Blog Archives

The Microbiome: Stress, Trauma, the Anna Karenina Principle, & Justice

5/3/2018

Personalized medicine is a big deal now -- recognizing the importance of individual differences to health outcomes.
We've argued for some time how critical personalized medicine is to mental health treatment, especially given how idiosyncratic the biological systems are for people with mental illness.
There are many, many reasons for differences -- but it turns out that one of them or trillions of them are the microbiota that make up our individual microbiomes.
Well what can our microbiomes affect:

Mood
Anxiety
Sleep
Personality
Etc.

When we have our Knowledge- Challenged Clinical Profession handing out "Personality Disorder" Diagnoses in the Justice System, how much longer can we ignore that they just don't have the knowledge available to make the determinations they are asked to make and that they are in fact making.

Good Bacteria, Mental Health Policy, & CU Research involving the Microbiome & PTSD

Nova Wonders: What's Living in You? Preview

Psychology Today

Chronic Stress Discombobulates Gut Microbiome Communities
Gut microbiome communities become unpredictable when someone is in distress.

When people are feeling healthy, relaxed, and safe, their gut microbiome communities generally work together harmoniously in a predictable symbiotic manner, according to a new study.

However, the Oregon State University researchers found that when someone is under stress, his or her gut microbiome communities become discombobulated and behave erratically, in ways that are unpredictable and vary from person to person.

This study, “Stress and Stability: Applying the Anna Karenina Principle to Animal Microbiomes (,” was published online August 24 [2017 in Nature Microbiology.]

Leo Tolstoy famously said: "All happy families are alike; each unhappy family is unhappy in its own way."

After realizing how unpredictably each individual's gut microbiome communities responded during "unhappy" stressful situations, the research team coined their discovery the "Anna Karenina principle" in honor of Tolstoy's dictum. In the study abstract, the authors write:

"The result is an ‘Anna Karenina principle’ for animal microbiomes, in which dysbiotic individuals vary more in microbial community composition than healthy individuals—paralleling Leo Tolstoy's dictum that “all happy families look alike; each unhappy family is unhappy in its own way."

We argue that Anna Karenina effects are a common and important response of animal microbiomes to stressors that reduce the ability of the host or its microbiome to regulate community composition."

https://www.psychologytoday.com/us/blog/the-athletes-way/201708/chronic-stress-discombobulates-gut-microbiome-communities

Multiple complex Interests & Involuntary Treatment -- Safety, Bed Space, Medicaid Network Adequacy, Parity & Olmstead -- We Need A LOT of DATA & Education

5/1/2018

I've maintained for a long time that the problem here in Colorado and around the Country is NOT our Civil Commitment Laws -- but lack of adequate treatment & housing.
But what about those people who present a danger? Well, law enforcement, mental professionals, and local media commentators don't seem to recognize that the "imminent danger" limitation just applies to emergency 72-hour holds.
There is a Colorado statutory provision to
seek a court-ordered evaluation based on "danger." Nobody seems to know about it, or if they do they don't want to use it because maybe it's more cumbersome.

[See CRS 27-65-106. Court-ordered evaluation for persons with mental health disorders]

I don't have a problem with getting rid of "imminent" before danger regarding emergency 72-hour holds or Red Flag Laws.
I'm changing my tune and saying there needs to be an INCLUSIVE stakeholder group made up of:

State Officials
Providers
Individuals with lived experience of mental illness and certification, homelessness, or incarceration.
Family Members, and
Advocates
Racially & Ethnically Diverse

To address:

Civil Commitment --Concerns some of the failure to seek a mental health evaluation on an emergency or non-emergency basis. Some of these decisions not to seek evaluation strike us as very questionable even given the problems with current law,
What is it going to take to address the practical problems of Safety & Humane Treatment and balance Constitutional & other Legal Concerns -- "Gravely Disabled" was meant in large measure to deal with the issue of people with mental illness who are homeless -- but it hasn't worked so far -- not because of the law -- because of lack of housing and intensive treatment [think Olmstead among other legal requirements].
Our apparent gross negligence involved with ignoring some homeless people who satisfy the criteria for "Gravely Disabled" -- there are many, not all, who would accept and want appropriate & person-centered, strength-based treatment and housing -- Is their openness to treatment working against them?
Greater Clarity, training and one on one Support for law enforcement, mental health professionals, and all Coloradans when it comes to emergency and non-emergency evaluations.
What about people with Brain Injury?
Are there sufficient inpatient beds?
What about Medicaid Network Adequacy and Housing?
Data Collection

Most Coloradans want Safety and sufficient inpatient beds, Medicaid Network Adequacy, & Housing for people with mental illness or brain injury.

