A Long Road Back To Sanity - States Finally Reversing Cuts to Mental Health

All over the country, governors are finally beginning to propose new mental health services funding in the aftermath of last year’s mass shootings in Aurora and Sandy Hook.

Notes: OH funding is from existing OHT appropriation.
CT funding is bond money, some of which may
be used by non-MHSA providers.

There will be a long road back to policy sanity.  We have to dig ourselves out of the mess caused by $4.6 billion in state mental health cuts over the last few years.  But these governors give us hope that the funding-cut nightmare over which many of them have presided may be finally coming to an end. 

In recent weeks, both Republicans and Democrats have announced new community behavioral health funding initiatives, typically ranging between $5 million and $20 million.  

But support for community mental health services is not universal.  In states with the worst track records in funding mental health services, their governors continue to be sadly out of step with their colleagues across the nation.

In Idaho, which has recently dropped to the bottom of mental health services spending, Governor Butch Otter’s major mental health initiative in the aftermath of the Sandy Hook shooting is for $70 million to construct a 579-bed “secure mental health facility” on the grounds of the state’s prison south of Boise.  That would be considered progressive by late 19^th century standards.

At least Otter’s proposing to do something.

Florida has been at or near the bottom of mental health spending for years.  But Governor Rick Scott – whose administration just cut millions more away from community mental health services in October – seems to think that if he just ignores the problem it will go away.  He requested no new dollars for mental health services in his 2014 budget.

But in the rest of the country, the emerging news is much better.  In the last month or so:

According to the Lansing State Journal, MichiganGovernor Rick Snyder said he will seek $5 million in new funding for mental health services to identify young people with mental health needs.  Michigan has cut $124 million from community mental health programs since 2004.

In Missouri, where eighteen months ago Anna Brown’s death in a St. Louis jail after she was refused care in a hospital emergency room drew national attention, Governor Jay Nixon is proposing $10 million in new mental health funding, primarily for a hospital emergency room diversion program.

In Colorado, Governor John Hickenlooper, whose state suffered through the Aurora mass shooting last summer, has proposed spending $18.5 million in new funding, including over $10 million for five urgent care centers for people with mental illness and a statewide 24-hour hotline.

In Connecticut, the site of the Sandy Hook massacre, Governor Dan Malloy proposed $20 million in new bond funding to assist community behavioral health providers with infrastructure projects that providers say have either been set aside because of budget cuts or have been draining money needed for direct services.

Kansas Governor Sam Brownback, saying that he was committed to strengthening the state’s community mental health system, announced his support for an additional $10 million to increase funding to 27 community mental health centers and to establish a regional system of peer support, intensive case management, crisis intervention, and other evidence-based services.

Oklahoma Governor Mary Fallin announced that she will seek $16 million in new mental health services funding - $8 million for existing programs and $8 million for new programs, including early intervention programs for children and a new state-supported mental health crisis center.

And in Ohio, Governor John Kasich reported that he was authorizing the expenditure of $5 million from an Office of Health Transformation discretionary fund to support children’s crisis intervention services.

These represent just a handful of states taking action, but a cross-section as well. 

The reasons the governors made these proposals may vary.  Some governors may be avoiding gun control debates.  Others may still erroneously equate mental illness with violence. 

The mental health funding initiatives the governors are proposing, however, are needed. 

The governors are working to improve community mental health systems.  They are calling for early identification and treatment of mental illnesses in children, adding new crisis intervention services, and addressing other neglected priorities in their own states. 

And while the numbers may pale in comparison to the cuts made in recent years and won’t undo the damage overnight, they are steps in the right direction. 

These steps should be embraced by legislators in their states, and in states with less understanding governors.  

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

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More on the lengths a hospital will go through to protect their EHR from discovery

At "The lengths a hospital will go to in order to protect their EHR - Motion for Reconsideration of Denial of Motion for Reconsideration of Denial of Objections" I wrote about obstruction of litigation by the defense regarding a case where an EHR contributed to patient injury and death.

The major basis for the new "Motion for Reconsideration" (a request for the court to reconsider its prior denial of an earlier Motion for Reconsideration of an initial court decision to dismiss defense objections to the Complaint) is this.  From the actual filing (emphases mine):

(click to enlarge)

Here is likely why the court "never addressed the issue":  they don't have time to address frivolous claims.  Neither does the Superior court that also declined to hear this argument.  (It's actually the defense who never addressed the following in all their filings):

From the official publication of the Civil Procedure Rules Committee in the state, effective a decade ago:

That's pretty clear.  One certificate for non-defendants for whom the defendant is vicariously liable.  The medical professional providing the justifying statement doesn't even need to name them.

The mandated Certificate was timely filed, as was a separate Certificate of Merit for direct corporate liability in the malpractice suit.

Further -  from the actual mandated Certificate of Merit document, direct from the State code:

I don't think the Courts expect parties to edit their documents to accommodate their own whims.

