Wednesday, December 31, 2008

Regulating Gifts and Research Practices for Physicians from Drug Companies?

According to the article, "State proposes rules for gifts to physicians," by M.McAuliffe, The Republican, (December 11th, 2008), Massachusetts wants to hold two public hearings across the state for feedback on proposed legislation to regulate gifts and research practices that physicians receive from pharmaceutical companies. Advocates want gifts to be banned as well as making public knowledge of physicians getting paid for drug research from these companies.

I support this legislation for the following reasons:

1) I agree with the advocates that doctors can be heavily influenced by pharmaceutical salesmen to inappropriately prescribe medications for their clients' symptoms.

For example, I attended one luncheon with one salesman from a drug company that manufactures antidepressants. Normally, I refuse to attend these "bribery meetings," because I don't support the way these drug companies push their medications on physicians. I went for curiosity purposes and to observe this process. While the lunch was good, the salesman's presentation was another story.

The representative educated the physician and the clinicians on how this particular antidepressant works on individuals who have a specific type of anxiety disorder. Charts demonstrated through the company's research studies showed that individuals who took this medication showed a decline in their anxiety symptoms. The last step the salesman did, in which I call the hook, was to try to "push" the physician to prescribe this medication for his clients. His tone and voice went up a notch higher when he asked the physician if and when he would start prescribing this medication to his clients. After careful consideration, the physician kindly thanked him for the information and said he had to get back to work. The physician left the room, and the salesman provided free pens, drug samples, and literature on this medication to his staff.

My observations made me think how physicians can be easily influenced by the "sweet talking" salespeople and the expensive gifts they can provide such as free trips and monetary incentives to support their drugs. Also, I have observed how some of these salespeople will "pester" physicians through on-going telephone calls and numerous visits to their offices to do their presentations. Some will even offer expensive dinners to get the physician to hear their spiels.

It is amazing how much money is spent on heavy advertising and marketing of drugs to physicians as well as through other mediums such as magazines and radio ads. Wouldn't money be better spent on lowering the costs of medications so those individuals can afford to pay for their medications? I would like to see future legislation to make the benefits manager-the negotiator-of drug prices between drug companies and health insurance plans to be a non-profit entity and not a lucrative for-profit enterprise. Also, the public needs to be aware that one of the reasons health insurance plans push mail order prescriptions is due to the benefits manager making a profit from it.

The Department of Public Health will holding a public hearing in Worcester on January 13th. Time and location is unknown. Please contact them for more information at

As mental health counselors, what do you think of physicians such as psychiatrists not being allowed to accept gifts and to make public their income made for doing research for these drug companies? Do you think these "bribes" hurt our clients?

Robbin Miller, LMHC

Tuesday, November 25, 2008

Questions to the Massachusetts Children Behavioral Health Initiative

1) Please clarify how an agency or provider can still input the CANS information on the virtual gateway when a parent has declined it, and still be available for viewing by the Departments of Mental and Public Healths and Mass Health.

2) If a clinician works for two different agencies, and is certified to do the CANS, will this individual be able to input CANS info on the virtual gateway with two different passcodes?

3) It is unclear to clinicians like myself who are still unsure about how to score the SED (Serious Emotional Disturbance) score. We were not trained on how to do this process. We were trained only on how to pass the test to be certified.

4) What will be the billing procedures for private practitioners like myself who give a CANS to an individual under 22 years of age? Will we get paid after the first administration of the CANS for subsequent assessments?

5) What happens if a parent declines intensive services for their child whose score qualifies them under SED?

6) What are the reimbursement rates for administrating the CANS?

Thank you,

Robbin Miller,LMHC
Private Practitioner
Facilitator for

Saturday, November 15, 2008

CANS Part III-Some Answers at Last!


Finally, I received some answers from a colleague who passed on my questions regarding the use of the CANS (Children Adolescent Needs Strengths) scale to Dr. Jack Simons, Ph.D
, Assistant Director, Children's Behavioral Health Interagency Initiatives, from the Massachusetts Executive Office of Health and Human Services. (See the answers highlighted in blue color). My responses are highlighted in brown.

Here are his answers:

What is the CANS?

The CANS forms are available at the CBHI website:\masshealth\childbehavioralhealth, click on "Information for Providers", click on "CANS Tools". The CANS is designed to provide a standard way of documenting important information from your assessment of the client; at this point the CANS is not being used to produce summary scores or profiles. As we gain experience with the tool, we may be able to use summary scores and statistical prediction rules to help us with service planning, but we are not there yet.

Comments have been made about how the CANS is not a clinical instrument and the category for rating cultural issues are confusing to understand.

Also, how do I explain to parents what I'm doing and why.

