What Does the Future Hold for Behavioral Health? Linda Rosenberg National Council for Community Behavioral Healthcare February 18, 2011

www.TheNationalCouncil.org

What Does the Future Hold for Behavioral Health?

Linda RosenbergNational Council for Community Behavioral Healthcare

February 18, 2011


The National Council: Serving & Leading

> Represent 1,782 community organizations that provide safety net mental health and substance abuse treatment services to nearly six million adults, children and families.

> National voice for legislation, regulations, policies, and practices that protect and expand access to effective mental health and addictions services.


Public Policy - Success

> Community Mental Health Services Improvement Act – 7 million for primary care into mental health organizations***

> Medicaid Regulatory Moratorium***

> Medicare HR 6331 (2010 to 2014)

> Second Chance Act and MIOTCRA

> Veterans M H Outreach & Access Act

> M H Parity & Addiction Equity Act of 2008

> Recovery Act - FMAP


Success – Healthcare ReformAmendments 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) > Mental illness classified as eligible chronic illness for Medicaid medical home demo

(Senate Finance Committee)> Behavioral Healthcare Organizations included as eligible providers in Medicaid

medical home demonstration program (Senate Finance Committee) > $50 million authorization for behavioral-primary care integration grants (Senate

HELP Committee)

>


Today…Through the Looking Glass

> Can healthcare reform really change healthcare? Will parity? Technology?

> How do we expect mental health and substance use management/payment structures to change?

> Does specialty behavioral health have the capacity to deal with expected changes?

> What about the effects of federal and state budget deficits?


SMHA Budget Cuts

Year Average Median Minimum Maximum Total

FY 2009 (35 States)

$18,979,310 $10,000,000 $0 $107,000,000 $664,275,843

FY 2010 (33 States)

$24,058,725 $12,300,000 $0 $203,000,000 $793,937,917

FY 2011(31 States)

$20,812,710 $11,267,905 $84,000 $162,000,000 $645,194,004

FY 2012(6 states)

$12,959,616 $6,150,000 $2,194,458 $32,000,000 $77,757,695

Preliminary Results based on 42 SMHAs Reporting

FY2009 to FY2012 Total $2.2 Billion in Cuts


FY 2011 Continuing Resolution and FY 2012: President’s Budget Requests> Congress must pass a continuing resolution (CR) to keep the government running through FY 2011

> Republican campaign pledge: cut $100 billion from the budget

> President Obama’s budget proposal includes:• Mental Health Block Grant: $434.7 million

($13.9 million increase from FY 2011)• Substance Abuse Block Grant: $1.494 billion

($39.6 million increase from FY 2011)


Hypothesis…

> The American healthcare system is moving into an era of “Disruptive Innovation” to improve quality and bend the cost curve

> That began before the passage of the Accountable Care Act

> And will proceed, regardless of what happens in the elections of 2012 and 2014


Changing Landscape…

˃ Parity, technology and reform will trigger dramatic changes in how health and MH/SU services are organized.

˃ Which will change the way MH/SU services are funded and fit into the new healthcare ecosystem.


Parity - Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act> Plans may not apply financial requirement or treatment

limitation to mental health or substance use benefits more restrictive than financial requirement or limitation for medical/surgical benefitsExamples: If in-network medical/surgical benefits are subject to $15 copay then no in-network MH/SUD can be subject to a copay greater than $15; combined deductible - separate deductibles not allowed

> Prescription drug formulary design; Fail-first or step therapy> Standards for provider participation in a network, including

reimbursement rates> Conditioning benefits on completing a course of treatment


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


Health Information Technology Requires > Shift to “measurement-based care” – adjusting

treatment based on success of the intervention> Enable providers to share patient information to

reduce redundant/unnecessary procedures> Ability to demonstrate that interventions improve

health outcomes and/or save money> Reporting of quality measures for incentive payments.> New relationships with hospitals, health centers and

other parts of healthcare delivery system > For true care coordination; success of healthcare

home and accountable care organizations models


Who is a Medicaid Eligible Provider?Eligible Providers in Medicaid

Eligible Professionals

Physicians

Nurse Practitioners

Certified Nurse-Midwives

Dentists

Physician Assistants working in a Federally Qualified Health Center or rural health clinic that is so led by a PA

Eligible Hospitals

Acute Care Hospitals (now including CAHs)

Children’s Hospitals


HR 5040/S 3709, HIT Extension for Behavioral Health Services Act

> Introduced in the House by Patrick Kennedy and Tim Murphy and in the Senate by Sheldon Whitehouse

> Makes psychiatric hospitals, mental health, and substance abuse treatment facilities eligible for facility payments

Hill Day Effect

> 80 co-sponsors in the House> 10 co-sponsors in the Senate


Healthcare Reform’s Four Key Strategies

The second (and most significant) wave of public behavioral health change in the last 25 years.


