1. Health Care Reform and Psychology
Katherine C. Nordal, PhD
Executive Director for Professional Practice
American Academy of Clinical Neuropsychology
June 22, 2012

2. Compelling Need for Health Care Reform
One of the only developed countries without universal health coverage
About 45 million Americans uninsured
Fragmented system with variable quality
Increased life expectancy but often with chronic illness

3. The Economic Context for Reform
2010 Healthcare expenditure = $2.7T
Healthcare is single largest contributor to national debt
Federal expenditures 2010: Medicare = 15%; Medicaid = 8%; Social Security = 20%; Defense = 20%
By 2020, Fed. Govt. will pay 49% of all health
State budgets in worst shape since WWII

4. The Economic Context for Reform
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

5. The Economic Context for Behavioral Health Care
Mental Health Spending
1986 = 7.5% of all health spending
2003 = 6% of all health spending
2014 = 5.9% of all health spending
Psychologists/LCSW/LPCs = only 8% of mental health pending, or 0.047% of mental health $$
Medications will be 30% of mental health spending by 2014
Psychologists are approximately 16% of the behavioral healthcare workforce
58% mental health spending is in public sector

6. Enactment of Health Care Reform
After 1½ years of tumult and negotiation, President Obama signed into law both the:
Patient Protection and Affordable Care Act (P.L ) on March 23, 2010
Health Care and Education Reconciliation Act of 2010 (P.L ) on March 30, which includes a package of amendments

7. Key Challenges Facing Health Care Reform

8. Overall Goals of Health Care Reform
To preserve employer-based health insurance
To expand coverage to 32 million more Americans (Medicaid, Insurance Exchanges)
To transform the health care system to address the needs of the whole patient through:
Preventive Services
Primary and Integrated Care
“Triple Aim”: better care experience; better health outcomes; lower cost

9. 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

10. Health Care Reform: Remains a Work in Progress
Many of the law’s key provisions – such as those that establish the state health insurance exchanges – will not go into effect until January 1, 2014
New law is facing serious challenges by House Republicans in Congress and by governors and state attorneys general through the federal courts

11. Ongoing Congressional Attacks on Health Care Reform
House voted in January 2011 to repeal the health care law, whereas the Senate voted in February against repeal
House voted in April to cut off funding for health care reform for Fiscal Year 2011, which the Senate did not support

12. State Legal Actions Pending Against Health Care Law
To date, 30 states have challenged the constitutionality of the ACA:
Two federal judges upheld the law
One judge invalidated the individual mandate provision
One judge struck down the entire law
Supreme Court Decision 6/2012

13. APA Health Care Reform Priorities
Integrated Health Care
Mental and Behavioral Health Care
Prevention and Wellness
Psychology Workforce Development
Elimination of Health Disparities
Support for Psychological Research

14. 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

15. 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

16. Psychology’s Strengths in Integrated Care
Psychological and neuropsychological assessment
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
Designing, monitoring, and evaluating interventions

17. APA and Integrated Health Care
APA Implementation Efforts:
Promoted the inclusion of psychology in the new integrated health care initiatives
Arranged meetings to enhance partnerships with primary care organizations representing nurses, physicians, and medical students
Joined the Executive Committee of the Patient-Centered Primary Care Collaborative, a coalition dedicated to promoting the “patient-centered medical home”

18. ACA Impacts Behavioral Health
Eligibility and Service Delivery
Covers persons up to 133% of FLP by 2014 (adds 16-22M folks)
Essential Health Benefits with parity for Medicare Advantage, Medicaid Managed Care, CHIP, and Benchmark Plans
Preventive Care and Wellness
Health Home options for SMI and those with 2 or more chronic illnesses (with significant federal $$ to Mcaid for first 2 years)

19. ACA Impacts Behavioral Health
Eligibility and service delivery:
Accountable Care Organizations (ACOs): composed of integrated provider networks with shared electronic records, practice protocols, performance incentives
Patient-Centered Medical Homes (PCMH)
Home and Community Based Services Options
Co-location grants for behavioral health and primary care—training grants for co-located care
Dual Eligible Care Management