You use the CANS as one way of documenting the info you obtain from the assessment. You don't need to show the CANS form to parents although we hope it will be useful to you in talking with them both during the assessment phase and during the treatment phase. So it is part of your documentation process, and is designed to organize data in a way that will be helpful to you and the parents in planning treatment. It is not a self-report that parents fill out.

Due to the immense information stated for each CANS category, this scale can take more than one hour to explain to parents in which clinicians do not get reimbursed for by insurance companies.

1) What is the threshold scores for determining whether or not a child falls into the Serious Emotional Disturbance category for more intensive services?

The determination of Serious Emotional Disturbance is not based on CANS scores. It is based on a series of questions that appear at the beginning of the CANS form, but are not technically a part of the CANS. (You can see this when you look at the CANS form -- see above on where to find it.)

Clinicians who took the training online or attended a workshop did not learn anything about this Serious Emotional Disturbance(SED) component at the beginning of the CANS form. Where do we find this information on how to determine SED? How can clinicians ethically give this assessment when they were not trained on how to assess for SED?

2) Are parents going to be allowed to sign waivers so providers can score their child's CANS on the virtual gateway?

The Virtual Gateway (VG) CANS application is not required to score the CANS -- that is something the clinician learns to do by taking the CANS training / certification. The CANS is a way of documenting information from the behavioral health assessment. Yes, a parent can decline consent to have the CANS information entered into the VG application. If the parent does not consent to putting the CANS information into the VG application, the clinician documents the CANS on paper and puts it in the record. The clinician uses the CANS either way.

Do we tell parents that the CANS will be used in house instead and put in the client's file?

3) What happens if a parent declines for their child to take the CANS due to the virtual gateway confidentiality issue? -- see previous question. If the parent declines, the clinician will still be expected to enter a limited amount of info (about SED determination) into the VG, but not the CANS itself.

Information posted on the VG can be still accessed by the Departments of Public and Mental Health and Mass Health.

4) How do you score a CANS?

This is covered in the training. Go to to register for training.

Some clinicians I spoke with still don't know how to score the CANS including myself? Do we add the points in each category? No scale is given to explain scores.

In summary, there are strengths to the CANS scale but implementation of the this assessment tool is still confusing and more information is still needed. What do you think?

Robbin Miller, LMHC

Monday, October 27, 2008

Research and Partnerships for Mental Health

The UMass, Dept. of Psychiatry’s Center for Mental Health Services Research printed a new issue brief written by Jodi Adams, MA, Joanne Nicholson, PhD, Susan Maciolek, MPP, Kate Biebel, PhD entitled, “Family Networks Implementation Study: Integrating Rigor and Relevance in Effective Research Partnerships” The new mental health law for children calls for more partnerships between providers/insurance companies to provide quality services for children with mental health needs. Research can be helpful but wasteful and redundant if nothing good comes out of it. Research can touch on certain topics of interest for critical thinking but it is worthless if other pertinent facts are not part of the equation. Read below my views on what I feel needs to be researched for practitioners in the "trenches" that directly impact our clients.

I would like the academic community to research on the outpatient clinical work for families who graduate from the Family Network Programs.For example, families who are involved with DCF tend to have higher no-shows than families not involved with DCF in outpatient counseling sessions. What are the reasons and causes for this high number of no-shows? If it is due to transportation issues, then what can be done about this? If the families are not motivated to want counseling anymore and have to go, then what are agencies supposed to do? I would like to see more reseach on the failure rate of families who just can't get back on their feet after terminating from the Family Networks Program. Maybe policy makers and Talking Heads can look at flagging families from the very beginning in identifying some parents who just incompetent and incapable of raising the child in their homes.

Isn't it ridiculous for DCF to continue take away children from some parents who have histories of drug abuse and domestic abuse and put them in foster care and not put them up for adoption? These parents don't learn anything when their kids are taken away. They tend to just make more children and become more entrenched in the broken child welfare system.

I would also like the academic community to do more research on low income families who attend counseling sessions and on Mass Health and not DCF. Here are some things for them to look at:

The high number of no-shows.

The turnover of clincians leaving the agency for other jobs that are not insurance dependent.

The relationship between families wanting to get on SSI and being committed to the therapy process.

Is their story on the same page as therapists who are there to work with them on their personal issues and not just for the SSI check?

It is amazing funds are being poured into research and not helping these agencies who need assistance to keep afloat. Researchers need to look at those agencies who have reduced staff; services; and have closed some of their other offices due to losing money. Children with mental health needs can't be served as a result.