Coverage Expansion: Most Members of the Safety Net Will Have Coverage Including SUDs & MH

> $15 to $23 billion more spending for MH/SU from insurance expansion

Impact of U.S. Health Reform on Coverage for Non-ElderlySenate Finance Committee Reform Bill

Current Reform Reform ReformLaw 2019 Impact Total Impact(Millions) (Millions) (Millions) %

Medicaid/CHIP 35 15 50 43%Private/Other Insured 193 16 209 8%Covered Non-Elderly 228 31 259

Senate Healthcare Reform Bill 2019Medicaid & SCHIP Expansion $87,000,000,000Healthcare Exchange Subsidies $106,000,000,000Total Expansion Funding $193,000,000,000

Behavioral Health Spending @ 8% $15,440,000,000Behavioral Health Spending @ 10% $19,300,000,000Behavioral Health Spending @ 12% $23,160,000,000

> $15 million increase in Medicaid enrollees (43%)

> $16 million increase in privately insured


CURRENTLY PROJECTED U.S. HEALTH SPENDING

SOURCE: CMS DATA & STATISTICS



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Key Cost Curve Bending Initiatives Include:1.Widespread Deployment of Medical Homes2.New Medical Home Payment Models3.Bundled Payments Related to Inpatient Admissions4.Accountable Care Organizations – the Homes for Medical Homes

Service Delivery Redesign and Payment Reform


Medical Homes: Primary Care Clinics that Look and Act Differently

Picture a world where everyone has...• An Ongoing Relationship with a PCP• A Care Team who collectively takes

responsibility for ongoing care• And Provides all Healthcare or makes

Appropriate Referrals• Helping ensure that Care is Coordinated and/or Integrated

And where... • Quality and Safety are hallmarks• Enhanced Access to care is available (evenings & weekends)• And Payment appropriately recognizes the Added Value

(Joint Principles of the Patient-Centered Medical Home: www.pcpcc.net)

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Accountable Care Organizations (ACOs): the homes for medical homes

> Accountable Care Organization (ACO) Model

Medical Homes

Hospitals

Medical Homes

Food Mart

Specialty Clinics

Food Mart

Specialty Clinics

Medical Homes

Hospitals

Clinic

Clinic

Accountable Care Organization

Health Plan

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Where is Behavioral Healthcare right now?

> Broad recognition that freedom from addiction and mental health is essential to overall health

> MH Parity/Addiction Equity in almost all federal programs

> Included in aspects of the PPACA as essential part of healthcare


Increased Demand for Services


Services Are Cost Effective

$22,500

$40,000

$65,000

$85,000

$175,000

$0 $50,000 $100,000 $150,000 $200,000

Supportive Housingwith ACT

Single RoomOccupancy with

Services

CommunityResidential Facility

Jail Cell

State Hospital


What is the Status of Behavioral Healthcare Organizations?

> Small margins> Lack of capital for improvements (Health IT,

human capitol, new service lines)> No federal status to support improvement> No national data to support investment


What is a….

Nursing home?• [42 U.S.C. 1396r]: An institution engaged in providing to

residents: skilled nursing care, rehabilitation services, or health-related care and services to individuals who require care in an institutional facility, and is not primarily for the care and treatment of mental diseases; Must provide required services and meet requirements related to residents’ rights

Hospital?• [42 U.S.C. 1395x]: An entity that is primarily engaged in

providing, by or under the supervision of physicians, to inpatients diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons


What is a…

> Federally Qualified Health Center?• An entity that receives a grant under Section 330 of the

Public Health Service Act• An entity that serves a population that is:

• medically underserved, or • a special medically underserved population comprised

of: migratory and seasonal agricultural workers, the homeless, and residents of public housing,

• Provides required primary health services, either through the staff and supporting resources of the center or through contracts or cooperative arrangements


How Many Are There?

