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Health Care Reform 2014: Implications for Professional Practice Dan Abrahamson, PhD Assistant Executive Director Kansas Psychological Association April.

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Presentation on theme: "Health Care Reform 2014: Implications for Professional Practice Dan Abrahamson, PhD Assistant Executive Director Kansas Psychological Association April."— Presentation transcript:

1 Health Care Reform 2014: Implications for Professional Practice Dan Abrahamson, PhD Assistant Executive Director Kansas Psychological Association April 5, 2014 Wichita, KS

2 Compelling Need for U.S. Health Care Reform  About 50 million uninsured Americans  Annual health expenditures of over $2.7 T  Health costs comprise about 17% of GNP  Fragmented system with variable quality  Increased life expectancy but often with chronic illnesses 2

3 The Economic Context for Reform  2010 Healthcare expenditure = $2.7T  Healthcare is single largest contributor to national debt: Medicare = 15%; Medicaid = 8%; Social Security = 20%; Defense = 20%  All Health Expenditures, 2009:  51% (34% Ins. & 13% out of pocket)  49% 37%, 22%, 16%)  By 2020, Fed. Govt. will pay 49% of all health  State budgets in worst shape since WWII 3

4 Economic Context: Mental Health  Largest purchaser of MH/SUD services is the government!  Mental Health Spending, 2009:  Private insurance, 26%; Out-of-pocket, 11%; Charity, 3%  Public funding, 60%  Medicare, 13%  Medicaid, 27%  Other federal, 5%  Other state/local, 15% 4

5 Economic Context : Mental Health  Mental Health Spending Trends 1986 = 7.3% of all health spending 2003 = 6% of all health spending 2009 = 6.3% of all health spending 2014 = 5.9% of all health spending  Spending by provider class:  Psychiatrists = 6% of all mental health $$  Non-psychiatric physicians = 5%  Psychologists/SW/Cs = 5% or 0.315% of total mental health $$; psychologists only 16% of this provider group  Hospitals = 26%  Specialty MH/SUD = 30%  Insurance Administration = 7% 5

6 Mental Health: Shifts in Spending Source: Substance Abuse and Mental Health Services Administration. (2011). National Expenditures for Mental Health Services & Substance Abuse Treatment Washington, DC. As cited in Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC. Distribution of Mental Health Expenditures by Type of Service, 1986 and % Prescription Drugs $32 Billion$113 Billion 19% Inpatient 33% Outpatient

7 Economic Context: RxP and Mental Health RxP: 50% of increased MH spending RxP: 3X growth rate as other services RxP: 28% of all MH spending in 2009 New drugs/new generics/patents expiring Fewer side effects More PCPs comfortable with prescribing 66% spent on antidepressants and antipsychotics 14% spent on ADHD medications 7

8 Treatment Settings for Behavioral Health Care Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC. Types of Mental Health Services Used in Past Year, Among Adults Receiving Treatment, 2009

9 Economic Context for Reform: Chronic Illness  Healthcare costs in 2009: 1% population = 21.8% of costs 10% population = 63.6% of costs 50% of population = only 2.9% of costs  Medicare spending: 5% beneficiaries = 43% costs 25% beneficiaries = 85% costs 50% beneficiaries have >5 chronic illnesses  Medicaid spending: 15% are disabled and = 43% of costs 10% are elderly and = 23% of costs Summary: 25% of population = 66% of costs 9

10 Patient Protection and Affordable Care Act of 2010  Culmination of a 100-year effort that challenged five former presidents  Comparable with passage of the Social Security Act in 1935 and Medicare in 1965  Almost on par with Civil Rights legislation in the 1950s and 1960s 10

11 Controversial Aspects of Health Care Reform  Cost estimate of $180 billion over 10 years (Congressional Budget Office, 2012, prior to Supreme Court ruling)  Individual mandate to purchase health insurance or pay a penalty upheld by Supreme Court ruling, June 2012  Medicaid expansion by states funded mostly by federal government with threatened loss of current funding for noncompliance. Loss of current funding not upheld by Supreme Court 11

12 Key Challenges Facing Health Care Reform 12

13 Overall Goals of Health Care Reform  To preserve employer-based health insurance  To expand coverage to 32 million more Americans (Medicaid, Insurance Exchanges)  To improve quality of care by addressing the needs of the whole patient through:  Preventive Services  Primary and Integrated Care  Reduce growth rate of healthcare costs 13

14 ACA Expands Eligibility & Coverage  Medicaid expansion covers persons up to 133% of FPL by 2014 (adds 16-22M)  Health Insurance Exchanges (up to 400% of FPL)  Essential Health Benefits with parity for Medicare Advantage, Medicaid Managed Care, CHIP, and Benchmark Plans  Preventive Care and Wellness 14

15 Insurance Market Reforms in Affordable Care Act  No lifetime or annual dollar limits  No rescissions of coverage except for fraud  Coverage of pre-existing conditions  Guaranteed coverage acceptance and renewal  Requirement of effective appeals process  Establishment of premium rating requirements  Prohibition of participant and provider discrimination  State consumer assistance offices 15

