HJR 225

Joint Subcommittee to Evaluate the Future Delivery of Mental Health, Mental Retardation and Substance Abuse Services

Summary

The results of the 1999 Session of the General Assembly Session hold great promise for the future of publicly funded mental health, mental retardation and substance abuse services. Action taken by the Assembly will serve to rectify some long-standing issues, deal with current service provision, and put the Commonwealth on the road to better, more appropriate, and accountable services to those in need.

Key legislation dealt with the following issues:

• Juvenile competency, which involves court procedures to determine the competency, restoration, and disposition of those juveniles determined to be unrestorable.
• Civil commitment of sexually violent predators whose mental disabilities render them so likely to commit again that they constitute a threat to health and safety.
• Substance abuse screening of certain offenders. Pilot sites for this program will be selected by the Chief Justice of the Supreme Court.
• A study of drug courts by the Department of Criminal Justice Services to determine the structure, funding, and services guidelines.
• Criminal background checks for those persons applying for jobs with an agency licensed by the DMHMRSAS and providing services for community services boards.
• Mental health insurance parity.
• Grant money for eligible caregivers.
• Enhanced human rights protections for Virginians with disabilities.
• Studies to examine housing for persons with disabilities and the use of existing mental health and mental retardation facilities by the Comprehensive Services Act program.

Budget

During the past two legislative sessions, the General Assembly provided a record increase of $171 million in general funds to strengthen the system of care for mentally disabled persons in Virginia. In response to hearings held across Virginia by the HJR 225 subcommittee, most of this funding was targeted at serving mentally disabled persons in the community.

Of the more than $100 million appropriated for community services, about $52.2 million was added to improve community services for mentally ill citizens and $42 million was added to improve services for mentally retarded citizens. Another $6.8 million in general funds and $8.2 million in federal funds was appropriated for community substance abuse services. Part of the increased funding, about $13.7 million, will support the gradual reduction in census within state facilities.

In addition to improving community services, the General Assembly has added about $62.1 million over the biennium to improve care in state institutions and meet federal requirements. Almost $6.9 million was added to measure outcomes and improve techniques for providing high quality care in the publicly funded mental health, mental retardation and substance abuse services system.

1999 Work Plan

In its first report, the subcommittee made a number of key decisions, including (i) the validation of the need for the Commonwealth to continue to operate facilities; (ii) validation of the basis for the system of community care, with the use of public and private providers; (ii) affirmation of the role of the community services boards (CSBs) as the single point of entry into the system; and (iv) proposing that the state and community system continue to implement the use of managed care technology.

Continuing its work in 1999, the joint subcommittee will:

• Continue to examine the issue of accountability with a review of the implementation of the provisions in HB 428 (1998) to assure that the provisions are appropriate and are providing useful and meaningful results.
• Review the allocation of the new funds in the biennial budget.
• Review the development of the necessary community-based services, including residential alternatives, availability of providers, and quality assurance.
• Review criminal justice system coordination with community services and identify gaps or overlaps in services and treatment available.
• Review the use of Medicaid for the provision of community and facility services and use of the MR waiver.
• Examine the potential use of state mental health and mental retardation facilities for CSA services.
• Analyze and act upon the reenactment clause placed on the human rights legislation in the 1999 Session.
• Review the results of a number of specific studies authorized by the Joint Subcommittee, including POMS, the Priority Populations pilot, the primary health care needs of the mentally disabled, the brain injury program, geriatric services, the welfare population substance abuse treatment program, human rights legislation, and the ACR pilot project.

The subcommittee estimates that work on these items will be completed by December, when final recommendations will be made and a public hearing will be held for comment. Meeting dates are scheduled for November 16 and December 15 in Richmond. Materials and a full meeting schedule for all work groups can be found at the study website (http://dls.state.va.us/hjr225htm).

