Transcripts For CSPAN2 Mental Health Care 20171216

We actually have office of Tribal Affairs we have ongoing meetings with tribal leadership. When i came, i learned one of the Addiction Technology transfer centers that was specifically put in place to it assist tribal nations was going to end it. That has now been funded with a funding announcement out and we will choose a grantee, who will work with tribes and meet their cultural needs as well as their Substance Abuse needs. We also work as i mentioned with Indian Health service. We have our chief medical officers meeting with theirs and working with them around what kinds of Technical Assistance and Training Needs it do they recognize and can help them with. I wont take a lot of time, but we have Training Programs that are quite good. Think you because i am out of time and before the hearing i spoke to you about Supportive Housing and i want to continue the conversation with you even as i leave this body. I think thats very important that people with Mental Health disorders and with addiction get Supportive Housing and Wraparound Services, so thank you for engaging my conversation before the hearing. Senator whitehouse. Thank you chairman. Appreciate it. Welcome, good to see you again before the committee. We in the negotiations got a commitment bipartisan commitment for an extra Million Dollars to be spent on opioid treatment. Of the first half of that was already distributed and we hope and expect the second half will come through at the end of this year funding measure, whatever that ends up looking like. We are counting on that. In the last one the measure by which the funding was distributed to states didnt correlate to the rate of the Opioid Epidemic, intensity and severity in that state nor did it connect to the recently passed tariff bill. Im hoping as we move forward on this you will be in a position to structure the grant process for that second half billion in such a way that it more accurately addresses the highimpact state and that it better connected to the terra bill. I think you can probably do that in the terms of the Grant Application request you structure from samsung. I just want to hear where you plan to go with that because highimpact states kind of got not treated so well. So, my understanding of this situation is that if we make any kind of changes to the previous funding announcement, then all states would have to reapply for the money. I can tell you we have been hearing from lots of states about their concern and having to reapply for the money and the decision was made to not have any substantive changes in the second year funding for that billion dollar, 500 million each year. For the sake of the process convenience for all the high intensity states pay the price . I would say couple of thinks. One when that decision was made i did go back and we looked very hard and did find money and put a new funding announcement out that does prioritize those states that have been hardest hit by the Opioid Epidemic. I will continue to do that. In addition, the other thing ive been able to do is to reallocate funding so that we are building a new Technical Assistance program that will be individualized to every state, so those states hardest hit who have certain types of special needs we will have local Technical Assistance available to them that we think will be important to helping them implement as efficiently and effectively as possible. Going forward from that two years of funding whatever congress and the president decide upon we will look at that and be very much aware of the kinds of issues you have just raised. Please also be an advocate for additional spending in this area. I think we were able to get 170 million in the last funding measure. That is 2 of the 8. 6 billion that the pharmaceutical industry makes selling just the prescribed opioid products, setting aside the illicit stuff that comes over the border, so 2 up against the devastation we see in the context of a multibilliondollar industry i would consider a beachhead, not a victory. I hope you agree. Yes, sir. Last quick thing. The Health Insurance commissioner is you know in rhode island is looking at the parity compliance of the Insurance Companies in rhode island and i know youre looking at that at the national level. Can i make sure you have someone on your staff coordinating to make sure you support their work if everyone is pulling smoothly together on parity disclosure it enforcement . 23 next. One, a parity tool kit for Insurance Commissioners we have made available to all of the states and we have an Office Around Health Care Reform issues and we have a person who works individually with the states and the Insurance Commissioners within the state so we will make sure that happens. Appreciate it. Chairman alexander. Thank you. Welcome. I want to follow up, senator whitehouse is question because if i remember right it was his language we put in to try to make sure the money distributed took into account highimpact state. Mi not correct about that . The problem is that it was based, as i understand it, on the number of opioid deaths. Right, but obviously the big number, but not a big impact. So our intention was to recognize the importance was to distribute money to highimpact state was our intention. That was not accomplished. So, what do we need to do to accomplish our intention . You are saying it would be impractical to cause the states to reapply again. I can see that, but there will be more money coming for opioids we dont know when or where or how much, but is it the language about the difference between highimpact states them in the number of total deaths, per capita death is at the issue were what kind of language would you recommend that we include in any new funding so we direct money with a particular sensitivity to