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GCS In the News
New year brings new push to overhaul patient privacy rule
By Darius Tahir
02/21/2019 04:44 PM EDT
Advocates for a privacy rule overhaul that would make it easier to share a patient's substance use treatment records are hoping the Trump administration will take action where Congress failed.
The advocates — including a cross-section of health groups, from the American Hospital Association to the American Society of Addiction Medicine — want to change 42 CFR Part 2, a 1970s-era law mandating explicit patient consent each time the records are shared with anyone.
The groups believe the law is cumbersome and ineffective at protecting patient privacy. Changing it could make it easier to detect and coordinate care for patients suffering in the enormous opioid epidemic, they say.
A legislative effort to change Part 2 fell short in the previous Congress. The bill (H.R. 6082 (115)) passed the House by a comfortable margin, but was never considered by the Senate. Advocates for the bill felt the intervention of the AMA, and persistent concerns from some powerful congressional Democrats, stymied the effort.
This year they're hoping to win changes at the administrative level. "We feel pretty confident that this administration is frustrated with the barriers to coordination for patients suffering with substance use disorder," said Duanne Pearson, senior director of federal affairs at Premier. "They are looking at every avenue to tackle care coordination."
"HHS has indicated that Part 2 reform is the final part of the regulatory sprint," agreed Rebecca Klein, director of government affairs at the Association for Behavioral Health and Wellness, which represents insurers.
HHS is expected soon to issue a request for information, which could lead to a rulemaking, Klein indicated during a press call held by the Partnership to Amend 42 CFR Part 2, an umbrella group.
Members of Congress have joined the effort. West Virginia's senators are circulating a "Dear Colleague" letter urging HHS to initiate rulemaking on Part 2, saying its provisions are "not compatible with the way health care is delivered currently." A spokesperson for Sen. Joe Manchin (D-W. Va.) said the letter is expected to go out next week with a list of co-signers.
In recent years, the department has twice conducted Part 2 rulemakings. Those efforts produced only minor changes, Klein said. But the department may have further room for maneuver.
While rulemakers "can't entirely abandon the idea of the statute," said Kirk Nahra, a privacy lawyer at Wiley Rein, "there are enormous parts of the existing regulations that didn't have to be written the way they're written."
Nahra argues that the substance use treatment data has special status: no other type of health care information receives such protection.
Privacy hawks believe the rule's protections are justified, given the stigma and societal penalties associated with substance use. But there are other, less protected medical conditions with stigma, such as sexually transmitted infections.
"It is a very tricky balance," said Lucia Savage, chief privacy and regulatory officer for Omada Health. "The opioid crisis is severe, but the rationale behind the statute's guarantee of confidentiality unless the individual consents, remains: people who are in recovery or who suffer from substance use disorder want to control who knows about this to protect their families, their jobs, their finances, and their very lives from health status discrimination or being criminalized for addiction."
Pearson argues that treating substance use data the same as other medical records, while still banning its use in criminal or civil proceedings, would be the best solution. Enforcement of violations of Part 2 have been minimal. By contrast, the HHS Office for Civil Rights' enforcement of HIPAA violations has been comparatively robust.
Advocates of Part 2 reform also say it would make it easier for medical systems to expand into addiction treatment by making data sharing easier. "Part 2 is unimplementable in an integrated setting," said Corey Waller, chair of the American Society for Addiction Medicine's legislative committee.
Whatever the results of rulemaking, "the best avenue forward would be the legislation," Pearson said.
The flip of the House makes that less likely, however. Rep. Frank Pallone, the new chairman of the House Energy and Commerce Committee, which has jurisdiction over the bill, voted against it last year. A spokesperson for the committee had no update on Pallone's position.
A spokesperson for Rep. Markwayne Mullin (R-Okla.), a legislative ringleader of Part 2 overhaul, said he would wait for any HHS rulemaking before deciding on a legislative strategy.
"If the administration drops a new rule" with significant changes in it, "I think people will come to the table on legislation," Pearson said.
GCS worked with Congressional sponsors to secure funding for the new report on child poverty from the National Academies of Sciences, Engineering, and Medicine. See below for recent Politico coverage.
National Academies report offers ways to reduce child poverty by half
By Bianca Quilantan
02/28/2019 11:01 AM EDT
Child poverty could be cut by half in 10 years, in part by expanding successful existing programs that offer food and housing assistance, according to a new report from the National Academies of Sciences, Engineering, and Medicine.
The options outlined in the report would require federal funding of between $90 and $110 billion per year, researchers said, but they said that's lower than the cost of child poverty.
