1. Health Reform: Implications and Options
Chuck Ingoglia
National Council for Community Behavioral Healthcare
Sept. 12, 2011

2. The National Council: Serving & Leading
Represent community organizations that deliver safety net primary care, mental health and substance abuse services to nearly six million adults, children and families
National voice for legislation, regulations, policies, and practices that protect and expand access to services that promote recovery
We educate and advocate…

3. Membership Driven

4. National Council Experience - Practice Change and Quality Improvement
Leadership:
Middle Management Academy – 1,500 managers
Psychiatric Leadership Project – 4th class
Health Disparities and Emerging Leaders
Bi-directional Integration:
Primary Care – Behavioral Health Learning Communities (149 pairs of BHOs and FQHCs)
SAMHSA/HRSA Center for Integrated Health Solutions

5. The SAMHSA/HRSA Center for Integrated Health Solutions (CIHS)
Purpose:
To serve as a national training and technical assistance center on the bidirectional integration of primary and behavioral health care and related workforce development (including healthcare homes)
To provide technical assistance to 56 PBHCI grantees and FQHCs funded through HRSA to address the health care needs of individuals with mental illnesses, substance use and co-occurring disorders

6. Improvement Initiatives continued…
Quality and Accountability- producing outcomes:
Access and Retention Projects
Transition Age Youth Initiative
Advancing Standards of Care for People with Schizophrenia
Depression Collaborative
Trauma Informed Care Initiatives
September - Online certificate program for practitioners working with veterans (partnership with DoD Center for Deployment Psychology and Essential Learning)
Health Promotion - Mental Health First Aid

7. A Changing Healthcare Landscape: Ensuring a Role for Behavioral Health
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 new demands.
Accountability is the cornerstone of the new healthcare environment.
All of these initiatives will require investment in new technologies, especially technologies that interface with other systems and also measure outcomes.

8. Two Hypotheses
Sick Care/Health Care: Federal, State and Local healthcare reform is in the process of dramatically changing the American healthcare system from a sick care system to a true health care system
Importance of Behavioral Health: Prevalence and cost studies are showing that this cannot be accomplished without addressing the substance use and mental health needs of all Americans.

9. The Affordable Care Act: Four Key Strategies
U.S. health care reform, with or without federal legislation, is moving forward to address key issues 9

10. Insurance Reform Requires guaranteed issue and renewal
Prohibits annual and lifetime limits
Bans pre-existing condition exclusions
Create essential benefits package that provides comprehensive services including MH/SU at Parity
Requires plans to spend 80%/85% of premiums on clinical services
Creates federal Health Insurance Rate Authority

11. Coverage Expansion Requires most individuals to have coverage
Provides credits & subsidies up to 400% Poverty
Employer coverage requirements (>50 employees)
Small business tax credits
Creates State Health Insurance Exchanges
Expands Medicaid

12. State Health Insurance Exchanges
For small employer and individual insurance
Pools risk across more individuals
Parity for SUDs/MH applies
Primary Functions:
Provides insurance plan info in easy-to-understand format
Monitors insurance plan marketing and competition
Standardizes plan benefits and cost-sharing
Some responsibility to control premium growth
Administration of tax credits for individuals between 134%-400% of FPL
Similar to the Massachusetts Connector or Federal Employees Health Benefit Program (FEHBP)

13. Health Insurance Exchanges
Current World Order:
If the ideal is met:
Employer offers insurance  you select from a few plan choices (or maybe just one).
Employer doesn’t offer insurance  you can get non-group insurance (which is often difficult) or remain uninsured
You’re unemployed and meet Medicaid disability/income requirements  you may get Medicaid
You’re unemployed and don’t meet Medicaid requirements  you can get non-group insurance or remain uninsured
Employer offers insurance  Same, but potential savings to employer via selecting plans through the exchange
Employer doesn’t offer insurance  you can enter the exchange and purchase insurance or remain uninsured (and pay penalty)
You’re unemployed and have an income up to 133% of FPL  you can access Medicaid (inc. childless adults, non-disabled)
You’re unemployed and don’t meet Medicaid requirements  you can get non-group insurance through the exchange, with sliding scale subsidies for people up to 400% FPL, or remain uninsured (and pay penalty)

