you have to testify, what is the signup procedure to register, how will written testimony be handled, etc. ???).

To watch a video recording of the 10/2/19 hearing, go to Video Archives for the MI House of Representatives, scroll down to "Appropriations Health and Human Services - Wednesday, October 02, 2019" and click on "Play Video". Presumably future hearings will also appear here after they have been held.

Here is the full schedule:

House Appropriations Subcommittee on HHS

Wednesday, Oct. 2

History and Overview of Public Behavioral Health Financing in Michigan

Jeff Patton - Kalamazoo CMH CEO

Jim Haveman - Former Director of Dept. of Community Health

Wednesday, October 16

CMH Perspective Benefits and challenges of the CMH, PIHP system including House fiscal analysis of Michigan’s behavioral health carve out
Bob Sheehan/Alan Bolter - Community Mental Health Association of Michigan (CMHAM)

House Fiscal Agency


Wednesday, October 23 

The case for Behavioral Health Integration from the former Medicaid Director of Arizona 
Thomas Betlach - former Arizona Medicaid Director

Wednesday, October 30
Public Input

Wednesday, November 6
Public Input

**********************************************

The Michigan Community Mental Health system serves people with developmental disabilities, mental illness, substance abuse disorders  and children with emotional disturbances. People with DD are a small proportion of the total population served, but DD services represent a proportionately larger part of the CMH budget. This is largely due to the need by many with DD for up to 24/7 home or residential care, the complications of complex medical and behavioral needs, and needed support for families. 

It is often the case, that people with developmental disabilities receive less attention than they should by state legislators, so make sure your voice is heard. 

Abelone Kelley October 04, 2019 0

Michigan Court of Appeals Upholds Guardian's Right to an Injunction to Prevent the Transfer of her Ward

A recently published decision by the State of Michigan Court of Appeals upholds the right of a guardian to seek injunctive relief from the Probate Court to prevent the transfer of her ward from one facility to another, based on showing that such a transfer would be detrimental to the wellbeing of the person under guardianship.

In re Guardianship of Lisa Brosamer v. Lenawee County Community Mental Health Authority (CMH) Is a case involving Lisa Brosamer who is severely developmentally disabled. Patricia Brosamer became Lisa’s guardian in 2009. Lisa’s mother cared for Lisa in her home from 1961 to 2006, when, due to the mother’s declining health, Lisa was moved into a residential treatment facility. Lisa is severely intellectually disabled and is unable to care for herself.

On Sept. 26, 2018, the guardian filed a petition with the Probate Court to stop a planned transfer of Lisa from one group home to another. Patricia Brosamer contended that the Lenawee CMH proposed transfer would be detrimental to Lisa. Lenawee CMH argued that the agency met the requirements of the law by determining that the transfer from one facility to another would not be detrimental and that the legislature did not intend for a guardian to be able to veto a decision by CMH. 

Lenawee CMH based its case on this excerpt from the Michigan Mental Health Code:

330.1536 Transfer of resident; notice; appeal.

Sec. 536.

1. A resident in a facility may be transferred to any other facility, or to a hospital operated by the department, if the transfer would not be detrimental to the resident and the responsible community mental health services program approves the transfer. [emphasis added]
2. The resident and his or her nearest relative or guardian shall be notified at least 7 days before any transfer, except that a transfer may be effected earlier if necessitated by an emergency. In addition, the resident may designate 2 other persons to receive the notice. If the resident, his or her nearest relative, or guardian objects to the transfer, the department shall provide an opportunity to appeal the transfer.
3. If a transfer is effected due to an emergency, the required notices shall be given as soon as possible, but not later than 24 hours after the transfer.

Probate Court findings

The guardian presented four witnesses, each of whom had a history with Lisa or daily interactions with her and “…might reasonably be capable of opining as to how the proposed transfer might affect Lisa’s wellbeing.” All four concluded that transferring Lisa from her current group home placement would be detrimental.

Lenawee CMH provided affidavits from three people, none of whom had a history with Lisa comparable to that of the guardian's four witnesses. According to the Lenawee Director of CMH, the decision that there would be no detriment was based on unnamed “expert” staff.

The Probate Court granted the injunction against moving Lisa out of her current placement. Lenawee CMH appealed the decision.