The study stemmed from a fiscal 2015 omnibus appropriations bill that included a provision directing the National Academies to conduct a comprehensive study of child poverty in the United States.
Researchers reviewed links between child poverty and child well-being, and analyzed major assistance programs directed at children and families including the Supplemental Nutrition Assistance Program, the earned income tax credit and the child and dependent care tax credit.
"The committee finds that many programs that alleviate poverty — either directly, by providing income transfers, or indirectly, by providing food, housing, or medical care — have been shown to improve child well-being," the report said.
Researchers found that more than 9.6 million children lived in families with annual incomes below the poverty line in 2015, and roughly 2.1 million children lived in "deep poverty." It also estimated that child poverty costs in 2018 ranged between $800 billion and $1.1 trillion annually.
"Capable, responsible, and healthy adults are the foundation of any well-functioning and prosperous society, yet in this regard the future of the United States is not as secure as it could be," the report said. "This is because millions of American children live in families with incomes below the poverty line."
The committee's 600-page report identifies four packages of potential policies and programs, two of which they said have the potential to reduce child poverty by 50 percent and increase employment among low-income families.
The proposals expand on existing policies and programs, and add new ones, including a national job training program and a universal child allowance. Simulations of the packages showed that the "means-tested supports and work package" and "universal supports and work package" could meet the 50 percent poverty reduction goal.
The "means-tested supports and work package" combined expansions of the EITC and Child and Dependent Care Tax Credit with expansions of SNAP and housing voucher programs. The committee estimated that the package would reduce both poverty and deep poverty by half, at a cost of $90.7 billion per year. The package is also estimated to add about 400,000 workers and generate $2.2 billion in additional earnings, researchers concluded.
The "universal supports and work package" relies on a new child allowance, a new child support assurance program, an expansion of the EITC and Child and Dependent Care Tax Credit, an increase in the minimum wage and elimination of the immigrant eligibility restrictions imposed by the 1996 welfare reform law.
The report says a child support assurance policy for single-parent families would set a guaranteed minimum child support of $100 per month per child, and the child allowance policy would pay a monthly benefit of $225 a month per child to the families of all children under 17.
It is estimated to cost $108.8 billion and would increase employment by more than 600,000 jobs and earnings by $13.4 billion.
The report recommends that the White House Office of Management and Budget coordinate an assessment of the conclusions and put together an implementation plan.
Lawmakers scramble to save funding for opioid treatment at mental health centers
By Brianna Ehley
02/15/2019 02:02 PM EDT
A $1 billion Medicaid pilot program providing opioid addiction treatment at mental health outpatient centers is likely to run out of money next month unless lawmakers on Capitol Hill find a way to replenish it.
More than 300,000 low-income people would lose access to services in eight states if funding for the two-year demonstration expires. After sponsors failed to attach the money to this week's congressional spending deal, they are looking for other must-pass legislation, which could include a bill to raise the debt limit or a measure setting spending caps for fiscal 2020.
"We are looking at every (legislative) vehicle," said Sen. Debbie Stabenow (D-Mich.), who developed the demonstration with Sen. Roy Blunt (R-Mo.). It gives extra Medicaid funding to at least 78 clinics that are certified community behavioral health centers and working to integrate mental health and addiction treatment into primary care.
A funding extension for the program failed to make it into a sweeping bill to address the opioid crisis because of cost concerns. The CBO at the time estimated that expanding the program to a total of 10 states and extending it for one year would cost $510 million. Lawmakers are now considering a similar measure and sources involved in discussions dispute CBO's projections and say it would cost closer to $400 million.
If that fails to get support, lawmakers are floating the possibility of an emergency funding bill to keep about $56 million flowing to the eight states through September to give negotiators more time to work on a full extension.
Clinics in Oklahoma and Oregon, both hit hard by drug addiction, are expected to be the first to run out of the money at the end of March unless Congress acts. Clinics in the six remaining states: Pennsylvania, Nevada, New York, New Jersey, Minnesota and Missouri, will run out of money at the end of June.
The clinics will remain open, but the special designation which gets them enhanced federal matching funds for treatment would disappear, potentially resulting in thousands of layoffs and diminished care, according to clinic operators.
"We're very worried," said Verna Foust, the CEO of Oklahoma-based Red Rock Behavioral Health Services. She estimates roughly 5,000 people stand to lose access to their services in more than a dozen clinics across the state and upwards of 125 health providers could be laid off.
