1. Behavioral Health in a world of Healthcare Reform Carl Clark, M.D. CEO Mental Health Center of Denver

2. Why Health Care Reform We are spending too much money We are not getting the outcomes we should get- ranked 37 th by the World Health Organization There is enough money if we spend it differently.

3. International Comparison of Spending on Health 1980–2004 3 Data: OECD Health Data 2005 and 2006. Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP Schoen C, Davis K, How SKH, Schoenbaum SC. US health system performance: A national scorecard. Health Aff. 2006;25(6):w457-w475.

5. The Overall Design for Healthcare Reform U.S. health care reform must address three issues 5 There are 10 key healthcare reform issues relevant to the public behavioral healthcare system

6. Health Reform meets Main Street by The Kaiser Family Foundation

7. Changing from a “sick care” system to a “health care” system

8. 8 Federal Health Care Reform The Patient Protection and Affordable Care Act (H.R. 3590) was signed into law on March 23, 2010 by President Obama. Provisions can be categorized into 4 broad buckets: –Insurance Reform –Medicare Reform –Medicaid Reform

9. 9 Insurance Market Reform All U.S. Citizens are required to have qualifying health care coverage by 2014. Requires guarantee issue and renewability, prohibits pre-existing condition exclusions. Prohibits lifetime limits on the dollar value of coverage. Provides dependent coverage for children up to age 26. Creates a temporary national high-risk pool for individuals with pre-existing conditions, effective through January 2014; 7/6/10 Creates temporary reinsurance program for plans that cover high-risk individuals

10. Provisions that started 9/23/10 elimination of pre-existing condition exclusions for children health plans permit parents to cover their adult children up to age 26 Elimination restrictions on annual insurance coverage limits and bans on lifetime limits increased access to primary and preventive care

11. Provisions that started 9/23/10 Rescission- the end of unjustified cancellation of insurance policies when people get sick requiring insurance companies to cover evidence-based preventive services and eliminating copayments for many of those services

12. 12 Medicare Reform Provides a $250 rebate for Medicare beneficiaries (102,000 in CO) who reach the Part D coverage gap in 2010 and eventually eliminates the prescription drug “donut hole” with 50% discounts on brand-name drugs. Freezes Medicare Advantage (MA) payments Bonus payments for quality, performance improvement and care coordination beginning in 2014. Reduces Medicare DSH payments beginning in 2014. Increases funding for the Health Care Fraud and Abuse Control Fund by $250 million over the next decade.

13. 13 Insurance/Medicaid Reform Individuals between 133%-400% FPL receive federally financed premium credits to purchase insurance through the Exchanges, as well as cost-sharing credits. Creates state-based American Health Benefit and Small Business Health Options Program (SHOP) Exchanges through which individuals and small businesses can purchase qualified coverage. Eligibility for subsidies and public coverage based on Modified Adjusted Gross Income (MAGI), which conforms to income tax definitions.

14. 14 Health Care Reform Coverage- 2020 Employer-Sponsored Insurance- 3,300,000 Medicaid – 1,200,000 Medicare – 1,000,000 Exchange – 300,000

15. 1. Behavioral Health is now on the Health Policy Community’s “Radar Screen” Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying earlier than the general population (average age of death is 53) While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006) OR state study found that those with co-occurring MH/SU disorders were at greatest risk (45.1 years) 15

16. Behavioral Health People with a serious mental illness on average die medical problems 25 years sooner than people without a serious mental illness 3 out of 5 medical illness are, preventable and will respond to treatment

17. Medical Conditions If a person has a general health diagnosis and a mental illness the cost of their care is three times higher. Lack of access to medical care. Lack of insurance coverage for mental health conditions

18. 49% of Medicaid beneficiaries with disabilities have a psychiatric illness one behavioral health condition doubles medical expenditure for physical health and also doubles emergency room visit rates and hospital admission rates The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions Center for Health Care Strategies, Inc., October 2009 18

19. 2. Mental Health and substance use treatment Are “essential health benefits” in health care reform. These conditions must be covered. This is a national priority People getting access to care is better for people and will help to decrease overall healthcare expenditures. Greater demand for mental health and substance use treatment services

20. Benchmark Benefit Package Benchmark Benefit Package in the Senate bill –Covers large employers, the Exchanges and Medicaid –In Medicaid most/all enrollees may be guaranteed a benchmark benefit package that at least provides “essential health benefits”

21. Parity Will Likely Improve Access and Available mental health and substance abuse Services must be provided at parity with general healthcare services (no discrimination) –Large Employers (Parity Act) –Medicaid (Health Reform Legislation) –Health Insurance Exchanges for Individual and Small Group Policies (Health Reform Legislation) –Medicare: on the way (Medicare Modernization Act of 2003) Key for public sector systems is scope of services; will plans cover system of care type of services? 21

22. 3. Most Members of the Safety Net will have Coverage Including MH and SU Benefits 31% to 43% increase in Medicaid enrollees, depending on the bill Large reduction in uninsured (54% to 67%) $16 to $25 billion in additional spending for mental health and substance use treatment from insurance expansion 22

23. 4. Disruptive Innovation is already underway in general healthcare The problems facing the American healthcare system mirror nearly every other industry in their early phases Healthcare reform speeds up the process This creates opportunities and threats for existing managers and provider of care 23