The only option for identifying those sued is “Name of Defendant.”  No fields are present specifying “Name(s) of Defendant’s agent, employee (etc.) for whom Defendant is being held vicariously liable”, or similar, nor is some other multi-labeled Certificate of Merit for such purposes in existence.

This is some rather inventive lawyering and misuse of court process, either to needlessly prolong the case, or to harass the plaintiff.  The judges will likely not be amused.

On the other hand, the delays have allowed me to be able to see and review metadata (e.g., audit trails and other "data about data") produced from the very same EHR system that was in use at this hospital, via my legal support work in another case in the state.  It took time for that production to occur.  This will make it much harder for the hospital to pull the wool over my eyes regarding metadata discovery.

That's one reason why I'd been patient with all this.

My patience is now long expired.

My mother, the original plaintiff, is unavailable for comment.

-- SS

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How to Make Homemade Childrens’ Books

I have a long-standing love affair with books – essentially ever since I discovered as a child that I could check out up to 12 Berenstain Bear books at my local library. Big fan.

And that love of books has definitely continued on with my 4-year-old, Max. My husband and I have made an effort to read to Max as much as we can. In fact, there are some books we read so often that Max knows all of the words – and that started a tradition between my husband and son of Max making up his own stories and telling them to us in lieu of one of his books at night. And then, we had an idea: why not make our own books? So we did!

Max and I have started writing our own tales, using stickers, craft paper and markers. Max absolutely LOVES it. He makes up the craziest stories, but I guide him through and we use stickers to illustrate his story (and to keep him on track!) Last night, we read a book we co-wrote called The Rescue Team twice and he seemed so proud. If you have a toddler who likes to read, I would absolutely recommend doing this! It’s a fun activity – really easy to do, inexpensive and fun!

I’ve made books two different ways. Here are detailed instructions:

Binder ring books:

1. I took two pieces of 12 by 12 scrapbook paper and cut it into four for a total of eight pages.
2. I took a hole puncher and punched a hole in the top left corner and put a binder ring (purchased at Staples for $3 per 10-pack bag) to hold the book together.
3. I got a marker and a large book of boyish stickers – everything from dinosaurs to trucks, cars, policemen and firemen
4. I let my son choose what he wanted his story to be about by choosing some stickers from the packet. He chose the page with policemen, firemen, ambulances, etc.
5. We wrote the story. I started it generically, and left sentences for him to fill in words. As we went, I would ask him, “What do you want to happen next?” And when characters talk, I would ask, “What do you want them to say?” And he did the rest! Children are very creative – the stickers help keep them on track and – bonus – when you read it later, you can read the words, then when you get to a sticker, they can “read” it. And boy, does my son love to “read!”

Laminated spiral-bound books:

If you want to spend a little more money and make a book virtually indestructible, this option is for you!

1. Take paper (same process as above) and decide which type of book you want. In these photos, I decided to make an alphabet book to help my son when he was learning his ABCs.
2. For the alphabet book, I gathered everything I could find – photos, stickers, etc. – and made a page for each letter of the alphabet of things that started with that letter.
3. Then I took the pages to Staples and paid to have them laminated and bound together with a spiral binding. The lamination and binding cost $26, but I will say, my son loved that book and it’s lasted nearly three years with no damage to it!

I’m sure there are tons of other ways to make your own books – If you have any good suggestions, send them my way! I have a feeling I’ll be making books for years to come!

Aleshia Howe is a communications specialist at Texas Health Harris Methodist Foundation and Texas Health Presbyterian Foundation and mother to two boys, ages 4 and 1.

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CPRIT, Part 7 (Conclusion): Reflections

The story of CPRIT is not over. Revelations and reactions come out almost daily as the power struggles continue. It is ultimately in the legislature's hands what will occur.

But the situation is not encouraging. There is no reason to believe that there is a way to put Humpty Dumpty back together again after this fiasco. Nothing I've seen looks at all hopeful about change even though the new CPRIT officials are making compliant noises. The vigorous pro-rapid-commercialization defenses being made are not reassuring. Those who promote a "business" or "engineering" approach to cancer drugs while disdaining scientific evaluation are misguided, but they with probably some sincerity think they are marvelous people who plan to combine "doing good" with "doing well." After all, if Governor Perry had my opinion of the dangers of unproven therapies, he would never have permitted his surgeon to inject him with multiplied stem cells. And, these people are extremely tenacious. The focus seems to be on saying there will be "better management procedures" henceforward and I don't have confidence that will address the impetus to eschew scientific evaluation.

There is some hope that some of the earlier monies spent by CPRIT may prove worthwhile, and there is some satisfaction that such a large group of people stood up for the principle that scientific review MUST be a part of deciding what is commercialized.

In her resignation letter, Monica Bertagnolli of Harvard Medical School said it best:

In awarding funding, I believe that it is critically important for commercialization potential to be secondary at all times to scientific quality. Many projects that have significant commercialization potential in the short term also lack scientific validity.

