ADDITIONAL COMPONENT OF GOVERNOR PATAKI’S BUDGET PROPOSAL: In addition to the numerous proposals that we articulated in last week’s Update, one noteworthy item was erroneously excluded from our list of the items in the Governor’s 2006-07 Executive budget submission.

Included in the Governor's budget proposal, he identifies savings in the 2006-07 fiscal year associated with moving up the mandatory date by which all individuals on Supplemental Security Income (SSI) must be enrolled in Medicaid managed care for health services (not including mental health services). In addition, these savings would also come from mandating that individuals considered "Seriously and Persistently Mentally Ill" (SPMI) be required to enroll in Medicaid managed care as well. The Governor currently has the administrative authority to make such a change, leaving the Legislature with few options if they do not agree with this change. On Thursday, the Assembly will hold a Public Hearing on this issue. As we learn more about the details and impact of this change, we will keep you informed.

EMERGENCY MEDICAID COVERAGE FOR DUAL ELIGIBLES EXTENDED ANOTHER WEEK: On Friday, Governor Pataki announced a continuation of a suspension of the Medicaid rules and regulations for dual eligibles unable to get their prescription medications through their Medicare Part D plan. Essentially, this allows pharmacists to bill Medicaid for prescription drugs when they are unable to bill the Medicare plan in which the dual eligible person is enrolled. Unforutnately, this extension is only for another 7 days and will expire again on Friday. Advocates continue to push for a continuation of this coverage until all of the issues with the Medicare prescription drug plans are ironed out.

ADVOCATES TESTIFY AND PUBLICLY CALL FOR PASSAGE OF LEGISLATION TO BAN SOLITARY CONFINEMENT FOR INMATES WITH MENTAL ILLNESS: Last week, members of the Mental Health Alternatives to Solitary Confinement campaign testified at a Public Hearing held by Assemblymember Jeffrion Aubry concerning the use of solitary confinement in prison, specifically as it relates to inmates with mental health needs. MHANYS played a major role in helping to coordinate a press conference which highlighted the need to end this practice. Rather than re-invent the wheel, following is the text from a recent NYAPRS E-News Update on that day’s events.

NYAPRS Note: On the same day they testified at an Assembly hearing that looked into the operations of new Behavioral Health Units at 2 NYS prisons, members of Mental Health Alternatives to Solitary Confinement (MHASC) held a news conference and meetings with key legislators this week that were resumed efforts to gain passage of legislation that would ban inhumane solitary confinements at prison special housing units (or SHUs).

The Assembly hearing featured testimony from representatives of the NYS Dep't of Corrections and Office of Mental Health on the operations of new mental health housing/treatment facilities (behavioral health units or BHUs) at Green Haven and Sullivan correctional facilities that were intended, legislators and advocates had thought, to provide alternatives to time spent in the SHUs, commonly termed the 'Box.' Instead advocates learned that the BHUs only accepted inmates whose conditions had already deteriorated to the point where they had been incarcerated at the SHUs, and that the BHUs accepted numbers of individuals who had no diagnoses of formal mental illnesses.

The units were created via a $13 million DOCS/OMH initiative that was approved in 2004. The Governor's 2006 budget proposal included $600,000 to add 8 new mental health treatment staff to the operation of these units.

The advocates held a news conference that attracted a number of Capitol reporters and later held meetings with key Senate officials that were aimed at gaining Senate passage of 'Ban the Box' legislation that has passed the state Assembly for the past two years.

Passage of SHU legislation is a top priority for NYAPRS members again this year and will be highlighted at NYAPRS Annual Legislative Day this January 31 and at a special MHASC Legislative Day planned for later this session.

See article – “End solitary for mentally ill inmates, advocates say” below.

IN THE NEWS:

N.Y. budget proposal a mixed bag for advocates.
Mental Health Weekly, January 3, 2006

Advocates seek increased funding for MH providers

New York mental health advocates say they are encouraged by some of the proposals in Gov. George E. Pataki’s proposed budget unveiled last week, including funding for children’s and senior mental health services; however they would like to see increased funding for the state’s community mental health providers. Advocates said they are also concerned about the state’s sex offender civil commitment initiative.

The governor has budgeted $7.7M million for the first year phase of the state’s New York/New York III Supportive Housing agreement, which will provide over the coming 10 years, 9,000 units of supportive housing for individuals and families with special needs who are chronically homeless or at risk for being homeless (see MHW, Dec. 5, 2005).

The governor’s 2006-2007 executive budget also includes funding for suicide prevention and $62 million for a new children’s mental health services initiative. Pataki’s plan also calls for an annual 2.5 percent cost of living adjustment (COLA) increase for residential and various community non-residential programs for three years.