Robbin MillerAdvocate/Private Practitioner

Sunday, October 12, 2008

CANS Reflection Part II

As of now as I write this post, I have not received any information on how the CANS (Children and Adolescent Needs Strengths) information will be private and confidential on the "virtual gateway" under the new Children's Mental Health law in Massachusetts. However, I have one tidbit that concerns me. I don't understand why the CANS labels 18-21 years old as "adolescents," when they are in fact, adults. The only possible exception would probably be for those individuals with certain physical, cognitive or psychiatric disabilities who are deemed incompetent by the court and would need decisions to be made for them. I don't know if advocates for these groups would approve such a condescending label for this population.

(Please note, the term, "Jerry's Kid", is offensive for those individuals with muscular dystrophy (MD)over the age of 18 years old. Individuals with MD despise being called this term. There are many people in this population who are fully competent and productive citizens in society).

I am wondering what can be done to advocate that individuals over the age of 18 years be called adults and not "adolescents" under the CANS. Talking Heads needs to know that these adults can decline to take the CANS period! If they are competent and not a danger to themselves or others, nothing can be done to force someone to take the CANS.

What do you think?

Robbin Miller, LMHC

Saturday, September 13, 2008

CANS Training Reflection Part I

I recently took the CANS (Child and Adolescent Needs and Strengths) training as mandated by the new Children's Mental Health Law for clinicians serving children and teens on Mass Health in Massachusetts. The training was 5.5 hours long with lots of information thrown at you in a short period of time. The theme was"Stick to the Script" as the purpose of this training was to get clinicians prepared and ready to take the exam through the "virtual gateway" to get certified. As we learned the different components of the CANS that sizzled our brain cells, clinicians were not told what the purpose of the CANS instrument was for. Though we were given the "Massachusetts CANS Frequently Asked Questions" sheet before the start of the training, no one really had a chance to review it as clinicians focused their efforts on passing the exam, and then, moving on with their daily activities afterwards.

As stated on the website, (, the CANS is designed not only as a care planning tool but to determine if the child or teen meets the criteria for Serious Emotional Disturbance(SED). If the child meets the latter, they will be eligible to receive intensive services known as Family Stabilization Services(FST) in the home for a certain period of time. There is one other thing the training did not address in terms of children fitting the criteria for SED services,that is, parents or caretakers can decline this intervention. There has been no information on whether the Department of Children and Family Services will be called into the home due to the child's CANS score fitting the SED criteria.

I have my concerns about some parents using the CANS instrument to get SSI benefits for their children when they don't engage in FST services or come to the agency for counseling and medication management services. Will Mass Health hold these parents accountable for not accessing these services for their children's mental health needs? As it stands now, SSI fraud, known as the new welfare, is rampant as some mental health professionals and myself have witnessed some parents coming in for diagnostics for their children only to apply for this benefit quickly afterwards. In fact, there has been some cases, where families have applied for SSI, and the agencies have received this paperwork before they even come into the agency for a diagnostic.

I hope the CANS instrument will serve its purpose in getting children the appropriate mental health services they need. One indirect measure that will come using this assessment is how some parents will be identified for not being capable of parenting their children. So what will happen to these children? Will the population of foster kids increase? Will legislation be passed to prescreened these parents in hospitals like adoptive parents have to go through, to warrant appropriate action and services for them? Will Massachusetts be proactive like Indiana and Florida to promote adoption choices for parents to make adoption plans for their children? This remains to be seen.

Part II of this blog will discuss the virtual gateway portal that Mass Health will be using to monitor the CANS and what parents need to know about it

I am interested in your comments on anyone who took the CANS training.

Robbin Miller, LMHC
Facilitator of

Thursday, August 28, 2008

Clinicians Deserve to get Reimbursed for their Time

Dear Executive Office of Health and Human Services:

Thank you for providing me this opportunity to email you my testimony for the Division of Youth, Children and Families. My testimony will focus on the new mental health law for children. I appeal to your office to seriously consider reimbursing clinicians in private practice and in mental health clinics who administer the CANS (Children and Adolescent Needs Strength Scale) instrument to children following the initial diagnostics.

As it stands, many clinicians who have taken the training for the CANS are concerned and not motivated to give the CANS to their clients due to lack of nonpayment in subsequent sessions. We feel our time is valuable and needs to be respected in paying us for this service. If Doctors' offices are reimbursed for administering their assessment tool for evaluating mental health issues for children and adolescents, then mental health clinicians with masters degrees and above need to also get paid.

The second item I wish to discuss is reimbursing for no-shows for clients (under twenty one years old) in non-profit mental health clinics. As it stands, clinicians don't get paid for no-shows. As a result, many have leaving the field to pursue other jobs that value their time and service in the counseling profession. There is all ready a shortage of qualified clinicians to treat children with mental health issues. I feel it would be prudent to have incentives and safeguards in place to retain clinicians in their jobs so these children can be served. In summary, mental health professionals needs to be reimbursed for their service and time in treating children with mental health needs.

