1. What Does the Future Hold for Behavioral Health?
Linda Rosenberg
National Council for Community Behavioral Healthcare
February 18, 2011

2. The National Council: Serving & Leading
Represent 1,782 community organizations that provide safety net mental health and substance abuse treatment services to nearly six million adults, children and families.
National voice for legislation, regulations, policies, and practices that protect and expand access to effective mental health and addictions services.

3. Public Policy - Success
Community Mental Health Services Improvement Act – 7 million for primary care into mental health organizations***
Medicaid Regulatory Moratorium***
Medicare HR (2010 to 2014)
Second Chance Act and MIOTCRA
Veterans M H Outreach & Access Act
M H Parity & Addiction Equity Act of 2008
Recovery Act - FMAP

4. Success – Healthcare Reform
Amendments to reform that passed in one or both chambers:
FQBHC (House Energy and Commerce Committee)
Inclusion of therapeutic foster care in Medicaid (Senate Finance Committee)
Mental illness classified as eligible chronic illness for Medicaid medical home demo (Senate Finance Committee)
Behavioral Healthcare Organizations included as eligible providers in Medicaid medical home demonstration program (Senate Finance Committee)
$50 million authorization for behavioral-primary care integration grants (Senate HELP Committee)

5. Today…Through the Looking Glass
Can healthcare reform really change healthcare? Will parity? Technology?
How do we expect mental health and substance use management/payment structures to change?
Does specialty behavioral health have the capacity to deal with expected changes?
What about the effects of federal and state budget deficits?

6. FY2009 to FY2012 Total $2.2 Billion in Cuts
SMHA Budget Cuts
FY2009 to FY2012 Total $2.2 Billion in Cuts
Year
Average
Median
Minimum
Maximum
Total
FY 2009
(35 States)
$18,979,310
$10,000,000 $0
$107,000,000
$664,275,843
FY 2010
(33 States)
$24,058,725
$12,300,000
$203,000,000
$793,937,917
FY 2011
(31 States)
$20,812,710
$11,267,905
$84,000
$162,000,000
$645,194,004
FY 2012
(6 states)
$12,959,616
$6,150,000
$2,194,458
$32,000,000
$77,757,695
Preliminary Results based on 42 SMHAs Reporting 6

7. FY 2011 Continuing Resolution and FY 2012: President’s Budget Requests
Congress must pass a continuing resolution (CR) to keep the government running through FY 2011
Republican campaign pledge: cut $100 billion from the budget
President Obama’s budget proposal includes:
Mental Health Block Grant: $434.7 million ($13.9 million increase from FY 2011)
Substance Abuse Block Grant: $1.494 billion ($39.6 million increase from FY 2011)

8. Hypothesis…
The American healthcare system is moving into an era of “Disruptive Innovation” to improve quality and bend the cost curve
That began before the passage of the Accountable Care Act
And will proceed, regardless of what happens in the elections of 2012 and 2014

9. Changing Landscape…
Parity, technology and reform will trigger dramatic changes in how health and MH/SU services are organized.
Which will change the way MH/SU services are funded and fit into the new healthcare ecosystem.

10. Parity - Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act
Plans may not apply financial requirement or treatment limitation to mental health or substance use benefits more restrictive than financial requirement or limitation for medical/surgical benefits
Examples: If in-network medical/surgical benefits are subject to $15 copay then no in-network MH/SUD can be subject to a copay greater than $15; combined deductible - separate deductibles not allowed
Prescription drug formulary design; Fail-first or step therapy
Standards for provider participation in a network, including reimbursement rates
Conditioning benefits on completing a course of treatment

11. Health Information Technology
The Obama Administration made a “down payment” on healthcare reform with the passage of the HITECH Act in 2009.
Supports the adoption and meaningful use of Health Information Technology

12. Health Information Technology Requires
Shift to “measurement-based care” – adjusting treatment based on success of the intervention
Enable providers to share patient information to reduce redundant/unnecessary procedures
Ability to demonstrate that interventions improve health outcomes and/or save money
Reporting of quality measures for incentive payments.
New relationships with hospitals, health centers and other parts of healthcare delivery system
For true care coordination; success of healthcare home and accountable care organizations models

13. Who is a Medicaid Eligible Provider?
Eligible Providers in Medicaid
Eligible Professionals
Physicians
Nurse Practitioners
Certified Nurse-Midwives
Dentists
Physician Assistants working in a Federally Qualified Health Center or rural health clinic that is so led by a PA
Eligible Hospitals
Acute Care Hospitals (now including CAHs)
Children’s Hospitals

14. HR 5040/S 3709, HIT Extension for Behavioral Health Services Act
Introduced in the House by Patrick Kennedy and Tim Murphy and in the Senate by Sheldon Whitehouse
Makes psychiatric hospitals, mental health, and substance abuse treatment facilities eligible for facility payments
Hill Day Effect
80 co-sponsors in the House
10 co-sponsors in the Senate

15. Healthcare Reform’s Four Key Strategies
The second (and most significant) wave of public behavioral
health change in the last 25 years.