16 ACA Impacts Care Delivery  Accountable Care Organizations (ACOs)composed of integrated provider networks with:  shared electronic records  evidence-based practice protocols  outcomes measurement  performance incentives  Patient-Centered Medical Homes (PCMH) will have features similar to ACOs  Home and Community Based Services Options 16

17 Why Focus on Integrated Care?  Aspects of overall health are missed by sole focus on physical or mental health  Behavioral factors are leading causes of chronic illness and mortality  Chronic illness accounts for 75% of nation’s health spending 17

18 Why Focus on Integrated Care? Adults with Mental Health Conditions 29% of Adults with Medical Conditions Also Have Mental Health Conditions 68% of Adults with Mental Health Conditions Also Have Medical Conditions Source: Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation. Percentage of Adults with Mental Health Conditions and/or Medical Conditions, Adults with Medical Conditions 18

19 Prevalence of Behavioral Health Conditions in US Percent of US Adults Meeting Diagnostic Behavioral Health Criteria, 2007 Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC.

20 Comorbidities Compound Costs Monthly Health Care Expenditures per Person for Chronic Conditions, with and without Comorbid Depression, 2005 Source: Melek, S., and Norris, D. (2008). Chronic Conditions and Comorbid Psychological Disorders. Cited in: Druss, B. G., and Walker., E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.

21 Interaction Between Medical Disorders and Mental Illness Model of the Interaction Between Medical Disorders and Mental Illness Source: Druss, B. G., and Walker., E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation. RISK FACTORS Childhood Adversity Stress SES -Loss -Abuse and Neglect -Household Dysfunction -Adverse life events -Chronic stressors -Poverty -Neighborhood -Social Support -Isolation Chronic Medical Disorders Adverse Health Behaviors and Outcomes -Obesity -Sedentary Lifestyle -Smoking -Self care -Symptom Burden -Disability -Quality of Life Mental Disorders

22 Why Focus on Integrated Care?  At least half of mental health treatment is provided in primary care  High co-existence of physical disorders and behavioral health problems  Adults with SMI in public sector die younger ( by 25 years)due to untreated physical health problems 22

23 Psychology’s Contributions to Integrated Care  Conducting thorough psychological assessments  Treating more complex, complicated patients  Applying behavioral principles to modify health-risk factors  Promoting patient responsibility and resilience  Attending to interpersonal barriers to behavior change  Understanding environmental determinants of behavior, including impact of families and systems 23

24 Psychology’s Contributions to Integrated Care  Supervision of M.A. level therapists, case managers  Development of programs designed to provide population-based care  Designing, monitoring, and evaluating interventions  Program administration  Enhancing health team and organizational development 24

25 ACA Impacts Payment and Performance  Move will be away from Fee-for-Service  Global, bundled, episode payments  Pay for Performance  Higher rates for PCPs  Medicare Shared Savings & other model  FQHC investment of $11B  Quality Measures (11 of 51 are behavioral health) 25

26 The Healthcare Environment  Declining reimbursements  Increased/incessant demands for cost containment  Increased cost of doing business (rent, labor, equipment, insurance, etc.)  Increasing “competition” in psychotherapy marketplace  Growing regulatory demands (billing, privacy, confidentiality, patient consent, F-W-A, EHR, retirement planning, occupational safety, etc.)  Lack of negotiation leverage  And ever escalating healthcare costs! 26

27 Evolving Healthcare Landscape  Increased regulation of price and volume of psychological services by public/private payers  Rapid and large-scale consolidation of health insurance market leading to more payer power: providers have lower reimbursement and less autonomy and consumers have higher premiums  Professional, market, and regulatory developments encouraging more collaborative care practices  Emergence of new reimbursement mechanisms to replace FFS: P4P, Global payments, Episode of care payments, Shared Savings 27

28 Evolving Healthcare Landscape  Federal/State policies pushing integration:  Quality payment programs with incentives to meet certain quality standards  Health Information Technology (HIT): cost and ability to meet “meaningful use” criteria to be eligible for incentives  Anti-trust Enforcement Policy: allows integrated provider organizations to negotiate with plans re: payment rates but groups without integration (financial and clinical) are prohibited from such negotiation 28

29 Reasons to Integrate  Aggregate capital to finance, develop, implement and maintain infrastructure (HIT & data reporting systems) necessary to collect, track, and report quality information required for performance- based reimbursement mechanisms  Develop collaborative care systems necessary to achieve real quality improvement in patient care  Insurers, employers, consumers demanding data on provider performance: adherence to quality outcome and process measurement, patient satisfaction, cost of care 29

30 Reasons to Integrate  Allows ability to collect your own monitoring and evaluation data that may be needed to correct inaccuracies in tiering or designations imposed on your practice by payers  Share risk as needed in capitated contracts where there will be high-cost patients  Negotiating efficiencies with TPAs by sharing a manager who can analyze and negotiate contracts  Larger integrated groups may be favored by payers due to geographic coverage, mix of services, etc.  #1 reason: Market a valuable/competitive product that you cannot produce acting independently 30

