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Champions of the Tennessee uninsured

8/6/2014

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Linda and Larry Drain

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DBSA PRESIDENT Allen Doederlein will visit across Tennessee

7/9/2014

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Daisy Jabas, Assistant Director, submitted this abbreviated itinerary:

I wanted to give each of you Allen Doerderlein's Tennessee visit intenery as it is known now.

July 23rd or 24th, arrive in Maryville, Tn
July 24th- 6 pm presentation for Larry Drain's Speaker Circuit
July 25th- 6 pm Nashville presentation/ reception
July 26th-Nashville Picnic for DBSA Members
July 27th - Arrive in Jackson, TN, DBSA Jackson Doerderlein event (leave Jackson that evening or on e 28th)
July 28th- DBSA Memphis Doerderlein event
Allen says "so long Tennessee, I shall return soon."  on Monday the 28th orTuesday the 29th
Return to Chicago.

More details of all events will be shared as they are organized. Everyone is invited to attend all events,and encouraged to do so, wherever the event is being held. I know that I am like all of you, eagerly awaiting and very excited about Allen's visit. Please keep me informed regarding all aspects of his visit as your Chapter creates them.

Our Doerderlein Event Committee is hard at work, planning and organizing details for a very productive and successful visit. Thank you everyone for your help with this and more so, thank you for your continued dedicated work for all those that live with mood disorders in Tennessee.

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Larry and Linda need help and get notice!

7/7/2014

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Exciting news is always welcome. One of our own steps out to bring national attention to those suffering due to lack of medical healthcare coverage.  Links to articles in The Tennessean and USA Today are below.

Larry Drain, DBSA Tennessee Legislative Liaison, is well known among many for his staunch work in advocacy for health care for all. Larry and Linda Drain share their story, open up their lives, in hopes that many will find the help they need. After 33 years of marriage, Larry and Linda had no other choice but to separate in order for Linda to keep the healthcare coverage she so desperately needs. Also, Larry is without healthcare coverage because his income is "too low" to meet the requirements for coverage.


The NBC Today show asked to interview Larry and Linda. The interview is expected to happen today. Airing of their interview is expected some time this week. Let's all send our best wishes and thoughts to this couple as they do all that they can to see that no one else needlessly suffers in like fashion.


Respectfully, 
Steve Brannon
State Director
DBSA Tennessee


Links to Larry and Linda's story:

http://usat.ly/VSQXne

http://tnne.ws/VSQCAY


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Medicaid Expansion as reported in Knoxville

6/22/2014

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KNOXNEWS.COM

Decision on Medicaid Expansion holds coverage for many Tennesseans in balance

By Kristi Nelson

Posted June 2, 2013, updated June 4 2013

It was supposed to be one of the strongest tenets of the 2010 Patient Protection and Affordable Care Act. Instead, it became a political football, a metaphor for states’ rights. After the Supreme Court ruled that the ACA could not force states to expand Medicaid, Gov. Bill Haslam was among those who rejected the Medicaid expansion, instead offering his alternative “Tennessee Plan” for federal government approval.

But whether the federal government and the General Assembly will accept Haslam’s plan remains to be seen, along with how well it will work to cover those who currently don’t have health insurance.

“He’s either politically brilliant, or he’s making one of the worst mistakes he could make,” Rep. Joe Armstrong, D-Knoxville, told the News Sentinel in March.

What the ACA intended

Originally, the Medicaid expansion provision was to give state health insurance coverage to a group of people who made too much to qualify for Medicaid but too little to afford insurance on the health insurance exchanges, even with the planned government subsidies.

It expanded Medicaid to qualify people younger than 65 whose income is below 138 percent of the federal poverty guideline (a little more than $15,860 annually for an individual, a little less than $32,500 annually for a family of four).

It meant that, for the first time, low-income adults who don’t have children could get state Medicaid coverage, and it standardized other qualifications.

Many states, including Tennessee, limit Medicaid enrollment to certain categories of people. To qualify for TennCare, for example, you have to be low-income and pregnant, a child, blind, disabled, aged, or fall under multiple, specific categories.

Tennessee has nearly 1 million uninsured residents, of whom at least 140,000 and maybe more than twice that number, by some estimates, likely would enroll in Medicaid if it were expanded under the ACA guidelines. About three-quarters would have been previously uninsured. Under the ACA expansion, the federal government would pick up the entire cost of new, previously ineligible enrollees for the first three years, phasing to 90 percent by 2020. In Tennessee, federal funds would have amounted to about $1.4 billion in the first year alone.

