New Committee Heads Groundbreaking Effort to Address Serious Mental Illness
by Marla Fogelman
he state of the nation’s mental healthcare delivery system has improved only slightly since 2003, when the President’s New Freedom Commission on Mental Health Report
found that the system was too fragmented and inadequate to meet the needs of Americans with mental illnesses.1
Worse still, because of the disconnectedness across public systems in providing appropriate behavioral healthcare services, the quality of life for U.S. adults (ages 18 and older) with serious mental illness (SMI) and children (under 18) with serious emotional disturbance (SED) continues to be much poorer than that of other Americans. Despite multiple reports issued by multiple mental health commissions across decades and administrations, individuals with SMI or SED not only are still dying sooner than others but also are at greater risk for incarceration, addiction, poverty, homelessness, and comorbid medical problems (see Figure 1).
Figure 1. Statistics on Persons With SMI and SED
But now, with the creation of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC), as authorized by the passage of the 21st Century Cures Act (Public Law 114–255) in December 2016, a transformative and groundbreaking initiative to reshape care for all persons with SMI and SED is under way. “What we’re trying to achieve is historic in its overall goal,” said ISMICC nonfederal member and addiction psychiatrist Dr. Kenneth Minkoff. “It’s a 6-year road map for something that has never happened.”
The ISMICC's Role and Mission
Trying to increase and improve access, quality, and affordability of care for those with SMI and SED and their families in every community in the nation is “an enormous task,” said Minkoff. SAMHSA, while providing management and support services, can’t do it alone. The mission of the ISMICC is to facilitate and enhance coordination across federal agencies to implement a national strategy for providing a system of care to address the needs of individuals and families affected by SMI/SED and to ensure that this system of care adheres to treatments and services that are informed by the best available scientific knowledge. Specifically, the ISMICC is charged with submitting two reports to Congress: 1) at 1 year after the enactment of the 21st Century Cures Act, which the committee provided on Dec. 13, 2017, and 2) 5 years after the Act’s enactment, in December 2022.
According to the ISMICC Charter,2
these reports must encompass the following:
The ISMICC’s Structure and Purpose
- A summary of advances in research on SMI and SED related to prevention, diagnosis, intervention, treatment and recovery, in addition to access to services
- An assessment of federal programs related to SMI and SED and their effect on public health outcomes, including a) suicide rates and attempts; b) substance use disorders, overdoses, and overdose deaths; c) emergency room visits and hospitalizations; d) justice system involvement; e) homelessness and unemployment; f) rates of enrollment in vocational and educational programs; and g) quality of behavioral health services
- Recommendations for actions that federal agencies should take to better coordinate services for adults with SMI or children with SED
One striking characteristic of the ISMICC membership is the breadth of its public–private collaboration. Chaired by the Assistant Secretary for Mental Health and Substance Use, Dr. Elinore McCance–Katz, the ISMICC consists of eight federal representatives (see Box 1) and 14 nongovernmental stakeholders who represent various constituencies, including mental health professionals, family members of those with “lived experience,” healthcare researchers, and national experts on SMI and SED.
In addition to psychiatrist Kenneth Minkoff, all the other nonfederal members have firsthand knowledge or expertise with the behavioral healthcare system, whether as practitioners, advocates, or recipients. For example, Pete Earley, a mental health advocate and former Washington Post
reporter, said he became involved in the ISMICC because he is the father of a child with lived experience and because his book, Crazy: A Father’s Search Through America’s Mental Health Madness,
for which he was a Pulitzer Prize finalist, helped provide the impetus for the passage of the 2015 Mental Health and Safe Communities Act, which would go on to be folded into the 21st Century Cures Act.
Box 1. Federal Department and Agency Representation on the ISMICC
- Secretary of the Department of Health and Human Services
- Assistant Secretary for Mental Health and Substance Use
- Attorney General, Department of Justice
- Secretary of the Department of Veterans Affairs
- Secretary of the Department of Defense
- Secretary of the Department of Housing and Urban Development
- Secretary of the Department of Education
- Secretary of the Department of Labor
- Administrator of the Centers for Medicare & Medicaid Services
- Commissioner of the Social Security Administration
Earley, who has a personal and professional stake in the issue of “unnecessary incarceration,” also said that he sees the ISMICC as different from previous committees or commissions in that “Congress wants us to be a watchdog and not only an advisory board.”