highimpact states . I was not here in the Previous Administration when the decision was made. However, my guess would be they were trying to implement as congress directed and i dont know. What would be a better way . Im not trying to criticize. Im just saying if you are doing it today how would you do it . For the new funding announcement that we just put out, what we said was we were looking at the rate of opioid Overdose Deaths within the state in the rate of increase yearoveryear. Of that tells you how hard a state is being hit. Will that affect the second round of the funding . When the second round of funding comes forward that doesnt require reapplication . If its a new source of funding, no. Everyone would have to apply for that funding. The second round the second half billion dollars that you just described. So, no. But, you would recommend what you just said would apply to any new money . Exactly. Would you work with our staff so if we write that properly and our intention is to recognize highimpact states that we do it in a correct way so we are not surprised. Absolutely, yes. In 2014, congress required i remember the discussion with senator whitehouse and i wanted to see we try to implement his intention and we can keep working on the. I am so grateful you followed up that way, chairman. In 2014 congress required states to set aside 5 of community Mental Health block grant funds for Mental Illness. This increase the requirement to 10. That sounds good, but reduces the flexibility the states had to address what my be different in rhode island and california. What is your opinion about the increased from five to make 10 . Does that help or hurt the ability of states to respond . The vast majority of payment of services delivered is not from samsara. The block grant having an increase of 10 has is it causes a focus on early identification of First Episode psychosis. We know the longer a person goes without having their psychotic thinking detected and treated the more refractory their illness comes over time and so that 10 in the block grant does a tremendous amount of good in terms of raising awareness of this important issue. Out is that encourage early prevention . The language just looks is serious Mental Illness or does it say about early . It talks about early identification of the serious early identification of serious Mental Illness. Yes. Not just serious, but early as the key really too effective and frequent. We consider psychosis to be indicative of serious Mental Illness. You think the 10 helps. I absolutely do. Because they pushed towards early identification of serious Mental Illness. Yes and we know the onset of most psychotic disorders is an outlet it adolescents and transitional age youth, so its important to the lies these folks will live going forward. Thank you, mr. Chairman. Thank you very much senator cassidy and mr. Chairman, thank you for holding this hearing and doctor, thank you so much for being here in the work you do. I want to follow up on a conversation we were just having about funding for those of us from states who have been incredibly disproportionately impacted by a horrible epidemic taking lives obviously across our country, but in New Hampshire heroine and Opioid Epidemics is that no killing people in my state at one of the highest per capita death rates in the country and we have been targeted by dealers. I was at a funeral saturday were eight family buried their second daughter from an overdose. A woman had been in recovery and working really hard and this disease is taking all of our efforts and im very grateful to everyone on the committee, but i will add my concerns and frustrations to what you heard from senator whitehouse. I have expressed record to the secretary and i think the fact that states are uncomfortable about reapplying is not an excuse in terms of the decision made for the second round of this funding and towards that end a senator capita kunz, myself and senator mansion have a bill called the targeted Opioid Funding act to change the funding to make clear what kind of priorities we should give to per capita death the states and i would love the committees attention and collaboration on the bill, but even if we fix this formula under the act, we know the money right now is only for two years and we know theres no quick fix for this epidemic. We desperately need funds to fight this epidemic. We need the administration to tell us what supplemental resources is proposing to turn the tide and i was appreciative of the doubt the white house in october when the president s declared this a Public Health emergency, but so far weve not seen followup to the declaration we have seen no proposal from the administration for the funds we need to tackle this epidemic everywhere in our country, and epidemic not only taking lives, but in New Hampshire cost us over 2 billion in our economy, so have you had conversations about the need for additional funding with hh s of the white house . Why hasnt this administration called for additional funding or proposed additional funding so we can get the dollars and resources to the frontline . I think there are many conversations going out about what the needs are and lots of efforts to look at the Data Available and Information Available its my understanding that the administrations interest in working with congress on developing those that both the president and congress can agree upon to bring more resources to bear. This congress had made clear we support additional funding that we need a partner in the administration to stop talking and start funding. I look for to continuing conversations. I also wanted to followup with another another question because we know how complex the opioid use disorder is. Its often accompanied by a variety of Mental Health disorders including post