Respectfully submitted,
Robbin Miller, LMHC

Thursday, August 14, 2008

Childrens' Mental Health Reform passes in Massachusetts

The Children's Mental Health Reform bill has passed in Massachusetts. Congratulations to parents, advocates, and to service providers for pushing for important changes on how mental health services are delivered to children. The Rosie D vs Romney case will result in positive changes to repair a broken system of mental health services for kids with serious emotional disturbances.

Below are four important components ( on how mental health services will be coordinated. My comments will be noted for each.

1. Screening children early to identify developmental, mental health and substance abuse needs:

Primary care physicians will be prescreening children in their offices to identify potential mental health issues. If doctors feel children need to be prescreened further for mental health services, they will be referred to family counseling centers and/or to private practitioners who see clients on Mass Health (Medicaid). Counselors with masters degrees and above will assess the child for serious emotional disturbance (SED) using the CANS (Children and Adolescent Needs Scale) instrument. If the child receives a certain scale for SED, he/she will receive intensive programs such as family stabilization services in the home. Parents can appeal for this service, if they feel their child's score is not reflective of their behaviors at home. The controversy is whether or not counselors will stop providing the CANS instrument if they feel too many parents are appealing for more intensive services for their child with SED. Professionally speaking, I don't mind if parents appeal, since they can be their child's best advocate on what their child needs for mental health services. It is hoped that some parents won't appeal to just get social security benefits for their children.

2.Giving schools the tools to identify and manage children with mental health needs:

I support the schools in getting more involved with improved resources to identify and to manage children with mental health needs. Over the years working at a family clinic, I have received numerous telephone calls from Guidance and Adjustment Counselors informing me about my clients' mental health issues in school. I thanked them for providing this information and giving them suggestions on how to work better with these clients. I had to let many of them know that due to insurance constraints, I was not able to attend school meetings if the child did not have Mass Behavioral Health Partnership for their insurance.

I look forward to working with schools when the client's health insurance pays for coordination of care with the schools.

3. Implementing policies for fixing the "stuck kids" problem by ensuring that children are in the most appropriate and least restrictive setting:

The Olmstead decision in 1999 set the precedence for persons with disabilities be given the opportunity to receive services in their communities as opposed to being stuck in nursing homes or in institutions. (See Olmstead video on One of the problems on why kids don't get placed in community based programs is the lack of qualified mental health counselors to treat them for their disabilities. The new law does not address how to recruit and retain counselors in community based services for children. The second problem is the lack of available slots-beds- to place children who need treatment in the communities. I don't know how the new law will provide more bed space for more community based services to be available. That remains to be seen.

4. Improving communication among state agencies to ensure coordination of care:

Some insurance companies that pay for mental health services for children on Mass Health will also pay a counselor's time in coordinating services with teachers; doctors; and other collaterals involved in a child's care. It remains to be seen whether or not commercial health insurance companies will pay for this care. In the past, one commercial insurance company said they only for pay a mental health visit, and it is not their responsibility to pay for additional services. As it stands, Mass Behavioral Health Partnership pays for 4-15 minute units-of collateral care once a month. I have seen my clients benefit when I am involved in the coordination of care with other collaterals because we are all on the same page in providing appropriate services.

One downfall of the new mental health law for children is the lack of incentive to prescreen at risk parents in the delivery rooms before the baby is born. Some physicians feel these parents are not their clients and that their focus is on providing healthcare for children's medical needs only. Hogwash! Physicians and nurses need to be proactive in identifying at risk parents for potential neglect and abuse before the baby leaves the hospital. Why wait until the damge is done to the infant/young child where the effects can be long-lasting and incurable?

Positive changes to improve the mental health system for children's mental health needs will be forthcoming. It remains to be seen how effective some of the changes will retain counselors; provide more bed space in the communities; and identify those parents who are responsible for providing unhealthy living conditions for their child's mental health issues.

Robbin Miller, LMHC

Friday, July 18, 2008

Blogging for Social Justice


Below is the link to Counselors for Social Justice's current newsletter, which is a subdivision of the American Counseling Association.

I wrote an article entitled, "Blogging for Social Justice."
In the future, I will be writing an opinion section on the new mental health reform bill that was passed in Massachusetts.

Robbin Miller, LMHC


Saturday, May 31, 2008

Should Adoption be Colorblind or not?

This past week, an article appeared in the Washington Post entitled, Major changes urged in transracial adoption, (May 27th, 2008) that called for changes in recruiting minority families to adopt African-American children in foster care and requiring white families to undergo training on transracial adoption.

I support training on transracial adoptions, as many families who want to adopt transracial children already are required to attend a mandatory training by most of their adoption agencies. I believe we need to be careful to not single out white adoptive and foster parents. Adoptive and foster parents have to pass rigid homestudy requirements in order to be considered and recommended to adopt transracial children. These parents are committed to providing loving homes for these children. Parenting comes from the heart and not from the womb. A child's love is colorblind when it comes to healthy attachments between parents and a child.

