Carlng for All:

A Plan to |mprove 8ehavloral Health Care

for Lveryone ln Massachusetts
P L 8PUAP 20l4

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Introduction

My brother Edward was a wonderful young man; he was bright, funny, a great
pianist. When Edward was just entering college, he began to show signs of depression
and bipolar disorder. For many years, he refused to seek treatment or take medication,
fearing that the stigma associated with mental illness would prevent him from following
his dreams in life. Tragically however, his reluctance to get help left him unable to hold a
job or carry on a real relationship. Then, shortly after the deaths of our parents, Edward
took his own life; he was 33 years old.

Only recently did my sisters and I begin speaking publicly about our familys
experience. Since we have, I have seen just how many people in Massachusetts are
experiencing a similar struggle, be it on a personal level, or with a family member, friend,
or neighbor who is grappling with a behavioral health disorder, whether that is mental
illness or substance abuse. As a result of my involvement with our behavioral health
system, both personal and professional, I have come to understand the challenges
people face, not only stigma, but barriers to access, especially to community-based
services, and lack of knowledge about what services exist and how to connect with them.
We need to do more to empower those struggling with mental illness and other
behavioral health problems, support families, and build capacity, so that person-centered,
recovery-oriented services are available to everyone who needs them.

Massachusetts must remain committed to creating an environment where
government partners with families, peers, service providers, and insurers to allow
individuals with serious mental illnesses to lead fuller and healthier lives, and help
people recover from substance abuse disorders.

There is no single policy that will fix our entire system of mental health and
substance abuse services. Removing barriers to access will require pursuing several
different strategies. These include:

1. Promoting peer support programs and expanding behavioral health education to
increase awareness, build understanding in the community, and help eliminate
the stigma around mental illness and other behavioral health disorders,
particularly among young people and returning veterans.

2. Effectively integrating behavioral health care with primary care and other services,
through various care models, and promoting evidence-based practices and
payment methods that ensure a comprehensive and effective health care system.

3. Increasing funding and reimbursement rates for person-centered, community-
based behavioral health programs, including outpatient, diversionary, and
transitional services, as well as acute inpatient care, to support longer stays in
acute care for those who need it and increase access to step down services.




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The Current Picture

Mental illness and other behavioral health issues are widespread, affecting
thousands of people in every community across the Commonwealth. One in four adults
nationwide experience some form of mental illness in a given year and, in
Massachusetts, more than 200,000 adults live with a serious mental illness, such as
schizophrenia, depression, or bipolar disorder. Among young people, the problem is
even more pronounced; nationally, one out of every ten children is living with a mental
illness that seriously impacts their life. In Massachusetts, that translates to more than
84,000 children between the ages of nine and eighteen.

For the individuals and families living with serious mental health disorders, the
challenges are every bit as real, and every bit as consequential, as physical health
problems. However, while Massachusetts has some of the highest health insurance
rates and best care providers in the world, far too many people struggling with mental
illness continue to go without needed services. The numbers are startling: among adults,
more than half of those living with a mental illness received no treatment in the past year.
Among children in Massachusetts experiencing serious depression, only 42% received
any treatment.
% of Persons, Ages 12 17, w/ Serious Depression Receiving
Treatment in the Past Year


Source: SAMHSA

% of Persons 18+, w/ Any Mental Illness, Receiving Treatment in the Past Year


Source: SAMHSA

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When we widen our view to include other aspects of behavioral health, including
drug and alcohol abuse, the scope of the challenge becomes even greater. More than
400,000 people in Massachusetts report having been dependent on or abusing alcohol
in the past year; thats one in every twelve people. In addition, nearly 200,000 people
report abuse or dependence on illicit drugs, including heroin; and the rates of treatment
for these issues are significantly lower even than treatment rates for mental health.
Between 2008 and 2012, only 14% of people struggling with drug abuse or dependence
received treatment; among those struggling with alcohol, the rate was even lower, only
8%.
% of Persons 12+, w/ Alcohol Abuse or Dependence, Who Received Alcohol Use
Treatment in the Previous Year


Source: SAMHSA

% of Persons 12+, w/ Illicit Drug Abuse or Dependence, Who Received Drug Use
Treatment in the Previous Year