The role of nonfederal members like Minkoff and Earley has also been critical in putting together the first report to Congress, as mandated in the ISMICC Charter. The December 2017 report, which includes information from the first ISMICC meeting in August 2017, also includes 45 recommendations across five focus areas that are in line with the ISMICC’s mission and vision to establish a system of care in the United States to address the unique needs of people with mental illnesses, and in their own communities.
These five areas involve
- Strengthening federal coordination to improve care
- Making it easier to get good care
- Making evidence-based treatment more available
- Helping divert individuals from the criminal justice system
- Developing financial strategies to increase availability and affordability of care
Members of the ISMICC also presented the recommendations in their first report to Congress during a Dec. 14, 2017, press conference.
“We were trying to shoot extremely high [while] curating a road map for interdepartmental action that is achievable,” said Minkoff.3
How the ISMICC Report Is Relevant to the Minority Fellowship Program
While this initial ISMICC report incorporates numerous suggestions and goals that are relevant to all the behavioral health disciplines represented in the Minority Fellowship Program (MFP) community, what stands out is the emphasis on increasing behavioral health workforce capacity, removing barriers to providing care, and addressing disparities for the populations served by those in the MFP, as encapsulated in the recommendations that appear in Box 2:
Box 2. Some Recommendations From the ISMICC Report That Apply to the MFP (p. 83)
- Remove exclusions that disallow payment to certain qualified mental health professionals, such as marriage and family therapists and licensed professional counselors, within Medicare and other federal health benefit programs.
- Remove reimbursement and administrative burdens associated with psychiatric care within Medicare, Medicaid, and other federal health benefit programs.
- Explore how to fully implement integrated team models that are the most effective in addressing the needs of people with SMI and SED.
- Enable health care providers to practice to the full extent of their education and
training. For example, remove barriers that prevent advanced practice registered nurses from prescribing medication.
- Develop a workforce that is representative of the populations served (including racial and ethnic minorities, people in rural areas, and populations facing health disparities such as lesbian, gay, bisexual, or transgender individuals) and able to provide services in a culturally competent manner.
But Minkoff cautioned that MFP members who read the report should not go looking for flaws in the lists of specific recommendations. “Don’t get caught up in the trees. Look at the whole forest,” he said.
What’s most important, Minkoff stressed, is to
What’s Ahead for the ISMICC
Let people know this is going on. Let your constituencies know that the more people [who] know and support this, the more likely Congress and the federal agencies will agree to implement the recommendations. And we need to work together to convey the importance of this issue with a single voice.
In the next 5 years, the ISMICC will continue to be involved in providing input and guidance on moving the initiative forward. The long-range charge of the ISMICC is to provide the final report to Congress in December 2022, at the date of the committee’s official termination. At that time, the Secretary of the Health and Human Services will submit a report to Congress on whether to extend the ISMICC’s operation. Meanwhile, the committee will meet periodically to collect data, evaluate current federal policies and programs, and track progress on the recommendations put forth in the first report. The ISMICC’s next whole group meeting is scheduled for this summer; however, the nonfederal members are planning a conference call to lay out a workplan.
And, although there are challenges ahead, such as managing all the tasks simultaneously, and—most important—waiting to see which recommendations will be agreed to and implemented by the federal agencies, Minkoff said he remains optimistic.
“If we keep at it,” he said, “there’s a possibility for progress that can be historic.”
1Interdepartmental Serious Mental Illness Coordinating Committee. (2017). The way forward: Federal action for a system that works for all people living with SMI and SED and their families and caregivers.
2SAMHSA. 2017. Charter for Interdepartmental Serious Mental Illness Coordinating Committee.
3Notably, and as stated in the report, the 45 recommendations were developed based on the views and comments of the nonfederal members and do not represent federal policy or formal recommendations from the federal government.