5 Lobbying US Chamber of Commerce $52,750,000 General Electric $23,660,000Pharmaceutical Research & Mfrs of America $22,733,400American Medical Assn $22,132,000American Hospital Assn $19,734,545AARP $19,540,000
6 Public Policy - Success 2008/09 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
7 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)$50 million authorization for behavioral-primary care integration grants (Senate HELP Committee)CMHCs included as eligible providers in Medicaid medical home demonstration program (Senate Finance Committee)Mental illness classified as eligible chronic illness for Medicaid medical home demo (Senate Finance Committee)
8 “Must Haves” for success… Broad and strong membership.Effective communications with members, media, advocates, policymakers & public.Reputation for quality - expert education & practice improvement initiatives.Assertive public policy agenda.Strategic alliances - industry leadership.
10 Summary of 2010 Member Engagement 1,720 members76% have participated in at least one activity; 67% in 200927% involved in fifteen or more activities/programs; 14% involved in 20 or more24% (410) not involved
11 Highly Engaged Members Colorado West (Glenwood Springs, CO)Meridian Behavioral Healthcare (Gainesville, FL)NHS Human Services (Lafayette Hill, PA)Rushford Center, Inc. (Meriden, CT)Mental Health Center of Denver (Denver, CO)Oakland County Community MH (Auburn Hills, MI)Centerstone (Nashville, TN)The Center for Health Care Services (San Antonio, TX)Heritage Behavioral Health (Decatur, IL)Mental Health Center of Boulder and Broomfield Counties (Boulder, CO)
13 Effective Communications Public Policy Update and AlertsNational Council MagazineTechnical Assistance NewsletterAddictions/Co-occurring NewsletterJournal of Behavioral Health Services & ResearchPrint Media and social media – online communities, blogging, and tweetingAnnual ConferenceWebinars – 1400 lines for “Understanding Anxiety”;604 for “Contracting with VA” 414 lines for “Accountable Care”
14 National Council LIVE Webinars Healthcare Reform Implementation SeriesAre You Ready to Become a Federally Qualified Health Center (FQHC)?Thu, August 1212:30 pm eastern, 11:30 am central, 10:30 am mountain, 9:30 am pacific, 8:30 am Alaska
15 Reputation for Quality Access and Retention InitiativesHealthcare Collaborative/Learning CommunitiesWorkforce: Middle Management Academy; Psychiatric Leadership Project; CEO UniversityMental Health First Aid
16 Increase Continuation Access and RetentionIf you don’t measure it you can’t improve it! Reduce Waiting TimesReduce No-ShowsIncrease AdmissionsIncrease ContinuationStandard slide – please do not modify.The four original NIATx aims. The foundation for a great deal of successful process improvement in the addiction treatment field.These aims are evolving into three new aims: increased access, increased engagement, and seamless transitions between levels of care.1616
17 Outcomes… Total Annual Savings: Produced an average annual savings of $199, per CBHO34% reduction in staff time18% reduction in the client time40% reduction in client wait time to treatmentBased on 28 grant CBHOs: Florida (7), Ohio (12), & Wyoming (9), total annual savings$5,599,703.99Phase III started in June - 45 organizations in WA, PA & MI
18 Behavioral and Primary Care Learning Communities 149 pairs of Community Behavioral Health Organizations and Federally Qualified Health Centers serving 98,000 consumersOutcomesScreening, detection and treatment of behavioral health disorders in primary care resulting in increased depression free daysIncreased screening and treatment for physical health issues in CBHOs with improved chronic illness health outcomes - diabetes, heart disease, and COPD
19 Psychiatric Leadership Program Executive leadership program for medical directors in community behavioral health organizations.One-year comprehensive curriculum designed to develop and enhance leadership and professional development.Participation since 2008 – 35 medical directors from agencies that serve more than 420,000 clients each year.