“Funding for COLA, services for children, services for the elderly, are all really tremendous things,” Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services, told MHW. While, advocates are generally pleased with the 2.5 percent increase they had hoped for more funding for “hard-pressed community providers,” he said. “The good news is that there are increases in our future. It’s a good move in the right direction.”

Rosenthal added, “We need an infusion beyond 2.5 percent. We’re looking for increases of 10 percent in the mental health budget. Our goal is to see 10 percent infusion no in annual increments.” Rosenthal said advocates will be looking to the state legislature to increase what the governor has already proposed. “That will be the top task of all events,” he said.

Other areas of concern include lack of funding for new case management/peer specialist services or other initiatives for adult home residents with psychiatric disabilities, particularly after advocating for many years for adult home reform, he said.

“There is no funding to enhance mental health services for adult home residents,” he said. “This is going to create real outrage among advocates for adult home residents.”

The elimination of ‘physician override’ protection in the state’s Medicaid Preferred drug program is another concern, said Rosenthal. “Physician override is essential and has to be preserved,” said Rosenthal. “Doctors need to decide what’s best for Medicaid patients, not bureaucracy aimed at saving money.”

Glenn Liebman, chief executive of the Mental Health Association in New York State, Inc. (MHANHS), said he is encouraged by the governor’s executive budget. “Several parts of the governor’s budget we’re generally pleased with,” Liebman told MHW. He said he appreciates the funding provided for New York State’s Geriatric Mental Health Act, which establishes a services demonstration grants program and an interagency geriatric mental health planning council. (see MHW, Sept. 5, 2005).

Sexual offender issues

The governor’s budget proposes $192 million to provide services to support sexually violent predators upon their release from prison. New York State officials also plan to renovate existing facilities and construct a new facility related to civil commitment.

While mental health advocates are encouraged about some parts of pending sexual offenders legislation, they have long held concerns over this issue of civil confinement and about the potential misuse of the mental health system (see MHW, Dec. 12, 2005).

The budget calls for funding to build or renovate facilities to house civilly committed sex offenders and pay for treatment staff deployed to serve them in these settings, said Rosenthal. “Advocates are troubled by the introduction of sex offenders into the mental health system, he added.

“Our biggest concern remains the sexual predator legislation,” said Liebman. “Our major issue is about the co-mingling of people with psychiatric disabilities with sexual predators. We also have serious concerns that mental health funding will be used for sexual predators.”

Liebman said the governor has proposed the construction of a new and separate facility in upstate New York in Chenango County. “We think they [sexual predators] should be in the correctional system,” he said.

A Place for Sex Offenders. Editorial
The New York Times, January 22, 2006

Gov. George Pataki has proposed turning a woodsy upstate prison into a pseudo-prison for certain convicted sex offenders who have already done their time. His impulse is understandable: rather than allow men who seem likely to repeat terrible crimes back onto the street, why not lock them up for psychiatric treatment until they get their impulses under control? The United States Supreme Court has declared the practice permissible for people deemed "mentally abnormal," and 16 other states have so-called civil-confinement laws.

But it isn't necessary to be a raging civil libertarian to be queasy about the Pataki plan, under which the state would spend $130 million to raze and replace Camp Pharsalia, 50 miles north of Binghamton, with a new treatment center run by the State Office of Mental Health.

There will never be an easy or wholly satisfying solution to the problem of violent sexual criminals. Sickened by highly publicized crimes against children and dubious about the odds of rehabilitation, Congress and the states have been adopting ever-tougher laws governing where and how sex offenders can live, work and travel.

But peace of mind has been elusive. An era that began with laws requiring freed sex offenders to register with local law-enforcement officials now features laws requiring notification of neighbors when offenders move in, the posting of offenders' names on the Web, electronic monitoring and restrictive "distance laws" meant to keep them away from places like schools and parks.

Preventive detention for violent sex offenders is the natural end point of the logic embraced by Mr. Pataki and his allies: that these are a special class of misfits whom existing laws are incapable of subduing, and that no price is too high for safety. But while no one disputes society's obligation to protect the innocent, it is fair to ask whether the state's limited resources might be better deployed at the front end of the problem. A bill sponsored in the Assembly by Speaker Sheldon Silver and Joseph Lentol, while allowing for the civil confinement of sexual predators, places a heavier emphasis on treatment behind bars. The current prison treatment system, underfunded and understaffed, typically offers six months of group therapy run by corrections officials. The Assembly bill would require at least two years of treatment by mental health professionals for everyone imprisoned for a felony sex offense, and provide for continued treatment after release.