14. National Council analysis:
$15 to $23 billion more spending for MH/SUDs from insurance expansion  potential new revenue sources for BH providers

15. Medicaid Expansions 133% Federal Poverty Level
Expanded Eligibility for Children and Parents
133% Federal Poverty Level
April 1, 2010 State Plan Option
Expanded Eligibility for Childless Adults
Benchmark Coverage for Newly Eligible Childless Adults
Based upon Deficit Reduction Act benchmark coverage
Limited array of services available
Increased Federal Share and PCP Payments
FMAP = % in years
100% of Medicare Reimbursement
Maintenance of Eligibility
Eligibility standards must be maintained until Exchanges are fully operational.
Compliance tied to receipt of federal matching funds.
Does not prevent states from expanding coverage.
Coverage for Former Foster Care Children
States may extend coverage, including EPSDT, to former foster children until age 26

16. Income at Admission (Michigan, 2010)
133% of Federal Poverty Level in 2011 = approx. $14,483
Income
Frequency
Percent
Cumulative Percent
None
32210
49.4
Under $5,000
8410
12.9
62.3
$5,000 to $9,999
11326
17.4
79.7
$10,000 to $14,999
6161
9.5
89.1
$15,000 to $19,999
3463
5.3
94.4
$20,000 to $24,999
1637
2.5
97.0
$25,000+
1981
3.0
100.0
Total
65188

17. Benefits for the Newly Eligible
Essential benefits include mental health and substance use treatment
MH and SUD must be offered at parity with medical/surgical benefits
This means…
…Most members of the safety net will have coverage, including mental health and substance use disorders
What is the health profile of the newly eligible?

18. Health Profile of the Newly Eligible
16 million new Medicaid enrollees
This group on average is healthier relative to those who are currently enrolled in Medicaid (due to the fact that many of those with the worst health conditions already receive coverage through SSI or other disability pathways)
But…
The newly eligible with the most serious health problems will likely be the first to enroll.

19. Co-morbidities in the Adult Population
Source: Druss & Walker. “Mental disorders and medical comorbidity.” The Robert Wood Johnson Foundation Synthesis Project, February 2011.

20. Payment Reform & Service Delivery Design “Follow the Money” (Deep Throat quote from Bob Woodward’s account of Watergate)
Prevention Activities must be funded and widely deployed
Primary Care must become a desirable occupation and
Mental Health and Substance Use Disorder Assessment & Treatment for all must become the Standard of Care
In order to Decrease Demand in the Specialty and Acute Care Systems
Specialists:
High performing
Retire
Decide to become PCPs
Less opportunities available as med students think about their specialties
PCPs
More NPs & PAs
Specialist conversions
More med students going into primary care

21. National Healthcare Reform Strategies and the MH/SU Safety Net
In Treatment: 2.3 million
Not in Treatment:
Tens of millions (McClellan)
21% + (Willenbring)
How do we even begin to address these gaps as states and health plans realize they have to provide SU services at parity?

22. A Population Health Approach
Need to think differently about health: move from a focus on providing services to a single individual… to measurably improving outcomes for the populations in our communities
Key strategies/elements:
Prevention
Care management
Partnerships with primary care providers and others in the healthcare system
Data collection & continuous quality improvement
Clinical accountability

23. Healthcare Models of the Future
Coverage expansions are ONLY sustainable with delivery system reform
Collaborative Care
Patient Centered Healthcare Homes
Accountable Care Organizations
Accountability and quality improvement are hallmarks of the new healthcare ecosystem

24. Collaborative Care Approaches to Co-occurring Disorders
>30 randomized controlled trials have found collaborative care approaches improve quality and outcomes
Key “active ingredients” = care managers and stepped care
Collaborative care approaches are highly cost effective
Variety of models, including:
Fully integrated
Partnership model
Facilitated referral model

