by

Laura Groshong, LICSW
Coalition Lobbyist

2009 Legislative Session Summary  

May 10, 2009

It has been a LONG and, at times, painful Legislative Session, ending April 26.  For mental health clinicians, there was mostly good news.  I have written a summary of the legislative activity I regard as successes (because bills were passed or were stopped) and the bills that may be problematic for us in the future.  Many thanks to the Coalition for your support of my legislative work.  I couldn’t do it without you!

Successes
                    
SB 1373 (Children’s Mental Health Services) - This bill was signed by Governor Gregoire on May 7.  It will expand the funding of mental health services available for children 0-5.  The implementation would be overseen by the UW Children’s Institute.  The bill requires that 36% of all services provided by Regional Support Networks (RSNs) be for children by 2011.

SB 5931 (Privilege) – This bill, giving the legal protection of privilege to the psychotherapy medical records of LICSWs, LMFTs, and LMHCs, was signed by Governor Gregoire on May 8, 2009.

SB 5546 (Confidentiality for Teenagers) – This bill is one that has been submitted for the last 4 years; it would take away the current right of 13- to 18-year-olds to confidentiality of mental health records, should they so choose.  We were able to stop the passage of this bill for the sixth time in as many years.

2009-2011 State Budget – With the help of $4 million in Federal funding, the cuts to state funds were about half of the total shortfall.  Amazingly, mental health services were not cut as severely as some other areas, such as education.  In addition, a mental health benefit was added to the General Assistance-Unemployable program for the first time, albeit only 12 sessions a year.  This is a huge improvement from the possible elimination of GA-U funding that serves some of the most mentally and physically disabled people in the state who do not qualify for SSI or other programs.

Overall GA-U Benefit for 2009-2011:

• Entitlement remains
• Eligibility requirements are unchanged
• Grant amount remains at $339
• Medical coverage may improve
• Mental health coverage will be included in medical benefit

Bills of Concern

HB 2025 (Coordination of Care) and HB 1300 (Release of Records) – These two bills require licensed mental health clinicians who are seeing patients with medical needs to coordinate care with physicians and release records to law enforcement personnel, respectively; psychotherapy notes are exempted. The information that must be shared is ‘minimum necessary’ but the meaning of that term may be debated as the bill is implemented.

This is a necessary step for making sure that physical health and mental health services are coordinated and that law enforcement officials know what the mental health problems of individuals in the corrections system are—a huge gap in current communication.  The problems would be if the information requested seems to violate the patient’s right to privacy.  I will be tracking this implementation closely and will keep you posted.

NATIONAL – Health Care Reform

As you are no doubt aware, there is a major effort to reform our national health care delivery system.  I have been involved in some of the deliberations through the Clinical Social Work Association, the national group I work for, in addition to state groups.  What follows is part of a report I wrote after a three-day immersion in health care reform meetings in Washington, D.C.  If you wish to view the whole report, you can find it at http://www.clinicalsocialworkassociation.org/alerts/health-care-reform-a-work-progress.

Background on Health Care Reform

I spent three beautiful early April days in Washington, D.C. discussing health care reform in a variety of arenas, including meetings with other mental health groups: a small group sponsored by the Center for American Progress with Sen. Max Baucus (D-MT), Paul Begala, and Norman Ornstein; the Kennedy “Workhorse” group studying recommendations for health care reform; and the National Academies of Practice Forum with presenters from private and public systems who have begun implementing coordinated care systems.

Coordinated care is likely to be a key element of changes to health care delivery, one reason the electronic medical record is so crucial to the changes being proposed.  Without electronic records, the coordination of care needed will be much more difficult to implement.  It may be that new clinics emerge that include all medical and mental health services, or contract with providers to provide a virtual clinic including all health care services.

Cost is the driver of health care delivery reform.  Unless a change produces cost savings, it is unlikely to be implemented.  The causes of increased costs are 1) increasing levels of the uninsured receiving the most expensive care, i.e., in emergency rooms; 2) duplication of health care services and/or omission of needed health care services; 3) lack of coordination among health care providers leading to duplicated and/or omitted services; 4) use of extreme measures for beginning-of life or end-of-life care; 5) businesses that have low co-pays and/or high levels of insurance coverage; and 6) increasingly high salaries for insurance executives and administrators.  All changes will be designed to address the expense of these areas.

