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MENTAL HEALTH SERVICES

MENTAL HEALTH SERVICES. FACTS. In any given year, about 5%-7% of adults and 5%-9% of children have a serious mental illness (22-23% diagnosable MI, 6% addiction) MIs are the leading cause of disability in the U.S. and Canada for ages 15-44

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MENTAL HEALTH SERVICES

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  1. MENTAL HEALTH SERVICES

  2. FACTS • In any given year, about 5%-7% of adults and 5%-9% of children have a serious mental illness (22-23% diagnosable MI, 6% addiction) • MIs are the leading cause of disability in the U.S. and Canada for ages 15-44 • 1 in 5 adults have a mental health condition. That’s over 40 million Americans, more than the populations of New York and Florida combined; more than 10 million live with serious mental illnesses and more than 7 million children and youth live with serious emotional disturbances • Rates of youth depression increase to 12.5% in 2015 from 8.5% in 2011 • Even with severe depression, 80% youth are left with no or insufficient treatment • 56% of American adults with a mental illness DID NOT receive treatment; and, only a third of those received treatments received adequate treatments • Mental health conditions have risen up to the most costly and disabling condition in the US since 2013 compared to the second behind heart diseases in 2009. • 50% of the condition occurs before the age of 14; and, 75% of the condition occurs before the age of 24 • Over 2 million Americans with serious mental illness are incarcerated each year

  3. Mood Disorders Among Adults

  4. Mood Disorders Among Adults

  5. Mood Disorders Among Children

  6. Mood Disorders Among Children

  7. FACTS (Centers for Medicare & Medicaid Services) • U.S. health care spending grew 5.8% in 2015, reaching $3.2 trillion or $9,990 per person.  As a share of the nation's Gross Domestic Product, health spending accounted for 17.8%. • However, only 7.6% was spent on mental health and substance use disorders • The faster growth experienced in 2014 was primarily due to the major coverage expansions under the Affordable Care Act, particularly for Medicaid and private health insurance • Hospital Care (32% share): Spending for hospital care increased 5.6% to $1 trillion in 2015 compared to 4.6% growth in 2014. The faster growth in 2015 was influenced by the continued growth of non-price factors, such as the use and intensity of services • Physician and Clinical Services (20% share): Spending on physician and clinical services increased 6.3% in 2015 to $634.9 billion from 4.8% growth in 2014. • Other Professional Services (3% share): Spending for other professional services reached $87.7 billion in 2015, an increase of 5.9%, which is an acceleration from of 5.1% in 2014. Spending in this category includes establishments of independent health practitioners (except physicians and dentists) that primarily provide services such as physical therapy, optometry, podiatry, or chiropractic medicine

  8. FACTS • Dental Services (4% share): Spending for dental services increased 4.2% in 2015 to $117.5 billion, faster than in 2014 when growth was 2.4% • Other Health, Residential, and Personal Care Services (5% share): Spending for other health, residential, and personal care services grew 7.8% in 2015 to $163.3 billion after increasing 5% in 2014. This category includes expenditures for medical services that are generally delivered by providers in non-traditional settings such as schools, community centers, and the workplace; as well as by ambulance providers and residential mental health and substance abuse facilities • Home Health Care (3% share): Spending growth for freestanding home health care agencies accelerated in 2015, increasing 6.3% to $88.8 billion following growth of 4.5% in 2014. The faster growth in 2014 was attributable to increased spending by the two largest payers of home health, Medicare, with growth of 2.6%, and Medicaid, with growth of 6%. Combined, both payers of home health care represented 76% of total home health spending

