1. Behavioral Health: Access Issues Allen J. Brenzel, M.D., MBA Medical Director, BHDID Cabinet for Health and Family Services

2. Overview Prevalence of Behavioral Health Conditions Insurance Coverage Mental Health Parity Workforce and Network Adequacy Public Sector Supports Integration of Health and Behavioral Health

3. BH Disorder Prevalence by Payor Source: 2012 NSDUH survey

4. Prevalence BH Disorders

6. Prevalence of BH Disorders ADHD is most prevalent current diagnosis in children age 3-17 years Diagnosis of BH disorders increases with age with the exception of autism (6 to 11) Boys more likely to have ADHD, behavioral or conduct problems, autism, anxiety, Tourette syndrome and cigarette dependence Adolescent boys more likely than girls to die by suicide Adolescent girls more likely to have depression or alcohol use disorder

7. BH Disorders in CSHCNs These children are not immune to BH disorders (Prevalence are at least as high) Risk of behavioral health consequences from –painful and repeated medical procedures –side effects and consequences of aggressive medical treatments –prolonged separation from caregivers –neurocognitive co-morbidity of condition –social isolation –thwarted drive to independence –Injury to self concept and self esteem

8. BH Disorders in CSHCNs Family Impact can be significant –increased rates of depression and anxiety –increased risk of marital separation and divorce Danger of the concept of the “brave little soldier” There may be protective factors associated with chronic medical conditions

9. Treatment Rates Studies indicate that of adults with Major Depression less than 50 percent get any form of treatment and of those who do only, 30 percent get treatment that is considered evidence based Estimates suggest that only 30 percent of children with behavioral health conditions get any form of treatment. 70 to 80 percent of psychotropic medications are prescribed in primary care

10. Overview Prevalence of Behavioral Health Conditions Insurance Coverage Mental Health Parity Workforce and Network Adequacy Public Sector Supports Integration of Health and Behavioral Health

11. When children acquire health insurance they receive more timely diagnosis of serious health conditions, experience fewer avoidable hospitalizations, have improved asthma outcomes and miss fewer days of school Institute of Medicine Also true for Behavioral Health Morbidity

12. Access: Insured Rates 2012 > 20% Un-Insured

13. Access: Insured Rates 2015 < 12% Un-Insured

14. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits.

15. CMS – Final Rule on Parity Applies certain Provisions of MHPAEA to Medicaid Managed Care Organizations Covers MCO’s, alternative benefit plans, and CHIPs Bans financial and treatment limitations for BH Services different than other health benefits MCO’s must make available to beneficiaries and providers the criteria used making medical necessity determinations Enrollees must be provided with specific reasons for denial of reimbursement

16. ACA Mandatory Benefits/Services 10 Essential Health Benefits (EHBs): 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Behavioral health including substance use disorder services 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive & Wellness services and chronic disease management 10. Pediatric services, including oral and vision care These apply to plans listed on the Health Benefit Exchange and any Medicaid Expansion covered beneficiaries.

17. Workforce- Child Psychiatrist

18. Workforce – Child Psychiatrist

19. Workforce – Other providers

20. SMHA Expenditures for BH in FY ‘13 NRI Survey 2013

21. Community Mental Health Centers

22. Individuals Served (2013) by CMHCs 147,000 with Behavioral Health Dx 27,236 with Dual BH and SA 3,673 with primary Substance Use Disorder

23. Percent SMI and SED Served in KY SMI 49% SED 60% Estimated 86,217 SMI Population in Ky. Estimated 51,169 SED Population in Ky. Served 42,357 SMI Served 30,871 Source: Ky DBHDID CMHC database Penetration Rate

24. Overview Prevalence of Behavioral Health Conditions Insurance Coverage Mental Health Parity Workforce and Network Adequacy Public Sector Supports Integration of Health and Behavioral Health

25. Behavioral Health Care is Traditionally Separate from Medical Care

26. The Case for Integration Workforce Current outcomes –Rates of untreated BH disorders –Poor medical outcomes for those with BH conditions Attitudes and stigma Evidence of at least cost containment and better patient satisfaction Cabinet for Health and Family Services

28. Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

29. Models on Integration Contracting with single entities as opposed to Behavioral Health Carveouts Patient Centered Medical Homes (PCMH) Health Home Models Cabinet for Health and Family Services

30. Thanks Cabinet for Health and Family Services