STATE BEHAVIORAL HEALTH LEADERSHIP IN A CHANGING HEALTH CARE ENVIRONMENT

2. STATE BEHAVIORAL HEALTH LEADERSHIP IN A CHANGING HEALTH CARE ENVIRONMENT Pamela S. Hyde, J.D. SAMHSA Administrator SAMHSA SSDP Conference Baltimore, MD • July 30, 2012

3. TODAY’S DISCUSSION

4. A PUBLIC HEALTH MODEL FOCUSES ON PEOPLE & COMMUNITIES • People – NOT money, diseases, programs, or authorities • People come with multiple diseases/conditions, social determinants, cultural backgrounds and beliefs • People come to multiple settings – primary or specialty care, schools, courts, places of worship, through social media • Healthy productive satisfying lives without disorder or in recovery are the outcomes we seek • Communities – People w/ common geography, culture, language, beliefs, or characteristics focusing together on common good • Health and disease/disorder occurs and is promoted or prevented in communities • State/Territorial/Tribal governments can help or be a barrier • Requires collaboration

5. PUBLIC HEALTH MODEL FOR BEHAVIORAL HEALTH

6. MISUNDERSTANDING LEADS TO INSUFFICIENT RESPONSES

7. BEHAVIORAL HEALTH IS NOT A MORAL OR SOCIAL PROBLEM • Social/moral problem context focuses on problems: • Homelessness • Crime/jails • Child welfare problems • School performance or youth behavior problems • Provider/system/institutional/government needs or failures • Public tragedies • Public (and public officials) often misunderstand, blame, discriminate, make moral judgments, exclude • Ambivalence about worth of individuals affected and investment in prevention/treatment/recovery • Ambivalence about ability to impact “problems” “caused” by persons with behavioral health needs

8. INTEGRATING INTO HEALTH CARE & COMMUNITY SETTINGS

9. BUDGET - CHALLENGES

10. SAMHSA’S BUDGET FY 2008 – FY 2013 • ACA • PHS • BA Total Program Level Includes: Budget Authority, PHS Evaluation Funds, and ACA Prevention Funds. FY2012 Enacted amount incorporates the 0.189% recession. *FY2013 also includes $1.5 M estimated for user fees for Extraordinary Data and Publication Requests.

11. FY 2013 LIKELY SCENARIOS • President’s Budget, Senate Committee Mark, and House Subcommittee Mark • All signal positions, not decisions • CR Through December or March • How long and how much depends . . . • Likely equal to or less than FY 2012 • Sequester Jan 2013 = ~ 7.8 percent ↓ from FY12 • Applied to FY 2013 (enacted or CR) • Exec’s/OMB’s role by September

12. SAMHSA’S FY 2014 PRINCIPLES(IF POSSIBLE . . .) • Maintain ~ Ratio of BG to Discretionary Dollars (~65/35) • Assumptions re health reform impacting need • Maintain Ratio of SA and MH Funding (~ 70/30) • Avoid Terminations/Reductions of Existing Awards • Continue Holistic Approach through Joint Funding • Build Off Innovations from Previous Funding Cycles • Maintain Support for SAMHSA’s Strategic Initiatives; Target Available Funding for Top Priorities

13. HEALTH REFORM - OPPORTUNITIES

14. CHANGING HEALTH CARE ENVIRONMENT Role of States Increasing Integration Rather than Silo’d Care – Parity Prevention and Wellness Rather than Illness Access to Coverage and Care Rather than Significant Parts of America Uninsured – Parity Recovery Rather than Chronicity or Disability Quality Rather than Quantity – Cost Controls Through Better Care Rather than More Care

15. SAMHSA’S HEALTH REFORM PRIORITIES – FY 2012 AND FY 2013 • Uniform Block Grant Application FYs 2014 & FY 2015 • In Fed Reg for 60-day public comment as of 7-13-12 • Enrollment Preparation • Exchanges and Qualified Health Plans • Parity in Medicaid and Essential Benefits • Provider Capacity Development and Workforce • Work with States and Medicaid • Health homes, rules/regs, service definitions and evidence, screening, prevention, duals, PBHCI, payment issues • Parity – MHPAEA/ACA Implementation & Communication • Quality (NBHQF) and Data (including HIT)

