INFORMING PUBLIC HEALTH STRATEGIES: CHALLENGES AND OPPORTUNITIES IN BEHAVIORAL HEALTH

2. INFORMING PUBLIC HEALTH STRATEGIES: CHALLENGES AND OPPORTUNITIES IN BEHAVIORAL HEALTH Pamela S. Hyde, J.D. SAMHSA Administrator 3RD Annual Public Health Law Research Meeting New Orleans, LA • January 18, 2013

3. TODAY’S DISCUSSION • BH’s Impact on Public Health – By the Numbers • BH Challenges and Opportunities for Public Health – What Confounds Public Health Officials • New Laws – MHPAEA/ACA • Electronic Health Records & Privacy/Consent • Guns, Violence and Other Disasters

4. BH PROBLEMS COMMON & OFTEN CO-OCCUR w/ PHYSICAL HEALTH PROBLEMS • ½ of Americans will meet criteria for mental illness at some point in their lives (CDC) • 7 percent of the adult population (34 million people), have co-morbid mental and physical conditions within a given year

5. BH PROBLEMS ALSO COMMON IN HIGH NEED MEDICAL POPULATIONS • Rates of cardiovascular disease, diabetes, and pulmonary disease are substantially higher among disabled individuals in Medicaid with psychiatric conditions • 12-month prevalence of depression is ~ 5 percent among people without chronic medical conditions, 8 percent among people with one condition, 10 percent among people with two conditions, and 12 percent among people with three or more conditions • People with asthma are 2.3 X more likely to screen positive for depression • 52 percent of disabled individuals with dual-eligibility for Medicare and Medicaid have a psychiatric illness • Dual-eligibles account for 39 percent of Medicaid expenditures

6. CO-MORBIDITY CHALLENGES Adults who had any mental illness, serious mental illness, or major depressive episodes in the past year had increased rates of hypertension, asthma, diabetes, heart disease, and stroke (NSDUH analysis, 2008-2009) Most psychiatric medications, particularly anti-psychotic medications, can cause weight gain, obesity and type 2 diabetes, all of which impact mental conditions such as major depression Major depression is a risk factor for developing medical conditions such as cardiovascular disease (CVD) ; Persons reporting CVD have 1.43 x elevated risk of lifetime anxiety disorder

7. BH IMPACTS PHYSICAL HEALTH • MH problems increase risk for physical health problems & SUDs increase risk for chronic disease, sexually transmitted diseases, HIV/AIDS, and mental illness • Cost of treating common diseases is higher when a patient has untreated BH problems • 24 percent of pediatric primary care office visits and ¼ of all adult stays in community hospitals involve M/SUDs • M/SUDs rank among top 5 diagnoses associated with 30-day readmission, accounting for about one in five of all Medicaid readmissions (12.4 percent for MD and 9.3 percent for SUD)

8. BH PROBLEMS = HIGHER MEDICAL COSTS • Co-morbid depression or anxiety increase physical and mental health care expenditures • > 80 percent of this increase occurs in physical health expenditures • Average monthly expenditure for a person with a chronic disease and depression is $560 dollars more than for a person without depression • Discrepancy for people with and without co-morbid anxiety is $710 • A HMO claims analysis found that general medical costs were 40 percent higher for people treated with bipolar disorder than those without it

9. WHY WORSE PHYSICAL HEALTH FOR PERSONS WITH BH CONDITIONS? • BH problems are associated w/ increased rates of smoking (1/3+ of all cigarettes smoked) and deficits in diet & exercise • People with M/SUD less likely to receive preventive services (immunizations, cancer screenings, smoking cessation counseling) & receive worse quality of careacross a range of services

10. PREMATURE DEATH AND DISABILITY • More deaths from suicide than from HIV or homicides • Half the deaths from tobacco use are among persons with M/SUDs People with M/SUDs are nearly 2x as likely as general population to die prematurely, (8.2 years younger) often of preventable or treatable causes (95.4 percent medical causes) BH conditions lead to more deaths than HIV, traffic accidents + breast cancer combined CDC, National Vital Statistics Report, 2009

11. BH-RELATED DISABILITY Years Lost Due to Disability in Millions (High-Income Countries – World Health Organization Data) More than 2 million Americans report mental/emotional disorders as the primary cause of their disability (CDC) Depression is the most disabling health condition worldwide; & SA is # 10

12. STEEP HUMAN AND ECONOMIC COSTS

13. PUBLIC PERCEPTION OF VALUE • Public is less willing to pay to avoid mental illnesses compared to paying for treatment of medical conditions, even when mental illnesses (including SUDs) are recognized as burdensome (NICHD, 2011) • Public willing to pay 40 percent less than what they would pay to avoid medical illnesses • Mental illnesses account for 15.4 percent of total burden of disease (WHO), yet mental health expenditures in U.S. account for only 6.2 percent

14. DAILY DISASTER OF UNPREVENTED AND UNTREATED M/SUDs 84 % receiving treatment 74.6 % receiving screenings 70.4 % receiving treatment 38.5 % receiving treatment 10.8 % receiving treatment