> Nursing homes• US: 15,531; MA: 415

> Hospitals• US: 5,010; MA: 75

> FQHCs• US: 1,048; MA: 33

> All data available on www.statehealthfacts.org

http://www.statehealthfacts.org/


What is…> What is an addictions treatment organization?

• No definition> What is a mental health treatment organization?

• No definition> What is a behavioral health organization?

• No definition> What is a community mental health center? [1913c1]*

• An entity through which comprehensive mental health services are provided to any individual residing or employed in the center’s service area regardless of ability to pay for such services, current or past health condition, or any other factor.


How Many Are There?

> Addiction Treatment Organizations:• 8,200 (as of 2009)

> Mental Health Treatment Organizations:• 508 residential treatment centers (as of 2004)

> Behavioral Health Organizations:• Data not available

> Community Mental Health Centers:• 672 (as of 1991)


Why Does This Create Problems?

> Medicaid accounts for nearly 50% of federal spending for behavioral healthcare


Why Does This Create Problems?

> All addiction/mental health services are optional in Medicaid


Federal Legislative Process

> Congressional Budget Office> Committees of jurisdiction> What are the entities that we are talking about

(show me the definition)> How many are there (to estimate cost)


Where Has This Caused Us Problems?> ARRA> HITECH ACT> Credibility problem with CMHC


ARRA Monies

> FQHC Construction: $1.5 billion> FQHC Expansion: $500 million> National Health Service Corps: $500 million


Affordable Care Act Monies

> FQHC Construction: $1.5 billion> FQHC Expansion: $9.5 billion> National Health Service Corps: $1.5 billion


An Example of Why FQHC/CBHO Parity is Important

The President’s Proposal – March 2010

> FQHCs are acknowledged as a critical component of healthcare reform; funding would nearly triple over 5 years

$0 $1,000,000,000 $2,000,000,000 $3,000,000,000 $4,000,000,000 $5,000,000,000 $6,000,000,000 $7,000,000,000 $8,000,000,000 $9,000,000,000

FY2010 FY2011 FY2012 FY2013 FY2014 FY2015

$2.98B$3.86B

$4.99B $6.45B

$7.33B$8.33B

Proposed FQHC Grant Funding


H.R. 5636 / S. 4038

> Establishes federal standards/definition for a Community Behavioral Healthcare Organization

> Makes every service provided by a CBHO MANDATORY within Medicaid

> Provides similar reimbursement for CBHOs and FQHCs/Rural Health Clinics


Eligibility and Requirements

> Eligibility restricted to nonprofit or public organizations> Must provide: (partial list)

• Outpatient clinic mental health services• Outpatient clinic primary care screening & monitoring of

key health indicators• Substance Abuse Services and Integrated Tx for Dual

Disorders• Crisis mental health services• Targeted case management & Psychiatric rehabilitation• Peer support/counselor services and family supports

> Must maintain linkages, and where possible enter into contracts with FQHCs


S. 4038 Additional Features

> 340(b) discount drug process for all organizations that receive funding from either SAMHSA block grant

> New construction/modernization loan fund for all organizations that receive funding from either SAMHSA block grant

> Extension of Medicaid HIT incentive payments to FQBHCs

> Extension of Medicare tele-health authority to FQBHCs


Ensuring a Role for Behavioral Health Organizations

Get a seat at the table:> Work to ensure that MH/SU interests and

perspectives are included throughout the implementation process

Know thyself:> Agencies will need to have a detailed and working

knowledge of their capacity, technological needs, community needs, and the most effective services for their community to cogently advocate for the right changes in policies.



Make new friends:> While the need to work with state Medicaid offices

has been true for a long time, the inclusion of MH/SU throughout the ACA makes working with Medicaid, insurance, and primary care essential.

Think outside the box: > 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 the demands of the new law.


Medicaid Benefits: Benchmark vs. Traditional

> Most newly eligible people will be enrolled in benchmark plans> Exemptions for:

• Blind or disabled individuals, regardless of SSI eligibility• Dual eligibles• Inpatients in a hospital, nursing facility, or ICF-MR• Medically frail and special needs individuals (includes people with

disabling mental disorders/children with serious emotional disturbances)

> Health reform also includes important improvements to benchmark benefits (e.g. parity, minimum required benefits)

> Consumers & advocates will have to decide whether benchmark or traditional coverage best meets their needs

> States will need to develop processes to identify individuals who have a disabling mental disorder or functional impairment



Build new bridges:> With each initiative, community behavioral

health organizations will have to think about how to build a greater capacity to provide services, both in terms of service providers but also service locations.