20 Mental Health First Aid USA 800+ instructors certified10,000 Mental Health First AidersLaw enforcement and corrections officersPrimary care workersSchool and college workersFaith community leadersMental health/substance use consumers and familiesCaring citizens1,500,000+ media impressions
21 Parity, Technology and Healthcare Reform Will Change Everything Parity, technology and reform will trigger dramatic changes in how health and MH/SU services are organized.These changes will create a tipping point in how the healthcare needs of persons with serious mental illness and the MH/SU healthcare needs of all Americans are addressed.Which will change the way MH/SU services are funded and fit into the new healthcare ecosystem.21
22 Parity - General Information on Interim Final Regulations Apply for plan years beginning July 1, 2010General rule – parity applies if a plan offers medical/surgical and MH/SUD benefits (> 50 employees)A plan may not apply any financial requirement or treatment limitation to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation for substantially all medical/surgical benefits in the same classification22
23 Analyzing Plan Benefits A requirement/limit applies to substantially all medical/surgical benefits in a classification if it applies to at least 2/3 of benefits in the classification -If not, it cannot be applied to MH/SUD benefitsExample: If 70% of the projected payments for inpatient, in- network medical/surgical benefits were subject to a $15 copay…. then… no inpatient, in-network MH/SUD could be subject to a copay greater than $15MH/SUD and medical/surgical benefits must accumulate toward the same, combined deductible - separate but equal deductibles are not allowed23
24 Non-quantitative Treatment Limitations Definition - Not expressed numerically - list of examples:-Medical management (e.g., utilization review, preauthorization, concurrent review, retrospective review, case management, etc.)-Prescription drug formulary design-Standards for provider participation in a network, including reimbursement rates-Fail-first or step therapy protocols-Conditioning benefits on completing a course of treatment24
25 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
26 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
27 Incentive Payments for Medicaid EPs First Calendar Year for which the EP receives Incentive Payment
28 Conceptual Approach to Meaningful Use Data Capture and SharingAdvanced Clinical ProcessesImproved Outcomes
29 HIT Extension for Behavioral Health Services Act (HR 5040) National Council driven - Introduced in the House on April 15 by Kennedy and MurphyMakes psychiatric hospitals, mental health and substance abuse treatment facilities eligible for facility paymentsAdds psychologists & social workers to listHill Day effect:Currently Have 68 House Co-SponsorsIntroduced in Senate by Sheldon Whitehouse (D-RI), co-sponsored by Sherrod Brown (D-OH), Al Franken (D-MN), Frank Lautenberg (D-NJ), Jeanne Shaheen (D-NH), and Debbie Stabenow (D-MI).
30 Healthcare Reform and the Behavioral Health Safety Net … We are on the cusp of the second (and most significant) wave of public behavioral health change in the last 25 years.
31 Healthcare Reform’s Four Key Strategies The second (and most significant) wave of public behavioral health change in the last 25 years.3131
32 Insurance Reform Requires guaranteed issue and renewal Prohibits annual and lifetime limitsBans pre-existing condition exclusionsCreate essential benefits package that provides comprehensive services including MH/SU at ParityRequires plans to spend 80%/85% of premiums on clinical servicesCreates federal Health Insurance Rate Authority
33 Coverage Expansion Requires most individuals to have coverage Provides credits & subsidies up to 400% PovertyEmployer coverage requirements (>50 employees)Small business tax creditsCreates State Health Insurance ExchangesExpands Medicaid
34 Medicaid Reforms 133% Federal Poverty Level Expanded Eligibility for Children and Parents133% Federal Poverty LevelApril 1, 2010 State Plan OptionExpanded Eligibility for Childless AdultsBenchmark Coverage for Newly Eligible Childless AdultsBased upon Deficit Reduction Act benchmark coverageLimited array of services availableIncreased Federal Share and PCP PaymentsFMAP = % in years100% of Medicare ReimbursementMaintenance of EligibilityEligibility 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 ChildrenStates may extend coverage, including EPSDT, to former foster children until age 26Increased Federal Share and PCP Payments100-90% in years100% of Medicare Reimbursement34
35 Unmet U.S. Mental Health Needs Source: Unmet Mental Healthcare Needs in the Health and Behavioral Healthcare Safety Net
36 National Healthcare Reform Strategies - the MH/SU Safety Net The underfunding problem is even greater in Substance UseIn Treatment: 2.3 millionNot in Treatment: 23 millionHow do we even begin to address these gaps as states and health plans realize they have to provide SU services at parity?
37 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 expansionEach person who goes from being uninsured to insured will bring with them a new funding stream that will pay for the mental health and substance use conditions. I estimate that coverage expansion will result in somewhere between $16 and $25 billion per year that will be allocated to behavioral healthcare, depending on how much emphasis is placed on treating behavioral health conditions.I have not yet gathered credible data to estimate how much additional money will be spent on behavioral health services due to the implementation of the Wellstone-Domenici Parity Act, but am assuming it will be greater than previously anticipated. We also have no way of knowing how much additional money in the health care “pot” will be spent on behavioral health.
38 Expected Effect of Health Care Reform Legislation on Arizona Coverage Rates 81,095 people in Arizona who were previously uninsured are newly eligible and expected to enroll in MedicaidThat is a reduction in Arizona’s uninsured rates of 13.6%
39 Expected Effect of Health Care Reform Legislation on Arizona Coverage Rates
40 Service Delivery Redesign and Payment Reform $700 Billion Question: Will the current legislative and regulatory tools at our disposal be enough to improve the health status of Americans and bend the cost curve?MH/SU Question: Is the answer to the above question the same for Americans with mental health and/or substance use disorders?