16. Coverage Expansion: Most Members of the Safety Net Will Have Coverage Including SUDs & MH
$15 million increase in Medicaid enrollees (43%)
$16 million increase in privately insured
$15 to $23 billion more spending for MH/SU from insurance expansion

17. CURRENTLY PROJECTED U.S. HEALTH SPENDING
SOURCE: CMS DATA & STATISTICS

19. Service Delivery Redesign and Payment Reform
Key Cost Curve Bending Initiatives Include:
Widespread Deployment of Medical Homes
New Medical Home Payment Models
Bundled Payments Related to Inpatient Admissions
Accountable Care Organizations – the Homes for Medical Homes

20. Medical Homes: Primary Care Clinics that Look and Act Differently
Picture a world where everyone has...
An Ongoing Relationship with a PCP
A Care Team who collectively takes responsibility for ongoing care
And Provides all Healthcare or makes Appropriate Referrals
Helping ensure that Care is Coordinated and/or Integrated
And where...
Quality and Safety are hallmarks
Enhanced Access to care is available (evenings & weekends)
And Payment appropriately recognizes the Added Value
(Joint Principles of the Patient-Centered Medical Home:

21. Accountable Care Organizations (ACOs): the homes for medical homes
Accountable Care Organization (ACO) Model

22. Where is Behavioral Healthcare right now?
Broad recognition that freedom from addiction and mental health is essential to overall health
MH Parity/Addiction Equity in almost all federal programs
Included in aspects of the PPACA as essential part of healthcare

23. Increased Demand for Services

24. Services Are Cost Effective

25. What is the Status of Behavioral Healthcare Organizations?
Small margins
Lack of capital for improvements (Health IT, human capitol, new service lines)
No federal status to support improvement
No national data to support investment

26. What is a….
Nursing home?
[42 U.S.C. 1396r]: An institution engaged in providing to residents: skilled nursing care, rehabilitation services, or health-related care and services to individuals who require care in an institutional facility, and is not primarily for the care and treatment of mental diseases; Must provide required services and meet requirements related to residents’ rights
Hospital?
[42 U.S.C. 1395x]: An entity that is primarily engaged in providing, by or under the supervision of physicians, to inpatients diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons

27. What is a… Federally Qualified Health Center?
An entity that receives a grant under Section 330 of the Public Health Service Act
An entity that serves a population that is:
medically underserved, or
a special medically underserved population comprised of: migratory and seasonal agricultural workers, the homeless, and residents of public housing,
Provides required primary health services, either through the staff and supporting resources of the center or through contracts or cooperative arrangements

28. How Many Are There? Nursing homes Hospitals FQHCs
US: 15,531; MA: 415
Hospitals
US: 5,010; MA: 75
FQHCs
US: 1,048; MA: 33
All data available on

29. What is… What is an addictions treatment organization? No definition
What is a mental health treatment organization?
What is a behavioral health organization?
What is a community mental health center? [1913c1]*
An entity through which comprehensive mental health services are provided to any individual residing or employed in the center’s service area regardless of ability to pay for such services, current or past health condition, or any other factor.

30. How Many Are There? Addiction Treatment Organizations:
8,200 (as of 2009)
Mental Health Treatment Organizations:
508 residential treatment centers (as of 2004)
Behavioral Health Organizations:
Data not available
Community Mental Health Centers:
672 (as of 1991)

31. Why Does This Create Problems?
Medicaid accounts for nearly 50% of federal spending for behavioral healthcare

32. Why Does This Create Problems?
All addiction/mental health services are optional in Medicaid

33. Federal Legislative Process
Congressional Budget Office
Committees of jurisdiction
What are the entities that we are talking about (show me the definition)
How many are there (to estimate cost)

34. Where Has This Caused Us Problems?
ARRA
HITECH ACT
Credibility problem with CMHC

35. ARRA Monies FQHC Construction: $1.5 billion
FQHC Expansion: $500 million
National Health Service Corps: $500 million

36. Affordable Care Act Monies
FQHC Construction: $1.5 billion
FQHC Expansion: $9.5 billion
National Health Service Corps: $1.5 billion

37. An Example of Why FQHC/CBHO Parity is Important
The President’s Proposal – March 2010
FQHCs are acknowledged as a critical component of healthcare reform; funding would nearly triple over 5 years