25. Core Components of Collaborative Care
Two Processes
Two New Team Members
Care Manager
Consulting BH Expert
Systematic diagnosis and outcomes tracking
(e.g. PHQ-9 to facilitate diagnosis and track depression outcomes)
Patient education/self-management support
Close follow-up to make sure pts don’t fall through the cracks
Caseload consultation for care manager and PCP (population-based)
Diagnostic consultation on difficult cases
Stepped Care:
Change treatment according to evidence-based algorithm if patient is not improving
Relapse prevention once patient is improved
Support medication Rx by PCP
Brief counseling (behavioral activation, PST-PC, CBT, IPT)
Facilitate treatment change/referral to BH
Relapse prevention
Consultation focused on patients not improving as expected
Recommendations for additional treatment/referral according to evidence-based guidelines

26. Person-Centered Healthcare Homes: A new paradigm
Picture a world where everyone has...
An Ongoing Relationship with a responsible healthcare provider
A Care Team that collectively takes responsibility for ongoing care
And where...
Quality and Safety are hallmarks
Enhanced Access to care is available
Payment appropriately recognizes the Added Value
What does this look like in practice?

27. What it’s not: A residential facility
Primary care provider as gatekeeper

28. Defining the Healthcare Home
Superb Access to Care
Patient Engage-ment in Care
Clinical Infor-mation Systems
Care Coor-dination
Team Care
Patient Feed-back
Publicly Available Infor-mation
Person-Centered Healthcare Home

29. Defining the Healthcare Home
Superb Access to Care
Everyone has a health home practitioner and team
Patients can easily make appointments and select the day and time.
Waiting times are short.
and telephone consultations are offered.
Off-hour service is available.

30. Defining the Healthcare Home
Health Home team has a patient-centered, whole person orientation
Care is tailored to the needs of each patient
Patients are active participants, with the option of being informed and engaged partners in their care.
Practices provide information on treatment plans, preventive and follow-up care reminders, access to medical records, assistance with self-care, and counseling.
Patient Engagement in Care

31. Defining the Healthcare Home
Clinical Information Systems
Systems support high-quality care, practice-based learning, and quality improvement.
Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments.
There is continuous learning and practice improvement.

32. Defining the Healthcare Home
Care Coordination
The health home team engages in care coordination & management within the team
The team also coordinates with other healthcare providers/organizations in the community
Systems are in place to prevent errors that occur when multiple physicians are involved.
Follow-up and support is provided.

33. Care Coordination
The Care Coordination Standard: When I need to see a specialist or get a test, including help for mental health or substance use problems, help me get what I need at your clinic whenever possible and stay involved when I get care in other places.
Services are supported by electronic health records, registries, and access to lab, x-ray, medical/surgical specialties and hospital care.

34. Health IT Requires More than an EHR
Requirements
Predictive modeling
Registries
EHR interfaces
Reminder Systems
Claims and clinical data warehouses
Episode of care analysis systems
Specifications for integrated claims & clinical databases
Patient portal options
Health enabling information exchange alternatives
Data Sources to be Mined
Medical records
Clinical outcomes data
Patient billing systems
Payer data
Quality measures abstracts
Charge master
Physician, payer, service line utilization data
Infection surveillance data
Labor, productivity and throughput records
Adverse drug events

35. Defining the Healthcare Home
Team Care
Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists).
Duplication of tests and procedures is avoided.

36. Defining the Healthcare Home
Patient Feedback
Publicly Available Information
Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans.
Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.

37. Additional Necessary Components
The health home is supported by a sustainable business model & appropriately aligned incentives
The health home is accountable for achieving improved clinical, financial, and patient experience outcomes

38. Are you ready to be a healthcare home? Do you…
Have a provider team with a range of expertise (including primary care)?
Coordinate consumers’ care with their health providers in other organizations?
Engage patients in shared decision-making?
Collect and use practice data?
Analyze and report on a broad range of outcomes?
Have a sustainable business model for these activities?