This really goes to Mental Health America's -- B4Stage4 Campaign & the Mental Health Parity & Addiction Equity Act which bans Medicaid and other Health Insurance Providers from requiring a "FAIL FIRST" practice to access sufficiently intensive treatment.

That ban on "Fail First" policies includes not just the written policies, but the actual practices.

CRS 27-65-102.
Definitions

(4.5) "Danger to self or others" means:
(a) With respect to an individual, that the individual poses a substantial risk of physical harm to himself or herself as manifested by evidence of recent threats of or attempts at suicide or serious bodily harm to himself or herself; or
(b) With respect to other persons, that the individual poses a substantial risk of physical harm to another person or persons, as manifested by evidence of recent homicidal or other violent behavior by the person in question, or by evidence that others are placed in reasonable fear of violent behavior and serious physical harm to them, as evidenced by a recent overt act, attempt, or threat to do serious physical harm by the person in question.

Medicaid Network Adequacy: Watered Down Some for Fee For Service -- Is CMS Going to enforce Access requirements for Managed Care?

5/1/2018

So the proposed CMS Rule to give some states a break on Network Adequacy for Fee For Service if they have large Managed Care Programs isn't wholly irrational.

BUT is CMS going to be willing to provide the Systems & Framework for REAL Network Adequacy in Medicaid Managed Care?

If you look at the Code of Federal Regulations and the new Rules on Network Adequacy -- it is pretty clear the Feds thought they were providing a Framework.

BUT it is really not enough, especially since states just haven't been providing this kind of data or analysis -- and it can be powerful evidence of non-compliance with various federal requirements, including Network Adequacy.

That is NOT escaping the States.

So the goal is NOT to bankrupt the States -- it's to bring REAL HONESTY to these processes and ultimately a reasonable plan to get into compliance if there is an issue.

We NEED REAL DATA AND THAT NEEDS TO BE POSTED ON THE HCPF Website.

Medicaid Network Adequacy --CMS

"We are still interested in developing and adopting meaningful access measures that could apply consistently regardless of the service delivery approach used by the state.

:Our ultimate goal is to better measure, monitor and ensure Medicaid access across state programs and delivery systems.

"While there is a longstanding requirement in 42 CFR 431.16 that states are obligated to provide all reports required by the Secretary and must follow the Secretary's instructions regarding the form and content of such reports, we are using this opportunity to state that, in the future and informed by stakeholder feedback, we may look to adopt a more standardized form and content for the states' AMRP submissions."

Excerpts

Medicaid Program: Methods for Assuring Access to Cover Medicaid Services- Exceptions for States With High Managed Care Penetration Rates and Rate Reduction

SUMMARY:
This proposed rule would amend the process for states to document whether Medicaid payments in fee-for-service systems are sufficient to enlist providers to assure beneficiary access to covered care and services consistent with the statute. States have raised concerns over the administrative burden associated with the current requirements, particularly for states with high rates of Medicaid managed care enrollment. T

This proposed rule would provide burden relief and address those concerns.

DATES:
To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on May 22, 2018.

FOR FURTHER INFORMATION CONTACT:
Jeremy Silanskis, (410) 786-1592, [email protected].

I. Executive Summary and Background
A. Executive Summary
1. PURPOSE
Current regulations at 42 CFR 447.203(b) require states to develop and submit to CMS an access monitoring review plan (AMRP) for Medicaid services provided through a fee-for-service (FFS) delivery system.

The AMRP must be updated at least every 3 years and address the following categories of Medicaid services:

Primary care services (including those provided by a physician, federally qualified health center (FQHC), clinic or dental care); physician specialist services (for example, cardiology, radiology, urology); behavioral health services (including mental health and substance use disorder); pre- and post-natal obstetric services (including labor and delivery); and home health.

The AMRP must identify a data-driven process to review access to care and address: The extent to which beneficiary needs are fully met; the availability of care through enrolled providers; and changes in beneficiary service utilization.