States could receive federal matching funds for covering additional low-income residents under Medicaid as early as April 2010, with wide-scale enrollment beginning this October and coverage starting Jan. 1, 2014. However, in June 2012, the U.S. Supreme Court ruled that the federal government could not make states expand Medicaid — making a linchpin of the ACA optional.

So far, 20 states have moved forward with Medicaid expansion. Ten have rejected it outright, while 10 others are not doing it now but are looking at alternatives and have not ruled it out for the future (the government gives no deadline, though states waiting much longer to decide stand to lose federal funds for the first year). Three states are still undecided, while seven — including Tennessee — are crafting their own, alternate plans.

On March 27, Gov. Bill Haslam announced that Tennessee would not expand TennCare rolls under the ACA, instead offering up an alternative he called the Tennessee Plan.

“I don’t think just pure expanding of a system that we all agree is too costly for us, is too costly for the federal government to afford long-term, is the right way,” he said then.

The ‘Tennessee Plan’

Haslam’s proposal is that the state use federal funds not to expand TennCare but to purchase private insurance through the insurance exchange for people who would have qualified for coverage under Medicaid expansion.

He outlined the proposal in the broadest terms, including five “key points”:

Individuals identified as being eligible for the Medicaid expansion group would instead be directed to the exchange, where they would be allowed to choose any qualified health plan that offers a certain level of benefits (the Silver Plan).

The state would pay the monthly premiums, matchable with 100 percent federal dollars, for those people to enroll in the Silver Plan.

People in the Medicaid expansion group would be treated like all other people enrolled in the Silver Plan, with access to the same benefits and appeals process as other people in the plans.

People in the Medicaid expansion group would have the same cost-sharing as other Silver Plan enrollees with incomes below 250 percent of the federal poverty guidelines. (On average, Silver Plan policies would pay for 70 percent of health care costs, with the remaining 30 percent paid by the planholder.)

The arrangement would have a “circuit-breaker,” or “sunset,” ending after the three-year period of 100 percent federal matching dollars, and could be renewed only with approval of the General Assembly. (This is true for states accepting the Medicaid expansion as well; they can stop using federal funds and drop the expanded coverage at any time.)

In addition, Haslam would seek to reform the way providers are paid for services, with payment based on outcomes rather than a set fee for services. The money saved, he said, would be enough to cover the state’s 10 percent share of costs after the government’s share goes to 90 percent.

“One option for covering the Medicaid expansion group is simply to add them to the Medicaid rolls, or the TennCare rolls, in our case,” Haslam said of the plan. “We don’t want to do that. There are a lot of federal requirements that come with Medicaid that make it difficult to provide quality care in the most cost-effective way possible.”

But the federal government may not allow Haslam to forgo some of those requirements. While national Centers for Medicare and Medicaid Services guidelines indicate that the main tenets of the plan — using federal dollars to pay premiums for low-income people to have commercial insurance, and reforming payment — meet federal requirements, some of the details don’t align with federal requirements intended to protect Medicaid enrollees.

For example, Tennessee would need to give those with serious health conditions a choice of enrolling in TennCare or private insurance, unless CMS were to grant Tennessee a waiver to that requirement.

The federal government would require supplementation of benefits (sometimes called “wraparound”) to make sure the commercial insurance plans include all services that would be available through Medicaid. Hypothetically, this could be done through a supplemental premium to the Silver Plan insurance provider.

The government also limits co-payments for Medicaid-eligible enrollees.

There is also an appeals process in place, required by past Supreme Court rulings, so that Medicaid patients and their doctors can challenge insurance companies’ refusals to cover “necessary treatments.” Under federal law, Tennessee would have to allow Medicaid-eligible patients this due process.

A federal entitlement program, Medicaid was designed for a population upon whom “poverty imposes special needs and the need for special protections,” said Carole Myers, a nurse practitioner and associate professor in the University of Tennessee’s College of Nursing. “They don’t have the same voice in government as those with different economic statuses and organizational affiliations.”

Haslam acknowledged in April that Tennessee probably would have to limit co-payments and provide the wraparound services for Medicaid-eligible enrollees for the federal government to approve his alternative, but he said he still thinks his overall plan is “workable.”

What’s next?

Haslam’s plan is modeled on a plan by Arkansas, which also wants to use federal matching dollars to pay commercial insurance premiums for those eligible for the Medicaid expansion. But while Arkansas got legislators’ approval before approaching the federal government, Haslam has taken the opposite approach, presenting his plan to CMS first.