  9. FACTS • Nursing Care Facilities and Continuing Care Retirement Communities (5% share): Spending for freestanding nursing care facilities and continuing care retirement communities increased 2.7% in 2015 to $156.8 billion, an acceleration from growth of 2.3% in 2014. The faster growth in 2015 was due to the increased spending in Medicare of 5.6% vs 2.5% in 2014 • Prescription Drugs (10% share): Retail prescription drug spending decelerated in 2015, growing 9% to $324.6 billion compared to the 12.4% growth in 2014. The growth in 2015 is attributed to the increased spending on new medicines, price growth for existing brand name drugs, increased spending on generics, and fewer expensive blockbuster drugs going off-patent • Durable Medical Equipment (2% share): Retail spending for durable medical equipment reached $48.5 billion in 2015 and increased 3.9%, slightly faster than the 3.5% growth in 2014. This includes items such as contact lenses, eyeglasses and hearing aids • Other Non-durable Medical Products (2% share): Retail spending for other non-durable medical products, such as over-the-counter medicines, medical instruments, and surgical dressings, grew 3.7% to $59 billion in 2015

  10. Health Spending by Major Sources of Funds • Medicare (20% share): Medicare spending grew 4.5% to $646.2 billion in 2015, a slight deceleration from 4.8% growth in 2014. This slightly slower growth in 2015 was largely attributable to slower growth in Medicare enrollment. • Medicaid (17% share): Total Medicaid spending slowed slightly to 9.7% in 2015, but continued the strong growth that began in 2014 at 11.6%. State and local Medicaid expenditures only grew 4.9% while federal Medicaid expenditures increased 12.6% in 2015. The increased spending by the federal government was largely driven by the newly eligible enrollees under the ACA, which were fully financed by the federal government

  11. Health Spending by Major Sources of Funds • Private Health Insurance (33% share): Total private health insurance expenditures increased 7.2% to $1.1 trillion in 2015, faster than the 5.8% growth in 2014. The acceleration in 2015 was driven by increased enrollment and strong growth in benefit spending. • Out-of-Pocket (11% share): Out-of-pocket spending grew 2.6% in 2015 to $338.1 billion which was slightly faster than annual growth of 1.4% in 2014. The increase in 2015 was influenced by the expansion of insurance coverage and the corresponding drop in the number of individuals without health insurance

  12. FACTS (Health Affairs, May 2016)

  13. FACTS

  14. FACTS

  15. FACTS

  16. History of Mental Health System • 1700’s – Family’s, poor houses, jails • 1840’s – First wave of public hospital development • 1880’s – Second wave of state hospital development shifts cost and responsibility to state level • 1920 & 1930’s – Departure of syphilitics and epileptics • Post World War II – Mental illness begin to depart to community • 1950’s – Arrival of effective antipsychotics and antidepressants; state hospitals develop outpatient medication clinics; arrival of child guidance movement; Eisenhower’s Commission on Mental Illness and Health (1955)

  17. History of Mental Health System • 1960’s – Medicaid/medicare shift many cost to the Fed; persons with dementia (and many MI) depart to nursing homes; growth of general and private acute inpatient; growth of outpatient; Community Mental Health Center (CMHC) movement and Fed grants • 1970’s – Institute for Mental Disease (IMD) exclusion exemptions; commitment limited to dangerousness; harsher drug laws increased number of MI in jail and prisons; First Presidential Report on Mental Health • 1980’s – IMD exclusion exemption for facilities of less than 16 beds; Fed block grants CMHC funds to state; states retarget CMHCs to SMI; states take advantage of DSH (disproportional shared hospitals) to shift costs to Fed • 1990’s – Medicaid waivers allow states to increase fed share of funding; behavioral managed care causes loss of private sector inpatient • 2000 – Second Presidential Commission on Mental Health (2002)

  18. Federal Role Emerges • Creation of NIMH: 1946 • Eisenhower Commission on Mental Illness and Health: 1955 • Action for MH  Deinstutionalization • CMHC Construction Act of 1963 (Community Mental Health Act) • Bush President’s New Freedom Commission on Mental Health: 2002 • Interdepartmental Serious Mental Illness Coordinating Committee: 2017