39. Health Homes Serving Individuals with SMI and Substance Use Disorders
Assure regular health status screening and registry tracking/outcome measurement
Locate medical nurse practitioners/primary care physicians in MH/SU facilities
Identify a primary care supervising physician
Embed nurse care managers
Use evidence-based practices developed to improve health status
Create wellness programs

40. New Paradigm – Primary Care in Behavioral Health Organizations
Funding starting to open up for embedding primary medical care into CBHOs, a critical component of meeting the needs of adults with serious mental illness

41. Primary Care in SU Settings
Many individuals served in specialty MH/SU have no primary care provider
Health evaluation and linkage to healthcare can improve MH/SU status
On-site services are stronger than referral to services
Housing First settings can wrap-around MH, SU and primary care by mobile teams
Person-centered healthcare homes can be developed through partnerships between MH/SU providers and primary care providers
Care management is a part of MH/SU specialty treatment and the healthcare home

42. Providers Need to Rethink their Service Approaches
Infrastructure development and process improvement are necessary
Continuing care should link the continuum of services together and support the individual’s change process
Recovery Oriented Systems of Care support recovery as a process
Motivational Enhancement Therapy or the Transtheoretical Model are effective, but must be delivered with fidelity
Other approaches, including medication-assisted therapy are also effective
Communities must work together to create a continuum of services and agreements about seamless access, stepped care and other transitions 42 42

43. 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. California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative. Vols. I, II, and III. September 14, 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. 43

44. What does it mean to provide primary care?
It’s more than having a nurse on staff
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a range of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
Partnerships with primary care providers/FQHCs

45. New Medicaid State Option for Healthcare Homes
State plan option allowing Medicaid beneficiaries with or at risk of two or more chronic conditions (including mental illness or substance abuse) to designate a “health home”
Community behavioral health organizations are included as eligible providers
Effective Jan. 2011
Additional guidance forthcoming from HHS

46. Eligibility Criteria To be eligible, individuals must have:
Two or more chronic conditions, OR
One condition and the risk of developing another, OR
At least one serious and persistent mental health condition
The chronic conditions listed in statute include a mental health condition, a substance abuse disorder, asthma, diabetes, heart disease, and obesity (as evidenced by a BMI of > 25).
States may add other conditions subject to approval by CMS

47. Designated Provider Types/Functions
Provider organizations may work alone or as part of a team
Functions include (but are not limited to):
Providing quality-driven, cost-effective, culturally appropriate, and person-centered care;
Coordinating and providing access to high-quality services informed by evidence-based guidelines;
Coordinating and providing access to mental health and substance abuse services;
Coordinating and providing access to long-term care supports and services.

48. Health Home Services
90% Federal match rate for the following services during the first 8 fiscal year quarters when the program is in effect:
Comprehensive care management
Care coordination and health promotion
Comprehensive transitional care from inpatient to other settings
Patient and family support
Referral to community and social support services
Use of health IT to link services (as feasible/appropriate)

49. Thoughts on the Implications for Behavioral Health
We guarantee we are all moving into a period of disruption
This is going to be hard stuff
Behavioral Health won’t automatically be included
BH stakeholders need to develop the value proposition
And we will likely have to ask to be involved
This will require thinking and acting differently
And what unfolds will depend, to a large degree, on what the people in this room do over the next 18 months 49

50. Be Efficient
Care Coor-dination
Team Care
Do you have the ability to identify patients with MH/SUD who represent the top 5% to 10% of high cost consumers of health care and provide effective care management services to help them manage their MH/SU disorders AND their chronic health conditions?

51. Care Management: Missouri Example
Identified the cohort of MO HealthNet participants for whom care management offers the greatest opportunity
Program components:
Outreach and engagement (door-to-door outreach, collaboration with other health providers)
Care coordination by mental health case manager
Nurse training
Chronic disease training
Evaluating outcomes: both process indicators and clinical outcomes

52. Connect with Other Providers
Do you use a collaborative care approach to clinical services?
Are you actively pursuing bi-directional involvement in your community as a person-centered healthcare home?
Can you electronically collect and share both demographic and clinical-level data with your partners in the healthcare community?
Clinical Information Systems

53. Focus on Episodic Care Needs
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 that consumers will get their needs met in a timely and effective manner?

54. Patient Engagement in Care
Stepped 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?
Patient Feedback
Patient Engagement in Care

55. Questions?
Chuck Ingoglia Vice President, Public Policy