But treatment is not the entire answer. Few would deny that the universe of sex criminals includes a small number of repeat offenders who do not respond to therapy, and that the criminal-justice system will eventually run out of ways to deal with them. The admittedly imperfect answer in that case would be to seek longer sentences for violent sex crimes to reduce the chances that dangerous predators will be released too soon, and to aggressively monitor offenders upon release with electronic bracelets and a strengthened parole system.

Psychiatric treatment in prisons, intensive outpatient therapy and close monitoring are, in the main, preferable to a questionable reliance on preventive detention. The remaking of Camp Pharsalia, in fact, seems more like an upstate jobs program. We should not forget that only last year lawmakers were urging Mr. Pataki to keep Camp Pharsalia open somehow, lest its neighbors lose 100 jobs and $11 million in economic activity.

We are all for upstate development, but the more urgent questions have to do with public safety and whether lavishing resources on a place for warehousing a small subset of sex offenders - rather than aggressively treating and keeping tabs on a far larger cohort of criminals - will really make all of us safer, or just make it seem that way.

State leaders asked to rethink push for civil confinement laws. By Joseph Gerace
Legislative Gazette, January 17, 2006

Pataki proposes new facility in Southern Tier specifically for sexual predators

The National Association on Mental Illness of New York is concerned about Gov. George E. Pataki’s urgent push for civil confinement of 5,000 sexual predators currently awaiting release from New York State prisons.

Civil confinement refers to the continued detainment, based on mental abnormalities, of criminals convicted of sexually violent crimes after their release from New York State prisons. The main points of contention from members of the state’s mental health community are the housing of sexually violent criminals without psychiatric diagnosis into Office of Mental Health facilities, for reasons of cost, capacity, safety and stigma.

Speaking at a press conference in Albany last week, J. David Seay, the executive director of NAMI-NY, expressed concern that patients within the mental health field would be unjustly bunched with violent criminals if sex offenders were dispersed throughout the system without regard. Another worry was that patients with mental disorders are “twelve times more likely to be victims of crime and violence” than those without.

“We oppose any legislation that would misuse facilities as a dumping ground for sexual predators,” Seay said at the press conference. “State psychological centers are state resources and should not be used as a warehouse for sexual predators.”

Also speaking at the press conference was Michael Seereiter, director of public policy for the Mental Health Association in New York State, who noted that state psychiatric facilities are already at 100 percent capacity and to release sexual predators into a system that has seen drastic cutbacks over the last quarter-decade would cripple it.

There are currently 17 adult psychiatric hospitals in the New York State system, with one closing on April 1 in Middletown.

“Over the past 25 to 35 years there has been a movement called deinstitutionalization where community-based services are able to handle more of the mentally ill’s needs,” said Seereiter. “The psychiatric system that once treated 93,000 patients total in the early 1950s now has downsized to about 3,900 [patients].” Sexual predators are a population, Seereiter said, that the psychiatric system was “never meant to treat, confine or even house.”

Much of the battle over civil confinement is being fought between mental health advocates and the state Assembly on one side and Pataki and the state Senate on the other. The former say state money and beds in psychiatric wards are scarce, and other options have to be explored before legislation is passed. The latter argue that dangerous sexual predators must be kept off the streets after their prison sentences.

At his State of the State address on Jan. 4, Pataki urged, “Our goal must be nothing less than to provide our children and families with every possible protection from sexually violent predators.”

At least 16 states and Washington, D.C. have existing laws that allow courts to civilly confine soon-to-be-released inmates considered to be at risk to repeat offenses or who have mental abnormalities.

Pataki announced last Tuesday that he would allocate $130 million in his 2006-07 Executive Budget to support his civil confinement proposal through the construction of a state facility near the Town of Pharsalia. The money would be used to raze the existing 258-bed minimum-security prison and construct a state-of-the-art, 500-bed, secure facility that Pataki said could be completed by 2009. Control of Camp Pharsalia, as it is currently called, would be transferred from the Department of Correctional Services to the Office of Mental Health.

In addition to $130 million, Pataki also made available $35 million for the renovation of current OMH facilities to hold sexual predators while Camp Pharsalia is being built and $27 million in “new operating support for OMH in connection with housing and treating sexual predators in existing facilities in 2006-07.”

The phrase being used to describe the Mental Health Association’s response to Pataki’s designation of funds is “somewhat mollified” according to Seereiter. His organization’s concerns regarding the safety of mental health patients is addressed by separate facilities at Camp Pharsalia, but the money to handle uptake of the long-term secure facility would still be coming from the Office of Mental Health’s budget.