Stabenow told POLITICO she is starting to rally support for legislation she and Blunt will introduce to extend the program for two years and expand it to other states. Reps. Doris Matsui (D-Cal.) and Markwayne Mullin (R-Okla,) are planning to introduce companion legislation in the House.
Mullin and Stabenow both acknowledged cost is a factor. So, too, is the legislative calendar, which offers limited opportunities to pass the funding extension. Still, they contend addressing the drug epidemic and mental health crisis is a priority for both parties.
Last year's opioid bill emphasized the need to expand access to treatment, including medication assisted therapies, which are considered the gold standard of care. The pilot program pays for such treatment available to more than 9,000 people in the eight states, according to the National Council for Behavioral Health.
"It definitely undermines the ability to provide ongoing opioid treatment services," Stabenow said.
Sponsors two years ago hoped to make the pilot program nationwide but dropped the idea over cost concerns. They now find themselves arguing for its survival, pointing to the need for a steady, dedicated stream of funds.
"This critical program must be extended so it can continue to serve individuals needing mental health or substance abuse treatment," said Matsui, who co-sponsored the original House legislation creating the demonstration. "Congress must act now to ensure that funding does not lapse."
Advocates say the demonstration is a crucial first step toward integrating mental health and addiction treatment into primary care services. They say this approach is more sustainable than providing behavioral health services through grants — a process that is favored by Congress.
Clinics participating in the demonstration must offer a variety of required services including addiction and mental health screening, 24-hour crisis services, care coordination and recovery services.
"The combination of the requirements for the program, coupled with the payment methodology make this kind of investment possible," said Chuck Ingoglia, senior vice president of policy for the National Council for Behavioral Health, which provides technical assistance to the clinics. "Providers don't usually expand capacity on grant dollars as these are too volatile and unpredictable."
According to a survey of clinics, conducted by National Council for Behavioral Health, 87 percent reported an increase in patients — the vast majority had an increase of up to 25 percent. Roughly 68 percent of clinics reported a decrease in patient wait times, while 30 percent have seen wait times remain steady. A federal evaluation is forthcoming.
Clinicians agree that the program shows promise but say the first two years of the demonstration was spent on building infrastructure and hiring staff. They say the program should be extended to realize its full potential.
"We need more time," said Jeffrey Eisen, chief medical officer for Oregon-based Cascadia Whole Health Care. "We already have preliminary data that suggests that were headed in the right direction."
Oregon is preparing to submit a state plan amendment to CMS to continue the demonstration as a contingency plan if Congress doesn't extend the program. Mullin said Oklahoma is looking at similar options.
"We're going to try to do what we can to keep this running," he said.
Still, the uncertainty has clinic operators concerned.
"We spent a lot of time and money changing our system," said Foust of Red Rocks Behavioral Health Services. "To have to turn the clock back to where we were, it's depressing."
Health advocates say schizophrenia should be reclassified as a brain disease
By Brianna Ehley
01/04/2019 05:17 PM EDT
Mental health advocates are lobbying Congress to help them get schizophrenia classified as a brain disease like Parkinson's or Alzheimers, instead of as a mental illness, a move that could reduce stigma and lead to more dollars for a cure.
Federal health officials, scientists and doctors say conditions that cause psychosis, such as schizophrenia and bipolar disorder, are poorly understood and, in the public mind, often associated with violent behavior. Patients are more likely to be homeless, incarcerated, commit suicide and die younger than those with any other neurological diseases.
"Look at the disconnect in the way these patients are treated. It's unconscionable," said Raymond Cho, professor of psychiatry research at Baylor College of Medicine and chairman of the Schizophrenia and Related Disorders Alliance of America.
His group is among those focusing on appropriators in Congress — particularly those who have championed mental health in the past — to include schizophrenia in a new CDC program that aims to collect data on the prevalence and risk factors of neurological conditions in the U.S. population. The findings could eventually be used to push the World Health Organization to reclassify the disorder — a complicated process that may take years.
The problem is the CDC only has enough money to study a finite number of conditions, putting disease advocacy groups in competition with each other.
The schizophrenia patient advocates' efforts are just beginning, and to date, no lawmakers have clearly adopted the cause as their own. The Trump administration hasn't taken a position at this point, although the chief mental health official Elinore McCance-Katz acknowledged there's data supporting a neurological underpinning to the condition.
John Snook, executive director of the Treatment Advocacy Center, a nonprofit that aims to eliminate barriers to treating mental illness, said the CDC has long ignored some less understood conditions despite alarming mortality rates. The death rate among people with schizophrenia is four times higher than the general population, according to one study.