Haslam did not ask state legislators to vote on whether to take the federal Medicaid expansion funds this session, though he said he has not ruled out calling a special legislative session later this year to meet federal deadlines for the health exchange enrollment starting in October.

The Medicaid expansion is the only provision in the ACA that provides insurance coverage specifically to those between 101 percent and 138 percent of the federal poverty guideline. If Haslam fails to reach an agreement with the federal government, or does not opt to accept the federal Medicaid expansion plan (which he could still do), that population likely would remain uninsured.

However, the latest word among hospital executives and advocates is that an agreement could be near.

“I think (Health and Human Services) Secretary (Kathleen) Sebelius is really eager to find some alternative plans that meet the goals of the ACA but do so in creative ways and allow states to create plans beneficial to those individual states,” said Jerry Askew, senior vice president for governmental relations for Tennova Healthcare.

Through Tennova’s parent company, Health Management Associates, Askew works with hospitals in seven states. All of them, except those in Kentucky and West Virginia, have said no to the expansion.

“They’re all trying to figure out what to do. It’s really interesting to watch how the state is to meet their individual objectives,” Askew said. As for Tennessee, he added, “It is fair to say that the governor’s plan is being built on principles that the majority in the Legislature would agree with. But it’s not a given. It’s a lot of hard work.”

Consumer-advocate groups and hospitals were in favor of the expansion, especially since hospitals stand to lose money on uncompensated “charity” care that would have been partially covered, at least, if more people were insured through Medicaid. The Tennessee Hospital Association has said the state stands to lose 90,000 jobs and nearly $13 billion.

Having that population continue to go uninsured also means higher costs in the long run, Myers said, as studies have shown that those without insurance are less likely to get preventive or early care.

“When you are resorting to getting care only when it becomes so bad you can’t stand it, and you’re in the emergency room, it’s causing a major human toll,” she said. “We know that intervention on the earliest point of the illness trajectory is the most cost-efficient. The true measure of whether we’re successful in what we’re doing in health care is in whether people have long, happy, productive lives.”

Business writer Carly Harrington contributed to this report.

 © 2013, Knoxville News Sentinel Co.


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Larry Drain sends out a thank you for help with letters to Governor Haslam

6/19/2014

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Thanks for the support
by Larry Drain, hopeworkscommunity

The following organizations have offered support of "Dear Governor Haslam".  They have put links to this site or printed the letters on their websites.  I really appreciate it.  I invite you or your organization to do the same.


Tennessee Health Care Campaign.
Tennessee Citizen Action.
Tennessee Disability Coalition.
Tennessee Chapter Depression and Bipolar Support Alliance.

AGAIN THANKS.

WRITE GOVERNOR HASLAM TODAY

hopeworkscommunity | June 1, 2014 

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CPR for the Murphy Bill

6/12/2014

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Murphy misunderstandings

byLarry Drain, hopeworkscommunity

Rep.  Murphy has not went gently into the good night.  Dr. Torrey will never go gently into the good night.  They are trying it sounds like to provide cpr to their bill. Rather the things that didnt work the first time will work on second effort is anyone's guess.  I think sometimes it is really hard for annointed national spokesmen to realize they are not and never were.

But this post is not about that.  It is about a fundamental misunderstanding of the American mental health system that was part of the reason that may have doomed the Murphy Bill from the start.

Murphy seemed to believe we were doing far too much for too many.  He thought people who were doing better in the system were robbing those who were doing poorly of help and resources. And he thought if resources were properly allocated things would be okay. Using terms like "worried well" he seemed to want to pit one group against another or at least give worried family members someone to blame. Somehow, I never really understood how, he seemed to think that this misallocation of resources was the fault of Samsha. It was us against them, with guys in black hats, just lacking an afternoon channel from being great soap opera. People were getting rich, famous and powerful off the worried well and just abandoned those in serious need. It had drama, moral outrage, and more than a little passion. It just lacked truth.

Anyone who had watched or been part of the last few years would tell you that state after state year after year had cut their mental health budgets to the bone. In some places there was only skin. The bone had long since disappeared. It was not that too much was done for too many. Too little was done for everyone. Many people lacked insurance and couldnt even access the services that were there. It wasnt misallocation of funds. It was abandonment. Never, not once, have I ever heard anyone touting the Murphy bill ever acknowledge this.