41 Healthcare Reform: Root Cause Analysis Wrong incentives and many disincentives that lead to:Lack of AccessOveruse of unnecessary, high cost tests and proceduresUnderuse of prevention, primary care and behavioral health servicesMedical errorsAs much as 30 percent of costs (over $700 billion per year) can be eliminated without reducing quality
42 Emerging Delivery System and Payment Reform Models Where the U.S. Healthcare System is headed (at a glance)
43 Payment Reforms Need to invert the Resource Allocation Triangle Primary Care must become a desirable occupation and…Decrease demand in the specialty and acute care systems43
44 Payment ReformsPayment reforms linked to demonstrating outcomes - managing costsThe payor environment:Medicare already federal incubator of design changes (Medical Home pilots underway)Commercial and self-insured plans (Boeing, GHC, Aetna, United Health) running Medical Home pilotsInsurance Exchanges, larger Medicaid programs, and new Dual Eligible (Medi-Medi) plans will be state incubators of changesQuestions…How will Medicaid programs implement parity and medical homes?How many Dual Eligible Plans develop?Will MH/SU providers be on Exchange and Dual Eligible Provider Networks?44
45 Payment Reforms (i)Patient Protection & Affordable Care Act improve optionState plan services now covered that were previously only available through 1915 (c) and 1115 waivers. No longer tied to “cost neutrality.”Increases income to 300% of FPLAllows states to target to specific populations, like persons with psychiatric disabilities.Must be developed through a person-centered process-beneficiaries, can self-direct their servicesPatient Protection Act added category of services of “other” allowing broader range of interventions.
46 Value-Based Purchasing – Medical Homes/Accountable Care Orgs Fee for Service is headed towards extinctionFFS layer shrinking over timeBeing replaced with case rate or capitation with a pay for performance layerPayment mechanisms will be tied to these measures in a variety of ways. Bundled payments that only pay for part of potentially avoidable complications (PACs) will penalize providers that have higher error rates. CBHOs that don’t have structures and staffing to provide effective prevention and early intervention services and manage chronic health conditions will not be eligible for case rates and capacity-based payments to fund that work. CBHOs that don’t hit performance measure targets will not earn their bonuses.A related issue from above is whether existing carve-out plans that have worked closely with CBHOs to develop innovative payment mechanisms such as sub-capitation, case rates, risk corridors with bonuses, etc. will still be in business in the near future. Should CBHO groups and existing behavioral health carve-outs look to align/merge with health plans such as members of the Association for Community Affiliated Plans? What other strategies could be used to ensure their survival?
47 Accountable Care Organizations (ACOs) Congress and CMS: ACO have at least one hospital, minimum of 50 physicians (primary & specialists), be in business at least 3-5 years, serve at least 5,000 patientsIf ACO met pre-established quality goals, it would receive an incentive paymentPenalties assessed if care didn’t meet quality goalsIncentive payments and penalties split between members of the ACOProviders in ACO to follow best practices, be patient-centered & contribute to best clinical practices to build evidenced-based medicine standards
48 Accountable Care Organizations (ACOs) ACOs to analyze patient experiences across a population and inform quality improvement strategiesVertical integration of primary care, specialty, hospital providers who share risk for quality and total healthcare costsACOs achieve this by addressing 3 barriersTackle fragmented payment/delivery systems by fostering local, organizational accountability for continuum of care including outcomes, quality and costsFocus provider payments on improved health outcomes, better quality, and reduced costsSupport patient choice by providing information on treatment risks and benefitsMH/SU providers must prepare to be a part of ACOs and advocate for bi-directional integration
49 Patient Centered Medical/Healthcare Homes Principles Ongoing Relationship with a PCPCare Team who collectively take responsibility for ongoing careProvides all healthcare or makes Appropriate ReferralsCare is Coordinated and/or IntegratedQuality and Safety are hallmarksEnhanced Access to care is availablePayment appropriately recognizes the Added ValueSee the site for more information4949
50 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
51 New Paradigm – Financing Specialty Behavioral Health FQBHC status creates single set of national standards that can serve as a blueprint for the types of services and infrastructure that need to be in place to better support the full healthcare needs of persons with serious mental health and substance use disordersIn addition, the FQBHC designation creates a single, common platform of assumptions, approaches, and expectations for FQHCs and FQBHCs to partner in providing person-centered healthcare homesThe ability to achieve FQBHC designation and the accompanying financial benefits are necessary for Community Behavioral Healthcare Organizations to be able to adapt to the changes that will occur in healthcare systemThe ability to achieve FQBHC designation and the accompanying financial benefits are necessary components for Community Behavioral Healthcare Organizations to be able to adapt to the changes that will occur in the general healthcare system.Question: Has there been discussion in Colorado about this and what do you think about FQBHCs?