15. TOP REASONS • Among the 8 million adults who had AMI in the past year and a past year SUD, only 6.9 percent received treatment for both conditions • Among top reasons for not receiving treatment • Inability to afford care (50.1%) • Problem can be handled without care (28.8%) • Not knowing where to go for care (16.2%) • Not having the time (15.1%)

16. PREVENTION WORKS • IOM Report 2009 • Half of adult mental illness begins before age 14 • Three-quarters before age 24 • Symptoms appear years before diagnosis or treatment • Trauma plays a critical role • Resilience can be developed • Prevention models – risk and resilience factors • Comprehensive approaches – multiple systems with consistent messages and approaches

17. 1. NEW LAWS – MHPAEA AND ACA 2008: Mental Health Parity and Addictions Equity Act (MHPAEA) signed into law 2010: HHS, DOL and Treasury (joint interpretive jurisdiction) issued interim final rule (IFR) 2010-2012: 5 sets of sub-regulatory guidance issued/FAQs published January 16, 2013: CMS letter to State Health Officials/State Medicaid Directors re: Application of MHPAEA to Medicaid MCOs, CHIP, and Alternative Benefit (Benchmark) Plans Secretary Sebelius clear: final reg soon (2013?)

18. MENTAL HEALTH PARITY AND ADDICTIONS EQUITY ACT (MHPAEA) • Does not require group health plans to cover M/SUDs • Requires group health insurance plans that do offer coverage for M/SUDs to provide those benefits in a way that is no more restrictive than all other Med/Surg procedures covered by the plan • Covered at levels no lower than the levels of other Med/Surg benefits offered by the plan • Treatment limitations no more restrictive than other offered benefits

19. COVERED BY MHPAEA • Insurance plans sponsored by private and public sector employers with more than 50 employees (large groups) • Plans that choose to offer a mental health and/or substance use benefit • Employers/plans can choose to not cover specified diagnoses • Medicaid benchmark and expansion programs (but not regular Medicaid) • Children's Health Insurance Reauthorization Act (CHIPRA) • In total, approximately 150 million Americans

20. PARITY IN AFFORDABLE CARE ACT • Affordable Care Act (ACA) embraces and goes beyond MHPAEA to create broader parity • Identified 10 categories of services must be included • In non-grandfathered plans • In individual and small group markets • Inside and outside of insurance exchanges (qualified health plans or QHPs) • In benchmark and benchmark-equivalent plans in Medicaid expansion • All beginning in 2014

21. ESSENTIAL HEALTH BENEFITS (EHBs) • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care

22. DUE TO ACA & MHPAEA . . . • Over 65 million people will have access to MH/SA benefits due to ACA and MHPAEA • 30 million currently without adequate BH benefits • 35 million currently uninsured • 11 million have mental or substance use disorders • Institutions for Mental Disease (IMD) Demo • IMD Exclusion – Congressional language • ACA Demo – 11 states + DC; pay psychiatric inpatient care for adults who have expressed suicidal or homicidal thoughts or gestures, and are determined to be a danger to self or others

23. 2. BEHAVIORAL HEALTH IT - UNIQUE Subjective diagnoses Majority non-pharmacological treatments Less emphasis on labs & imaging Need for strong & continued patient engagement Role of family, social support structure, peers & mutual aid Growing concern re prescription drug abuse More stringent privacy requirements

24. NATIONAL HIT LANDSCAPE • Health Information Technology for Economic and Clinical Health Act ( HITECH Act) • Large national investment in HIT; largely excludes BH providers • Physicians 57%; 52% applying for meaningful use incentives • CMHCs 21%; 2% able to meet meaningful use incentives • ACA • Coordinated, integrated, patient-centered care (PBHCI, ACOs, Partnership for Patients, Million Hearts Campaign)

25. PRIVACY/CONFIDENTIALITY LAWS & REGS • HIPAA – includes BH • Confidentiality of Alcohol and Drug Abuse Patient Records Act – 1970s; consolidated 1992 (42 CFR Part 2 1975; FAQs 2011/2012) • Law enforcement use of records (cf PDMPs) • State Laws re Mental Health Confidentiality Vary Widely

26. 42 CFR PART 2 – PRIVACY & CONSENT Applies to any federally assisted individual/entity that provides alcohol or drug abuse diagnosis, treatment, or referral for treatment Primary care providers who work in a general medical facility and do not hold themselves out as providing alcohol or drug abuse diagnosis, treatment, or referral to treatment (DTRT) are not affected Permits patient information to be disclosed to HIE organizations when certain requirements are met, i.e., patient consent (w/ some exceptions)

27. BEHAVIORAL HEALTH IT CHALLENGES • How should HIT systems be designed to control disclosure and re-disclosure of sensitive information? • How can we ensure when data are shared they are interpretable across providers and by third parties (i.e. researchers, public health, surveillance)? • How can systems evolve rapidly along with research and changing best practices? • How can new technologies take us to the next level of care delivery and quality?