According Dr. Barbara Okun, Ph.D., in her book, Understanding Diverse Families-What Practitioners Need to Know (1996), "one can't assume that the problems are due to adoption or multiraciality,but one can explore possible influencing factors." (P.297). Dr. Okun supports transracial families to be open to the discussion of race and racial differences within the family.

Adoptive and foster parents are open to educational resources, supports, and advocacy in providing the best home environment for their children. Let's hope that these child welfare groups don't limit or take away the right of white families who want to adopt transracial children. What is the alternative if these children are languishing in foster care and being unloved?

I urge mental health professions to increase their knowledge, skills, and self-awareness when counseling transracial families and to not use their biases and judgements to dissolve these loving families based on ethnic factors. Embrace the uniqueness and honor the differences in these families.

Robbin Miller, LMHC
Facilitator for

Saturday, May 10, 2008

What can we learn from Business Leaders about success and change?

This week's issue (May 12th, 2008) of Fortune magazine, has a very good section entitled, "The Best Advice I Ever Got," by J.Birger, C.Chandler, Business leaders from walks of life were asked to answer the above question.

Here are some quotes:

"Doing the wrong thing is not worth the loss of one night's good sleep," by Thomas S. Murphy, Former CEO of Capital Cities/ABC.(P.76). This topic pertains to ethics. Do you practice what your preach of being ethical in your practice or profession? For example, do you bill accurately? The choice is yours. Another quote by Murphy,"Don't spend your time on things you can't control. Instead, spend your time thinking what you can?" (P.76). How does this apply to you? Are therapists promoting self-care when they feel overwhelmed from the magnitude of their clients' problems?

"Customers will give you the reality. They don't care about your title, they just want value. You'll never get anything straighter than from a customer," by Charlene Begley, President and CEO, GE Enterprise Solutions (P.77). Are private practitioners providing quality and value services to their clients? How about in clinics? Graduate programs need to teach customer service skills to future clinicians so they can retain their clients and grow their practice, if they wish to do so.

"Humor takes away tension and helps you realize you're wrong," by Craig Newmark of Craigslist, (P.78). This pertains to the work culture and using humor to decrease or break the thick paste that develops in trying times at clinics or in private practice. How do you handle tough times in your job? I have been using my humor in observing how some clinicians in private practice are not respectful of each other in possible networking situations. I went to an interview for a group practice. I asked about peer supervision among the clinicians in the practice. The head leader make a face and looked up in the air while the other followers were repositioning their "feathers" after being ruffled by this question. I laughed when I left the interview because I could not believe how educated professionals can be so rude to a prospective group member. To say the least, I found another group practice to go to.

In summary, we can learn from business leaders in growing our practice, making changes in our profession, and treating each other respectfully through humor.

Robbin Miller, LMHC

Monday, May 5, 2008

Questions to the Commissioners

Questions to the Commissioners:
(Mental Health; Public Health; and Mass Health)

Here are two questions I have for the commissioners:

1) What can be done to decrease no-shows for children on Mass Health receiving mental health services? After speaking with providers across the domains, this population has the highest no-show rate for services. As a result, mental health clinics have challenges retaining mental health clinicians to work there. Will the commissions support paying for their no-shows?

2) What can be done to change the mindset that biology is destiny? Massachusetts is behind the times that any biological parent can parent their child without consequences. There are issues of high risk families leaving the hospitals with their infants when there are known facts that the parents may have mental health(untreated) or substance abuse problems. How come nothing is done to be prevent future damage these kids? I support prescreening these parents before they leavthe hospitals like they do for adoptive parents. Parenting comes from the heart and not from chromosomes.

Robbin Miller
Advocate/Private Practitioner

Friday, April 18, 2008

Children's Mental Health Coalition Introduces Bill of Rights for Families Living With Mental IllnessesWashington, D.C., April 15, 2008 -- The children's mental health coalition has created a Bill of Rights for Children with Mental Health Disorders and their Families. The coalition includes the American Academy of Child and Adolescent Psychiatry (AACAP), the Autism Society of America (ASA), the Child and Adolescent Bipolar Foundation (CABF), Children and Adults with Attention-Deficit Hyperactivity Disorder (CHADD), the Federation of Families for Children's Mental Health (FFCMH), Mental Health America (MHA), and the National Alliance on Mental Illness (NAMI)."This Bill of Rights represents the standard of what families living with mental illnesses should expect from treatment," said AACAP's President, Robert Hendren, D.O.
"Children do better when they receive consistent, tailored treatment. Few children receive any treatment and fewer still receive the sustained, quality care that they require.