Court of Appeals

The Court of Appeals stated that “Although respondent [CMH] frames its argument on appeal as one regarding statutory interpretation, respondent’s [the guardian’s] argument actually concerns the probate court’s factual findings” of detriment to Lisa.

On the CMH agency's responsibility to other clients, the Court stated:

"Being sensitive to the fact that respondent must walk the tightrope of balancing the needs of consumers—sometimes against one another—with the limited resources that it has, MCL 330.1536 is clear that respondent cannot transfer a consumer if the transfer would be detrimental to that consumer. Thus, the relative hardship on respondent that the injunction imposes is no greater than the hardship imposed by MCL 330.1536 itself. Contrarily, the hardship Lisa may endure if she were to be transferred to the detriment of her wellbeing is significant. [emphasis added] Additionally, although third parties and the public have an interest in respondent’s ability to transfer consumers and balance its resources for the benefit of the community, Lisa has the right to be free of detrimental transfers, and with respect to MCL 330.1536, the interests of third parties in transfers that might be detrimental to Lisa are not relevant to whether the transfer is permissible; and, we note that nothing bars respondent [CMH] from seeking to have the injunction lifted if a transfer that would not be detrimental to Lisa’s wellbeing arises. Finally, the injunction will not be impractical to enforce.

“Based upon the above factors, and considering there was no adequate remedy at law to ensure that respondent would not be transferred, the probate court’s injunction was not outside the range of reasonable and principled outcomes.”

******************************

This summary leaves out a number of interesting details in this case. 

For instance, at about the same time that Lisa's case manager of ten years retired in June 2018, a new case manager was brought in. This coincided with when Lenawee CMH determined that another consumer needed a bed at Lisa's current group home and concluded that moving Lisa to another group home would not be a detriment to Lisa. The guardian asked for a new case manager, “because [she] could not understand how the case manager could conclude that a transfer was appropriate while being so new and unfamiliar with Lisa.” The Court found evidence that this was true by comparing the testimony of the guardian's witnesses to the affidavits presented by Lenawee CMH.

The guardian's witnesses included:

• Lisa's doctor of 14 years who testified that, considering Lisa's age and disabilities, she lacked the "coping mechanism" to adjust to an unfamiliar setting. 
• A witness who had known Lisa for 20 years and had worked at the home where CMH wanted to transfer Lisa, said the proposed placement was not as suitable and feared that Lisa might have altercations with another resident with aggressive behaviors. 
• The guardian testified that Lisa had thrived at her current placement and had strong bonds with the staff and other residents. 
• Lisa's court-appointed attorney, who had been involved in the case since 2011, indicated that, because of the guardian's "extensive involvement with [Lisa] over the years," she was in "a superior position to any of the other witnesses or affiants know what [would] be detrimental to Lisa."

Abelone Kelley May 22, 2019 0

Michigan: Medicaid eligibility is not the only way to qualify for services for people with DD and other disabilities

A letter of clarification from the Michigan Department of Health and Human Services, dated 12/14/2018, was sent to Executive Directors of Prepaid Inpatient Health Plans (PIHPs) and Community Mental Health Services Programs (CMHSPs) concerning misinformation about eligibility for mental health services, including services for people with intellectual and developmental disabilities. The letter is from Jeffery L. Wieferich, the Director of the Michigan Bureau of Community Based Services. [PIHPs are the regional administrative agencies that pass on Medicaid funding to local Community Mental Health agencies (the CMHSPs).] 

The body of the letter clarifies access and eligibility for Community Mental Health (CMH) services and corrects inaccurate information being provided to the public. Some CMH agencies and PIHPs have been misinforming the public that their agencies will serve only people eligible for Medicaid. This is not correct.

For one thing, many people do not apply for Medicaid until they are in need of services. There is some funding to serve people not eligible for Medicaid, and they are placed on a waiting list, if funds are not available. Services must be provided to all Medicaid eligible individuals. Everyone who contacts a CMH agency is entitled to an evaluation to determine his or her level of need. 