“We are concerned this would sap existing mental health resources,” said Seereiter. “This should be laid out separately in the budget.”

Assemblyman Peter Rivera, D-Bronx, the chair of the committee on mental health, last week proposed to the Assembly a system of civil confinement that offers a comprehensive trial that results in civil confinement, outside supervision similar to parole or, if a jury of peers in court located in the county in which the crime was committed cannot come to a unanimous decision, the release of the sex offender. The proposal also includes an expansion of the sentencing for sex offenders pending their first crime.

“What we’re promoting is a change in the punishment,” said Rivera. “We’ll see what happens; the Senate and the Governor are not looking at that issue.”

Another take on what to do to keep children safe from sexual predators is being advocated by Richard Hamill, president of the New York State Alliance of Sex Offender Services Providers.

“Sex offender management is a complex problem, as is civil confinement,” said Hamill. “What my professional group is advocating for is lifetime probation or parole for sex offenders.”

Hamill contends that sex offenders respond very well to personal attention from parole. One-on-one supervision results in a recidivism rate of about 50 percent, according to Hamill.

Many legislators in both houses are acting in good faith, according to Hamill.

“The Assembly is taking a careful look at the research in the field,” said Hamill. “It’s a complex problem that, hopefully the discussion will help to solve.”

End solitary for mentally ill inmates, advocates say. By Cara Matthews
Elmira Star-Gazette, January 19, 2006

ALBANY - Mental health advocates called for ending solitary confinement of prisoners with mental illness Wednesday, saying it amounts to inhumane punishment for a population that needs special health treatment.

A coalition called Mental Health Alternatives to Solitary Confinement urged passage of legislation that would create treatment facilities for prisoners with serious mental illnesses by redeveloping existing prison space.

"We believe that solitary confinement has been used primarily as a punitive measure for individuals living with mental health needs, inmates in the correctional system, for oftentimes behaviors that are a function of mental illness or substance abuse as well," said Michael Seereiter of the Mental Health Association of New York State.

Gov. George Pataki said Wednesday that he wasn't familiar with the proposal but said prison conditions have improved in the state as the number of inmates and the recidivism rate have declined.

"Obviously our correctional system, our parole officers, our entire criminal justice system working together are doing an excellent job," he said.

A representative of the state Department of Correctional Services could not be reached for comment Wednesday afternoon.

The state Assembly has passed the legislation in previous years, but it hasn't gone anywhere in the state Senate, said Bob Corliss of the National Alliance on Mental Illness of New York.

Inmates with mental illness are disproportionately placed in solitary confinement, also known as the box and special housing units, Corliss said. Eleven percent of the state prison population - about 7,400 people - can be classified as mentally ill, while nearly 25 percent of inmates currently in the box have mental illness, he said.

Prisoners in solitary confinement are there 23 hours a day, and there is no limit in New York on how long an inmate can be kept in such units, according to the coalition. The average time mentally ill inmates spend there is 38 months, six times longer than the population overall, the group said.

Corliss said the practice of locking people with serious mental illness up in special housing units is "repugnant." Anyone would deteriorate while in the box, he said, but that is exacerbated among the mentally ill.

"We know that there are many people with a mental illness who are in our state prison system ... who can't handle the regimen of prison, who don't do well in prison, who don't deal well with obeying the rules, who may go off their medication, who wind up getting into different kinds of misconduct, they violate prison rules, they get into trouble," he said.

Myra Hutchinson of New York City said a 32-year-old friend of the family who has schizophrenia will be in the box until the end of his prison term, which is 2010. He has been in prison nearly 10 years for a nonfatal shooting, six of those years in solitary confinement. She described his quarters as a "prison within a prison." She tried to send him warm socks because he complained of the cold, but he is not able to receive packages while in confinement, she said.

Linda Sargent of Rensselaer said her emotionally disturbed son, 25-year-old Mark Cooper, is in solitary confinement in Southport Correctional Facility. Cooper received a sentence of 10 to 20 years for carjacking and robbery, and he has been confined to the box for seven of the 10 years he has been in prison, she said.

The legislation the coalition is lobbying for also would require additional training for correction officers on how to identify and interact with mentally ill inmates and increased oversight of the treatment of prisoners with psychiatric disabilities.

Mentally ill inmates in solitary may end. By Rick Karlin
Albany Times Union, January 21, 2006

Opponents of the practice see positive signs, including federal lawsuit and money for mental health facilities

ALBANY -- Opponents of putting mentally ill prison inmates in solitary confinement say there are signs their efforts to end the practice will gain traction this year.

For the last several years, mental health advocates have called for legislation that would give mentally ill inmates more treatment rather than punishment in the so-called SHUs, or special housing units, for misbehavior.

