2009 Social Policy Priorities

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1. The Vermont Association for Mental Health will work to transform our public mental health system, closing the Vermont State Hospital and building a new system of care

For the past four years, we (a collective "we") have not been successful in the complex and major task of addressing what has become known as the Vermont State Hospital Futures Project.  

While there have been several significant changes and improvements that we think bode well for more thoughtful and ultimately successful public debate in 2009, the weak Vermont economy casts a pall over discussion.  Certainly the successful implementation of the Second Spring program in Williamstown represents a small but significant accomplishment.  And a decision to bid out another community based program to be located in a different part of the state, (southeast) to a partnership between the Brattleboro Retreat and Health Care and Rehabilitation Services, holds promise of good programming as well as important geographic "diversity".  And the introduction of new crisis beds within Vermont communities certainly represent a good and appropriate method for "hospital diversion".

In the year ahead, we anticipate, with support, the idea of proposing the construction of a state-of-the-art fifteen bed Rehabilitation Center in Waterbury.  The notion of building a new structure is our preference as compared to using old space which obviously would require major renovation.  While the design and cost of alternatives will be front and center by the winter, perhaps the most important issue is clarifying the exact role for the facility as well as plans for introducing "quality care" into the effort.

The Vermont Association for Mental Health continues to express concern that the most complex, essential and expensive part of this initiative remains unclear.  After several years of on-going negotiation, there still is no agreement to partner with regional medical centers in Vermont which is indeed the key to closing the Vermont State Hospital.  Patience is running thin and this issue cannot remain unsettled much longer.

With appreciation, the Association applauds the work of a loyal and dedicated staff at the Vermont State Hospital with appropriate leadership from the Department of Mental Health.  While improvement and stability seems at hand, (we applaud the recent accreditation by the Joint Commission), no one should sleep comfortably until there is a defined closing date for the VSH.  The Governor and the legislature should reaffirm their intention to close the hospital and target a specific date if we are to move forward.

The current facility represents the past.  This antiquated space reflects poorly on Vermont and challenges the notion of an environment that promotes "parity in care for those with a severe illness".  If Vermont does not move forward this coming year with comprehensive plan, we run the risk of relying on the Vermont State Hospital into the foreseeable future.  This in not an option we can afford.  This is not an option for Vermonters who need access to quality care.

2. The Vermont Association for Mental Health will work to fully sustain Vermont’s designated community mental health and substance abuse treatment system which not only provides services to more than 40,000 Vermonters annually but whose vitality is necessary to the ultimate success or failure of the Vermont State Hospital Futures project

After three years of strong support from both the Douglas administration and the Legislature for the state’s designated community mental health centers and substance abuse treatment systems, the broader economic down-turn now poses serious major challenges for public mental health and substance abuse services whether they be treatment, prevention or recovery programs.   With painful irony, there is much evidence to suggest that the need for services actually increases when state services face retraction and reduction.  And new populations, such as Iraqi war veterans, need access to community based care and community based intervention.

This issue is simple, complex and profound.   If Vermont’s community mental health and substance abuse treatment systems erode, so too does the probability of successfully implementing the massive Vermont State Hospital Futures project.  Further cuts and recessions, beyond those announced in August of 2008, will in fact tear at the fabric of the system, creating instability and painful service cuts.  After paring millions from the community services system in August, the Association will do what it can to hold the line on further reductions.

3. VAMH will work to reduce, if not eliminate, the potential conflict and intrusive influence of the pharmaceutical industry in public policy discussions and in treatment practices in the fields of mental health and substance abuse and throughout all of medical practice.

Psychotropic medications are one vitally important aspect of treatment in both behavioral and "physical" health care.  However the business goals of the pharmaceutical industry have proven to be at odds with the best interest of patients and consumers.  It is time, actually it is past time, to take a public stand.   The mixture of "marketing and medicine" has distorted practice in the health care field.  Our quest is to change the environment so that patients and consumers have access to evidence based "best practice" not drug company marketing.  

