Impact of the Affordable Care Act on Behavioral Health

1. Impact of the Affordable Care Act on Behavioral Health March, 2014

2. My Background • Medicaid Director • Previously DMH Medical Director – 20 years Practicing Psychiatrist CMHCs – 10 years FQHC – 18 years • Distinguished Professor, Missouri Institute of Mental Health, University of Missouri St. Louis

3. Endorsements • "He is not only dull himself, he is the cause of dullness in others.“-Samuel Johnson • "He uses statistics as a drunken man uses lamp-posts... for support rather than illumination." -- Andrew Lang • "He can compress the most words into the smallest idea of any man I know." -- Abraham Lincoln

4. Today… It’s not just Arkansas • Status of our world • Healthcare delivery and payment “change” strategies • Future of specialty behavioral health

5. Our niche: caring for complex, costly patients You Are Here Source: Health Affairs: VA Lewis, et al.“The Promise and Peril of Accountable Care for Vulnerable Populations: A Framework for Overcoming Obstacles.” 2012. Health Affairs: VA Lewis, et al.“The Promise and Peril of Accountable Care for Vulnerable Populations: A Framework for Overcoming Obstacles.” 2012.

6. Co-morbidities in the Adult Population Source: Druss & Walker. “Mental disorders and medical comorbidity.” The Robert Wood Johnson Foundation Synthesis Project, February 2011.

7. Opportunities… Defined by Tragedies • 2020, behavioral health disorders surpass all physical diseases as major cause of disability • MI most common reason for SSD/SSI • More deaths due to suicide than to accidents, homicides, and war combined • Most mental health treatment is in primary care - medication, poorly managed Sandy Hook Tucson Aurora Virginia Tech

9. Effective Treatments

10. 62 million people will gain access to coverage that includes MH/SUD at parity

11. Parity Robust final rule

12. Role of Parity • Essential Health Benefit (EHB) for private insurance must be at parity. What does parity mean? • Medicaid Benchmark Benefit must be at parity. • Parity does extend to all new individual and small group plans beginning in 2014. • What about parity for current Medicaid beneficiaries?

13. State Estimates of the Uninsured • You can access state estimates for the Medicaid Expansion and for the State Health Insurance Marketplace at http://www.samhsa.gov/healthReform/enrollment.aspx • Three estimates are provided: • Adults with Serious Mental Illness • Adults with Serious Psychological Distress • Adults with a Substance Use Disorder

14. Essential Benefit Plans (EBP) on the Insurance Exchanges • The plan selected by a state to be its EBP benchmark for ACA may not comply with parity. • States had until exchanges went live to make it comply with parity - then it became an EHB benchmark plan • But so far its unclear if CMS will enforce this – especially since the final ACA rule stated that “We do not intend to require or request states to include specific services within EHB categories offered by their ABP.” • States resisting ACA implementation will not enforce it either • High deductibles and co-pays will be an obstacle

15. Alternative Medicaid Benefit (AMB) for Medicaid Expansion Groups • Wellstone – Domenici Parity does not apply • If the individual meets that states definition for “medically frail” they reverts to the standard Medicaid benefit • Serious Mental Illness and Substance Use Disorders constitute Medically Frail • But - states get to define which diagnosis is “SMI” • Many states are not expanding Medicaid

16. Parity and Case Law Monitoring and reporting… • Anthem Health Plans’ Connecticut rate schedule changes violate the Mental Health Parity and Addiction Equity Act • New York against UnitedHealth Group • California class-action lawsuit against United Behavioral Healthcare for reviews of outpatient treatments • Vermont held Cigna has burden of proving that disparate treatment of mental health and medical surgical justified by clinical standards

17. Four key elements of the Affordable Care Act

18. 2010 • Prohibits lifetime benefit limits • Dependent coverage up to age 26 is mandated • Cost-sharing obligations for preventive services are prohibited • Recissions are prohibited • Pre-existing condition exclusions for dependent children (under 19 years of age) are prohibited • Coverage for emergency services at in-network cost-sharing level with no prior-authorization is mandated

19. More 2010 • Require coverage of tobacco cessation programs for pregnant women under Medicaid free of cost-sharing • Begin Community Health Centers and National Health Service Corps Fund expanded funding to total $11 billion over five years • Begin Medicaid global payments demonstrations to fund large, safety-net hospitals in five states to alter payment from fee-for-service to a capitated, global payment structure. • Establish Patient-Centered Outcomes Research Institute. Create a private, nonprofit Patient-Centered Outcomes Research Institute to set a national research agenda and conduct comparative clinical effectiveness research.