The baggage from Dr. Torrey obscured their vision. No state bought his love affair with psychiatric hospitals. It was too little bang for way too much bucks. No one believed. It was a cash cow around their necks that threatened to bankrupt their community systems. There was little or no proof it worked. When insurance companies basically stop paying for a service that service is on borrowed time. No one drank the kool aid any more.

There will probably always be psychiatric hospitals. But they will never be the centerpiece of the mental health system again. Putting your money into backline services, what you do when things go wrong, destroys your ability to keep things from going wrong. There was never any conspiracy. People just decided what they thought mattered and all of Dr. Torrey's pr and marketing campaigns just didnt change that. In the end I dont think federal law can bring back psychiatric hospitalization as the gold standard of mental health care. The truth is that even people with "severe mental illness" can and do make it in their communities with effective support and services.

The notion that one group of people needing help was more worthy than another and that they were in competition just seemed like such a mean and stupid notion. It completely just ignored the reality of the bloody battle for funding that is the reality for so many states. It was a pseudo explanation for the fact that state after state just said "Dr. Torrey we dont buy what you say and your way will not increase the amount of services for people with severe needs but radically decrease it."

Count me cynical. Count me way cynical. Murphy lost because it was never about a battle for the "severely mentally ill." It was a battle for Dr. Torrey and a vision found lacking a long time ago.

hopeworkscommunity | June 11, 2014

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Borderline Personality Disorder relations with BP

5/8/2014

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Differentiating Borderline Personality Disorder from Bipolar Disorder
By BERNADETTE GROSJEAN, MD

Borderline personality disorder (BPD) and bipolar disorder frequently co-occur (numbers range from 8% to 18%), although they are distinct clinical entities (Paris J et al, Compr Psychiatry2007;48(2):145–154). A proper diagnosis guides the most effective treatment, but you’ve probably faced the difficult challenge of diagnosing these conditions, which share several clinical features.

BPD can be described by four types of psychopathology: affective disturbance, impulsivity, cognitive problems, and intense, unstable relationships. What’s most important—in addition to seeing that your patient meets DSM-IV criteria for BPD—is to establish that patterns of affective instability, impulsivity, and unstable relationships have been consistent over time. Thus, obtaining a detailed history is crucial. Also, the key features we see in BPD, such as dissociation, paranoia, and cognitive problems, are often affected by the patient’s environment and, particularly, his or her relationships. A patient might have a history of rapid and sudden deterioration when relationships change—such as threatening suicide after a breakup or severe mood swings when separated from her family. Generally, the more intense or significant the relationship is, the greater the risk of chronic stress and mood dysregulation.

Many of the same features are seen in patients with bipolar disorder, such as dysphoria, hyperactivity, impulsivity, suicidality, and psychotic symptoms. As a result, borderline patients with this cluster of symptoms are often misdiagnosed with bipolar disorder, possibly because of the effectiveness of psychopharmacological treatments for such symptoms. In fact, a more thorough assessment might show that these patients actually suffer from a personality disorder. In one study, more than one third of those misdiagnosed with bipolar disorder met DSM-IV criteria for BPD (Zimmerman M et al, Compr Psychiatry2010;51(2):99–105).

In BPD, mood changes are generally short-lived, lasting only for a few hours at a time. In contrast, mood changes in bipolar disorder tend to last for days or even weeks or months. Mood shifts in BPD are usually in reaction to an environmental stressor (such as an argument with a loved one or a frustration in the waiting room), whereas mood shifts in bipolar disorder may occur out of the blue. Some clinicians consider BPD an “ultrarapid-cycling” form of bipolar disorder, but there’s little evidence to support this link (Gunderson JG et al, Am J Psychiatry 2006;163(7):1173–1178). Patients with BPD might rapidly cycle through depression, anxiety, and anger, but these mood shifts rarely involve elation; more often, the mood shifts are from feeling upset to feeling just “OK.” Likewise, the anxiety or irritability of BPD should not be mistaken for the mania or hypomania of bipolar disorder, which usually involve expansive or elevated mood.

At a more existential level, patients with BPD—particularly younger patients— often struggle with feelings of emptiness and worthlessness, difficulties with self-image, and fears of abandonment. These are less common in bipolar disorder, where grandiosity and inflated self-esteem are common, especially during mood episodes. And while both conditions may include a history of chaotic relationships, a patient with BPD may describe relationship difficulties as the primary—or sole—source of her/his suffering, while the bipolar patient may see them as an unfortunate consequence of his behavior.