According to the National Alliance for the Mentally Ill's New York state branch, about 11 percent of state prison inmates suffer from mental illness, including schizophrenia, which means they sometimes have a tenuous grasp on reality. Of those in SHU, about 30 percent are mentally ill, NAMI-NY estimates.

"We know that there are many people who are in the state prison system who for better or worse can't handle being in prison," said Robert Corliss, associate director for criminal justice at NAMI-NY. "People in that kind of setting (solitary) deteriorate and people who are mentally ill deteriorate very badly."

Corliss cited two events he and others hoped would move legislation forward, including a federal lawsuit contending that SHUs amount to cruel and unusual punishment. The lawsuit, which dates back some four years, is slowly wending its way through the judicial system and a trial could start in the spring. However, the case could still take years to resolve.

Also, the state allocated $13 million in the 2003-04 budget, which meant that last year 102 mental health beds were created in the Great Meadows and Sullivan correctional facilities, said Corliss.

Two bills have been introduced by Assemblyman Jeffrion Aubry, D-Queens, and state Sen. Michael Nozzolio, R-Seneca Falls, that would create alternative and therapeutic settings for mentally ill patients.

Friends and parents of mentally ill inmates confined to SHU, or "the box" as it's also known, spoke during a hearing last week of how their loved ones have deteriorated mentally after being put in the isolation units, often for years at a time. Typically, inmates in the box spend 23 hours a day in tiny cells with stainless steel fixtures. Breaking rules there can result in additional box time, and some prisoners have sentences that last for years.

"He's been in 'the box' for seven years, 23 hours a day and I'm watching him slowly die," Lynn Sargent of Rensselaer said of her son, Mark Cooper, 25, who is serving a lengthy sentence in the Southport correctional facility for carjacking and abduction. Sargent said her son has suffered from mental and psychiatric problems almost from birth.

"The policy is so insane," added Myra Hutchinson of New York City, who has a family friend who has been serving time since 1996, much of it in the box.

Introduction of Medicare drug benefit creates nightmare for providers, patients.
Mental Health Weekly, January 23, 2006

Solving initial glitches could take months, advocates fear

At last years’ annual conference of the National Council for Community Behavioral Healthcare (NCCBH), standing before a group of uneasy mental health providers, a representative of the federal Centers for Medicare & Medicaid Services (CMS) had this to say about the planned 2006 implementation of the Medicare Part D drug benefit:

“There has been enormous concern about people falling off the cliff on Jan. 1. We are absolutely certain that no one will fall off the cliff.” (see MHW, March 21, 2005)

Now it’s providers’ and consumers’ turn to speak, and they’re saying that if no one has indeed fallen off a cliff, life along the precipice is proving to be a harrowing experience for mental health clients and their case managers.

From the start of implementation of the new Medicare drug benefit on Jan.1, the overall experience of clients trying to obtain prescriptions has been marked with denials at the pharmacy, interminable waits on jammed phone lines, and conflicting information about which prescription plans clients are in and what these plans cover.

Ironically, while most of the intense national media attention on this subject has focused on an elderly population that is relatively informed on health care matters, little attention has been placed on the group that before Jan. 1 had been receiving prescription though Medicaid. This group of more than 6 million “dual eligibles,” which includes many vulnerable individuals with serious mental illness, has seen a complete transformation of its prescription drug coverage and in many cases is having severe difficulty coping with the results.

One source of extreme frustration for mental health providers is that even in cases where they offered their clients a great deal of outreach and assistance prior to the Jan. 1 launch of the Part D benefit, many clients are finding trouble in navigating the system. Many mental health leaders fear that these kinds of problems are bound to persist in a program featuring numerous private prescription drugs plans, all with a different list of what medications they cover and under what terms.

“How could there not be problems?” Linda Rosenberg, NCCBH’s president and chief executive, told MHW. “Are we going to make things more complicated in the private sector? A single-payer system is always easier than a multi-payer system.”

Too many surprises

NCCBH last week hosted a media briefing in which community-based providers and their clients related frustrating experiences with the new prescription drug program.

For many community-based agencies, about 30 to 40 percent of the clients they serve fall under the dual eligible category, and most providers estimate that at least half of this patient group has had trouble receiving its prescriptions since Jan. 1.

Many participants in the briefing reported that pharmacy workers could not find dual eligibles’ records in the computer system when they sought to have a prescription filled. Some consumers talked of being asked to pay high deductibles or significant copayments, even though Par D regulations prohibit deductibles and keep copayments at nominal levels of $1 to $3 per prescription.