38. H.R / S. 4038
Establishes federal standards/definition for a Community Behavioral Healthcare Organization
Makes every service provided by a CBHO MANDATORY within Medicaid
Provides similar reimbursement for CBHOs and FQHCs/Rural Health Clinics

39. Eligibility and Requirements
Eligibility restricted to nonprofit or public organizations
Must provide: (partial list)
Outpatient clinic mental health services
Outpatient clinic primary care screening & monitoring of key health indicators
Substance Abuse Services and Integrated Tx for Dual Disorders
Crisis mental health services
Targeted case management & Psychiatric rehabilitation
Peer support/counselor services and family supports
Must maintain linkages, and where possible enter into contracts with FQHCs

40. S Additional Features
340(b) discount drug process for all organizations that receive funding from either SAMHSA block grant
New construction/modernization loan fund for all organizations that receive funding from either SAMHSA block grant
Extension of Medicaid HIT incentive payments to FQBHCs
Extension of Medicare tele-health authority to FQBHCs

41. Ensuring a Role for Behavioral Health Organizations
Get a seat at the table:
Work to ensure that MH/SU interests and perspectives are included throughout the implementation process
Know thyself:
Agencies will need to have a detailed and working knowledge of their capacity, technological needs, community needs, and the most effective services for their community to cogently advocate for the right changes in policies.

42. Ensuring a Role for Behavioral Health Organizations
Make new friends:
While the need to work with state Medicaid offices has been true for a long time, the inclusion of MH/SU throughout the ACA makes working with Medicaid, insurance, and primary care essential.
Think outside the box:
With new policy changes and more people with access to care, we will have to think creatively about how to increase capacity, reach out to underserved populations, and provide services in a way to meet the demands of the new law.

43. Medicaid Benefits: Benchmark vs. Traditional
Most newly eligible people will be enrolled in benchmark plans
Exemptions for:
Blind or disabled individuals, regardless of SSI eligibility
Dual eligibles
Inpatients in a hospital, nursing facility, or ICF-MR
Medically frail and special needs individuals (includes people with disabling mental disorders/children with serious emotional disturbances)
Health reform also includes important improvements to benchmark benefits (e.g. parity, minimum required benefits)
Consumers & advocates will have to decide whether benchmark or traditional coverage best meets their needs
States will need to develop processes to identify individuals who have a disabling mental disorder or functional impairment

44. Ensuring a Role for Behavioral Health Organizations
Build new bridges:
With each initiative, community behavioral health organizations will have to think about how to build a greater capacity to provide services, both in terms of service providers but also service locations.
Go back to the future:
These initiatives require investment in new technologies, especially those that interface with other systems and measure outcomes.

45. Ensuring a Role for Behavioral Health Organizations
Follow the money:
As always, the money trail will be a deciding factor in how programs will be implemented.
National Council Roadmap for State Associations
Explains critical areas of health reform implementation
Provides “To-Do” checklists for each area
Lists helpful resources & educational materials

46. Here’s a 10 Question “Test”
To explore if we’re ready to succeed in the brave new world and help ensure that persons with MH/SA/DD are part of the new healthcare ecosystem…

47. 1. Leadership & Relationship Building: Getting to the ACO Table
Are you in conversation with local Integrated Health Systems and at the table of Accountable Care Organization development efforts in order to “pitch” the importance of MH/SUD services to improve quality & bend the cost curve and building a case for how you can help these organizations succeed in the new world of risk?

48. 2. Leadership & Relationship Building: Planning for Expansion
Are you assessing the compatibility and capacity of your clinical workforce to operate in an environment of increased demand where most consumers have Medicaid or Insurance and Health Plans will be looking to contract with high-performing MH/SU Providers that can offer licensed professionals and certified peers?

49. 3. High Performing Specialty Provider Rapid Access
Can Schools, Child Welfare, ACOs and Medical Homes get clients/patients into specialty MH/SU with same day/next day access, especially for high risk, high need patients?

50. 4. High Performing Specialty Provider Caseload Management
Do you have well defined assessment processes and defined levels of care based on clinical pathways, functionality in daily living activities, symptom severity indicators, service volumes, etc. to match client need with the type, location, and duration of evidence-based care that increases the likelihood of positive outcomes?

51. 5. High Performing Specialty Provider Consumer-Centered , Recovery- Oriented Care
Is your clinical delivery process consumer-centered and supportive of “stepped care”?
The ability to rapidly step care up to a greater level of intensity when needed?
The ability to step care down so that a consumer’s MH/SU care is provided in primary care with appropriate supports?
The ability to offer “back porch” services for consumers who graduate from planned care?
All offered from a client-centered, recovery-oriented perspective?