Go back to the future:> These initiatives require investment in new

technologies, especially those that interface with other systems and measure outcomes.



Follow the money:> As always, the money trail will be a deciding

factor in how programs will be implemented. National Council Roadmap for State

Associations> Explains critical areas of health reform

implementation> Provides “To-Do” checklists for each area> Lists helpful resources & educational materials> http://www.thenationalcouncil.org/galleries/polic

y-file/Assoc%20Exec%20Advocacy%20Toolkit.pdf

http://www.thenationalcouncil.org/galleries/policy-file/Assoc%20Exec%20Advocacy%20Toolkit.pdf




Here’s a 10 Question “Test”To explore if we’re ready to succeed in the brave new world and help ensure that persons with MH/SA/DD are part of the new healthcare ecosystem…

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1. Leadership & Relationship Building: Getting to the ACO Table> Are you in conversation with local Integrated Health Systems and at the table of Accountable Care Organization development efforts in order to “pitch” the importance of MH/SUD services to improve quality & bendthe cost curve and building a case for how you can helpthese organizationssucceed in the newworld of risk?

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Medical Homes

Hospitals

Medical Homes

Food Mart

Specialty Clinics

Food Mart

Specialty Clinics

Medical Homes

Hospitals

Clinic

Clinic

Accountable Care Organization

Health Plan


2. Leadership & Relationship Building: Planning for Expansion> Are you assessing the compatibility and capacity of your clinical workforce

to operate in an environment of increased demand where most consumers have Medicaid or Insurance and Health Plans will be looking to contract with high-performing MH/SU Providers that can offer licensed professionals and certified peers?

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3. High Performing Specialty Provider Rapid Access> Can Schools, Child Welfare, ACOs and Medical Homes get clients/patients into specialty MH/SU with same day/next day access, especially for high risk, high need patients?

New Patient’s first Visit to PCP includes

behavioral health screening

Possible BH Issues?

Behavioral Health Assessment by BH

Professional working in primary care

Need BH Svcs?

Clients with Low to Moderate BH need enrolled in Level 1; to be case managed and served in primary care by PCP and BH Care Coordinator with support from Consulting Psychiatrist and

other clinic-based Mental Health Providers

Clients with Hi Moderate to High need referred to Level 2 specialty care; PCP continues to

provide medical services and BH Care Coordinator maintains linkage; this is a time-

limited referral with expectation that care will be stepped back to primary care

YES

YES

Referrals to other needed services and supports (e.g. CSO, Vocational Rehabilitation) 49


4. High Performing Specialty Provider Caseload ManagementDo 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 of positive outcomes?

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5. High Performing Specialty Provider Consumer-Centered , Recovery- Oriented 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-orientedperspective?

High Performing, Prevention, Early Intervention, Recovery and Wellness Oriented Services and Supports

Front Porch, Easy Accessible, Consumer Run

Services

Full Range of Crisis and Planned Care

Services & Supports

Back Porch Resources for

Consumer Graduates

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6. High Performing Specialty Provider Outcome Assessment Capacity> Do you use standardized tools to measure improvement (or not) in symptomology, level of functioning, resilience and recovery?

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7. High Performing Specialty Provider Care Management> Do you have ability to identify patients with MH/SUD who represent the top 5% to 10% of high cost consumers of health care & provide effective care management to help them manage their MH/SU disorders AND their chronic health conditions?

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8. Person Centered Healthcare Home Participation> Are you actively pursuing bi-directional involvement as a person-centered healthcare home?

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Person-Centered Healthcare Home Development

Fully Integrated or Focused Partnership

Healthcare Home

Supporting Mental Health and Substance Use

Services in Primary Care

Food MartCBHO

CBHO with Embedded Medical Clinic

Providing Primary Care Services in Community Behavioral Healthcare

Organizations

Food Mart

CBHO


9. Revenue Cycle Management> Do you have (and use) established billing policies, procedures,

and practices regarding client and third party billing?

55


10. Change Management and Decision-Making

> Do you use Rapid Cycle Improvement methods to improve clinical, business and administrative processes?

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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. http://www.thenationalcouncil.org/cs/resources_services/resource_center_for_healthcare_collaboration/clinical/personcentered_healthcare_homes

> California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative. Vols. I, II, and III. September 14, 2009.