Source: SAMHSA

Every day, we see the tragic consequences of allowing mental health and
substance abuse challenges to go unaddressed and untreated. Suicide claims the lives
of more than 500 people in Massachusetts every year, and more than 90% of people
who commit suicide have one or more diagnosable mental health conditions, just as my
brother Edward did. Substance abuse is a growing crisis in the Commonwealth; recently,
the Boston Globe reported that at least 185 people in Massachusetts have died from
heroin overdoses in the past four months alone, and that doesnt even include Boston,
Worcester, or Springfield, so the total is likely to be much higher. Unaddressed mental

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illness and other behavioral health issues are also some of the primary contributing
factors to homelessness; among those in Massachusetts who are homeless, more than
a quarter are struggling with a severe mental illness, and more than one in three have
some form of substance abuse issue. Finally, in our prison population, nearly a quarter
of inmates have open mental health cases, and officials estimate that up to 80% of
inmates have substance abuse disorders.

In my personal life, as a sister, and my professional life, as a District Attorney
and Attorney General, I have seen the consequences of failing to address mental illness
and other behavioral health problems until it is too late. Too many individuals and
families in Massachusetts who struggle with these challenges continue to face barriers
to hope and recovery, just as my brother did. We can, and should, do better here in
Massachusetts.

Moving Forward

The next Governor must make it a priority to work with individuals, families,
communities, providers, and insurers to develop effective strategies to address the
challenges that currently face individuals and families struggling with mental illness or
other behavioral health problems. As Governor, my plan to improve and expand
behavioral health care options for everyone in our Commonwealth will include:

Promoting peer support programs and expanding behavioral health education to
increase awareness, build understanding in the community, and help eliminate the
stigma around mental illness and other behavioral health disorders, particularly
among young people and returning veterans.

Fear of social and professional isolation is one of the biggest reasons so many
people suffering from mental illness or other behavioral health disorders choose not to
seek help. It is crucial that individuals struggling to overcome these challenges feel
empowered to reach out for help, and that others in the community are prepared to be
supportive.

This starts with our young people. Nearly half of all chronic mental health
conditions present before the age of 14, and its often classmates, friends or teachers
who first notice changes in an individuals behavior. Reaching young people with mental
health disorders early can significantly improve long-term outcomes, so it is critical that
classmates, teachers and school personnel know how to handle this situation, are aware
of the services available, and that they feel comfortable reaching out for help.

Another key group is our returning veterans. Some estimates put the rate of
PTSD among veterans near 40%, and the rates of depression and alcohol abuse at
more than one in four. At the same time, too many veterans continue to be trapped by
the perception that seeking help for these problems is shameful, or a sign of weakness.

In order to meaningfully reduce stigma and increase awareness, our next
Governor needs to:


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Promote programs like Mental Health First Aid and Massachusetts Young Adult
Councils, programs that train people how to recognize and support someone who
is in psychological crisis, and connect individuals and families struggling with
mental illness or other behavioral health issues with peers who have experienced
similar challenges;

Create a series of working groups charged with reviewing ongoing anti-stigma
efforts and identifying best practices across a range of constituencies, including
young people, veterans, and the elderly;

Work with teachers, school administrators, and health professionals to
incorporate behavioral health education into school curricula, create awareness
of community resources, and give students the knowledge to recognize a peer in
distress and the comfort level to seek out appropriate help; and,

Use the considerable influence of the Governors office to be a constant, vocal
advocate for incorporating behavioral health care more effectively into our
ongoing health care reform efforts, and promoting societal acceptance of
individuals struggling with mental illness and other behavioral health issues.

Effectively integrating behavioral health care with primary care and other services,
through various care models, and promoting evidence-based practices and
payment methods that ensure a comprehensive and effective health care system.

Massachusetts leads the nation in providing physical health care to its residents,
but our physical health care delivery system continues to be substantially segregated
from our behavioral health care system. Our next Governor needs to promote a person-
centered, team model of health care delivery that will improve outcomes by addressing
the whole individual.

Currently, the separation between the behavioral and physical health care
systems can impede access to services for mental illness and substance abuse, and
hinder communication between providers. This can lead to misdiagnosis, over
prescription of psychiatric medications, failure to address behavioral health factors that
complicate the treatment of other medical conditions, or failure to help individuals
manage and prevent physical health side effects that sometimes accompany behavioral
health medications, and can increase the risk of chronic health problems.