Additionally, when states reduce rates for other Medicaid services, they must add those services to the AMRP and monitor the effects of the rate reductions for 3 years.

Section 447.204 requires states to undertake a public process and submit specific information regarding access to care when proposing to reduce or restructure Medicaid provider payment rates.

This proposed rule would provide an exemption to the regulatory requirements in §§ 447.203(b)(1) through (6) and 447.204(a) through (c) for states with comprehensive, risk-based

Medicaid managed care enrollment rates above 85 percent of the total covered population under a state's Medicaid program, including managed care comprehensive risk contracts under a state's section 1115 Medicaid demonstration.

The proposed rule would also provide an exemption to the regulatory requirements in §§ 447.203(b)(6) and 447.204(a) through (c) for states that submit state plan amendments (SPAs) to reduce rates or restructure payments where the overall reduction is 4 percent or less of overall spending within the affected state plan service category for a single state fiscal year (SFY) and 6 percent or less over 2 consecutive SFYs. Additionally, the proposed rule would modify the requirements in § 447.204(b)(2) so that, for SPAs that reduce or restructure Medicaid payment rates, states would be required to submit to CMS an assurance that data indicates current access is consistent with Start Printed Page 12697 requirements of the Social Security Act (the Act) instead of an analysis anticipating the effects of a proposed change in payment rates or structure.

Modern Healthcare

17 states could get a pass on Obama-era network adequacy rule

The CMS is letting some states off the hook when it comes to complying with an Obama-era rule that's meant to ensure Medicaid beneficiaries have adequate access to care.

In 2015, the CMS finalized a rule requiring states to assess how easy it is for fee-for-service Medicaid beneficiaries to receive primary care; pre- and post-natal obstetric services; and specialty and behavioral health care, among other services.

On Thursday, the CMS issued a proposed rule that would exempt states if the majority of their Medicaid population received services through managed-care plans.

"These new policies do not mean that we aren't interested in beneficiary access but are intended to relieve unnecessary regulatory burden on states, avoid increasing administrative costs for taxpayers, and refocus time and resources on improving the health outcomes of Medicaid beneficiaries," CMS Administrator Seema Verma said in statement.

Since the finalized rule's release in 2015, states with large managed-care populations have pushed back against the rule saying it would affect only a few thousand of people in their respective states. Of the 75.2 million beneficiaries in Medicaid in 2016, 73% were in private plans, up from 55% in 2013 according to PricewaterhouseCoopers.

In the final access rule, the CMS estimated it could take states as long as 15,000 hours to develop the plans.

If the changes are finalized, states with an overall Medicaid managed-care penetration rate of 85% or greater would be exempt from most access monitoring requirements. The CMS estimates that 17 states including Arizona, the District of Columbia, Florida, Kansas and Kentucky fall into that category.

States that cut Medicaid rates by up to 4% in one year or up to 6% in two consecutive years will no longer be required to conduct an analysis to determine if access to care will be harmed by the reductions.

"We generally believe changes below the 4% threshold to be nominal and unlikely to diminish access to care," the CMS said in the rule.

In total, the proposed changes are estimated to reduce state administrative burden by 561 hours with a total savings of over $1.6 million.

http://www.modernhealthcare.com/article/20180322/NEWS/180329960

CMS State Medicaid Director Letter:
RE: Medicaid Access to Care Implementation Guidance

Proposed Rule

Forward>>

Val's Blog

The Microbiome: Stress, Trauma, the Anna Karenina Principle, & Justice

Multiple complex Interests & Involuntary Treatment -- Safety, Bed Space, Medicaid Network Adequacy, Parity & Olmstead -- We Need A LOT of DATA & Education

CRS 27-65-102.
Definitions

Medicaid Network Adequacy: Watered Down Some for Fee For Service -- Is CMS Going to enforce Access requirements for Managed Care?

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Val's Blog

The Microbiome: Stress, Trauma, the Anna Karenina Principle, & Justice

Multiple complex Interests & Involuntary Treatment -- Safety, Bed Space, Medicaid Network Adequacy, Parity & Olmstead -- We Need A LOT of DATA & Education

CRS 27-65-102. Definitions

Medicaid Network Adequacy: Watered Down Some for Fee For Service -- Is CMS Going to enforce Access requirements for Managed Care?

Author

Archives

Categories

CRS 27-65-102.
Definitions