Presentation on theme: "What Does the Future Hold for Behavioral Health?"— Presentation transcript:
1 What Does the Future Hold for Behavioral Health? Linda RosenbergNational Council for Community Behavioral HealthcareFebruary 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 MIOTCRAVeterans M H Outreach & Access ActM H Parity & Addiction Equity Act of 2008Recovery 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 CutsFY2009 to FY2012 Total $2.2 Billion in CutsYearAverageMedianMinimumMaximumTotalFY 2009(35 States)$18,979,310$10,000,000$0$107,000,000$664,275,843FY 2010(33 States)$24,058,725$12,300,000$203,000,000$793,937,917FY 2011(31 States)$20,812,710$11,267,905$84,000$162,000,000$645,194,004FY 2012(6 states)$12,959,616$6,150,000$2,194,458$32,000,000$77,757,695Preliminary Results based on 42 SMHAs Reporting6
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 2011Republican campaign pledge: cut $100 billion from the budgetPresident 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 curveThat began before the passage of the Accountable Care ActAnd 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 benefitsExamples: 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 allowedPrescription drug formulary design; Fail-first or step therapyStandards for provider participation in a network, including reimbursement ratesConditioning 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 interventionEnable providers to share patient information to reduce redundant/unnecessary proceduresAbility to demonstrate that interventions improve health outcomes and/or save moneyReporting of quality measures for incentive payments.New relationships with hospitals, health centers and other parts of healthcare delivery systemFor true care coordination; success of healthcare home and accountable care organizations models
13 Who is a Medicaid Eligible Provider? Eligible Providers in MedicaidEligible ProfessionalsPhysiciansNurse PractitionersCertified Nurse-MidwivesDentistsPhysician Assistants working in a Federally Qualified Health Center or rural health clinic that is so led by a PAEligible HospitalsAcute 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 WhitehouseMakes psychiatric hospitals, mental health, and substance abuse treatment facilities eligible for facility paymentsHill Day Effect80 co-sponsors in the House10 co-sponsors in the Senate
15 Healthcare Reform’s Four Key Strategies The second (and most significant) wave of public behavioralhealth 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 HomesNew Medical Home Payment ModelsBundled Payments Related to Inpatient AdmissionsAccountable 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 PCPA Care Team who collectively takes responsibility for ongoing careAnd Provides all Healthcare or makes Appropriate ReferralsHelping ensure that Care is Coordinated and/or IntegratedAnd where...Quality and Safety are hallmarksEnhanced 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 healthMH Parity/Addiction Equity in almost all federal programsIncluded in aspects of the PPACA as essential part of healthcare
25 What is the Status of Behavioral Healthcare Organizations? Small marginsLack of capital for improvements (Health IT, human capitol, new service lines)No federal status to support improvementNo 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’ rightsHospital?[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 ActAn entity that serves a population that is:medically underserved, ora 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: 415HospitalsUS: 5,010; MA: 75FQHCsUS: 1,048; MA: 33All 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 availableCommunity 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 OfficeCommittees of jurisdictionWhat 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? ARRAHITECH ACTCredibility problem with CMHC
35 ARRA Monies FQHC Construction: $1.5 billion FQHC Expansion: $500 millionNational Health Service Corps: $500 million
36 Affordable Care Act Monies FQHC Construction: $1.5 billionFQHC Expansion: $9.5 billionNational Health Service Corps: $1.5 billion
37 An Example of Why FQHC/CBHO Parity is Important The President’s Proposal – March 2010FQHCs are acknowledged as a critical component of healthcare reform; funding would nearly triple over 5 years
38 H.R / S. 4038Establishes federal standards/definition for a Community Behavioral Healthcare OrganizationMakes every service provided by a CBHO MANDATORY within MedicaidProvides similar reimbursement for CBHOs and FQHCs/Rural Health Clinics
39 Eligibility and Requirements Eligibility restricted to nonprofit or public organizationsMust provide: (partial list)Outpatient clinic mental health servicesOutpatient clinic primary care screening & monitoring of key health indicatorsSubstance Abuse Services and Integrated Tx for Dual DisordersCrisis mental health servicesTargeted case management & Psychiatric rehabilitationPeer support/counselor services and family supportsMust maintain linkages, and where possible enter into contracts with FQHCs
40 S Additional Features340(b) discount drug process for all organizations that receive funding from either SAMHSA block grantNew construction/modernization loan fund for all organizations that receive funding from either SAMHSA block grantExtension of Medicaid HIT incentive payments to FQBHCsExtension 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 processKnow 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 plansExemptions for:Blind or disabled individuals, regardless of SSI eligibilityDual eligiblesInpatients in a hospital, nursing facility, or ICF-MRMedically 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 needsStates 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 AssociationsExplains critical areas of health reform implementationProvides “To-Do” checklists for each areaLists 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 ResourcesBehavioral 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_homesCalifornia 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 ProjectAddressing Health Disparities Leadership ProjectAccess and Retention InitiativesPrimary Care/Mental Health Learning CommunitiesStandards of CareTransition Age Youth ProjectAddiction News Now and Compliance Watch electronic newsletters
61 Mental Health First Aid USA 10,000 Mental Health First AidersLaw enforcement and CorrectionsPrimary Care ProvidersSchools and CollegesFaith communitiesMilitaryHuman Resource ManagersAddiction ProvidersEntry Level Behavioral Health staffConsumers and families and caring citizens
63 Executive LeadershipCOMPSTAT – 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 AccessIntegration not Co-locationEarly InterventionHealth Information TechnologySocial 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 benefitsExamples: 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 allowedPrescription drug formulary design; Fail-first or step therapyStandards for provider participation in a network, including reimbursement ratesConditioning benefits on completing a course of treatment
66 Consumers and Families What Health Care Reform Provisions Are "Live"?Expanded coverage for young adultsElimination of coverage exclusions for children with preexisting conditionsExpansion of annual coverage limits and prohibitions on rescinding coverageStandardization of a process for appealing coverage determinations with insurersFree preventative care for seniors through MedicarePrescription drug savings for seniors through Medicare Part DAdditional care coordination for Medicare beneficiaries after being discharged from the hospital healthInsurers 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.