dramatic stress disorder leading to complex and sometimes dangerous outcomes. Veterans in other populations with ptsd are often prescribed higher doses of opioid putting them at a greater risk for accidental overdose at best are treating one disorder does not address symptoms of the other. Is imperative we work to ensure patients have access to comprehensive treatment to address both Substance Abuse disorder and Mental Health needs has it helped sam thought enhance availability from dual diagnosis to Mental Health disorder . I believe they have and specifically i can speak speak to the issue around department of defense and veterans affairs, which has developed into a very strong relationship where samsara works collaboratively in an ongoing way and we specifically address the issues of mental disorders and Opioid Epidemic as well as suicide. Those are the big issues we are working on right now and we also can use the information that we learn from the va which actually does a lot of research of its own and we share this and we promulgated to communities. I thank you for that in the vision of the integrated healthcare in this area. Im most concerned we are delaying some of our work that would be made possible with xo funding because of the stigma attached as some other senators have referenced and i appreciate your efforts. Doctor, good to see you. I read a book some months ago by sebastian younger, small little book called tribe he discusses the challenges our veterans face as they reintegrate back into Society Makes a point from an evolutionary standpoint we are more comfortable in Tribal Society like military platoons embedded in a military structure then we are in the Current Society where people tend to feel lonely so there are challenges of reintegration and adaptation so we turn it on its head the challenges our veterans are facing, not per se with the veteran, but maybe broader society. Its an interesting read and when i lay that line of argument, that analysis on top of the study, the depth of despair study that indicates we see increasing rates of morbidity among middleaged men, white men in this country and the reason for the death and heightened suicide, alcohol use and so forth start to think loneliness is driving so many of the Mental Health issues in our country. Can you give me your assessments of that perhaps popular reading of the literature . I do think that those are important points and i actually think theres Research Data that says people who are isolated who will endorse loneliness and feeling ostracized within their communities died at much younger ages, so thats important. Is a driver is what im hearing, a driver of some for Mental Health challenges what interventions work . Senator young, i think its a topic and evolution. I think there is some accumulating evidence for the value of recovery supports as they relate not only to Substance Abuse disorders, but mental disorders and so one of the things im working on and at this is one of my priorities, actually is to bring psychiatric medicine into closer contact in collaboration with Community Recovery support. Its not enough to just provide medical care and psychiatric medical care. People need those recovery supports in their communities. They can be a veteran based, faithbased, so you get where im going and i think that it will go a long way towards assisting people to live the fullest life to think it seems consistent with common sense that theres more needed in medicating these problems away. People need genuine human contact, relationships that are meaningful to them. They need to feel like they are part of broader community. So, i just have a couple of minutes left. If we could turn to how the federal government incorporates or fails to incorporate feedback loops in terms of addressing Mental Health and the policies we have. Theres a recent governing Magazine Article on this written by Health Economic professional at Harvard Med School and former Obama Administration official and authors advocate for he peered evidence approach to allow scaling up of evidence based approaches while supporting fuel generated innovations. Have you considered including evidence approach and some of your programs say the national Mental Health Substance Abuse policy lab . Thank you for that question and i think we spoke a bit about this when i was going through the confirmation process. I want to publicly speak about it. The answer to your question is yes, we are and im happy to tell you that the policy lab is stood up now. We have hired a director who i think is very experienced and knowledgeable who will do exactly that kind of work. I continue to have great interest in this and we will followup with you to see how it might be supported from a legislative standpoint. Senator franken. Thank you, mr. Chairman. I was glad to hear you talk about recovery support. We had rebecca boss from rhode island i know you are from rhode island. I used it to work for her. She was doing unbelievable work. They do exactly what youre talking about as getting into the community. One of the things that we put in 21st century is more crisis intervention training for police we talked before the hearing about judge lightman in miami who has implemented a system where people with Mental Illness and Substance Abuse who get arrested instead of going to jail, which they used to do an posthumous amount of money or go to the emergency room which also cause a lot of money is getting them housing and Wraparound Services and that is it something that i think talking about i know senator young and i have talked about housing as a way and we have done this in minnesota as well, but that is something that i want senator young and others on the committee to keep advocating for and keep thinking about and be bugging you even from outside. I want