The letter makes these clarifications:

• Staff from a CMHSP may not state that the CMHSP only serves Medicaid beneficiaries. For those individuals that do not have Medicaid coverage, the Mental Health Code…is clear that a CMHSP must serve anyone in an emergent (crisis) situation…Following that, an assessment is required to be completed so that level of need is determined. If an individual’s level of need is not as severe as other individuals, then the CMHSP may determine that it does not have sufficient general funds to provide services and the individual is to be placed on a waiting list for CMHSP services (non-Medicaid only) and the CMHSP should maintain the list.
• CMHSP Access Center staff must screen anyone that calls for a crisis and then assure that applicants are offered appointments for assessments with mental health professionals of their choice within the…contract-required standard timeframes. For those individuals without Medicaid coverage, the Mental Health Code also states that a waiting list must be maintained for anyone that is determined not as severe as other individuals…
• When an individual with mental health needs [including people with intellectual and developmental disabilities] is denied community mental health services, for whatever reason, he/she is notified of the right under the [Mental Health Code] to request a second opinion and the local dispute resolution process…
• CMHSP websites should not be conveying only Medicaid eligible beneficiaries are served.
• When an individual has private insurance, this is not solely a reason to deny CMHSP services. The CMHSP is required to complete an assessment of the individual’s needs and then prioritize based on the [Mental Health Code]. The CMHSP shall not deny an eligible individual a service because of individual/family/income or third party payer source…

Another source of funding for children under the age of 18 is the Michigan Children's Waiver Program (CWP).

From the CWP Website: "To be eligible for the CWP, the child must have a documented developmental disability and need medical or behavioral supports and services at home. In addition, the child must have behavioral or medical and habilitative needs at home on a consistent daily basis that meet requirements for the level of care for an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)."

The CWP waives the requirement that the family qualify for Medicaid and allows the child to be considered for services regardless of the family's income. There are a limited number of children's medicaid waivers, but it is worth getting on the needs-based waitlist.

**********************

See the letter of clarification for references to the Michigan Mental Health Code.

See also Michigan Protection and Advocacy Service on eligibility for services.

Abelone Kelley March 14, 2019 0

Michigan: Law affecting minimum wage and sick leave is undermined by lame duck legislature

December 3, 2018

What the legislature giveth, the Lame Ducks taketh away...

The Michigan Community Mental Health system that provides services to people with developmental and other disabilities is in a crisis caused in part by the low wages of direct service professionals who provide care to people with disabilities. Whether an individual lives in a licensed setting or unlicensed home of their own or shares a home with others or with their family, the help they need to survive is often provided by a caregiver paid for by Medicaid.

Before the November 2018 election, hundreds of thousands of signatures were gathered to support a ballot initiative that would raise the state’s minimum wage to $12/hour by 2022 and allow employees to accumulate sick leave of 1 hour for every 30 days worked. The ballot initiative proved to be extremely popular which prompted the legislature to pass a law that would do exactly what the ballot initiative would do, but with the intention of amending the law during the lame duck session to scale way back on its requirements. This is exactly what happened. A bill scaling back the promises of the ballot initiative has passed the Michigan Senate and is now in the Michigan House of Representatives.

According to the Community Mental Health Association of Michigan (CMHAM) and other state organizations, a wage increase above minimum wage for direct care workers is needed to stabilize the work force that now has a 37% turnover rate. The difficulty and responsibility of the jobs these workers perform should be recognized and supported with better pay and working conditions.

Further complicating the CMH crisis is the necessity for the legislature to assure adequate Medicaid funding to pay workers to provide the services needed for people with disabilities. An increase in the minimum wage overall should bring an upward pressure to raise wages for direct care workers and to acknowledge the importance of adequate Medicaid funding to provide services. 

**********************

More on the need to raise direct care workers wages above minimum wage...

See also, "Michigan state senators on Wednesday dramatically scaled back two citizen-backed laws to raise the minimum wage and require paid sick leave."

And furthermore, this is from a Detroit Free Press column by Brian Dickerson on  12/2/18: 

• Lock 148 elected representatives in a couple of large rooms.
• Remind those assembled that more than a third of them will be out of their jobs in 30 days.
• Sit back and enjoy the fun as dozens of lawmakers with nothing left to lose take the $57-billion-a-year enterprise called the State of Michigan for one last, wild spin around the block.