28. 3. RESPONDING TO DISASTERS/TRAGEDIES • Sandy Hook (person-made) compared to Hurricane Sandy (non-person-made) • Federal responses • Presidentially declared disaster (Katrina) compared to Gulf Oil Spill w/o declaration • Limits in the law – FEMA CCP v SERG • BH needs and response efforts • Newtown, CT – State MH Commissioner as lead

29. SOCIAL PROBLEM VERSUS PUBLIC HEALTH PROBLEM • Don’t recognize until too late • Inadequate responses • Guards in schools • Homeless shelters • Jails

30. Sandy Hook School Newtown, CT 2012 – 26 Lost TRAGEDIES Grand Rapids, MI 2011 – 8 Lost Aurora, CO 2012 - 12 Lost Asher Brown 2010 – 1 Lost 13 yrs old Tucson, AZ 2011 – 6 Lost Nickel Mines, PA 2007 – 6 Lost Virginia Tech, VA 2007 - 33 Lost Red Lake Band of Chippewa, MN, 2005 – 10 Lost Columbine High School Littleton, CO 1999 - 15 Lost

31. FACTS: MENTAL ILLNESS AND VIOLENCE • Most w/MI not violent; most violent crimes not committed by people w/MI • Only 3 to 5 percent of violent acts attributable to individuals w/ SMI and most (76 percent) do not involve guns • People w/psychiatric disabilities far more likely to be victims than perpetrators of violent crime including being > 2 ½ times more likely to be attacked, raped, or mugged than general population • Most common form of violence associated w/MI is not against others, but against oneself • Most violence not predicted; most patients predicted to be violent are not   •  2012 GAO report: From 2004 to 2011, total number of MH records states made available to National Instant Criminal Background Check System (NICS) ↑ by ~800 percent—from about 126,000 to 1.2 million records

32. PRESIDENT’S ANNOUNCMENT ON GUN LAW – MAJOR IMPLICATIONS FOR BH • Among the 23 Executive Actions • No. 2: "Address unnecessary legal barriers, particularly relating to the Health Insurance Portability and Accountability Act, that may prevent states from making information available to the background check system.“ – Advance Notice of Proposed Rule-Making (ANPRM)

33. BRADY BILL • No. 4: "Direct the attorney general to review categories of individuals prohibited from having a gun to make sure dangerous people are not slipping through the cracks.“ – Brady Bill • convicted in any court of a crime punishable by imprisonment for a term exceeding one year; • a fugitive from justice; • an unlawful user of or addicted to any controlled substance; • adjudicated as a mental defective or who has been committed to a mental institution; • an illegal or unlawful alien or a non-immigrant alien (with certain exceptions); • discharged from the Armed Forces under dishonorable conditions; • having been a citizen of the US, has renounced his citizenship; • subject to a domestic violence protection order that meets certain requirements; • convicted in any court of a misdemeanor crime of domestic violence; or • under indictment for or has been charged with a crime punishable by imprisonment for a term exceeding one year.

34. RESEARCH • No. 14: "Issue a presidential memorandum directing the Centers for Disease Control to research the causes and prevention of gun violence.“ – Congressional language chilling federal research and physician inquiries re gun safety among those at risk • Prohibits research and data collection re gun control or promotion of gun control – position is any data collection can be used to develop policies to promote or effect gun control • Limits data collection under authorities created by ACA relating to “the presence or storage of a lawfully-possessed firearm or ammunition” or relating to the “lawful use, possession, or storage of a firearm or ammunition.” • Within the ACA section, there is a limitation on databases maintaining “records of individual ownership or possession of a firearm or ammunition,”

35. RESEARCH NEEDED • Impacts of policies re: • Access to firearms • Technology to prohibit firearms from being used unintentionally or intentionally by the wrong person • Firearms policy • Enforcement of firearms laws • Firearm safety • Expansion of access to treatment

36. EXECUTIVE ACTIONS, CONT’D • No. 17: "Release a letter to health care providers clarifying that no federal law prohibits them from reporting threats of violence to law enforcement authorities.“ *January 16: Letter issued by Secretary Sebelius • No. 20: "Release a letter to state health officials clarifying the scope of mental health services that Medicaid plans must cover.“ *January 16: Letter issued by CMS • No. 21: "Finalize regulations clarifying essential health benefits and parity requirements within ACA exchanges.“ • No. 22: "Commit to finalizing mental health parity regulations.“ • No. 23: "Launch a national dialogue led by Secretaries Sebelius and Duncan on mental health."

37. POINTS TO CONSIDER: RESPONSE TO NEWTOWN AND OTHER TRAGEDIES Given low rates of gun violence by people w/ MI additional restrictions solely for persons w/ MI would have little measurable impact Will losing rights enjoyed by others, e.g., right to possess firearms, deter people from seeking treatment? Will it reinforce stereotypes? Increase negative attitudes? Build fear?

38. SAMHSA’S VISION A nation/community free of substance abuse and mental illness and fully capable of addressing behavioral health issues that arise from events or physical conditions Can’t have individual or community health without behavioral health It’s just as important to protect people from lost hope as it is to protect them from influenza, bacteria, or physical injury