31 Implications for Professional Practice  New care delivery models/systems: PCMHs, ACOs  New skills and training models for integrated, inter- professional team-based care  Implementing advances in telehealth, HIT, and electronic health records  Increasing demand for the use of EBPs (Evidence- based practices) and quality measures  Payment reforms: P4P, Global payments, Bundled payments, Shared-savings models 31

32 Primary Work Setting of APA Practicing Psychologists Independent solo practice Institution-based Practice Independent Group practice Academic: teaching and/or research Other 32

33 APA’s Health Care Reform Team  Staff Working Group:  CEO, Deputy CEO, and Senior Policy Advisor  Government Relations Offices: Practice, Public Interest, Education, and Science  Public & Member Communications Office  Involvement of APA Leadership and Members, as well as other organizations  Collaboration with the APA Practice Organization (APAPO) – APA’s affiliated 501(c)(6) entity that works to advance the interests of practitioners 33

34 The APA Center for Psychology and Health 34

35 APA Center for Psychology and Health Organizational Chart *The APA Practice Health Care Team and the State Implementation Advisory Group are combined APA Practice Directorate (c3) and APA Practice Organization (c6) activities. Ellen Garrison, PhD Coordinator APA Practice Health Care Team State Implementation Advisory Group Collaborating Units* Health Leadership Team Working Group of APA Member Primary Care Experts (TBD) Director of Integrated Health Care (TBD) Assistant Coordinator Health Team Norman Anderson, PhD Director Randy Phelps, PhD Office of Health Care Financing *The APA Practice Health Care Team and the State Implementation Advisory Group are combined APA Practice Directorate (c3) and APA Practice Organization (c6) activities. 35

36 APAPO is dedicated to serving the interests and needs of its members: APA members who pay the annual Practice Assessment to APAPO. The mission of the APAPO is to advance, protect and defend the professional practice of psychology. APAPO Mission

37 501(c )(6) Business/Trade Association As a 501(c)(6) organization, APAPO can:  Focus on advancing a particular trade – professional psychology  Engage in unrestricted lobbying  Work with a political action committee to facilitate political giving

38 Top Priorities for 2014 Medicare and Medicaid reimbursement “Physician” definition in Medicare HITECH incentive payments for electronic health records Legislative Advocacy

39 Medicaid: H&B Codes 39

40 Serving SPTAs: 2013 CAPP Grant Examples Minnesota Pursuing funding for the development of electronic health records; ensuring psychologists role in behavioral health homes. Vermont Supporting the inclusion of psychologists in legislative process during Vermont’s restructure to a Single Payer Plan. Kentucky Ensuring parity in private insurance and Medicaid; addressing workforce capacity challenges with Medicaid expansion. Georgia Pursuing efforts to defend scope of practice regarding psychological assessments.

41 HEALTHCARE REFORM AT THE STATE LEVEL  Established in fall 2011 in response to the passage of the Affordable Care Act  Composed of the Practice Health Care Team and the State Implementation Advisory Group  Facilitated administratively through the State Advocacy Office  State Implementation Updates 41

42 State Implementation Initiative & APA Communities  Launched by the association in April  Designed as a professional network that enables users to connect and work collaboratively online, in real time.  Securely accessed via MyAPA ID.  The APA Practice Initiative: State Implementation of Health Care Reform is now using APA Communities to link leaders to resources and state efforts on health care reform. 42

43 State Health Care Reform Group on APA Communities A Document Library A Discussion Forum Categorization of Resources: Mental Health Priority Areas in ACA 1.Accountable Care Organizations 2.Health Care Financing 3.Health Care Medical Homes 4.Health IT 5.Insurance Exchanges 6.Integrated Care 7.Medicaid Redesign 8.Primary Care Additional Categories: 9.SPTA Health Care Summits 10.Updates: APA State Implementation of Health Care Reform 43

44 SPTAs and Health Care Reform Education  2011 New York State Psychological Association Massachusetts Psychological Association Maryland Psychological Association  2012 North Carolina Psychological Association Idaho Psychological Association Maine Psychological Association California Psychological Association Indiana Psychological Association Oregon Psychological Association Washington State Psychological Association  2013 Connecticut Psychological Association Wisconsin Psychological Association Nevada Psychological Association Minnesota Psychological Association South Carolina Psychological Association Rhode Island Psychological Association Ohio Psychological Association Oklahoma Psychological Association Vermont Psychological Association 44

45  Funding level maintained for 2014  Organizational development, legislative, emergency and Canadian  $250,000 awarded in organizational development grants to 25 states and DC in 2014  $185,000 awarded in legislative grants to 13 states in 2013 (for 2014) Serving SPTAs: CAPP Grants

46 Contact Information Phone: Web: 46


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