52 What We Can DoThere is one critical thing you must all do to be ready for healthcare reform – you have to be at the table for the discussions taking place in your communities, states and at the national level. If behavioral healthcare providers and stakeholders don’t succeed in that task, your consumers, your organization and the overall healthcare system may suffer.”
53 Be At The TableActively Pursue Relationship-Building with leaders in the healthcare community – Hospital CEO, Health Plans, Multi-Specialty Clinic Medical Directors, Medicaid Directors, the Chairs of the Legislature’s Health Care Committees, etc.Explore Developing a Regional Health Authority that integrates management and funding of health, behavioral health, public health, housing, and social services.Influence State and Health Plan Decision-Making Process regarding Parity, ACOs, Medical Home Standards and Payment Models, Health Insurance Exchanges, and Medicaid Expansion.Become a Founding Member of your Local Accountable Care Organization - if one hasn’t begun, start it!
54 When You’re At The Table Under an Accountable Care Organization and Primary Care Practice Medical Home Models the Value of Behavioral Health Services will depend upon our ability to:Be Accessible (Fast Access to all Needed Services)Be Efficient (Provide high Quality Services at Lowest Possible Cost)Produce Outcomes!Engaged Clients and Natural Support NetworkHelp Clients Self Manage Their Wellness and RecoveryGreatly Reduce Need for Disruptive/ High Cost Services (both medical and behavioral services)
55 Healthcare Home Participation Decide your Healthcare Home involvement level – Full Integration, Partnership or Linkages? And begin.Provide Primary Care Services in the Behavioral Health Center – either provide basic set of screening, education and linkage to primary care; or be part of full scope Person Centered Healthcare Home.Provide Behavioral Health Services in Primary Care – support mental health/substance use care in primary care using clinical practices appropriate to those settings.Develop Linkages as Specialty Behavioral Healthcare Providers to Medical Homes – ensure medical home pts. can get rapid access to quality behavioral health services .Develop a Strategy for Your Participation in FQHC Expansion – decide how you’ll help FQHC system double in size over the next five years.
56 Measure and Get PaidDevelop Technology Infrastructure to Integrate Clinical, Quality, and Finance – including HER for each clinician that includes pt. registries and data warehouse that integrates clinical, quality and financial data.Build High Performing Quality Improvement Infrastructure – through quality management process that includes annual plan to address quality assurance, quality improvement, risk management, utilization/resource management, credentialing, and performance contracting.Develop Effective Revenue Cycle Management Infrastructure – building on the service delivery process to capture and collect every dollar owed to the organization.Prepare to Participate in the Health Insurance Exchanges – ramp up ability to work with Private Insurance Plans, ACOs, and Employers that will be operating under parity.
57 Measure and Get PaidPrepare for Value-Based Purchasing – including infrastructure to support Case Rates, Capitation, and Pay for Performance Bonus Arrangements.Develop Bullet-Proof Compliance Plan for era of increased scrutiny overseen by compliance officer that ensures internal monitoring/ auditing.Review Your Human Resources Function and Plan for Workforce Expansion in order to be prepared for the newly covered population and increased demand in 2014; and as public recognizes importance of quality behavioral healthcare.
58 Help Consumers Get Coverage and Services Support Parity Implementation through the active monitoring and reporting of parity violations and the education of consumers, advocates, community groups, health plans, state officials and others about how to comply with the private health plan and Medicaid parity regulations.Develop an Enrollment Strategy for Your Uninsured Consumers and Potential Consumers that identifies persons eligible for coverage through Medicaid and the Exchange, assist with enrollment process, and advocate for the removal of structural barriers.
59 Reform Implementation Checklist What can you tell me about your readiness to:Participate in Healthcare HomesFacilitate Rapid AccessMatch Need with Type and Level of CarePractice Stepped Care (Up and Down)Provide Care Management for High Cost PatientsMeasure Individual Improvement and Adjust CareParticipate in P4P Bonus ArrangementManage Under Case RatesPlay in the ACO/IHS WorldOperate in an Insurance World, Contracting with InsurersAdvocate for Consumers Affected by Non-Compliance with ParitySupport Consumer Access to Medicaid and the ExchangesAnd what needs to be added to the list?
60 “The most effective way to cope with change is to help create it” L.W. Lynett60