BEHAVIORAL HEALTH: CHALLENGES AND OPPORTUNITIES IN CHANGING TIMES

1. BEHAVIORAL HEALTH: CHALLENGES AND OPPORTUNITIES IN CHANGING TIMES 2012 Alternatives Conference Portland, Oregon • October 10, 2012

2. TONIGHT’S DISCUSSION

3. A LOOK BACK: CONSUMER MOVEMENT MILESTONES GOAL IS HEALTH

4. RICH HISTORY & MANY ACHIEVEMENTSCHALLENGES & OPPORTUNITIES REMAIN • BH affects most Americans; often co-exists with other health conditions – yet still often seen as social/moral issue • Increases risks for other diseases (e.g., HIV/AIDS) • High proportion of pediatric visits and community hospital stays, as well as readmissions • High impact of disparities (race, gender, ethnicity, LGBT, poverty) & social issues (homelessness, jails, child welfare) • High # of BH related deaths; premature death and preventable illnesses

5. TODAY IS WORLD MENTAL HEALTH DAY • World Mental Health Survey: conducted in 17 countries found ~1 in 20 people reported having an episode of depression in previous year • Depression affects > 350 million people of all ages, in all communities, and is a significant contributor to global burden of disease • At worst, depression can lead to suicide – ~ 1 million lives lost yearly due to suicide; 3000 suicide deaths every day • Despite the known effectiveness of treatment for depression, majority of people in need do not receive it • Globally fewer than 50 percent receive treatment; < 30 percent in most regions; < 10 percent in some countries • In U.S., ~ 45 percent; < 10 percent of those needing treatment for substance abuse receive it

6. THE PRESENT

7. A BUSY FALL • 2012 National Recovery Month--first year that included those in recovery from MH problems! • 2nd Annual National Wellness Week • Release of 2011 NSDUH SA data • Release of Surgeon General’s National Strategy for Suicide Prevention • SAMHSA celebrated 20th birthday (October 1, 1992) • New CMHS Director appointed

8. PAOLO DEL VECCHIO APPOINTED NEW CMHS DIRECTOR • In BH field for over 40 years • With SAMHSA for 17 years • Former CMHS Acting Director • Former CMHS Associate Director for Consumer Affairs • Former Acting Director for Office of External Liaison • First Consumer Affairs Specialist hired by SAMHSA • Promoted consumer participation in all aspects of policy development and operations • Promotes public education in developing evidence-based practices to address needs of people with MH conditions • Initiated historic dialogue meetings between consumers/peers and practitioners, regional peer meetings, social inclusion efforts, training programs, and grant development • A self-identified MH consumer, trauma survivor, and person in recovery from addictions

9. SURGEON GENERAL’S NATIONAL STRATEGY FOR SUICIDE PREVENTION • Every year, over 11 million Americans seriously consider taking their own lives; over 38,000 died from suicide in 2010 • Almost 2.5 million Americans > 14 yrs are distressed enough to actually attempt it • America loses ~100 people every 24 hours – not to battles of war or acts of terrorism, not to natural disasters, but to incredibly shattering act of suicide • NSSP developed with input from survivors of suicide attempt and suicide loss; released 9/10/12 on World Suicide Prevention Day

10. DEFINING RECOVERY Working common definition of recovery from mental disorders and/or substance use disorders A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential Incorporating into grants Exploring differences between recovery from MH conditions and from addictions

11. MAKING RESOURCES AVAILABLE • SAMHSA’S Community Support Program (CSP) • Provides consumers opportunities to come together • Supports state/national consumer organizations • Promotes peer-run programs, shared decision-making, and person-centered care • Consumer-Operated Services Program (COSP) Multisite Research Initiative • Establish evidence base for alternative programs • Participation in mutual support programs, drop-in centers, and other consumer-run services significantly boosts consumers’ well-being and empowerment • More consumers use these, greater their gains • Consumer-Operated Services EBP Kit

12. ELEMENTS OF A PUBLIC HEALTH MODEL

13. PARTICIPANT-DIRECTED CARE IN A PUBLIC HEALTH MODEL 13 • Goal is HEALTH for Everyone • Identify and address risks (data-driven) • Build capacity and infrastructure to prevent (within individual or community) • Access treatment when necessary • Maintain and restore to health • Community will override individual where required for the public’s health • E.g., immunization, flouride, STDs, tuberculosis, child abuse • Community and individual responsibility

14. SAMHSA’S QUALITY CONSTRUCT 14 • National Quality Strategy (from ACA) • Participant-directed care as one goal • National Behavioral Health Quality Framework • Evidence-based/effective prevention, treatment, recovery • evidence-based care often rejected by consumers and people in recovery and by courts, by provider systems, and by policy-makers – for different reasons • Person/family/community-centered • Coordinated (within BH; between BH and other health care) • Promote healthy living • Safe • Accessible/affordable

15. SHARED DECISION-MAKING – 1 • Overcomes historical assumption that persons with BH issues cannot possibly know what they need to get and stay well • History of mandated treatment – civil commitment, MH courts – as well as ineffective treatments with unwanted side effects • Assumption – disagreement w/proposed treatment = symptom “lack of insight” or “denial” of illness • Assumption – medications are bad; treatment professionals don’t know me; want to “medicalize” my uniqueness or my life experience • Disagreement = may be beginning of recovery; beginning of taking responsibility for own symptoms, health and well-being • Recovery = hope, individually directed process of self-determined wellness and quality of life