One of the main points in a New Yorker article on health care reform (Gawande, Atul. “Getting There from Here: How Should Obama Reform Health Care?”, The New Yorker, January 26, 2009) was that a national health care system in each country has grown out of the health delivery systems that were in place and specific conditions existing at the time of implementation.  For the US, that would mean building on our Medicare and Medicaid programs, i.e., possibly making Medicare available for the uninsured down to age 50-55 (with increased premiums for younger enrollees), and making Medicaid available to those who earn up to 150-200% of the poverty level, instead of the current 100% (some states have already covered at this level and above; the recession may eliminate some of this state funding).  In addition, covering all those who are eligible for Medicaid is a likely goal—at this time only about 50% of those who are eligible are covered (Anne Gauthier, The Commonwealth Fund, “Achieving a High Performance Health System”, NAP Forum).

What seems unlikely at this time to all the legislators and analysts I spoke with is the implementation of a ‘single payer’ health care delivery system.  This would require the removal of the private insurance market, a change that would be highly difficult to implement and one that President Obama has explicitly said he would not support.  Though this type of system is appealing in the same way that a ‘flat tax’ system is appealing—it is ‘fair’ in that it gives everyone basic health care—there are other ways to move toward meeting this goal.  If Medicare and Medicaid are expanded, the uninsured will become a much smaller group.  Finding ways to integrate the public and private health care systems and to provide more communication within and across these systems seems more realistic at this time.

Health Care Delivery Paradigm Changes

In line with more coordination of care by health care providers, the bundling of Medicare services is a possibility being explored.  This could impact the delivery of services in private insurance as well.  As you probably know, bundling for cost saving was used in Skilled Nursing Facilities in 1997 and resulted in the inability of clinical social workers to charge independently for services in Medicare Part A.  The Congressional Budget Office is developing a report on the financial impact of bundling all health care services, including the services of psychologists and psychiatrists.  A report to the Senate Finance Committee last September by the Medicare Payment Advisory Commission discussed this possibility:
“The health care delivery system we see today is not a true system: care coordination is rare, specialist care is favored over primary care, quality of care is often poor, and costs are high and increasing at an unsustainable rate.  Part of the problem is that the Medicare’s fee-for-service (FFS) payment systems create separate payment “silos” (e.g., inpatient, physician).  They do not encourage coordination among providers within each silo or among different types of providers across payment silos.  We must now move beyond those limitations—creating new payment systems that will encourage providers to change how they interact with each other.  Providers need to increase care coordination and be jointly accountable for quality and resource use.  The objective is a delivery system that is focused on the beneficiary, improves quality, and controls spending. (Report to the Congress: Reforming the Delivery System, September 16, 2008, Statement of Mark Miller, Executive Director, Medicare Payment Advisory Commission, to U.S. Senate Finance Committee, http://www.medpac.gov/documents/20080916_Sen%20Fin_testimony%20final.pdf)

The removal of “silos” in health care was also a major topic at the National Academies of Practice Forum I attended on March 27.  The impact of this on clinical social work practice could be a return to the principles of casework and possibly basing reimbursement on coordination of care with other health care providers.

Electronic health records seem to be a given within the next two to four years.  All mental health groups are committed to maintaining the privacy of our patient records as much as possible within this new framework.  This new form of recordkeeping can also be seen as a sea-change in the way providers interact with each other.  More coordination of care and understanding of overall care are likely to break down the silos that have created the unsustainable way health care is now delivered.  (More at CSWA Website, http://www.clinicalsocialworkassociation.org/alerts/health-care-reform-a-work-progress.)

Laura W. Groshong
4026 NE. 55th Street, Suite C
Seattle, Washington  98105

206-524-3690 (O)
206-368-9390 (F)
lwgroshong@comcast.net