24. System design changes Patient centered healthcare homes with integration of primary care and behavioral health services Accountable Care Organizations Regional Collaborative care organizations Early intervention and prevention programs

25. Person-Centered Healthcare Homes 45 percent of Americans have one or more chronic conditions. Over half of these people receive their care from 3 or more physicians. Treating these conditions account for 75% of direct medical care in the U.S. 5. Healthcare Reform Legislation has it “Right” about Service Delivery Design and Payment Reform 25

26. Healthcare Home Principles Ongoing Relationship with a PCP Care Team who collectively take responsibility for ongoing care Provides all healthcare or makes Appropriate Referrals Care is Coordinated and/or Integrated Quality and Safety are hallmarks Enhanced Access to care is available Payment appropriately recognizes the Added Value 26

27. Person-Centered Healthcare Homes 27 They are all about Improving Quality and managing Total Healthcare Expenditures! Service Delivery Design and Payment Reform

28. Regional Collaborative Care Organization Pilot 6700 Medicaid consumers which will be taken care of by a group of providers. Both physical and mental health conditions are to be addressed. 7 regions in Colorado Currently being implimented

30. 6. Total Healthcare Costs of Persons with MH/SU Disorders will Drive Integration Recognizing the need to embed behavioral health clinicians in medical homes and how will these models evolve? Will medical homes partner with CBHOs or hire their own BH staff? Will Accountable Care Organizations [ACOs] (networks of primary care providers pooling medical home support functions) become the employers of the BH clinicians? 30

31. 7. There is No Guarantee that New BH Revenues will Spent on CBHO Services A recent study of US MH/SU spending estimates that in 2014 less than 16% of U.S. spending on MH/SU services will occur in Community Behavioral Healthcare Organizations [CBHOs] We should not assume that new behavioral health expenditures will be more heavily weighted towards CBHOs (Note: Figures are summarized from Table A2 of the 2008 SAMHSA Report, “Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment 2004 – 2014”) 31

32. 8.Payment Reforms will be Linked to the Ability to Demonstrate Outcomes and Manage Costs New funding mechanisms will be utilized to better fund services that manage total healthcare expenditures Many Person-Centered Healthcare Homes will be funded with a 3-layer reimbursement mechanism 32 Note: PPS = Prospective Payment System, the FQHC cost-based reimbursement system

33. Payment for inpatient care will bundle hospital and physician services Bundled payments that only pay for part of Potentially Avoidable Complications (PACs) will penalize providers that have higher error rates and reward those with lower PAC rates Bundled payments may include all costs in the 30 days post an inpatient stay, including any return to the hospital 33

34. Payment Reforms will be Linked to the Ability to Demonstrate Outcomes and Manage Costs RCCO and Global payment Who do we partner with? Payment Reforms will be Linked to the Ability to Demonstrate Outcomes and Manage Costs RCCO and Global payment Who do we partner with? 34

35. Colorado’s Relative Level of MH Underfunding is Incompatible with Meeting the Needs of All Individuals in Quadrants I - IV Drawing on the California Integration Policy Initiative framework of Mild, Moderate, Serious and Severe Levels of Care, and … Assuming meaningful cost offsets can be achieved by treating the persons with Mild and Moderate BH disorders in primary care... 35

36. Aligning the Behavioral Health Delivery System Core competencies needed in order to continue being an important part of the healthcare delivery system. 1.A full Array of Specialty Behavioral Health Services 2.A well defined Assessment Process and Level of Care System 3.A solid approach to Prevention, Early Intervention, and Recovery 4.The ability to practice as a Team to Coordinate Care 5.Demonstrated use of Clinical Guidelines 6.Measurement Systems and Tools that measure consumer improvement 7.A robust Electronic Health Record that includes Patient Registries 8.Quality Improvement Processes and supporting Data Systems 9.Financial Systems to manage Case Rate Payments & the FQBHC Prospective Payment System And these competencies will need to be communicated to the Medical Homes in your community with whom you want to partner. 36

37. 9. Current Behavioral Health Payor Structures may be Disrupted as Medicaid Authorities and Health Plans Attempt to Bend the Cost Curve Different Scenarios will play out across the country –Some states will end their carve-outs “tomorrow” to achieve clinical integration –Others will stay with the status quo and attempt to avoid change –A 3 rd group will work with their MH/SU partners to move into the next generation –A 4 th group will stay with carve- out model but re-procure the entire system 37

38. 10. Health Insurance Reforms Shift “Risk for Total Cost of Care” Plans will no longer be able to –Discriminate against pre-existing conditions, –Rescind coverage except in cases of fraud, –Nor apply lifetime limits or unreasonable annual limits on benefits. These changes combined with Parity requirements will make it harder for private plans to “kick” persons with SMI/SUD over into the public system If the plans are forced to hold the full risk for these persons, CBHOs will become much more valuable resources to health plans 38

39. For Consumers You decide who you and where you want your health care home to be. It could be your primary care physicians office It could be your mental health center.

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41. For Mental Health Providers How will you assure that consumers with mental health needs are getting their general medical care. Collocating Imbedding primary care services Improved coordination with primary care

42. Model for Improving Primary Care 42

43. Colorado’s healthcare system rank in 2007 * The equity dimension was ranked based on gaps between the most vulnerable group and the U.S. national average for selected indicators. Comparisons were made by income, insurance, and race/ethnicity. 43