"The Bill of Rights was created because of the inconsistency of accessible mental healthcare services throughout the country.The Bill of Rights:
1. Treatment must be family- driven and child-focused. Families and youth, (when appropriate), must have a primary decision-making role in their treatment.

2. Children should receive care in home and community-based settings as close to home as possible.

3. Mental health services are an integral part of a child's overall healthcare. Insurance companies must not discriminate against children with mental illnesses by imposing financial burdens and barriers to treatment, such as differential deductibles, co-pays, annual or lifetime caps, or arbitrary limits on access to medically necessary inpatient and/or outpatient services.
Comment: Bravo! 20-24 sessions a year is not enough.

4. Children should receive care from highly- qualified professionals who are acting in the best interest of the child and family, with appropriate informed consent.
Comment: We need hold some families accountable who try to commit SSI fraud for ther children when in reality, they are doing it to avoid working.

5. Parents and children are entitled to as much information as possible about the risks and benefits of all treatment options, including anticipated outcomes.

6. Children receiving medications for mental disorders should be monitored appropriately to optimize the benefit and reduce any risks or potential side effects which may be associated with such treatments.

7. Children and their families should have access to a comprehensive continuum of care, based on their needs, including a full range of psychosocial, behavioral, pharmacological, and educational services, regardless of the cost.

Comment: Yes, valid research on how medications work by the literature and not by "high pressure" tactics and gifts by drug companies to prescribers.

8. Children should receive treatment within a coordinated system of care where all agencies (e.g., health, mental health, child welfare, juvenile justice, and schools, etc.) delivering services work together to support recovery and optimize treatment outcome.
Comment: What do we do about those parents who abuse substances and/or have psychiatric isssues and are allowed to have their children back and/or those who walk out of the hospitals with their babies? What about parent pre-screening for these issues like adoptive parents have to go through?

9. Children and families are entitled to an increased investment in high-quality research on the origin, diagnosis, and treatment of childhood disorders.

10. Children and families need and deserve access to mental health professionals with appropriate training and experience. Primary care professionals providing mental health services must have access to consultation and referral resources from qualified mental health professionals.
Comment: Who will pay for these consultations?

Robbin MillerAdvocate/private practitioner

Wednesday, March 26, 2008

Supporting Disabilities as a Cultural Competence

MassHealth under the Rosie D vs. Romney settlement calls for proposals/discussions to promote cultural competence and to reduce disparities for healthcare services for its citizens.

I am writing in this blog to advocate one component of cultural competence. I am aware that there are some organizations in the Boston area who are hired to train mental health professionals and social service workers on multicultural sensitivity training. I attended one such training last year and though the information and presentation was excellent by "Families First," it did not provide any information on how to work with individuals with disabilities.Mass Health can implement Disability sensitivity as one component of Cultural Competence. By coincidence, Blue Cross/Blue Shield of Massachusetts interviewed me two weeks ago about the need to include the above topic as a cultural competence for mental health professionals. It is also important that medical professionals also receive the same training in this area as well. Currently, Tufts University and I believe UMASS has patient-doctor trainings in which "hired" patients train doctors on how to interact with them and to understand their symptoms. I heard positive feedback from persons with disabilities who participate as patients in this training.Mass Health can recommend that clinics/facilities that staff receive trainings similar to the Patient/Doctor model that is currently being used. The question is how to pay staff to attend such trainings. That is always the tricky part of the equation. For mental health professionals, CEUs can be awarded to going a training during a staff meeting or a special meeting time. But again, mental health clinicians do not get paid for mandated staff meetings. This issue of payment or compensation has to worked between Mass Health and the provider.Why do medical and mental health professionals need to learn to be more culturally competent in this area?1) The is a new population of veterans coming home from Iraq and Afganhistan who are newly disabled and will need both medical and mental health services. The current health insurance benefit for vets is not adequate to cover all their healthcare needs.2) More and more persons with disabilities across the board are living in the community and not necessarily in institutions. Governor Patrick's plan for Long Term call for more funding to be used for community based services for individuals with psychiatric disabilities; developmental disabilities with physical disabilities to live in the community across the commonwealth.3) Professionally and personally speaking, I heard numerous complaints from consumers and advocates with disabilities vent their frustrations on how their medical or mental health professional treated them for their symptoms. An example is when an individual goes to a health facility with a personal care attendant, the medical professional tends to talk to the PCA and not to the client. Another example is when a colleague of mine who is a wheelchair user told me how her mental health clinician told her to go fight her "revolution" during the last session. The revolution is about the barriers in the environment that prevent persons with disabilities from enjoying the same freedoms as their able-bodied counterparts. We both wondered if she would tell a person from a multicultural background the same information. I think not..