I would like to shout her last sentence out from the rooftops, or put it on a sign:  Many projects that have significant commercialization potential in the short term also lack scientific validity.

When evidence is ignored or suppressed while "products" are put on the market, people are bilked, money is wasted, and very often people are physically harmed as well (cf. Ben Goldacre's sensible reflections on Health Care's Trick Coin). The more commercialization without evidence becomes the norm, the more people are injured by bad medicine.

Of course, there is another way to look at this. Money out of one person's pocket is indeed money into another person's, and, as Governor Perry astutely observes, this makes for a lot of "wealth creation." (And as he also astutely observes, basic research doesn't always do that.) If we want to make some people very wealthy and our medical system even more ahead of the rest of the world in being most costly -- hey, way to go! If we want to turn a supposed cancer research endeavor into yet another of the Governor's taxpayer-funded slush funds for campaign contributors -- great work!

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The Story of CPRIT, Part 6: Reactions

There has been a lot of dismay in Texas as all this has become public (with the word "cronyism" being mentioned very frequently). As the Houston Chronicle asked in May:

Why is CPRIT even funding commercial enterprises? Didn't voters expect the bond money to support research?

[Answer: Voters did, and there was no mention of commercialization in the ballot measure. Legislators did get language about commercialization into the enabling legislation, however.]

Newspapers and bloggers have not been happy with what is going on. Nor have some former supporters. Cathy Bonner, a cancer survivor and activist who had worked hard to get the agency established, said succinctly: 

The vision was to make Texas the center for curing cancer. It wasn't to make Texas the center for capitalizing on cancer.

But those in power show few signs of giving ground. After the resignations in October, a joint letter from the governor, lieutenant governor and speaker of the House urged more commercialization:

It is now time for CPRIT to take further steps to fulfill its statutory mission and expedite innovation that will deliver new cancer treatments to patients within three to five years.

In an October appearance at CPRIT, Perry stated:

Since CPRIT's creation, you all have helped lay a sound foundation to establish one of the greatest cancer-fighting tools in human history. The challenge that remains before us is to build on that foundation and finally begin curing cancer once and for all.

As The Cancer Letter tartly observed :

This statement could mean either that (a) Perry doesn’t realize that his claim that Texas has done all the basic science required to proceed to cranking out cancer cures would not gain wide traction among scientists and clinicians, or (b) CPRIT has become precisely what the governor and others in Texas politics want it to be: a pot of public money that can be dispensed for commercial or political purposes.

Interviewed by the Houston Chronicle in January, Perry continued in the same vein: 

The way that the Legislature intended it was to get cures into the public's area as soon as possible and at the same time create economic avenues (from) which wealth can be created. Basic research takes a long time and may or may not ever create wealth.

Matt Winkler, a member of CPRIT's Scientific and Prevention Advisory Council, last week expressed his opinion to the Austin Statesman that the criticism of commercialization -- Winkler prefers the term "product development" -- was totally on the wrong track. "Continuing to short-change commercialization, Winkler said, comes at the expense of patients because money for basic research is unlikely to benefit patients during the 10-year lifetime of CPRIT. Winkler says lawmakers should insist on more investment in commercialization companies, not less." According to Winkler:

Much of the essential basic research that has given us our fundamental understanding of cancer has been done. The challenge now is to fill in the details and to move this knowledge into the clinic.

Disagreeing strongly with these ways of thinking,Walt Goodpastor, who lost a son to cancer, angrily wrote: 

I don't know where Perry studied economics. But CPRIT's wealth has already been created. It was created by the productive citizens of Texas. What Perry wants to do is transfer that wealth into the pockets of private corporations.

I do not believe the industry is particularly interested in finding true cures. Its business model is based on treating cancer. As in prevention, there is little profit to be made in a cure. Treating cancer provides an ongoing stream of revenue. Curing or preventing cancer would end that revenue stream.

I believe that the most bang for our buck would come from awarding grants to independent individual scientists who are working on promising leads.

And the Houston Chronicle editorialized on January 15:

To get the most cancer-fighting bang for its bucks, CPRIT ought to focus on important research that private companies won't do: the slow, might-not-pay-off basic research that sometimes yields enormous breakthroughs; and research on cheap therapies and prevention measures - stuff that, even if it works beautifully against cancer, won't yield a patentable, profitable drug.

     If there's a high probability that a given line of research will create wealth in a short amount of time, you can bet that a pharmaceutical company will bankroll that project on its own - no government help needed.

Nobel laureates Gilman and Sharp, who had led the walkout, wrote their own editorial, which says in part: 

Texans deserve to hear the truth about cancer. They must understand that miracles will not happen in a short time. Progress will not be made by those who simply proclaim without explanation that they can do better than hundreds of skillfully staffed and well-financed pharmaceutical and biotechnology companies. . .

Reliance on peer review to identify the best science must continue to guide CPRIT in the future. Of course, there are other ways to distribute public funds, but they are worse. 

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