to i want to talk about Indian Country again. The senator talked about ptsd or talked about trauma and we see tremendous amount of trauma in Indian Country, not just a historical trauma, but the trauma of extreme poverty of domestic violence, drugs, sexual abuse and all of those things so that is why we see such high incidence of opioid deaths in that Indian Country. I went to a rehab of four teenagers in the northern minnesota a couple of years ago and i have been to a number of rehabs and i had never seen such hopelessness in a rehab. Usually when you go to rehab there are people feeling hope at a certain point and what i really got was that these kids, most of them started use with their parents and the hopelessness that i saw was what they were going back to and they seemed to this is true also not without Indian Country. I was in rochester minnesota without roundtable on opioids and a woman whose daughter had gotten treatment 20 back to my felon with the old crowd and now is gone. One of the things i was thinking of again with housing is a model of and may be piloting this of a sober living housing in Indian Country where instead of going back to where you are living, going to a facility that has people like you, you know, and it could be very close to the reservation or on the reservation, but where you are getting continuous the support in being tested and you have a fellowship with people there who are living sober, also. Especially with opioids this is a longterm thing. Its is in 25 days of detox and then 28 days. Its much longer than that, so thats something that i would really like to advocate for and one last thing about culturally specific in Indian Country i think its important, but i did a roundtable in minneapolis and one of the providers there, one of the counselors said to me i said what is that mean culturally specific and she said when an indian woman sees me as her counselor because im indian she knows i know what shes been through, so i think a culturally specific means more than i think it means actually in Indian Country making sure we train the providers, so thank you. Yes and i agree with you, yes. Senator warren. Thank you, mr. Chairman. Doctor, one of the most important things we did in tears was to create an office of the assistant secretary of Mental Health and Substance Abuse which is now that you have been nominated to head up. We need to ramp up our response to the Opioid Epidemic meaning using every single tool in the toolbox and one tool is to put more resources into Mental Health, so can i ask you to tell us why its so important that we address Mental Health if we wanted to beat back the Opioid Crisis . Yes because there is such a very high rate of occurring mental disorders with Substance Use disorders in the genesis of these mental disorders often predate the Substance Use disorder itself and we also know that if we do not address both the disorders, treating one does not treat about. Good, very distinct way to put it. Its clear making progress on the Opioid Crisis means putting resources into treating Mental Health disorders. Medicaid is the largest Funding Source for Mental Health services, but sam set has a number of Health Programs that funds of services not covered through public and private insurance. Mental Health Services block grant and a group of other Grant Programs are sam says main Mental Health programs providing funding for all 50 states and supporting the work of Mental Health agencies of local governments and nonprofits working in this area. Of these programs are absolutely critical to improving Mental Health in this country and they serve the millions of americans, but let me ask you, is everyone who needs Mental Health care able to get that help right now . I would say the short answer is no. Why not . There are a variety of reasons. We know a lot of people who we would say need this kind of assistance dont want it, but then there are also barriers that prevent people from getting care and treatment they need. It can be difficult to access care. Do you havent estimate of how many people need Mental Health treatment that are able to get it . I think data told us around 12, 13 million. That is a stunning number and now the Mental Health Services Block grant are sam says to largest Mental Health program and combined we spend less than a billion dollars in year on this programs, so the White House Council of economic advisers released a report last month estimating the cost of the Opioid Crisis to this country. Could do you know what figure they came up with . Im guessing it was high. 504 billion. Think about that. The cost to this country annually to the Opioid Crisis is more than half a trillion dollars in 2015. We are investing only one fifth of 1 of that amount in helping samsara of the Mental Health peace of this problem. I think we need to do more and thats why it called for an additional billion dollars of funding in next years budget to double the samsara budget and let them double what they put into the two largest Mental Health programs. Yesterday the National Council which represents 2900 Mental Illness and addiction organizations wrote me a letter and i want to quote. They said now is the time to support the highest possible level of funding for Health Care Programs in the federal budget and today this morning the Massachusetts Association for behavioral healthcare sent a separate letter requesting congress double these fonds and i could not agree more that doubling the funds for these mental help Health Programs would help give americans access to the treatment they need and start making a dent in the astra nominal the astronomical price that its putting on our country. Thank you. Senator game. Thank you, mr. Chair. I want to ask about the issue i hear about all the time in virginia from my Law Enforcement