20. 2011 • 85% MLR for large group (with refund) is mandated • 80% MLR for individual and small group (with refund) is mandated • Primary care physicians and General surgeons in shortage areas begin 10 percent Medicare payment bonus for next 5 years • Medicare adds annual wellness visit with no copayment or deductibleand eliminates cost-sharing for evidence-based preventive services

21. 2012 • Medicaid starts option funding Health homes for persons with chronic conditions • Prohibit federal payments for Medicaid services related to hospital-acquired conditions. • Begin Medicaid Emergency Psychiatric Care Demonstration Project. to expand the number of emergency inpatient psychiatric care beds available.

22. 2013 • Medicaid payment rates to primary care physicians for furnishing primary care services raised no less than 100 percent of Medicare payment rates in 2013 and 2014. • Medicaid coverage of preventive services approved by the U.S. Preventive Services Task Force with no cost-sharing will receive an increased federal funds

23. 2014 • Health insurance exchanges established • Guarantee issue is required • Community rating required limits use of age and illness as a rating factor • All annual and lifetime limits prohibited • Essential Benefit established and required to cover MH and SA at Parity • Individual Mandate Starts

24. Insurance Exchanges • To Date: • 16 states have selected a state-based model, • 7 are partnering with the federal government and • 26 states have chosen federally-run exchanges. • Current enrollment deadline is March 31, 2014 • In non- expansion states low-income individuals may experience more difficulty finding affordable coverage because they are not Medicaid-eligible and do not qualify for federal subsidies in the exchange.

25. ACA Affordable Health Insurance Marketplace • Fact: Enrollment system went live in ALL STATES on October 1, 2013. Insurance will became effective on January 1, 2014. Scope is all uninsured adults above 133 percent of poverty (plus discounted 5 percent of income). • Overall 25% will have a Behavioral Health Condition. (About 6% will have a Serious Mental Illness and 14% will have a Substance Use Disorder). • KEY ISSUES TO CONSIDER: • Are eligible uninsured persons aware of the opportunity? • Will persons with mental health and substance use conditions actually enroll? • Will the insurance benefits be adequate?

26. 2014 Medicaid Expansion • To date, 26 states are planning to expand coverage in 2014 • Some include non-traditional models such as Medicaid premium support. • Decisions to expand Medicaid or discontinue Medicaid expansion in 2015 will impact bids that insurers submit in the spring of 2014 for the 2015 enrollment period.

28. ACA Medicaid Expansion • Fact: For states that choose this option (now 26 + DC), enrollment system went live on October 1, 2013 and coverage began on January 1, 2014. Designed for all uninsured adults up to 133 percent of poverty (plus discounted 5 percent of income). • Overall 40% with Behavioral Health Conditions. (About 7% will have a Serious Mental Illness and about 14% will have a Substance Use Disorder). • KEY ISSUES TO CONSIDER: • What is the effect of a State opting out? • Are eligible uninsured persons aware of the opportunity? • Will persons with mental health and substance use conditions actually enroll?

29. Increased competition in MH/SUD • Managed care • Accountable Care Organizations • New MH/SUD coverage under essential benefits • New parity requirements

30. EHR Meaningful Use BehavioralHealth Quality Measures (Phase 2) • Quality metrics for chronically ill: • Tobacco screening and cessation • Weight screening and counseling • Depression screening and intervention • Hypertension screening • Depression remission rates using PHQ9! • Depression followup using PHQ9 • Substance Abuse assessment in Bipolar patients • Alcohol Treatment initiation and Engagement • Maternal depression screening at < 6 month child visit • Suicide assessment for depressed patients

31. Delayed Changes • Employer mandate delayed from 2014 to 2015 • First reduction of Disproportionate Share Hospital (DSH) funds delayed from 2104 to 2015 • Compliance of small business Existing Plans with new Rules • CMS has delayed until September 2015 • 15 States will permit renewal of non-compliant plans • 18 States will not • 17 States are undecided