"What could possibly go wrong?"

Abelone Kelley December 03, 2018 0

MI: Urgent Action needed to shore up direct care worker wage crisis

This is a request for urgent action from the Community Mental Health Association of Michigan (CMHAM). Many other state and local organizations have sent out the same message. The gist of it is that changes to the Fiscal Year 2019 budget should reflect the dire need to stabilize the direct care work force for people with disabilities by adding additional Medicaid funding for a wage increase: As you may know, the executive office submitted to the legislature a FY19 supplemental budget request - that request did NOT include any additional funding for a direct care worker wage increase. We know the Legislature will adopt a FY19 supplemental budget before they complete their lame duck session and we anticipate that final budget being quite large, which is why we want to add this important request to their list. REQUEST FOR URGENT ACTION: Please contact your House and Senate members urging them to support additional Medicaid funding for a $0.75 per hour wage increase for direct care workers in the Fiscal Year 2019 Supplemental Appropriations Budget. This allocation is intended to recognize the impact of the upcoming minimum wage increase that was passed by the Michigan Legislature in September and stabilize the workforce for these individuals. EXPLAIN that a staff wage increase advances the objectives of improving the quality of life for individuals with disabilities and increasing their access to supports and services. SHARE stories on how the staffing crisis negatively impacted your agency or the people you serve. We also need you to ask that the members of your Board of Directors, your staff, and your community partners make those same contacts - SIMPLY FORWARD THEM THE ACTION ALERT. These contacts are critical, legislators must hear from us as there will be numerous requests for final appropriations during lame duck. Quick Talking Points People with developmental disabilities, mental illness or substance use disorder rely on direct care workers for essential supports which enable them to access their community, work, and live full, meaningful lives.  Inadequate wages have created a critical direct care shortage.  Turnover rates average 37%. Some providers have been forced to discontinue services.  Direct care starting wages, which are tied to Medicaid funding, are too low. Service providers cannot compete with other businesses that hire at the same level, often with fewer work demands.  Click the link below to log in and send your message: [The names of your Michigan State House Representative and Michigan State Senator will appear along with a message that you can edit for a more personalized request.] https://www.votervoice.net/BroadcastLinks/6_u9aJTBLijvrafO_qb7fA

Abelone Kelley November 30, 2018 0

Michigan 2018: Making Sense of the political landscape for people with disabilities, Part 3

This is a continuation of “Making Sense of the political Landscape…” based on a PowerPoint presentation by Alan Bolter, the Associate Director of the Community Mental Health Association of Michigan (CMHAM) and his oral presentation at a Town Hall meeting at Washtenaw County Community Mental Health on 11/15/18.

Here is how the CMHAM describes itself: 

"Community Mental Health Association of Michigan (CMHAM) is a trade association representing the 46 Community Mental Health Boards, 10 Prepaid Inpatient Health Plans, and more than 90 provider organizations that deliver services to adults with Mental Illness, children and adolescents with emotional disturbances, persons with Intellectual/developmental disabilities, and those with substance use disorders in every community across the state." 

"Part 3" gets into the nitty gritty of Medicaid funding for people with disabilities, some of which I do not understand, but then I am not alone. Many people dealing with this important benefit for people with disabilities are at times at a loss to explain Medicaid policies and why and how they are what they are. The following includes excerpts from the PowerPoint with a few notes of explanation thrown in and links to more information.

***************************************

Budget Issues/Medicaid Underfunding

Budget impact due to Medicaid enrollment shift – Shift of DAB Population

• Since FY16 our members have seen a significant shift in Medicaid enrollment involving individuals identified as Disabled, Aged, and Blind (DAB) moving to Healthy Michigan Plan (HMP) & Temporary Assistance for Needy Families (TANF) programs. Our members conducted a study that showed nearly 42,000 individuals in FY16 & FY17 categorized as a DAB and are now categorized as HMP or TANF, which has resulted in nearly $100 million in lost revenue to our PIHP system.  [This loss of funds reflects the difference in Medicaid reimbursement to CMH agencies under these programs. Reimbursement to a CMH from the state is much less if an individual is identified under the Healthy Michigan Plan (Michigan’s Medicaid Expansion for people with an income above the poverty level) than under the DAB program.] 
• The base rate amount for a DAB enrollee payment is $266.90, which includes state plan ($135.84) & 1915 (b)(3) ($131.06) (x age & gender x geographic region). The base rate for a Healthy Michigan enrollee is $29, while each TANF enrollees is $15.28. [Michigan has a modified managed care system that reimburses CMH's based on how many individuals are eligible for services under various categories plus other factors.