community, the intersection between Mental Health and people who are in jails and prisons who should not be. I have a lot of tough Law Enforcement sheriffs and Police Chiefs who lament the fact that their jails are filled with people who have diagnosed, untreated or never diagnosed Mental Health so they feel these people should not even be in jail and if not treated they will harm themselves or others. They feel like they are being asked to be the Mental Health provider for society that doesnt fund Mental Health services and they feel a compassionate anger and also a resource challenge that makes it hard for them to do their job, so i went to ask about that and i also talked to Police Chiefs sometimes after high profile incidents of Police Shooting and they will say at the bottom some of this was the police approach. Someone had a Mental Health need and we are not completely trained and his spirals into something worse and i can become a flashpoint for community anger, but at the bottom there was an untreated Mental Health issue. The 21st century cures act had important provisions around Mental Health in the criminal Justice System including a serious Mental Illness coordinating committee and a provision that called for the attorney general to establish a Pilot Program to determine the effectiveness of diverting eligible offenders from the federal court system into drug and Mental Health courts. Can you tell us a little bit about work with the coordinating committee in conjunction with the criminal Justice System and the attorney general and department of justice have they been supportive of these efforts so, a lot of questions there, but yes. We call it the Inter Department series coordinating committee including the department of justins have been good partners with us and we expect to continue as you know its a fiveyear process. You will be getting that report from the committee today and the issues around the interface between serious Mental Illness and the Justice System is one of the primary areas of focus within that report and i will tell you also that we have programs at samsara that are dedicated to diversion, Mental Health courts with programs for offender reentry so they dont get lost through the cracks because my own experience having run a Hospital System in rhode island was that we frequently would get folks back because they didnt get into appropriate Outpatient Care at the time they were leaving and even though we might provide treatment to them while they were incarcerated that stopped so that is nick has addressed this and i hope you will be pleased with some recommendations. I look forward to reading it and the thing im most familiar with at the state level with the use of Mental Health courts, which are significant, can you talk about about how the mental court system working at the federal level . What you will be reading this that we need more of these types of programs and these programs are very effective in diverting people away from incarceration and into treatment, appropriate care including medication because a lot of these individuals need medications and have not gotten it and dont continue to get it and thats part of what the committee has recommended that the issues around civil commitment laws be looked at to try to maintain a person in care once they leave. Also, the other thing we talked about in the report is the Crisis Center. The use of a Crisis Center that is specifically geared to the treatment of people who have Substance Abuse and mental disorders rather than going to the Emergency Department which is not appropriate and where Law Enforcement off to get stuck, so these interventions can be helpful in freeing up Law Enforcement in getting people to care they need. I have one more question if i could ask. Should i just go ahead . Yes. I know many of the questions asked have been about opioid issues and i worked with colleagues to introduce eight prescribing safe lives act and i was pleased to see that it was a bipartisan effort. How much progress has been made in terms of making it more available to the average population and can you speak to the availability of prescribing guidelines . So prescribing guidelines we have a toolkit that speaks to the use of all of the available formulations and its in the process of being updated because there have been improved to formulations, so thats available. Also encouraged hope kos prescribing. We train our copra scribe in we have programs available that train First Responders and also provide for funding for persons. I have kind of a followup. If followup not only to what i asked earlier, but a previous hearing where you were. My previous line of questioning i asked how would monitor outcomes. Last Committee Hearing i asked how do we monitor a specific program if we have Treatment Program a and Treatment Program be in Treatment Program a has high recidivism with a lotta folks overdosing in the emergency room two weeks after discharge and program be where they have a more effective approach and we dont see that they are billing and i asked you last time if the answer to i think the answer i got was great idea but probably not at this point. In relation to asking this earlier, is it possible for samsara to do that without agreement with cms to look at billing data to see if there is a marker of recidivism for example emergency room visit a week after discharge. How do we look at programs treating folks for addiction and no if the programs are effective in the taxpayer gets the best deal for her daughter dollar, but more importantly the patient gets the best outcome relative to recovery for their addiction. Thoughts . The issue around a cms and their billing data is when we have to work on guess i am reviewing all of the Data Collection programs right now and we are going to be making that data more available publicly, so its not just a matter of its not just a matter of collecting the data so we can see whether the programs are good, but making it available to the public and so we are working with our center for behavioral assistance and quality to look at means by which we can make the data more available. The other thing we do is i will tell you for that fdr. Fcr . 