A pattern of self-harm and suicidality often serves as a cue for diagnosing BPD (but are not necessarily required). But both can be seen in bipolar disorder, too. In BPD, suicide threats and attempts may occur along with anger at perceived abandonment and disappointment. Patients often explain these impulses as a way to be relieved of pain, or to “stop their thinking,” more so than to end their lives, per se. Patients with BPD may experience “micropsychotic” phenomena of short duration (lasting hours or at most a few days), including auditory hallucinations, paranoia, and episodes of depersonalization. However, patients generally retain insight, and can acknowledge that “something strange is happening” without strong delusional thought. When psychotic symptoms occur in bipolar disorder, they happen in the context of a mood episode, they tend to last longer, and patients may be unable to reflect on their behavior.

Accurate diagnosis of BPD and bipolar disorder can be difficult, but it’s essential for proper treatment and optimal outcome. Remission rates in BPD can be as high as 85% in 10 years (Gunderson et al, Arch Gen Psychiatry 2011;68(8):827–837), particularly with effective psychotherapeutic treatments (Zanarini MC, Acta Psychiatr Scand 2009;120(5):373– 377). Unfortunately, such treatment is not always available. Some medications can be used in BPD, such as an SSRI for impulsivity, severe and persistent depression and/or suicidality, or an atypical antipsychotic for recurrent dissociative symptoms or disinhibition. However the only consensus seems to be that medications should be used as adjuncts to psychotherapy (Silk KR, J Psychiatric Practice 2011;17(5):311–319). The long-term use of a mood stabilizer or atypical should be reserved for known cases of bipolar disorder.

TCPR’s VERDICT: Clinicians sometimes think of a BPD diagnosis as pejorative (chronic and untreatable) and may be reluctant to disclose it, but patients and their families often find it helpful to be informed of the diagnosis. Similarly with bipolar disorder, accurate diagnosis often determines prognosis and effective treatment. For the clinician, however, it’s imperative that you make the proper diagnosis in these two often overlapping, but fundamentally quite distinct, conditions in order to optimize your patients’ outcomes.


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If the Mental Health System was Sane . . .

5/3/2014

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If the mental health system was sane…

By Hopeworkscommunity

There would be a range of services availible reflecting the human needs of those it serves.

Those services would be availible to those that need them.

Those services would be based on what works, not what makes money, reflects any particular philosphy or interest, and not because it is what we are used to doing.

Asking for help would not label someone, brand them, be a cause of shame, a source of discrimination.  Asking for help should not be a problem.

It would realize that lack of a place to live, lack of food, lack of adequate clothing, lack of a job are frequently barriers and problems for the people they serve and address them in a direct and effective manner.

It would know that inadequate health and inadequate health care are common problems for the people they serve and be part of an effort to serve the entire person in an integrated fashion.

The goal would be to empower, educate, and support people towards gaining control over their lives so as to maximize their chances of leading happy, meaningful and successful lives.

This would not be empty words, but a passionate conviction that fuels and structures everything done in the system.

It would not mistake the people it serves for the labels it places upon them.

It would know that the most important thing about help is that it is what you do with people and not what you do to them. It would see itself as partnering with the people it serves.

It would know that people can say no and that not be a symptom of illness or distress.

It would view peoples values, hopes, thoughts, and aspirations as a source of strength and not a symptom of illness.

It would take substance abuse ultimately seriously. Drinking and drugging are the two primary ways people with mental health issues try to treat themselves.

It would make sure that one of the core experiences that someone seeking help has is contact and interactions with others who have dealt with similiar issues. It would treat seriously the idea that you can learn from the experience of others and them from you.

It would not tell people who have hard times or more problems they have failed or are failures.

It would take the issue of trauma seriously. Knowing how people have been hurt and not being part of hurting them further should be cornerstones of the system.

It would treat the issue of what happens in jails and prisons to people with mental health issues as a moral outrage and the impulse to do something about it as a moral necessity.

It would be honest about the risks and benefits of psychotropic medication. Help people to make real and informed choices.

It would treat families as important and not as irrelevant or a threat to what it is doing.

It would treat justice as a driving force and value in everything it does.

It would be honest with the people it serves about what it doesnt know if it wants them to have trust in what it does know.

It would attack the issue of suicide with passion. No one should ever feel like death is the best solution to life.

It would tell people that no problems make you less human,

It would view hope as realistic and know that when they dont they do more harm than good.

Larry Drain

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