Robbin Miller, LMHC

Friday, March 21, 2008

Testimony to Health and Human Services

Dear Health and Human Services:

I support new reforms for the children's mental health in the Commonwealth. The system is broken on how mental health services are delivered and paid for. It was only a matter of time until a lawsuit was filed by parents to advocate for improved mental health services for their children known as the Rosie D vs Romney case. As an independent advocate and mental health professional, I was appalled how parents had to take their kids to the local emergency rooms to get evaluated for mental health services when in fact some of the services that did not involve immediate medical treatments ( for example, life threatening situations) and stablization could have been done at outpatient clinics. I support more intensive care management and family stabilization services to be conducted on the outpatient level and be in place from six months to a year for some families that are in danger of having their children taken away. Staff needs to be trained on how to interact and to counsel children who are dual diagnosed with psychiatric and physical disabilities.

I further advocate that parents be held accountable for some of their children's mental health issues. It is found after some investigations by the Department of Social Services that parents have their own mental health issues that need immediate attention. I don't understand why these parents are not pre-screened by their doctors before the leave the hospitals with their babies. The system is reactive, and after the fact, as damage is done to these children. Possibly a proactive measure would be to implement pre-screening tools for pregnant mothers and fathers to determine if they are capable of taking care of their children's phyiscal and mental health needs. If adoptive parents have to go through the same measures, then these parents need to go through the same thing as well.

Regarding the infrastructure, the mechanisms to pay providers, particularly social workers and mental health counselors are unfair and inequitable. There are some counselors across the state who are making the same money as their clients on SSI with children. It is demoralizing to hear my colleagues vent about they are not paid for no-shows and how difficult it is to make a sustainable living with a masters degree and/or advanced degree in their field. It is utmost important that the commonwealth change the way they pay mental health clinicians for their work. It is agreed as a consensus that there is a shortage of qualified mental health clinicians, and changing the infrastructure and values on how clinicians are paid for their work will decrease the shortage and children with mental health needs will be served.

Robbin MillerAdvocate/Counselor

Saturday, March 1, 2008

Consumer awareness for prescription drugs

Have you ever noticed when you go to a mental health or family clinic, there are pens, paper, highlighters, and other free goodies from drug companies in the waiting rooms and in the providers' offices? Do you ever ask your prescribing physician, psychiatric nurse or psychiatrist about the safety of the drugs they are giving you for your health conditions? The community needs to be more aware that sometimes the prescriptions you are getting may not be really safe to take due to doctors falling for high pressure sale tactics from pharmaceutical salespeople. Read below about the movement to reform how drug cost are marketed to doctors:

Who We Are:
The Massachusetts Prescription Reform Coalition (MPRC) is a diverse group of non-profit national and local organizations, community organizations, healthcare advocates, private insurers, public payors, and healthcare providers. Members include:
AARP Massachusetts
Blue Cross Blue Shield of Massachusetts
Commonwealth Care Alliance
Commonwealth of Massachusetts Group Insurance Commission
Health Care For All
Massachusetts Senior Action Council
National Physicians Alliance
Neighborhood Health Plan
The Prescription Project
Why We Have Come Together

Massachusetts’ healthcare access expansion can only be maintained if healthcare costs are controlled. The cost of prescription drugs is among the fastest growing segments of health care spending. Between 2000 and 2007 the price of many of the most commonly prescribed brand name drugs rose by nearly 50%, far exceeding inflation. These rising costs threaten the stability of health care reform and the Commonwealth’s budget. The costs also threaten people's ability to access the medications that they need to maintain their health.

Our Priorities

The Coalition urges the Commonwealth to take action against industry marketing practices that inflate the cost of prescription drugs. Pharmaceutical companies spend more than $7 billion annually on marketing to physicians alone. These costs get passed along to consumers and the state through the high price of medications. The Coalitions top priorities are:
Pharmaceutical Industry Gifts to Prescribers: Studies show that gifts from pharmaceutical companies to prescribers inherently impact prescribing decisions.
Data-Mining: Pharmaceutical companies purchase prescription data to target their marketing efforts, magnifying their influence.
Evidence-Based Outreach: Much of the information that prescribers get about drugs comes directly from pharmaceutical salespersons and is, therefore, biased. An evidence-based physician education program (often referred to as “academic detailing”) would provide doctors with unbiased evidence to guide them in their prescribing decisions. Such programs have been shown to more than pay for themselves with savings to public programs in other states. Data
Pharmaceutical industry marketing expenditures directed at physicians doubled (from $3.5 billion to $7.2 billion) between 1996 and 2005.
Nationwide prescription drug spending rose 500% (from $40.3 billion to 200.7 billion) between 2000 and 2005.
Overall, the pharmaceutical industry spent $29 billion on promoting and marketing prescription drugs in 2005.
$7.2 billion spent on marketing directly to physicians, which is an average of about $8,800 per physician, per year.
The industry employs a sales force of over 90,000 representatives or “detailers,” which is about one for every nine physicians
Generics cost 30% to 80% less than brand name counterparts.
Spending would be reduced by $8.3 billion or 11% annually if adults substituted generics for brand names.
94% of physicians receive meals, medication samples, and other payments from pharmaceutical companies.