Delays and bureaucratic hassles are not without consequence for many of these vulnerable clients, participants in the briefing warned. “I can’t be without my medication for a day or two; it will put me in the hospital,” said Beverly Thomas, a consumer in Carbondale, Ill., who was denied service at her pharmacy and later received the help she needed through efforts of her community provider, Southern Illinois Regional Social Services.

In a later interview with MHW, Rosenberg said she believes that even nominal copayments are causing particular problems for consumers with limited incomes, and that CMS should consider eliminating copayments for dual eligibles entirely.

“How can a consumer budget $600 a month when the rent is $400?” Rosenberg said, offering a typical scenario for a seriously mentally ill clients receiving public aid. “This is a poverty issue. It’s another way we’re punishing people who are ill.”

Perhaps the most shocking development to be uncovered in last week’s briefing was the prevalence of situations in which a consumer enrolled in a specific prescription drug plan (PDP) before Jan.1, only to find out that the government had subsequently enrolled him/her in an entirely different plan with different regulations. Under Part D, most consumers have a choice from among several PDPs in which to enroll.

The problem apparently stems from the fact that late last year, CMS decided that in order to guard against anyone dropping from prescription coverage altogether, it would “auto-enroll” in a plan any dual eligible who had not enrolled on his/her own. Unfortunately, providers and consumers are reporting in droves that this effort inadvertently included some dual eligibles who has in fact enrolled in a plan – or at least thought they had.

“Jan. 1 came, and suddenly consumers discovered that they weren’t singed up for the plan we helped sign them up for,” said Susan Flippin, clinical services assistant at Peninsula Community Mental Health Center in Port Angeles, Wash. “The 800 Medicare number was our only source of information, and it was totally overloaded. It was chaos. Clients were in panic, and case managers were overwhelmed.”

Rosenberg believes it may take months to work out this many glitches in an extremely complex system. “This has been so much work for the providers, to the detriment of much of their other work,” she said.

Evidence of harm

Thomas Riggs, president and chief executive of the provider agency Directions for Mental Health in Pinellas County, Fla., said that last year he attended several workshops that conveyed the message that the Jan. 1 transition shouldn’t be cause for concern. He had heard that all PDPs in his region would include wide access to psychotropic medications. The reality for his program workers and their clients has been much different so far, however.

With 8,000 people receiving services last year from Directions for Mental Health, which operates a large clinic in Clearwater and conducts numerous site visits to homes, homeless shelters, and jails, there was little time for program staff to assist dual eligibles in their decision-making about a Medicare PDP, Riggs told MHW. “We were trying not to have a paternalistic role,” he said.

Program officials have found in recent weeks that some clients who thought they were enrolling in a PDP actually switched their entire health plan, meaning that some are presently ineligible to receive services from the clinic. Others have discovered that in their transition from Medicaid to Medicare, they somehow lost their Medicaid transportation benefit. No one has been able to determine why that happened, Riggs said.

“We’ve had a significant drop in our day program census as a result of this, “Riggs said of the transportation problem. “That program serves a relatively acute population. There have probably been rehospitalizations as a result of this. We’ve heard anecdotally of a significant increase in psychiatric hospitalizations.”

While some state governments this month have stepped in with emergency funding and other support to ensure that people covered under Part D are receiving the medications they need, that has not been the case in Riggs’ home state of Florida, he said.

“They’ve done nothing.” Riggs said of state officials.

Looking ahead

Rosenberg emphasized in her comments last week that staff members at CMS are working hard to try to correct problems. “I don’t want to sound like an apologist for CMS, but they were basically handed a bill [by Congress],” she said.

In fact, Rosenberg and several speakers at the media briefing said that one of the only reasons why some progress is being made at solving the problems is that federal workers are acting as case managers themselves, working painstakingly to resolve beneficiaries; coverage issues individually.

But once all of these problems are resolves, Rosenberg foresees an even bigger challenge ahead: determining how the various prescription plans will operate and how restrictive they may become on access to the most widely used psychotropic medications.

“These are independent, for-profit companies,” she said. “The restrictions they impose won’t be overt, but they could make the appears process impossible to navigate, or they could impose onerous paperwork requirements for providers,”

And while at least the lines of communication are open between providers and CMS officials, “The PDPs haven’t been as willing to engage with us,” Rosenberg said.

Medicare Woes Take High Toll on Mentally Ill. By Robert Pear
The New York Times, January 21, 2006

HILLIARD, Fla., Jan. 16 - On the seventh day of the new Medicare drug benefit, Stephen Starnes began hearing voices again, ominous voices, and he started to beg for the medications he had been taking for 10 years. But his pharmacy could not get approval from his Medicare drug plan, so Mr. Starnes was admitted to a hospital here for treatment of paranoid schizophrenia.