500 million year for two years. , clinician and im meeting with my staff about every single grant. We are looking at every Single Program to see how states are using their money. Let me ask. In followup if states are doing it differently as their common way you can say this is how we should evaluate because absent billing data which is apparently only available from cms, it seems to be difficult to reevaluate recidivism rates. Many Treatment Programs are geographic distance from where the patient begins, so if there is a way to evaluate the billing data, when does it exist and to his cms promulgating this . So the answer to your question is we have several evaluations of the Program Ongoing and we are monitoring the state to make sure theyre using evidence based practices. We have one of valuation done by cdc in another by a contractor and that data will be made available publicly, so thats an ongoing project. By the way, i dont personally think that data should be used [inaudible] the other thing we do is because we are working closely with the state and because we have a new program we will also be asking the states to bring forward data on their programs because they have abilities to see when will the data be available for the general public or congress to review . I dont know the exact answer, but i will find out and get it to you. Thank you. I wanted to ask, on the challenge of broadening our Mental Health workforce, senator cain accurately talked about converting individuals out of criminal Justice System and often your first interaction with the criminal Justice System happens at school. Many kids with Mental Illness will misbehave at school, run into a Police Officer and be sucked into the criminal Justice System never to emerge. We talked about Mental Health first aid training. To the extent schools have Police Officers onsite should in every Single School base resource officer have some basic training in identifying Mental Illness so they can divert kids away from jails and into treatment if they present with symptoms . Yes, sir without endorsing a particular program i believe that is the best way to approach that issue, absolutely. Tell me about for instance worked to develop more pure capacity. Peers occupy a very specific and useful role in treatment with lots of emerging data telling us for many people in recovery that connection is what matters most. Give me initiative that samsara is working on now to broaden in proof the quality of peers in our system today. Santa has had a pretty substantial role in the development of the pure workforce. However, its my view that no Government Agency should be in the business of trying to figure out how to credit if the together type of workforce so we are we have an office for consumers and families that is working with National Organizations on developing criteria for accreditation of peers. The states are different, but we are working with states and with stakeholders to move that process along. Its i believe that peers due to be integrated into the Healthcare Team because its so important to not just give medical care, but for Recovery Services and thats what we are working towards. One must question. You mentioned you were not satisfied with the data you were receiving from states and i think thats in relation to block grants. Can you just tell us why you are not satisfied with the data you are getting . Is that the amount of data or quality of data . Was the problem . Because the data does not tell us anything about diagnoses and doesnt tell us anything about basic standard of care issues like did a person gets the medication assisted treatment. How do i know if the program is working if i dont know if they got the standard of care. What are you getting . Number of people served, things that approximates earned types of diagnoses. Did you feel sad. Do you use certain substances, thats not enough to tell us what these programs are doing for who and what [inaudible] thank you for your focus. To the extent we can avoid duplication require states to then that is something we should Work Together on. I would echo that and i think this administration i think the administration for 40 you. Finish by thinking senator Alexander Murray and murphy for calling, convening and participating in this and thank you for an excellent testimony. Of the hearing record will remain open for 10 days and members may cement Additional Information for the record within that time if they like. Thank you for being here today. The committee is adjourned. Jefferson probably knew more about more things than any single man in north america and i include franklin in that who would be his only rival and everyone was impressed by jefferson extent of his knowledge. Adams was smart but did not have the breadth, but had depth in history and law that jefferson didnt have. Not because jefferson couldnt, he just wasnt as interested in the law. Sunday on cspan to q a professor and historian courted word on his book about the relationship in different political views of john adams and thomas jefferson. Adams was a realist who did not believe all men are created equal. He did not believe in american exceptionalism. We americans are no better, no different than other nations. I think that is what most americans believe in thats why we in other words and the differences different experiences, different environments. Thats why education is so important to us americans and important j