Contact Health Care for All for more information. Their website

Robbin Miller, LMHC

Sunday, February 17, 2008

Blue Cross opens their panel

What a coincidence that the day after the letter to editor was published (see in blog), I receive a telephone call from a Blue Cross representative inviting me to join their panel as they decided to let more mental health professionals in. Another colleague of mine also received the same call as well.

This is great news as more families will be served in the next common months.

Robbin Miller, LMHC

Monday, February 11, 2008

Letter to the Editor:

Letter to the Editor:

(Published in the Worcester Telegram and Gazettee)

Monday, February 11, 2008

Children need services for mental health

I applaud Massachusetts officials for implementing stage one of the Rosie D v. Romney case this year. Doctors will be paid $18 per evaluation for assessing the mental health needs of children at their clinics across the state. While this method is a positive step in identifying possible mental health issues affecting our children, much more work is still needed. Currently, there is a shortage of qualified mental health professionals due to inequitable productivity requirements and low reimbursement rates from health insurance companies.

Additionally, commercial health insurance companies such as Fallon Community Health Plan and Blue Cross/Blue Shield (under their behavioral health network) will not open their panels for licensed mental health counselors to join their networks. As a result, there are waiting lists at area clinics to serve children with mental health needs. I’m asking the Legislature and parents to lobby the above entities to open their panels so our children can get quality mental health services. Also, for the state to implement more efficient ways to pay clinicians fairly and to retain them for the benefits of our children with mental health needs.



Saturday, February 9, 2008

Mental Health Crisis PT 2:

I have written about how the Rosie D. vs Romney settlement calls for increased mental health services for children in Massachusetts. While the first phase calls for primary care doctors to prescreen children for mental health services in their offices, there are still other barriers that exist as well.

We are aware of the shortage of qualified mental health clinicians to provide the above services due to low reimbursements and not being paid for no-shows in mental health clinics (non-profit) in Massachusetts. There is another barrier that I need to make everyone aware of.

I have spoken to mental health professionals who are having difficulty getting on commercial insurance panels. There is discrimination by a few who are refusing to open their panels because of the false perception and assumption that the market is saturated. This is not true at all. The irony of this belief is that children are not getting the mental health services they need from private practitioners due to long waiting lists. In fact, several mental health clinics in Central Massachusetts have stopped taking one comercial health insurance company due to the shortage of qualified licensed mental health professionals.

As a result, many children are not getting the mental health services they need. It is estimated that over 100,000 children in Massachusetts need these services according to Health Care For All website,

What can parents and mental health professionals due to stop this injustice for our clients?

Here are few pointers:

1) Talke to your legislators to create new laws to make insurance companies open up their panels for mental health services for children when there is an unmet need.
2) Write letters to the editor in your local newspapers.
3) Contact the associations that represent social workers and mental health counselors in your state and ask them to lobby for changes that will benefit the clients.
4) Request meetings with these insurance companies to create an open dialogue of voicing your concerns.

Robbin Miller, LMHC

Monday, January 21, 2008

Childrens' Mental Health

Health Care for All has information on the Childrens' Mental Health Campaign in Masschusetts. I urge all mental health professionals to read the latest updates on reforming mental health delivery and services to children in Massachusetts. Their website is:

It is important that we as mental health professionals speak up on what our concerns are regarding the above issue. Your voices need to be heard by your state legislators.

It would be interesting to find out what the statewide chapters for mental health professionals and social workers are doing to support this legislation.

Robbin Miller, LMHC

Saturday, January 19, 2008

New Presecreening tool in Mass

Doctors are getting paid $ 18.00 per client to assess children from mental health issues. This new regulation is result of the Rosie D vs Romney cases in Massachusetts that calls for reforming mental health services for stuck kids and for those children who need outpatient services. While it is a good first step to have a prescreening tool to evaluate for mental health needs, there is still the problem of the shortage of qualified mental health clinicians to serve these children. While the change to increase reimbursements and to change the inequitable productivity requirement will take five years to implement, some of these childrens' mental health needs will not be served.

What you can do to promote change for our profession are the following:

1) Write letters to the editor to promote swift changes in increased reimbursements and different and creative ways to pay for mental health services that are not insurance dependent.

2) Write emails on advocacy listservs such as for parents with children with special needs to ask them to promote the above changes.

3) Speak out publicly on how you feel about five year wait for change for mental health services is ridiculous and will hurt children accessing services.