Comprehensive Services Act

SJR 478 of the 1999 Session authorized the HJR 225 joint subcommittee to establish a work group to examine the potential uses of any portion of state mental health and mental retardation facilities which may be vacant for the provision of services to children and families under the Comprehensive Services Act (CSA). The CSA originally was intended to serve those children who needed help from many agencies and to pool funding streams to better access services. Unfortunately, although prevention is still an important part of the program, reality has shown that there are many children who are so out-of-control that residential placement and treatment is a necessary, but very expensive, component. In one case cited, over half of a locality's almost $1 million CSA budget was spent on only 10 children in one year. Placements may not even be available in-state, which results in out-of-state placements. These children are unique in that they do not qualify for involuntary commitment in psychiatric facilities.

The work group held its first meeting on July 30, at which time localities were given an opportunity to present their perspective on the need for alternative arrangements. Future meetings will include presentations from the Joint Legislative Audit and Review Commission, which last year completed an in-depth review of the program; private and other providers of services; advocates; state agencies; and additional input from local governments. A report with recommendations will be presented to the full joint subcommittee for approval.

Human Rights

The joint subcommittee heard presentations at its August meeting from the executive director of the Department for the Rights of Virginians with Disabilities (DRVD) and members of the disability rights advocacy community concerning human rights issues. The presentation was in response to two recent events involving DRVD. First, Executive Order 46 (99) transferred DRVD to the Secretariat of Administration effective July 1, 1999. Second, a coalition of disability rights advocacy groups sent a letter dated July 26, 1999, to Secretary of Health and Human Services Donna Shalala requesting a withdrawal of federal funds to DRVD. The advocacy organizations claimed in their press release that "tax dollars are squandered on DRVD because the agency has consistently failed to advocate for disabled persons as required by federal and state guidelines."

The DRVD's executive director responded: "The transfer of DRVD administrative support from Health and Human Resources to Secretary of Administration... was fulfillment of an administration promise to make DRVD more independent.... No additional funding, no new hires, no operational changes will result." She further stated that "DRVD will not be defunded by Secretary Shalala, and the Governor is not obligated to change its state agency status." At the conclusion of the presentations, Delegate Hall requested that Delegate Bloxom reconvene the Human Rights Work Group in order to help resolve these ongoing issues. The Human Rights Work Group will meet September 9, 1999.

Medicaid Work Group

HJR 212 (1998) directed the joint subcommittee to study the "the impact of a carve-out of Medicaid-financed mental health, mental retardation and substance abuse services from any managed care contracts negotiated with health maintenance organizations and the feasibility of contracting out the administration of all Medicaid-covered... services to the Department of Mental Health, Mental Retardation and Substance Abuse Services." Toward that end, the Medicaid Work Group established a work plan to examine eligibility; amount, duration and scope of services; and structure and financing.

The work group has considered information concerning access to atypical antipsychotic medications, the impact of current eligibility requirements, and statewide access to services provided by community services boards (CSBs). The Department of Medical Assistance Services (DMAS) reported that statewide access to services is restricted because few CSBs are able to provide the full array of Medicaid-reimbursable services. In response, CSBs say that restrictive Medicaid criteria and limited funding have affected statewide service availability. The work group has also received a number of recommendations from advocates and providers, including reimbursement for assertive community treatment as a bundled package of services, increases in rates of reimbursement to keep pace with inflation, more flexible eligibility requirements, and increased choice among providers.

Representatives from the Health Care Financing Administration (HCFA) stressed the importance of adequate planning, reliable data and information systems, attention to children's services, and coordination with health services and other state agencies. HCFA and the federal Department of Health and Human Services view Medicaid as a federal/state partnership and want to support leadership in the states. States should decide what they want to accomplish and then HCFA will help in reaching the goals.

The work group is currently considering several alternative models for the structure of Medicaid for mental health, mental retardation and substance abuse services. Two of the models consist of a carve-out of the administration of Medicaid to the Department of Mental Health, Mental Retardation and Substance Abuse Services. Other states have found it important to spend time and resources on developing integrated information systems, building capacity (including technology) at the local level and providing incentives to achieve desired outcomes among consumers. Some states have also learned the importance of maximizing Medicaid revenue before seeking additional managed care waivers; states can incorporate managed care technologies into the system of care while they refine the system.

The Honorable Franklin P. Hall, Co-Chair
The Honorable Joseph V. Gartlan, Jr., Co-Chair
Legislative Services contacts: Gayle Vergara, Amy Marschean, Nancy Roberts

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