52. 6. High Performing Specialty Provider Outcome Assessment Capacity
Do you use standardized tools to measure improvement (or not) in symptomology, level of functioning, resilience and recovery?

53. 7. High Performing Specialty Provider Care Management
Do you have ability to identify patients with MH/SUD who represent the top 5% to 10% of high cost consumers of health care & provide effective care management to help them manage their MH/SU disorders AND their chronic health conditions?

54. 8. Person Centered Healthcare Home Participation
Are you actively pursuing bi-directional involvement as a person-centered healthcare home?

55. 9. Revenue Cycle Management
Do you have (and use) established billing policies, procedures, and practices regarding client and third party billing?

56. 10. Change Management and Decision-Making
Do you use Rapid Cycle Improvement methods to improve clinical, business and administrative processes?

57. Resources
Behavioral Health/Primary Care Integration and The Person-Centered Healthcare Home, April 2009, The National Council.
Substance Use Disorders and the Person-Centered Healthcare Home, March 2010, The National Council. thcare_collaboration/clinical/personcentered_healthcare_homes
California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative. Vols. I, II, and III. September 14, 2009.
The Business Case for Bidirectional Integrated Care: Mental Health and Substance Use Services in Primary Care Settings and Primary Care Services in Specialty Mental Health and Substance Use Settings. June 30,
Oregon Standards and Measures for Patient Centered Primary Care Homes. February Office for Oregon Health Policy and Research. PCH.pdf

60. Practice Improvement Middle Management Academy
Psychiatric Leadership Development Project
Addressing Health Disparities Leadership Project
Access and Retention Initiatives
Primary Care/Mental Health Learning Communities
Standards of Care
Transition Age Youth Project
Addiction News Now and Compliance Watch electronic newsletters

61. Mental Health First Aid USA
10,000 Mental Health First Aiders
Law enforcement and Corrections
Primary Care Providers
Schools and Colleges
Faith communities
Military
Human Resource Managers
Addiction Providers
Entry Level Behavioral Health staff
Consumers and families and caring citizens

63. Executive Leadership
COMPSTAT – New York City Police Department concept where police data are mined and mapped to show where the city's crime problems concentrated -- and to direct police activity to where it is most needed.
High Cost, Complex Needs - using Medicaid claims and other state/local administrative data to identify high-need individuals with psychiatric disabilities whose patterns of service use indicate lapses in needed services.
Missouri, 5 percent of their high risk, high need medicaid recipients (with mental health and substance use disorders) represented 93 percent of the costs for hospital readmissions of people considered to have had conditions that would be responsive to outpatient services.
Single Points of Accountability - address weaknesses in uncoordinated fee for service care and in care provided by health plans, keeping these most-at-risk individuals engaged in care or connecting them to treatment again when they become disconnected.

64. Executive Leadership continued…
Same Day Access
Integration not Co-location
Early Intervention
Health Information Technology
Social Media - As more consumers turn to web-based tools to evaluate their health care options, you and your organizations need to develop a strategy for how to incorporate social media into marketing and communication plans, outreach, and treatment.

65. Consumers and Families
Parity - According to a Dec American Psychological Association (APA) survey, only 10 percent of Americans have even heard of the law, 29 percent don't know whether their existing mental-health benefits are adequate, and 45 percent don't know whether their insurance companies reimburse them for such services.
Plans may not apply financial requirement or treatment limitation to mental health or substance use benefits more restrictive than financial requirement or limitation for medical/surgical benefits
Examples: If in-network medical/surgical benefits are subject to $15 copay then no in-network MH/SUD can be subject to a copay greater than $15; combined deductible - separate deductibles not allowed
Prescription drug formulary design; Fail-first or step therapy
Standards for provider participation in a network, including reimbursement rates
Conditioning benefits on completing a course of treatment

66. Consumers and Families
What Health Care Reform Provisions Are "Live"?
Expanded coverage for young adults
Elimination of coverage exclusions for children with preexisting conditions
Expansion of annual coverage limits and prohibitions on rescinding coverage
Standardization of a process for appealing coverage determinations with insurers
Free preventative care for seniors through Medicare
Prescription drug savings for seniors through Medicare Part D
Additional care coordination for Medicare beneficiaries after being discharged from the hospital health
Insurers must spend 85 percent of every dollar paid in premiums on the cost of direct care and quality improvement

67. Consumers and Families
Consumer “Zagat” Ratings - Consumer attitudes and perceptions count more and more and there is disproportionate patient dissatisfaction in New York, New Jersey, and Pennsylvania—with more satisfied patients in Iowa, Kansas, Minnesota, Montana, Nebraska, and North and South Dakota.