32. 2015 - 2017 • Innovation Waivers • Beginning 2015, states may consider developing proposals to waive portions of the ACA beginning in 2017. • “Innovation Waivers” must cover at least as many people as under the ACA and provide coverage that is at least as comprehensive and affordable, at no extra cost to the federal government. • States that receive waivers may finance their reforms with federal funding that otherwise would have been provided for premium tax credits, cost-sharing reduction and small business tax credits

33. Estimated changes in payer mix Source: The Commonwealth Fund: “Including Safety Net Providers in Integrated Delivery Systems: Issues and Options for Policymakers”

34. 50 Years of Federal Spending Chart depicting 50 years of federal spending; image taken from NPR.org

36. The future… The greatest danger intimes of turbulence is notthe turbulence. It is to actwith yesterday’s logic. Peter Drucker www.thenationalcouncil.org Contact: communications@thenationalcouncil.org | 202.684.7457

37. Population based - Health homes… 37

38. Health Home Functions: CMHCs are well positioned • CMHC teams already fulfill many Healthcare Home functions: • Providing individualized services and supports • Linking consumers to community and social supports • Hospital admission and discharge follow-up • Communicating with collaterals • CMHCs already serve people with high rates of chronic medical conditions • Many CMHCs have been trained by PBHCI Grant Project

39. Defining Health Homes • Enumerated in Sec. 1945 of the Social Security Act • Provides states the option to cover care coordination for individuals with chronic conditions through health homes • Intended to improve access and quality of care • Eligible Medicaid beneficiaries have: • Two or more chronic conditions, • One condition and the risk of developing another, or • At least one serious and persistent mental health condition

40. Defining Health Homes • Provides 90% FMAP for eight quarters for: • Comprehensive care management • Care coordination • Health promotion • Comprehensive transitional care • Individual and family support • Referral to community and support services • Services by designated providers, a team of health care professionals or a health team

41. What is a Health Home? Not just a Medicaid Benefit Not just a Program or a Team A System and Organizational Transformation

42. Treatment as Usual Health Homes What is Different about Health Homes? • Individual Practitioner • Episodic Care • Focus on Presenting Problem • Referral to meet other Needs • Managed Care • Manages access to care • Does not change clinical practice • Integrated Primary/Behavioral Health Care Team • Continuous Care • Comprehensive Care Management • Coordinates care across the healthcare system • Data driven population management • Transforms clinical practice • Emphasizes healthy lifestyles and self-management of chronic health problems

43. Apples and Oranges

44. Health Care Home Strategy Case management coordination and facilitation of healthcare Primary Care Nurse Care Managers Disease management for persons with complex chronic medical conditions, SMI, or both Behavioral Health management and behavior modification as related to chronic disease management for persons with Medical Illness Preventive healthcare screening and monitoring by MH providers Integrated Primary Care and Behavioral Healthcare

45. Health Home Strategy Health technology is utilized to support the service system. “Care Coordination” is best provided by a local community-based provider. MH Community Support Workers who are most familiar with the consumer provide care coordination at the local level. Primary Care Nurse Care Managers working within each Health Home provide system support. Behavioral Health Consultants in each Primary Care Health Home Statewide coordination and training support the network of Health Homes.

46. Principles • One Team • CMHC’s composed of pre-2012 CPRC staff plus NCM and PC Consultant • PCHH’s composed of new infrastructure and team members • One Treatment Plan for the Whole Person • Rehab Goals • Medical Goals • Healthy Lifestyle Goals • Some Goals and Outcomes reference Health Home Performance Measures • Wrap –Around approach to outside treating PCP, mental health providers, community supports, etc

47. What is a Health Home? Not just a Medicaid Benefit Not just a Program or a Team A System and Organizational Transformation

48. Treatment as Usual Health Homes What is Different about Health Homes? • Individual Practitioner • Episodic Care • Focus on Presenting Problem • Referral to meet other Needs • Managed Care • Manages access to care • Does not change clinical practice • Integrated Primary/Behavioral Health Care Team • Continuous Care • Comprehensive Care Management • Coordinates care across the healthcare system • Data driven population management • Transforms clinical practice • Emphasizes healthy lifestyles and self-management of chronic health problems

49. Disease ManagementDiabetes( 2434 Continuously Enrolled Adults)* *29% of continuously enrolled adults

50. Hypertension and Cardiovascular Disease 302 3176