16. 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

17. 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

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

19. FOCUS: ENROLLMENT – PREPARATION • Consumer Enrollment Assistance (AZ, NM, MO, CA, NY, VT, ME, MD) • Outreach/public education • Enrollment/re-determination assistance • Plan comparison and selection • Grievance procedures • Eligibility/enrollment communication materials • Enrollment Data, Best Practices TA, and Toolkits – with CMS & ASPE • Testing new common application • SAMHSA learning collaborative with 7 state stakeholder coalitions • Communication Strategy – Message Testing, Outreach to Stakeholder Groups, Webinars/Training Opportunities • Incorporating Enrollment Requirements into RFAs • SOAR Changes to Address New Environment

20. ESSENTIAL HEALTH BENEFITS (EHB) 10 BENEFIT CATEGORIES • 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

21. FOCUS: BENCHMARK PLANS • Serves as Reference Plan • Reflecting scope of services and limits offered by a “typical employer plan” in that state • Parity applies • States Allowed to Select a Single Benchmark Plan: • 1 of 3 largest small group market plans (default), or • 1 of 3 largest state employee plans, or • 1 of 3 largest federal employee plans, or • Largest HMO plan in a state • EHB Mini Rule – Thru 9/30/12 Critical

22. BENCHMARK PLANS • If State Does Not Select, Default To Largest Plan By Enrollment In Largest Product in Small Group Market • Must Include All10 Essential Health Benefit Categories Regardless What Selected Benchmark Plan Covers/Excludes • Supplement from other plans if category not sufficiently covered • Substitution within categories • Parity Applies in Individual, Small & Large Group Markets • Both MHPAEA and ACA parity requirements • Parity work within HHS and with DOL and Treasury

23. BENCHMARK AND EHB REVIEW • HHS Will Assess Benchmark Process for 2016 • State choices in 2012 will remain for two years (2014 & 2015) • Periodically Review and Update EHBs • Difficulties with access due to coverage or cost • Changes in medical evidence or scientific advancement • Market changes • Coverage affordability • SAMHA’s Good and Modern Service Definitions & Assessing the Evidence Process Will Inform

24. QUALIFIED HEALTH PLANS – NETWORK ADEQUACY • Qualified Health Plans (QHPs) • Offered through affordable health exchanges (marketplaces) • State choice to set up exchange or use federally facilitated exchange (FFE) • QHPs’ Networks – Providers Sufficient In Number/Types To Assure Services Accessible w/o Unreasonable Delay • Encourages QHPs to provide sufficient access to broad range of MH/SUD services, particularly in low-income & underserved communities • Highlights MH/SUD providers – must be sufficient providers available to deliver!

25. PROVIDERS ACCEPTING HEALTH INSURANCE PAYMENTS* • Inpatient – 95 percent • Outpatient – 68 percent • Primary MH plus some SA – 85 percent • Primary SA (w/ none or some MH) – 56 percent • Residential SA – 54 percent • Other (e.g., Homeless Shelters, Social Services Agencies) – 37 percent *Source: NSATSS

26. SOURCE OF FUNDS FOR CMHCs* • State/County Indigent Funds – 43 percent • NOTE: State MH ↓$5 B in last 5 years; SA ↓$2-3 B • Medicaid – 37 percent • Private health insurance – 6 percent • Self-pay – 6 percent *Source: 2011 National Council Survey

27. HEALTH REFORM RESOURCES • http://www.samhsa.gov/HealthReform/ • General information about health reform and BH • http://www.healthcare.gov/news/factsheets/2011/05/exchanges05232011a.html • Information re state-by-state exchange funding & plans • http://cciio.cms.gov/resources/other/index.html#hie • State Exchange Blueprint • http://cciio.cms.gov/resources/regulations/index.html#hie • States three largest small group plans

28. NEW KIND OF LEADERSHIP – CHALLENGES & OPPORTUNITIES • New Partners • Different Policies • Collaborative Practice • Multiple Party Structures • Influence v Direction • Funding Capacity v Funding • Integrated Service Delivery • BG – State MH & SA Authorities Roles • Changing not declining