There are several strategies for moving towards a holistic health care system that
addresses both behavioral and physical health needs, including:

Assigning a point person within the Governors office to take the lead on working
with all stakeholders to identify the best strategies for implementing the
recommendations produced by the states Behavioral Health Integration Task
Force, created as a result of the recent health care reform legislation, and to
ensure a coordinated response to improving behavioral health care;


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Transitioning away from the traditional fee-for-service model and implementing
payment methods that incentivize and support integrated behavioral health care
by:

o Facilitating communication and collaboration among health care,
education, and social service providers;
o Promoting the implementation of evidence-based practices but also the
testing of innovative treatment options in care delivery;
o Funding the development of health homes, a model for integrating
services for individuals with persistent behavioral health issues; and,
o Including cost and quality measures, and adequately supporting
implementation, to ensure available funding is allocated as effectively as
possible.

Addressing workforce challenges associated with integrating behavioral health
care, which includes ensuring that licensure standards promote an integrated,
multi-disciplinary approach to health care, and expanding telemedicine to help
individuals in more remote parts of the state access critical behavioral health
services.

Increasing funding and reimbursement rates for person-centered, community-
based behavioral health programs, including outpatient, diversionary, and
transitional services, as well as acute inpatient care, to support longer stays in
acute care for those who need it and increase access to step down services.

Offering individuals struggling with mental illness and other behavioral health
problems services that allow them to stay in their community and close to family, work,
and social supports is essential to creating a system that is person-centered and
recovery-oriented. It is also important that we increase funding and reimbursement rates
for acute inpatient hospitals, to ensure access to these critical services for individuals
who need them, while, at the same time, remaining focused on expanding step-down
and community-based services to make sure people can transition effectively out of
acute inpatient care.

Our community-based mental health services are critically underfunded; this
includes critical outpatient, diversionary, and transitional services. As a result, many
community-based service providers are making substantial cuts, leading to an access
crisis for individuals dealing with mental illness and other behavioral health issues. This
not only denies too many people the essential services that would allow them to stay in
their community and close to their family, but it creates a logjam in our inpatient care
system and increases unnecessary inpatient hospitalizations. Further exacerbating the
problem is that our inpatient care system is also underfunded, due in large part to
inadequate reimbursement rates and a lack of funding for step-down services, creating
barriers to access for those in need of acute care services and overburdening hospitals
providing acute inpatient care.

In order to expand capacity and make these critical services available to
everyone, we need to:


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Work with insurers to expand coverage, and increase reimbursement rates for
community and school-based services that are critical to promoting recovery,
including outpatient care, peer supports for veterans, children, and families, case
management services, transitional care such as short-term residential services,
and diversionary services like crisis stabilization beds and emergency response
teams.

Increase reimbursement rates for hospitals providing acute inpatient services,
and expand coverage to include longer acute care stays and critical step-down
services that allow people to successfully transition out of acute care, back into
the community, and avoid readmission.

Increase state funding for essential, community-based services. Governor
Patricks proposed budget for FY15 calls for reducing Individual and Family
Flexible Support Services and Community Based Flexible Supports, programs
which provide individuals and families access to a range of services, including
case management and youth support groups. As we look to realign our priorities
in our state budget, we need to ensure adequate funding for community-based
behavioral health services, rather than reducing funding.

Promote strategies to avoid the unnecessary incarceration of individuals
struggling with behavioral health issues, including the use of specialized courts,
partnering law enforcement with mental health clinicians, creating targeted
reentry programs, to decrease the number of individuals with behavioral health
issues who end up in prison rather than treatment.

Focusing on fair and consistent implementation of Massachusetts parity law,
including increasing reporting transparency, empowering the Division of
Insurance to enforce the law, and assisting families in appeals related to covered
services. In addition, we need to ensure there is parity in disability benefits for
individuals living with mental illness.

Conclusion

We lost my brother nearly 20 years ago; the behavioral health landscape and my
understanding of the issues have changed since then, but too many individuals and
families facing behavioral health challenges continue to struggle, whether its with stigma,
lack of access to needed care, or insufficient coverage. I have seen the tragic
consequences when we fail to empower and support people struggling with behavioral
health issues. It is long past time to educate everyone about the realities of behavioral
health, to better integrate behavioral health care and our primary care system, and to
ensure adequate coverage for critical community-based services, all to help individuals
and families struggling with behavioral health issues live more hopeful and healthier lives.