20. ACA Impacts Behavioral Health
Payment and Performance:
Global, bundled, episode payments
Pay for Performance
Higher rates for PCPs
Medicare Shared Savings
Integrated care grants and training grants (like GPE)
FQHC investment of $11B
Quality Measures (11 of 51 are behavioral health)
Clinical Effectiveness Research

21. Implications of Health Care Reform for Psychology
Psychology’s expanded role: primary care, integrated delivery systems, assessment and care planning, behavior change for wellness and treatment of chronic disease, prescribing and medication management
Increasing demand for the use of EBPs and clinical outcome measures
Implementing advances in telehealth, HIT, and electronic health records
Addressing health disparities and increased emphasis on cultural competencies

22. Implications of Health Care Reform for Psychology
Need to adapt to new models and systems of health care delivery
New skills and training models needed for integrated, interdisciplinary and team-based care
Payment reforms: bundled payments, shared-savings models, ACOs, etc. How will psychologists in both public and private sector be paid?

23. Opportunities for Psychologists
Prevention and Health Promotion:
Elimination of cost sharing for eligible preventive services
Depression screening for adolescents and adults
Screening and counseling for child and adult obesity
Counseling for alcohol misuse and tobacco use for adults
New initiatives funded under the Prevention and Public Health Fund
New incentives for corporations to promote employee health and reduce workplace stress

24. Opportunities for Psychologists
Client Populations and Clinical Settings:
Increased client access due to insurance reforms and new state health exchanges at parity
New grant program to establish community-based, interdisciplinary health teams to support primary care
New Medicaid state option for health teams and health homes to treat persons with at least two chronic conditions (including serious mental disorders)

25. Challenges to Psychology Practice
Difficult economic times
Stigma surrounding seeking mental health care
Pressures from public and private payers to reduce costs
Psychologists are a small part of the pool of mental health providers and psychotherapy has become a commodity to be purchased at the lowest possible cost

26. Challenges to Psychology Practice
Accessing capital to meet health information technology demands
Adjustment from FFS to other payment mechanisms that may be required for participation in ACOs
Provider reimbursement if global rates are not risk adjusted and performance payments do not take into account disparities in outcomes for individuals with SMI and substance use disorders

27. APA Practice Organization at Work
Coordinated over 300 Capitol Hill visits for the 2012 State Leadership Conference:
SGR
Medicare Physician Definition (HR.831, S.483)
BHIT (5.539)
Advocated successfully for law enacted in December that halted the threatened 25% cut in the Medicare Sustainable Growth Rate (SGR) through 2012

28. APA Practice Organization at Work
Medical Economic Index (MEI): Objected to revisions that would negatively impact psychologists due to their low practice expense. 22 MOCs wrote to CMS on our behalf.
Advocacy for additional protection of psychological test data under HITECH
Letter to Secretary Sibelius to urge inclusion of psychologists as participants in ACOs, thereby ensuring better access of Medicare beneficiaries to mental health, substance abuse, and behavioral health services

29. APA Practice Organization at Work
Supported repeal of Medicare Independent Payment Advisory Board whose cost-cutting measures prior to 2020 would impact only health professionals and drug manufacturers
Continuously monitor proposed Medicare reimbursement policies as they might impact psychological practice.
Urged CMS to include psychologists as providers of behavioral services for obesity. Unsuccessful to date.

30. APA Practice Organization at Work
Supporting S. 539, The Behavioral Health Information Technology Act of 2011 which would allow mental health facilities and practitioners to receive reimbursement for purchasing electronic health record keeping systems
Closely monitoring parity implementation at the state level and successful in working with SPTAs to addressing violations
State Implementation of Health Care Reform Initiative involving staff and governance: State Leadership Conference programming focused on this initiative

31. APA Practice Organization at Work
Medicare Physician Definition Bills:
H.R. 831 (Rep. Jan Schakowsky + 34)
S. 483 (Sen. Olympia Snowe + 7)
Also Supported by:
National Council for Community Behavioral Healthcare
Association for Ambulatory Behavioral Healthcare
Bazelon Center for Mental Health Law

32. 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 professional and business interests of practitioners

33. For Updates on APA Health Care Reform Initiatives

34. Contact Information
Slide 26 – Contact APAPO 
Phone:
Web: