Healthcare Reform and New Opportunities to Support Whole Health

Transcription

1 Healthcare Reform and New Opportunities to Support Whole Health Mohini Venkatesh, MPH Senior Director, Public Policy National Council for Community Behavioral Healthcare JMHCP National Training and TA Event: Collaborating to Achieve and Communicate Positive Public Health and Public Safety Outcomes

2 The National Council: Serving & Leading Represent 1,782 community organizations that provide safety net mental health and substance abuse treatment services to nearly six million adults, children and families. National voice for legislation, regulations, policies, and practices that protect and expand access to effective mental health and addictions services. effective mental health and addictions services.

3 Problem Statement High rates of MH/SUDs problems in prisons and jails Challenges: Access to treatment, both in and outside of CJ system Eligibility for Medicaid SU doesn t qualify as a disability Termination, rather than suspension, of Medicaid benefits Barriers that limit systems (health care, social services, CJ, etc.) from working together

4 Why Whole Health? People with SMI are dying 25 years younger than the general population SU/MH disorders are prevalent in primary care SU/MH disorders add to overall healthcare costs, especially for Medicaid SU/MH disorders can cause or exacerbate other chronic health conditions SU/MH interventions can reduce healthcare utilization and cost

5 Health Reform Won t Solve Every Problem But More individuals with MH/SUDs will have coverage under Medicaid and private insurance ACA will trigger dramatic changes in how health and MH/SU services are organized. These changes will create a tipping point in how the healthcare needs of persons with serious mental illness and the MH/SU healthcare needs of all Americans are addressed. Which will change the way MH/SU services are funded and fit into the new healthcare ecosystem.

6 Patient Protection & Affordable Care Act The second (and most significant) wave of public behavioral health change in the last 25 years.

7 Insurance Reform Requires guaranteed issue and renewal Prohibits annual and lifetime limits Bans pre-existing condition exclusions Create essential benefits package that provides comprehensive services including MH/SU at Parity Requires plans to spend 80%/85% of premiums on clinical services Creates federal Health Insurance Rate Authority

8 Coverage Expansion Requires most individuals to have coverage Provides credits & subsidies up to 400% Poverty Employer coverage requirements (>50 employees) Small business tax credits Creates State Health Insurance Exchanges Expands Medicaid

9 Medicaid Expansions Expanded Eligibility for Children and Parents Expanded Eligibility for Childless Adults Benchmark Coverage for Newly Eligible Childless Adults Increased Federal Share and PCP Payments Maintenance of Eligibility Coverage for Former Foster Care Children 133% Federal Poverty Level April 1, 2010 State Plan Option 133% Federal Poverty Level April 1, 2010 State Plan Option Based upon Deficit Reduction Act benchmark coverage Limited array of services available FMAP = % in years % of Medicare Reimbursement Eligibility standards must be maintained until Exchanges are fully operational. Compliance tied to receipt of federal matching funds. Does not prevent states from expanding coverage. States may extend coverage, including EPSDT, to former foster children until age 26

10 Medicaid Benefits: Benchmark vs. Traditional Most newly eligible people will be enrolled in benchmark plans Exemptions for: Blind or disabled individuals, regardless of SSI eligibility Dual eligibles Inpatients in a hospital, nursing facility, or ICF-MR Medically frail and special needs individuals (includes people with disabling mental disorders and children with serious emotional disturbances) Health reform also includes important improvements to benchmark benefits (e.g. parity, minimum required benefits) Consumers & advocates will have to decide whether benchmark or traditional coverage best meets their needs States will need to develop processes to identify individuals who have a disabling mental disorder or functional impairment

11 Expected Sources of Coverage Under Healthcare Reform 26% 33% 29% 12% Health insurance exhange -- with subsidies or tax credits (adults) Health insurance exhange -- employer or individual responsibility (adults) Medicaid expansion (adults) Children National Council analysis: 43% increase in # of Medicaid enrollees $15 to $23 billion more spending for MH/SUDs from insurance expansion Source: RUPRI Health Reform Simulation Model

12 Service Delivery Redesign and Payment Reform Opportunities to Consider Whole Health Needs: Widespread Deployment of Medical Homes New Medical Home Payment Models Bundled Payments Related to Inpatient Admissions Accountable Care Organizations the Homes for Medical Homes 12

13 Medical Homes: Primary Care Clinics that Look and Act Differently Picture a world where everyone has... An Ongoing Relationship with a PCP A Care Team who collectively takes responsibility for ongoing care And Provides all Healthcare or makes Appropriate Referrals Helping ensure that Care is Coordinated and/or Integrated And where... Quality and Safety are hallmarks Enhanced Access to care is available (evenings & weekends) And Payment appropriately recognizes the Added Value 13 (Joint Principles of the Patient-Centered Medical Home:

14 Accountable Care Organizations (ACOs): the homes for medical homes Health Plan Accountable Care Organization Clinic Food Mart Specialty Clinics Medical Homes Medical Homes Medical Homes Clinic Food Mart Specialty Clinics Hospitals Hospitals 14

15 Medicaid Medical Home Requirements (B) SERVICES DESCRIBED. The services described in this subparagraph are (i) comprehensive care management; (ii) care coordination and health promotion; (iii) comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; (iv) patient and family support (including authorized representatives); (v) referral to community and social support services, if relevant; and (vi) use of health information technology to link services, as feasible and appropriate.

16 Primary Care Behavioral Health Care (PBHCI) Integration Grant Program Program purpose: To improve the physical health status of people with SMI by supporting communities to coordinate and integrate primary care services into publicly funded community-based behavioral health settings Expected outcome: Grantees will enter into partnerships to develop or expand their offering of primary healthcare services for people with SMI, resulting in improved health status Population of focus: Those with SMI served in the public behavioral health system Eligible applicants: community behavioral health agencies, in partnership with primary care providers

17 Services Delivered Facilitate screening and referral for primary care prevention and treatment needs Provide and/or ensure that primary care screening/assessment/ treatment and referral be provided in a community-based behavioral health agency Develop a registry/tracking system for all primary care needs and outcomes Offer prevention and wellness support services (>10% of grant funding) Build processes for referral and follow-up for needed treatments that are not appropriately provided in a primary care setting

18 New Paradigm Primary Care in Behavioral Health Organizations Funding starting to open up for embedding primary medical care into CBHOs, a critical component of meeting the needs of adults with serious mental illness component of meeting Clinical Design for Adults with Low to Moderate and Youth with Low to High BH Risk and Complexity Primary Care Clinic with Behavioral Health Clinicians embedded, providing assessment, PCP consultation, care management and direct service Food CBHO Mart Partnership/ Linkage with Specialty CBHO for persons who need their care stepped up to address increased risk and complexity with ability to step back to Primary Care Clinical Design for Adults with Moderate to High BH Risk and Complexity CBHO Food Mart Community Behavioral Healthcare Organization with an embedded Primary Care Medical Clinic with ability to address the full range of primary healthcare needs of persons with moderate to high behavioral health risk and complexity

19 Preparing for the Future HHCJustice- Involved Population HHCHHHNational Health Reform HHWhole Health

20 It s All About the Details States will need to expand capacity considerably to meet demand Communication pathways between systems will be important How to coordinate when individuals additional services may become an issue Eligibility rules

21 State Role in Reform Implementation States are responsible for many elements of reform Health Insurance Exchange planning and implementation Medicaid enrollment simplification Grants and demonstration projects Responsibility for changes rests with governors, state government agencies, and state legislatures (in cases where changes to state law are necessary) It will be crucial to establish strong relationships at the state and federal levels

22 Getting Involved in Reform Discussions Get a seat at the table: Work to ensure that your perspective (and that of the pop you serve) are included throughout the implementation process Know thyself: Have a detailed and working knowledge of your local system s capacity, population demographics, and technological needs to cogently advocate for the right changes in policies.

23 Getting Involved in Reform Discussions Make new friends: > While the need to work with state Medicaid offices has been true for a long time, the inclusion of MH/SU throughout the ACA makes working with Medicaid, insurance, and primary care essential. Think outside the box (& encourage others to do so): > With new policy changes and more people with access to care, we will have to think creatively about how to increase capacity, reach out to underserved populations, and provide services in a way to meet the demands of the new law.

24 Case Study: Medicaid Enrollment

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27 Incentive for States to think about Enrollment Process States must: Set aside funding for establishing enrollment systems Opportunity for CJ system to get involved? Create website to facilitate enrollment

28 Resources

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30 Questions? Mohini Venkatesh This material was developed by presenters for the February 2011 event: Collaborating to Achieve and Communicate Positive Public Health and Public Safety Outcomes. Presentations are not externally reviewed for form or content and as such, the statements within reflect the views of the authors and should not be considered the official position of the Bureau of Justice Assistance, Justice Center, the members of the Council of State Governments, or funding agencies supporting the work.