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Health Care Reform Impact on Primary Care and Behavioral Health John OBrien Senior Advisor on Health Financing, SAMHSA Statewide Policy Summit on Advancing.

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Presentation on theme: "Health Care Reform Impact on Primary Care and Behavioral Health John OBrien Senior Advisor on Health Financing, SAMHSA Statewide Policy Summit on Advancing."— Presentation transcript:


2 Health Care Reform Impact on Primary Care and Behavioral Health John OBrien Senior Advisor on Health Financing, SAMHSA Statewide Policy Summit on Advancing Bidirectional Behavioral Health and Primary Care Integration June 22, 2011 -- Chicago, IL

3 3 Be careful about reading health booksyou may die of a misprint Mark Twain 3

4 4 Affordable Care Act Major Drivers – More people will have insurance coverage – Medicaid will play a bigger role in MH/SUD than ever before – Focus on primary care and coordination with specialty care – Major emphasis on home and community based services and less reliance on institutional care – Rethink what is offered as a benefit – Outcomes: improving the experience of care, improving the health of the population and reducing costs

5 5 What Is SAMHSA Concerned About? People Are Dying Younger Younger People in our systems are not exempt from (or at risk of) chronic conditions Significant connection between heart conditions and drug use--Hospitalizations About 1/3 of all cigarette smokers have an MH/SUD 30% of all individuals with a MH/SUD may have 3 chronic conditions

6 Other Major Drivers Primary Care and Specialty Coordination Why All the Fuss? – 20% of Medicare and Medicaid patients are readmitted within 30 days after a hospital discharge – Lack of coordination in handoffs from hospital is a particular problem – More than half of these readmitted patients have not seen their physician between discharge and readmission – Most FQHCs and BH Providers dont have a relationship

7 7 So Whats The Response Health Homesstart with folks that have a variety of chronic conditions Accountable Care Organizationsstart with Medicare population Patient Safety Initiativereward hospitals and other facilities for fewer incidents Quality Measuresfocus on identifying people who are at risk of certain conditions

8 8 Health Homes2703 New Medicaid State Plan Option 2703 Goals: Expand upon the traditional and existing medical home models Build linkages to community and social support Enhance the coordination of medical, behavioral, and long-term care.

9 9 Eligibility Criteria Medicaid eligible individual having: two or more chronic conditions, 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 chronic conditions (e.g. HIV/AIDs) 9

10 10 Designated Provider Types There are three distinct types of health home providers that can provide health home services: designated providers, a team of health care professionals, and a health team. 10

11 11 Health Home Functions Health home providers are expected to address several functions including, but not limited to: Providing quality-driven, cost-effective, culturally appropriate, and person- and family-centered health home services; Coordinating and providing access to high-quality health care 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.

12 Health Homes – Health homes (several new services): Comprehensive Care Management Care Coordination and Health Promotion Patient and Family Support Comprehensive Transitional Care Referral to Community and Social Support Services – Models Still emergingchronic disease and depression Fewer models on chronic disease and alcohol or substance use

13 13 Enhanced Federal Match There is an increased federal matching percentage for the above health home services of 90 percent for the first eight fiscal quarters that a State plan amendment is in effect. The 90 percent match does not apply to other Medicaid services a beneficiary may receive. 13

14 14 Accountable Care Organizations Recently released draft rules on ACOsresponses due early June Initially targets Medicare populationestimated savings of $960M first three years Implications for Medicaid and Commercial plans 14

15 15 Accountable Care Organizations ACOs have been compared to the elusive unicorn: everyone seems to know what it looks like, but no one has actually seen one. 15

16 16 Accountable Care Organizations Network of doctors and hospitals that shares responsibility for providing care to patients. Premise: Make providers jointly accountable for the health of their patients, Strong incentives to cooperate and Save money by avoiding unnecessary tests and procedures. 16

17 17 Accountable Care Organizations Shared Informationfor ACOs to work theyd have to seamlessly share information. Shared savingsACOs that save money while also meeting quality targets would keep a portion of the savings. 17

18 18 Accountable Care Organizations Better Screeningfocus on red flag conditions that may indicate higher risk clients Care coordination especially between hospitals and primary care Specialty care has a rolenot well articulated yet Minimum of 5,000 Medicare beneficiaries for at least three years 18

19 Partnership for Patients National partnership that will help save 60,000 lives Goal is to stop millions of preventable injuries and complications in patient care over the next three years. Focus on nine types of medical errors and complications: preventing adverse drug reactions, pressure ulcers, childbirth complications and surgical site infections.

20 Partnership for Patients HHS has committed $500 million to community-based organizations partnering with eligible hospitals to help patients safely transition between settings of care.

21 Other Implications There will be more and new payment strategies – Quite a contrast from 3 years ago Widgets versus bundling Overly accounted rates versus add ons or tiered rates Prescriptive versus creative definitions of services – Shared savings: Need upfront $ to play May not see the returns immediatelydo you (or board) have the stomach for that – Payment on successful episode of care Will have to define successful and episode Price it out based on what will be needed to be successful

22 Implications Whats old is newlots of discussion about capitation (again) Lessons learned from the 90s – Although many providers signed capitation contracts, most of these efforts ultimately failed – Providers were not organized to coordinate care efficiently. – Providers did not change their practice – Many large payers continued to pay through grants or FFS – As providers began losing money on capitation contracts, patients became fearful that clinical decisions were affected by financial considerations. – Providers largely not have data to prove value to payers, so ever at risk of services being eliminated from benefits when dollars tight

23 Compliance and Payment Providers and managed care organizations must report/repay any overpayment from Medicare or Medicaid within 60 days. More rigorous screening procedures for providers seeking Medicares approval to bill Require providers as a condition of participation in Medicare, to adopt compliance programs that meet federal Soon all claims submitted online Bundling should not be mechanism to hide the services rendered

24 Implications Changes in Mission of Block Grant – The who changesmore people are covered by insurance. Who is left uninsured: Individuals that dont enroll or lapse coverage Individuals not eligible for exchangestoo much income but cant afford private pay – The what what changes We need to buy what is good and modern - ACA requires essential MH/SUD Need to make sure we dont duplicate payment for same services

25 25 So Why Should You Care? Feast or Famine Health homeslots of opportunities for SUD providers to participate Clear focus on SUD as a chronic condition Health homes for other chronic conditions are being encouraged to screen for MH/SUD Provider descriptions specifically cite behavioral health providers as a possible HH provider ACOsNot as clear of a role Initial focus on Medicarenot out clients Proposed rules lean on behavioral health conditions Sharing information is daunting

26 26 So Why Should You Care? Feast or Famine Patient Safety Initiative No mention of BH conditions ButSUD patients have high rates of hospitalization SUD patients may actually be more susceptible to medical errors and complications $500 million available now for local initiatives

27 27 So What Can You Do? Mandatory Requirements: – Do outreach to primary carestart with larger organizations (FQHCs, CHCs) Business Case Recommend screening tools and processes Help them with concerns regarding 42 CFRdecipher myth from reality Develop a workable hand off/referral strategy

28 28 So What Can You Do? Mandatory Requirements: – Make recommendations regarding ACOs regulations and SUD conditions (SAAS) Screening tools Measures – Find out who is forming ACOs Hospital executives Local foundations Large consulting firms

29 29 So What Can You Do? Mandatory Requirements: – Assess how prevalent hospital errors and illnesses are among newly discharged patients – Lead or form the partnerships re: Patient Safety now – Develop plan and make investment for sharing informationmost challenging – Assess your compliance strategies

30 Additional Information John OBrien

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