Mr. Starnes, 49, lives in Dayspring Village, a former motel that is licensed by the State of Florida as an assisted living center for people with mental illness. When he gets his medications, he is stable.

"Without them," he said, "I get aggravated at myself, I have terrible pain in my gut, I feel as if I am freezing one moment and burning up the next moment. I go haywire, and I want to hurt myself."

Mix-ups in the first weeks of the Medicare drug benefit have vexed many beneficiaries and pharmacists. Dr. Steven S. Sharfstein, president of the American Psychiatric Association, said the transition from Medicaid to Medicare had had a particularly severe impact on low-income patients with serious, persistent mental illnesses.

"Relapse, rehospitalization and disruption of essential treatment are some of the consequences," Dr. Sharfstein said.

Dr. Jacqueline M. Feldman, a professor of psychiatry at the University of Alabama at Birmingham, said that two of her patients with schizophrenia had gone to a hospital emergency room because they could not get their medications. Dr. Feldman, who is also the director of a community mental health center, said "relapse is becoming more frequent" among her low-income Medicare patients.

Emma L. Hayes, director of emergency services at Ten Broeck Hospital, a psychiatric center in Jacksonville, said, "We have seen some increase in admissions, and anticipate a lot more," as people wrestle with the new drug benefit.

Medicare's free-standing prescription drug plans are not responsible for the costs of hospital care or doctors' services. "They have no business incentive to worry about those costs," said Dr. Joseph J. Parks, medical director of the Missouri Department of Mental Health, who reported that many of his Medicare patients had been unable to get medicines or had experienced delays.

At least 24 states have taken emergency action to pay for prescription drugs if people cannot obtain them by using the new Medicare drug benefit. Florida is not among those states.

In an interview, Alan M. Levine, secretary of the Florida Agency for Health Care Administration, said: "We've set up a phone line and an e-mail address for pharmacists. We try to solve these problems on a case-by-case basis. We have stepped in to get drug plans to pay for prescriptions, so people don't leave the pharmacy without their medications."

Federal officials said they were moving aggressively to fix problems with the drug benefit. About 250 federal employees have been enlisted as caseworkers to help individual patients. The government has told insurers to provide a temporary supply - typically 30 days - of any prescription that a person was previously taking. And Medicare has sent data files to insurers, supposedly listing all low-income people entitled to extra help with premiums and co-payments.

But in many cases, pharmacists say, they still cannot get the information needed to submit claims, to verify eligibility or to calculate the correct co-payments for low-income people. And often, they say, they must wait for hours when they try to reach insurers by telephone.

S. Kimberly Belshé, secretary of the California Health and Human Services Agency, said the actions taken by the federal government "have not been sufficient to address the problems that California residents continue to experience."

At Dayspring Village, in the northeast corner of Florida near Jacksonville, the 80 residents depend heavily on medications. They line up for their medicines three times a day. Members of the staff, standing at a counter, dispense the pills through a window that looks like the ticket booth at a movie theater.

Most of the residents are on Medicare, because they have disabilities, and Medicaid, because they have low incomes. Before Jan. 1, the state's Medicaid program covered their drugs at no charge. Since then, the residents have been covered by a private insurance company under contract to Medicare.

For the first time, residents of Dayspring Village found this month that they were being charged co-payments for their drugs, typically $3 for each prescription. The residents take an average of eight or nine drugs, so the co-payments can take a large share of their cash allowance, which is $54 a month.

Even after the insurer agreed to relax "prior authorization" requirements for a month, it was charging high co-payments for some drugs - $52 apiece for Abilify, an anti-psychotic medicine, and Depakote, a mood stabilizer used in treating bipolar disorder.

The patients take antipsychotic drugs for schizophrenia; more drugs to treat side effects of those drugs, like tremors and insomnia; and still other drugs to treat chronic conditions like diabetes and high blood pressure.

"If I didn't have any of those medications, I would probably be institutionalized for the rest of my life," said Deborah Ann Katz, a 36-year-old Medicare beneficiary at Dayspring. "I'd be hallucinating, hearing voices."

Michael D. Ranne, president of the Jacksonville chapter of the National Alliance on Mental Illness, said the use of powerful psychiatric medications "virtually emptied out state mental hospitals" in the 1970's and early 80's. Ms. Katz said she had been "in and out of hospitals" since she was 13.

Sponsors of the 2003 Medicare law wanted to drive down costs by creating a competitive market for drug insurance. They focused on older Americans, not the disabled. They assumed that beneficiaries would sort through various drug plans to find the one that best met their needs. But that assumption appears unrealistic for people at Dayspring Village.