> 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, 2010. http://www.cimh.org/Initiatives/Primary-Care-BH-Integration.aspx

> Oregon Standards and Measures for Patient Centered Primary Care Homes. February 2010. Office for Oregon Health Policy and Research. http://courts.oregon.gov/OHPPR/HEALTHREFORM/PCPCH/docs/FinalReport_PCPCH.pdf

http://www.thenationalcouncil.org/cs/resources_services/resource_center_for_healthcare_collaboration/clinical/personcentered_healthcare_homes

http://www.thenationalcouncil.org/cs/resources_services/resource_center_for_healthcare_collaboration/clinical/personcentered_healthcare_homes

http://www.cimh.org/Initiatives/Primary-Care-BH-Integration.aspx

http://courts.oregon.gov/OHPPR/HEALTHREFORM/PCPCH/docs/FinalReport_PCPCH.pdf

http://courts.oregon.gov/OHPPR/HEALTHREFORM/PCPCH/docs/FinalReport_PCPCH.pdf


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Practice Improvement

> Middle Management Academy> Psychiatric Leadership Development Project> Addressing Health Disparities Leadership

Project> Access and Retention Initiatives> Primary Care/Mental Health Learning

Communities> Standards of Care> Transition Age Youth Project> Addiction News Now and Compliance Watch

electronic newsletters


Mental Health First Aid USA

> 10,000 Mental Health First Aiders • Law enforcement and Corrections• Primary Care Providers• Schools and Colleges• Faith communities• Military• Human Resource Managers• Addiction Providers• Entry Level Behavioral Health staff• Consumers and families and caring citizens



Executive Leadership> COMPSTAT – New York City Police Department concept where police

data are mined and mapped to show where the city's crime problems concentrated -- and to direct police activity to where it is most needed.

> High Cost, Complex Needs - using Medicaid claims and other state/local administrative data to identify high-need individuals with psychiatric disabilities whose patterns of service use indicate lapses in needed services.

Missouri, 5 percent of their high risk, high need medicaid recipients (with mental health and substance use disorders) represented 93 percent of the costs for hospital readmissions of people considered to have had conditions that would be responsive to outpatient services.

> Single Points of Accountability - address weaknesses in uncoordinated fee for service care and in care provided by health plans, keeping these most-at-risk individuals engaged in care or connecting them to treatment again when they become disconnected.


Executive Leadership continued…

> Same Day Access> Integration not Co-location> Early Intervention> Health Information Technology> Social Media - As more consumers turn to web-based

tools to evaluate their health care options, you and your organizations need to develop a strategy for how to incorporate social media into marketing and communication plans, outreach, and treatment.


Consumers and FamiliesParity - According to a Dec. 2010 American Psychological

Association (APA) survey, only 10 percent of Americans have even heard of the law, 29 percent don't know whether their existing mental-health benefits are adequate, and 45 percent don't know whether their insurance companies reimburse them for such services.

> Plans may not apply financial requirement or treatment limitation to mental health or substance use benefits more restrictive than financial requirement or limitation for medical/surgical benefitsExamples: If in-network medical/surgical benefits are subject to $15 copay then no in-network MH/SUD can be subject to a copay greater than $15; combined deductible - separate deductibles not allowed

> Prescription drug formulary design; Fail-first or step therapy> Standards for provider participation in a network, including

reimbursement rates> Conditioning benefits on completing a course of treatment


Consumers and FamiliesWhat Health Care Reform Provisions Are "Live"?> Expanded coverage for young adults > Elimination of coverage exclusions for children with

preexisting conditions > Expansion of annual coverage limits and prohibitions on

rescinding coverage > Standardization of a process for appealing coverage

determinations with insurers> Free preventative care for seniors through Medicare> Prescription drug savings for seniors through Medicare Part D> Additional care coordination for Medicare beneficiaries after

being discharged from the hospital health > Insurers must spend 85 percent of every dollar paid in

premiums on the cost of direct care and quality improvement


Consumers and Families

> Consumer “Zagat” Ratings - Consumer attitudes and perceptions count more and more and there is disproportionate patient dissatisfaction in New York, New Jersey, and Pennsylvania—with more satisfied patients in Iowa, Kansas, Minnesota, Montana, Nebraska, and North and South Dakota.

Documents

What Does the Future Hold for Behavioral Health? Linda Rosenberg National Council for Community Behavioral Healthcare February 18, 2011