16. SHARED DECISION-MAKING – 2 • SAMHSA’s integrated suite of support tools for BH service users and providers • Example: computer-based, interactive decision aid re “What is the Role of Antipsychotic Medication in my Recovery Plan?” • Scientific data on range of medication, other treatment options; outcomes, risks, benefits • Weighing side effect protocols of every anti-psychotic medication on market • Opportunities to identify/consider personal values/preferences in relation to options • Printable personalized report, video & multi-media tools, tip/worksheets • To date: 15,630 visitors to the decision aid on website • Reflect standards by International Patient Decision Aid Standards Collaboration • Global researchers, practitioners, stakeholders

17. EXPANDING INVENTORY OF DECISION SUPPORT RESOURCES/AIDS • Wider topics and broader audiences; e.g.: • Medication Assisted Treatment (MAT) for Recovery from Opioid Dependence • Antidepressant medications (AHRQ has created one for primary care setting) • Psychoactive medications prescribed for children and youth with behavioral/emotional problems

18. THE PATH FORWARD: MHPAEA/PARITY AND AFFORDABLE CARE ACT (ACA)

19. UNDERSTANDING MHPAEA & PARITY • October 3, 2008: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) • HHS, DOL and Treasury Federal regulations issued to implement are now effective (as of 2010) for all plans covered by MHPAEA • 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 medical and surgical (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

20. WHO IS 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 managed care programs • Children's Health Insurance Reauthorization Act (CHIPRA) • In total, approximately 150 million Americans

21. WHO IS NOT COVERED BY MHPAEA? • Employer groups 50 and under in size (small groups) • Individual insurance plans (individual market) • Medicaid plans not covered by managed care • Medicare • State and local government plans requesting exemption • Covered employer group plans that can prove after implementing their costs have increased by >2% for 1 yr

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

23. 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

24. GOALS FOR DEFINING EHBs • Encompass the 10 categories of services • Reflect typical employer health benefit plans (“benchmark” plan) • Reflect balance among the categories • Account for diverse health needs across many populations • Ensure there are no incentives for coverage decisions, cost sharing or reimbursement rates to discriminate by age, disability, or expected length of life • Ensure compliance with MHPAEA • Balance comprehensiveness and affordability • Provide states a role in defining essential health benefits

25. YOUR ROLE IN MHPAEA/PARITY • Learn • Take advantage of opportunities; ask! • Participate • With each other and with other stakeholders • Advocate • Collectively and individually • Give SAMHSA information and feedback

26. IN 2014: MILLIONs MORE AMERICANS WILL have health coverage OPPORTUNITIES • Currently, 37.9 million are uninsured < 400% FPL* • 18.0 M – Medicaid expansion eligible • 19.9 M – ACA exchange eligible** • 11.019 M (29%) – Have BH condition(s) • * Source: 2010 NSDUH • **Eligible for premium tax credits and not eligible for Medicaid

27. PREVALENCE OF BH CONDITIONS AMONG MEDICAID EXPANSION POP CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

28. PREVALENCE OF BH CONDITIONS AMONG EXCHANGE POPULATION CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

29. HEALTH COVERAGE IN 2014 29 Coverage Options for Adults without Medicare or Employer-Based Coverage Income as a percent of the federal poverty level 0 133 400+ States must choose to expand States must create or let feds do it (FFE) Individuals must act A Continuum of Coverage – Everyone Fits Somewhere!

30. 2014 ENROLLMENT CHALLENGE Enroll at least 21 million people in new coverage options (another 11 million must take up employer or other coverage) } 8 million in Exchange coverage Millions } 13 million in Medicaid or CHIP Source: March 2012 CBO estimates

31. A NEW WAY TO ENROLL IN COVERAGE

32. SIMPLE STREAMLINED APPLICATION PROCESS Now 2014 A single application as gateway to all coverage programs Must be available online, by telephone through a call center, by mail, and in person Interview requirements prohibited • Different applications for different programs • Denied? Back to the drawing board • Applications often only available on paper or as PDFs if online • In-person interview requirements

33. CONSUMER ENROLLMENT ASSISTANCE IN ACA • Navigator Functions • Include at least one consumer-focused non-profit • Maintain expertise in eligibility and enrollment and facilitate enrollment in QHPs • Conduct public education activities to raise awareness about the state’s exchange • Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman

34. SAMHSA ENROLLMENT ACTIVITIES • Consumer enrollment assistance subcontracts (BRSS TACS) • Outreach/public education • Enrollment/re-determination assistance • Plan comparison and selection • Grievance procedures • Eligibility/enrollment communication materials • Learning collaboratives in AZ, CA, ME, MD, MO, NM, NY, VT • Enrollment assistance best practices TA – Toolkits • Communication strategy – message testing, outreach to stakeholder groups, webinars/training opportunities • Data work with ASPE and CMS

35. ENROLLMENT ASSISTANCE OPPORTUNITIES 35

36. HEALTH REFORMROLE OF ADVOCATES Learn Educate yourself and others on implications of HR – ask! http://www.samhsa.gov/HealthReform/ Participate Work with states and with local advocacy groups – behavioral health and other stakeholders Advocate Make your voice heard to further shape HR Speak out and motivate America to better understand how behavioral health is essential to health 36

37. MOVING FORWARD TOGETHER • Goal is lives healthy and meaningful rather than lives managed • Focus is on people’s lives – prevention, treatment, and services are means to that end • Safe, healthy, supportive communities and people