Heidi L. Fretheim, a case manager for Dayspring residents, said: "If I take them shopping at Wal-Mart, the experience is overwhelming for them. They get nervous. They think the clerks are plotting against them, or out to hurt them."

Residents of Dayspring Village see worms in their food. Some neglect personal hygiene because they hear voices in the shower. When nurses draw blood, some patients want the laboratory to return it so the blood can be put back in their veins.

Under the 2003 Medicare law, low-income people entitled to both Medicare and Medicaid are exempted from all co-payments if they live in a nursing home. But the exemption does not apply to people in assisted living centers like Dayspring Village.

Douglas D. Adkins, executive director of Dayspring Village, said: "Some of the pharmacists have been saying, 'No pills unless we get a co-payment.' Well, how are these people going to get the money for a co-payment? They don't have it."

Eunice Medina, a policy analyst at the Florida Department of Elder Affairs, said the state was trying to "find a solution" for people in assisted living centers.

"We are all aware that the next couple of months will be difficult for these clients, and that the possibility of a transition to a nursing home is their only option if prescriptions are not covered in assisted living facilities," Ms. Medina said in a memorandum to local social service agencies.

Luis E. Collazo, administrator of Palm Breeze, an assisted living center for the mentally ill in Hialeah, Fla., said many of his residents were forgoing their medications on account of the new co-payments.

"Because of their mental illness," Mr. Collazo said, "they don't have the insight to realize the consequences of not taking their medications. Without their medicines, they will definitely go into the hospital."

The Medicare Drug Mess. Editorial
The New York Times, January 22, 2006

After getting off to a promising start last fall, the new Medicare prescription drug program has stumbled badly in recent weeks, leaving tens of thousands of patients unable to obtain essential medicines. We can only hope that Medicare officials fix the glitches quickly before public disenchantment undermines prospects for enrolling enough people to give the new program real prospects for success. When the dust settles, it will be imperative to pinpoint how the problems arose, how much they reflect government ineptitude or malfeasance by private companies, and how further fiascos can be avoided.

The immediate problems have little to do with the most common complaint against the program, namely that many people find it dreadfully confusing to choose a good drug plan from a bewildering array of options offered by private insurers. Instead, most of the snags occurred in the part that should have been the easiest to execute smoothly - the automatic switchover of more than six million poor people from the Medicaid programs in their home states to the new Medicare drug program.

The Medicaid recipients were randomly assigned to a private drug plan, with the option to switch to another if they were dissatisfied. Along the way, as data bounced from one bureaucracy and set of computers to the next, some people's names dropped out of the system. Others, though listed as enrolled, were not earmarked as they should have been for the lowest level of co-payments. Thus many poor people found that when they showed up at the pharmacy they either were denied coverage or were asked to pay hundreds of dollars in deductibles or co-payments. Pharmacists who tried to call the private drug plans could seldom get through. And some plans improperly refused to approve drugs during the transition as they were required to.

Nobody knows how many people were affected, but officials acknowledge it may be in the tens of thousands. California alone says that some 200,000 of its one million Medicaid patients had trouble getting medications during the switchover, an astonishing error rate. More than 20 states stepped in to guarantee drug coverage until the glitches are resolved. They had little choice, given the potentially catastrophic consequences for people who depend on their medicines to keep mental illness at bay, pain at tolerable levels and diabetes or other ailments under control.

This is a disheartening setback for a critical program and we can only hope that Michael Leavitt, the secretary of health and human services, is right that after everyone has used the new drug card at least once, the system will run more smoothly.

If not, any further snags are apt to throw a cloud over the whole program just when it desperately needs to attract more participants. Officials have been trying to deflect the recent bad news with exaggerated claims of success. Mr. Leavitt announced with great pride that some 24 million of the elderly had drug coverage. But 20 million of those 24 million already had drug coverage, through retiree plans, Medicaid or other programs.

The real measure of success will be how many people sign up who previously had little or no drug coverage - a pool estimated at 12 million to 14 million, or possibly more. Only about 3.6 million signed up voluntarily for Medicare's new stand-alone drug plans in the first 60 days of the enrollment period - a modest figure undoubtedly due at least in part to the complexity of the system. Worse yet, those who would benefit the most from the new drug coverage, namely low-income people entitled to special subsidies, have been disproportionately slow to sign up.

Federal officials and private health plans will have to reach out more vigorously to raise the numbers before the enrollment period ends on May 15. They have a long way to go to prove their argument that their approach was better than that of a classic federal program like the original Medicare. Their efforts will not be helped if further glitches continue to tar the program's image.