  19. President’s New Freedom Commission on Mental Health (07/22/03) • Fragmentation and gaps in care for children • Fragmentation and gaps in care for adults with serious mental illnesses • High unemployment and disability for people with serious mental illnesses (MI) • Lack of care for older adults with MI • Lack of national priority for mental health and suicide prevention

  20. The National Mental Health Act of 1946 created the NIMH (National Institute of Mental Health) and increased appropriations for therapy and research Deinstitutionalization which began in the late 1950s was ushered in by President JFK as the result from the Action for Mental Health Report in 1961 Community Mental Health Centers Act in 1963 started the construction of community mental health centers

  21. One unfortunate result is the numerous homeless, mental ill people (33%, range from 15-70%) who would once have lived in state institutions but are now left to the understaffed, financially limited, and often grossly inadequate public health services Barriers: Civil Commitment laws and the right to (refuse) treatment

  22. RECOMMENDATIONS Address mental health with the same urgency as physical health Align relevant Federal programs (ie housing, training, quality employment) to improve access and accountability for mental health services Create a Comprehensive State Mental Health Plan www.mentalhealthcommission.gov/reports/FinalReport

  23. 2008 through 2010Suddenly A New Environment • 2008 - MH and SA Parity Act • 2009 – Economic Crisis • 2009 – HIT Act • 2010 – Health Care Reform

  24. Four key elements of the Affordable Care Act

  25. Insurance Reform • Severely curtails ability of Insurance plans to use segmentation and avoidance of risk as a business strategy • Severely curtails limited forms of coverage • Standardizes Benefit packages • Standardizes and improves affordability of coverage • Standardizes information and formatting for billing • Improves transparency and comparability of coverage • Expands parity of coverage for Mental illness and Substance abuse

  26. Delivery System Redesign • Data Driven Care • Population Management • Integration of Behavioral Healthcare and general Healthcare • Increase use of Preventive care • Increase access to Primary care • Health Information Technology interoperability stds

  27. Payment Reforms • Bundled Payments • Global Payments • Pay for Performance • Accountable Care Organizations (ACOs) • Reduces Hospital Payments • Increases Primary Care and Preventive care payments

  28. The 21st Century Cures Act • $6.3 Billion bill, signed into law on Dec 13, 2016; with 3 arms: • Discovery – $4.8 B to NIH to research genetic, lifestyle and environmental diseases, to support Joe Biden’s “Cancer Moonshot” initiative to speed research for a cure, and to invest more funds in the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) initiative to investigate diseases like Alzheimer’s • Development – advancing new therapies for patients through many avenues • Modernizing clinical trials and involving patients in the regulatory review process • Streamlining regulations • Providing more clarity and consistency for developers of health software and medical apps • Incentivizing drug development for childhood diseases • Allowing the FDA to use flexible measures when reviewing breakthrough technologies • Delivery – making sure that anything gained in the Discovery and Development branches is available to patients when they want and need it • Incorporated the Helping Families in Mental Health Crisis Act, first introduced by then Congressman Tim Murphy (R-Pa), to improve mental health system of care, improve parity and address the opioid epidemic

  29. Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC), 2017 • Authorized by the 21st Century Cures Act • Seeks to enhance coordination across federal agencies to improve service access and delivery of care for adults with Severe Mental Illnesses (SMIs) and children with Severe Emotional Disorders (SEDs) • Its charge: • Report on advances in research on SMI and SED related to prevention, diagnosis, intervention, treatment and recovery, and access to services and supports; • Evaluate the effect federal programs related to SMI and SED have on public health, including outcomes across a number of important dimensions; and • Make specific recommendations for actions that federal departments can take to better coordinate the administration of mental health services for adults with SMIs and children with SEDs

  30. ISMICC’s First Report, 12/13/17 • The Way Forward: Federal Action for a System That Works for All People Living with SMI and SED and Their Families and Caregivers • Five focus areas for the federal government and the mental health care system: 1. Strengthen federal coordination to improve care 2. Make it easier to get care that is an evidence-based best practice 3. Close the gap between what works and what is offered 4. Increase opportunities for individuals with serious mental illness and serious emotional disturbance to be diverted from the criminal and juvenile justice systems and to improve care for those involved in the criminal and juvenile justice systems 5. Develop finance strategies to increase availability and affordability of care