[See the PowerPoint on Budget Shortfalls not just a DAB issue - other Medicaid factors that describes a systemic funding problem creating a budget deficit of $133 Million "that is causing fiscal and client services difficulties across the state."]

Medicaid Funding Issues Moving Forward 

Community expectations and State requirements continue to grow.

• Increased requirements for independent living settings (HCBS) 
• more jail diversion and reentry requirements 
• housing and crisis stabilization programs 

Insufficient Medicaid funding

• Medicaid enrollment shifts (DAB issue) 
• 2-year look back for rates(does not allow for real time adjustments) 
• staffing costs continue to rise (minimum wage increases) 
• insufficient rates for both Healthy Michigan and autism have lead to an erosion of the Medicaid benefit in some areas. 

Failure to fund federally required contributions to PIHP/CMH risk reserves.

• ISF [Internal Service Fund - I think this has something to do with holding money in reserve to cover unexpected expenses?] Contribution - Late in the budget process we recommended to include, in the FY 19 Medicaid rates paid to PIHPs, revenue to support reasonable contributions, by the PIHPs, to their ISFs, as is done with any at-risk health plan. 
• Recent Medicaid rate certification letter indicates (for the first time in a certification letter) that a portion of the administrative costs provided to the PIHPs is intended for a risk margin, the amount (0.75% for DAB, the largest component of the PIHP’s revenue), this level of risk margin is far too low given the 7.5% risk corridor. If the ISF were never used, it would take a PIHP ten years to fund the 7.5% needed to share risk with the state. 

[For some unknown reason the amount of funding sent from the state to fund CMH services is $133 Million less than is actually spent. Mr. Bolter speculated that it may have to do with dollars being moved around within the Department of Health and Human Services, but he could not say for sure. In other words $$’s sent out from the state is less than what is actually spent. The deficit caused by this is $133 Million. in a system that is not allowed to have deficit spending.]

What does the Future Hold?

We would expect to see more of a deliberative (slower) process in Lansing.

• Budget process should slow down 
• Completed in June? Governor Snyder and Republican legislature completed all 8 budgets in June. 
• Return to [former Governor] Granholm vs Republican budget process? State budget process not completed until deadline 

Section 298 – what will Governor Whitmer do? [Under Section 298, the Michigan Legislature directed the department of HHS to develop a set of recommendations regarding the most effective financing model and policies for behavioral health services for individuals with mental illnesses, intellectual and developmental disabilities and substance use disorders - it has created a boatload of controversy.] 

• Regardless of 298 direction expect change 
• Too much $$ at stake and involved 
• National movement/trends in health care 
• In 2020 the Medicaid Health Plan managed care contract can be revised - Signed in 2015 – 5-year contract w/ three 1-year extensions available. 

Governor – Elect Whitmer’s To-Do-List (in the next 60-100 days)

• Hire executive office staff 
• Appoint cabinet members (Department Directors) 
• Write an Inaugural Address 
• Write a state of the state speech 
• Write/develop FY20 state budget 

Useful Information to stay informed

Michigan Votes – plain language descriptions of every bill, amendment, and vote that takes place in the Michigan legislature.

Michigan Legislature – copies of the bills, find the status, summaries, etc.

Michigan House of Representatives & Michigan Senate – find legislative contact information, committee and session calendars, and you can watch committees and session live.

Contact Information: Community Mental Health Association of Michigan 

• Alan Bolter, Associate Director  
• abolter@cmham.org 
• (517) 374-6848 

[Additional information: Work is under way to replace the Caro psychiatric facility in Tuscola County with a new facility that will increase the number of psychiatric hospital beds from 150 to 200.]

********************************

See also MI Political Landscape 2018, Parts 1 - 3

Michigan's CMH system: Facts and Figures

Abelone Kelley November 26, 2018 0