In June of this 2007, the Board of the Vermont Association for Mental Health voted unanimously to refuse any funding from the pharmaceutical industry.  Hopefully other medical providers and researchers and physicians will also "say no".

During the past year, the Vermont Association for Mental Health held numerous meetings, and forums, not to mention press conferences, in order to create a new dialogue on the subject.  Our concerns were many and varied:

The VAMH revealed that in 2007, our state Medicaid program spent approximately $20 million dollars on psychotropic medications for children under the age of 18.  And few psychiatrists were the physicians doing the prescribing.

The VAMH found that in 2006, Vermont’s Medicaid program spent $4 million on the controversial drug Zyprexa at a point in time when more than a dozen states already had lawsuits claiming that drug maker Eli Lilly hide information about serious side effects.

The VAMH monitored closely the Vermont Attorney General’s Annual Disclosure report that indicated that Vermont doctors in 2007 accepted 3.1 million in gifts from pharmaceutical companies as part of their marketing campaign, a 33% increase from the previous year.

The VAMH noted with concern, that psychiatrists were the leading specialty group recipient with eleven psychiatrists accepting a total of $630,000 in gifts. 

The Vermont Association for Mental Health has a three pronged approach to addressing this issue in the coming year.

First and foremost, we will promote disclosure and transparency in the relationship between drug companies and the medical profession, doctors, hospitals and universities.  In order to further this initiative, we will support legislation that will seek to remove the trade secret clause in Vermont’s current disclosure law.

Secondly, we will promote the creation of accessibility to information to all Vermonters that records any and all gifs from drug companies to Vermont doctors and health care institutions.  This process is an important step in the direction of citizen and patient empowerment.  This approach, we hope, will encourage a voluntary response from the medical community which hopefully will establish guidelines and public policy positions about the acceptance of gifts from drug companies.

Thirdly, the VAMH will identify and support initiatives that promote independent standards and evaluation reviews of medications, especially psychotropic medications.  The Association is encouraged by projects like the academic detailing work at the Vermont College of Medicine as well as several model programs that enhance the role of Vermont psychiatrists in promoting public education about these medications to other physicians and to consumers and families. 

4. The VAMH will work to promote and expand the definition of parity in both our public and private sectors as it relates to consumer access to care and practitioner access to fair and decent reimbursement rates

It is now eleven years since Vermont passed the nationally acclaimed mental health and substance abuse parity bill (1997).  This legislation is still the nation’s most comprehensive model of parity for mental health and substance abuse and the positive impact of this legislation has been applauded by a number of national studies.

In order to strengthen the law and promote assess to mental health and substance abuse treatment, the Association mounted a major campaign last legislative session to better regulate the work of "behavioral health" managed care industry.  Passage of the bill, S – 114, was viewed as a major victory for consumers.   It also validated the concerns of many practitioners who toil in an environment which at times seem designed to limit access rather than enhance it.

As a result of this legislation, the Vermont Health Care Administration, along with advocates, providers and leaders of our insurance and managed care industry are working to create regulations (Act 142) which capture the purpose and design of the legislation.  Given the work so far, there is reason to believe that this regulatory approach can and will work.

Another important issue that needs to be addressed is the perceived lack of parity in reimbursement in both the public and private sectors for mental health and substance abuse treatment.  While Vermont’s parity bill opened up access for Vermonters with insurance, one unintended outcome has been the perceived strategy of reducing reimbursement rates for mental health and substance abuse treatment providers.  Low reimbursement rates should be seen as another "barrier to parity"; inadequate reimbursement rates in federal, state and in the private insurance marketplace will ultimately threaten the very viability of this field.  The VAMH will work to review strategies for creating a "parity environment" for all treatment providers of mental health and substance abuse services.

Ken Libertoff, Director
Vermont Association for Mental Health
October 2008

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