  31. MENTAL HEALTH CARE DELIVERY

  32. Psychiatric hospitals: VA, state and county, and private • Psychiatric units of private hospitals • Residential treatment centers for emotionally disturbed children • Federally funded community mental health centers • Independent psychiatric outpatient clinics • Private practice psychiatrists (5%) • Private practice psychologists and therapists (LCSWs and MFTs)

  33. PARITY OF MENTAL HEALTH SERVICES

  34. Approximately 75% of privately insured receive mental health services under some form of manage care • Medi-Cal and Medicare transferred services to HMOs • Cost control by tightening criteria defining medical necessity for mental health services • Discounted fees or case rates or capitation

  35. History of Parity • Mental Health Parity Act of 1996 • Federal law addressing annual/aggregate lifetime dollar limits • Mental Health Parity Act of 1999 • California law requiring private insurers to cover treatment of specific severe mental illnesses under the same terms and conditions applied to treatments of other illnesses • Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 • Expands the scope of MH parity requirements at the federal level and includes SUD

  36. With the MHPAEA,Congress eliminated discriminatory co-payments in Medicare • Up until 07/08 medicare beneficiaries pay 20 percent of the government-approved amount for most doctors' services but 50 percent for outpatient mental health services • With this new law, the co-payment for mental health care has gradually reduced to 20 percent over six years

  37. Health Care Reform:PATIENT PROTECTION AND AFFORDABLE CARE ACT – ACA (HR-3590)

  38. Signed into law by President Barack Obama in March 2010, the ACA is projected to extend insurance coverage to more than 30 million Americans through 2019 • On September 23, 2010, a number of key provisions kicked in. Insurers, for example, are no longer able to rescind an individual's coverage if he or she becomes ill. Neither are they able to deny coverage to children with preexisting conditions. And young adults are now able to stay on their parents' plan until age 26 years • In the first 3 months of 2016, 27.3 million (8.6%) persons of all ages were uninsured at the time of interview—1.3 million fewer persons than in 2015 and 21.3 million fewer persons than in 2010. • In the first 3 months of 2016, among adults aged 18–64, 11.9% were uninsured at the time of interview, 19.5% had public coverage, and 70.2% had private health insurance coverage. • In the first 3 months of 2016, among children aged 0–17 years, 5.0% were uninsured, 42.1% had public coverage, and 54.9% had private coverage

  39. ACA Up to date • In 2012, the Supreme Court gave states the right to opt out of the expansion • The biggest winners from the law include people between the ages of 18 and 34, African Americans, Hispanics, and people who live in rural areas • The share of the California population ages 18 to 64 enrolled in Medi-Cal rose 52% • Kaiser Family Foundation estimated that 4.7 million previously uninsured Californians now have health care coverage as of March 2016. The Commonwealth Fund recently estimated that California’s uninsured rate has dropped from 22 percent to 8 percent

  40. Increased Access to Coverage • Allows states to expand Medicaid to new populations • Example: Low-income adults with no dependent children • Federal government picks up 100% of costs for first three years; reduced to 90% by 2020 • Individual Mandate • Penalty for being uninsured — $695 per adult; max of $2,085 per family • Provides subsidies (tax credits) to purchase coverage through health benefits exchange • 138% to 400% of the Federal Poverty Level (FPL)

  41. Medi-Cal Expansion — Eligibility • Medicaid is called Medi-Cal in California • About 11.9 million covered currently in California • Children under 5 with family income up to 133% FPL • Children 6–18 with family income up to 100% FPL • Parents with income up to 106% FPL • Approximately 4.7 million have been newly eligible • Mandatory: Existing aid categories up to 138% FPL (includes 5% income disregard) • Optional: Adults under 65 without dependent children

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