"To not have the CDC engaged in this sort of outsized burden is very much a signal to other researchers and people in the pharmaceutical industry and to everyone that we aren't taking mental illness as serious as other illnesses," he said.
Part of the attitude may stem from the fact the cause of schizophrenia is unknown. Genetics, environment and an imbalance in brain chemistry all contribute to the risk of developing the condition, which may afflict upward of 2 million Americans, according to the National Institute of Mental Health. It's long been considered a severe mental illness because people with it experience episodes of psychosis involving delusions and hallucinations — often beginning in early adulthood. Treatments typically focus on minimizing symptoms.
Groups pushing for reclassification hope to do the same for other conditions like bipolar disorder, which can also involve psychosis, but are starting with schizophrenia because of its dire consequences. The NIMH ranks the condition among the top 15 causes of disability worldwide and estimates serious mental conditions like it can reduce the average lifespan by 28 years.
"The science is clear, it's a neurological condition," said Snook. "If schizophrenia was a disease that we just discovered today there would be no question that's how we would classify it."
"It's a brutal disease," added Linda Stalters, executive director of the schizophrenia alliance. "We are still treating people like they did in the medieval times."
But discussions of the disease and its telltale symptoms are often confined to the aftermath of mass shootings, when the focus typically turns to the shooter's mental health.
Cho's group, along with the Treatment Advocacy Center and the National Alliance on Mental Illness, said reclassification as a neurological condition would potentially unlock more research funding. The agencies that make up the National Institutes of Health were on pace to spend $1.9 billion on Alzheimer's research alone in 2018, more than the entire $1.2 billion budget for the National Institute for Mental Health.
Heightened awareness could also increase access to treatments that aren't always fully covered by insurance. Mental health services aren't always covered at the same level as other medical conditions, despite federal parity laws.
Arman Fesharaki-Zadeh, an instructor of psychiatry and neurology at Yale School of Medicine, said separating people with schizophrenia and other serious mental illnesses from other brain diseases is an outdated approach that he described as "insane."
"They've been shunned away from society," he said. "I don't believe in the separation of this diagnosis at all."
But some in the mental health community aren't sure that reclassifying the condition will transform attitudes.
"I'm skeptical that officially classifying it is going to change how the general population thinks about it," said Joe Parks, medical director at National Council for Behavioral Health.
"I think it's more like a Hail Mary," said Paul Gionfriddo, president and CEO of Mental Health America. "I'm not sure that this could catch on just yet. There's not the kind of science yet behind this that would generally have people think about it the same way" as Alzheimer's and other common brain diseases.
But the groups lobbying for reclassification said that's exactly why they want schizophrenia included in the CDC surveillance: to convince researchers and the public the condition is biologically based with probable causes.
Schizophrenia research "would probably glean more funding once we have actual numbers showing there are more people suffering from this than we currently know," Stalters said. "There would be more of an emphasis on discoveries and treatment."
On December 12, 2018, Politico Morning eHealth featured a quote from GCS’s Al Guida on the low level of EHRs within behavioral health provider settings.
“Noting that while CMMI — due to the SUPPORT Act (H.R. 6 (115) ) — will have future opportunities to help extend tech, Rucker argued that the government has an opportunity to improve things rather simply making sure admit, discharge, and transfer (or ADT) data is disseminated through health information exchanges that tell doctors when their patients have been hospitalized. That might help for patients admitted for a drug overdose.
"There may be low-hanging fruit and we are looking at how to expand that," Rucker said. His comments back up our earlier reporting about last week's White House interoperability meeting, during which CMS Administrator Seema Verma stated that the government is hoping to promote more fulsome release of ADT data.
It's "not enough," said Al Guida, a lobbyist for the Behavioral Health IT Coalition, noting increased usage of EHRs was a critical prerequisite for safe expansion of medication assisted treatment. Such treatment can be most safely used if prescribers check whether there are any patient allergies or interfering medications — both of which are best with an EHR.”
On December 5, 2018, Politico Morning eHealth featured an update from the BHIT Coalition.
BEHAVIORAL HEALTH IT COALITION LETTER TO CMS: The Behavioral Health IT Coalition wants CMS to boost health IT as it implements the new SUPPORT Act, H.R. 6 (115), law to combat the opioid crisis. Specifically, the coalition — with members like the American Psychological Association and Association of Behavioral Health and Wellness — wants proof of interoperability capability to be mandated to be eligible for CMMI demonstrations, as well as use of ePrescribing for medication assisted therapy demonstrations.