Financing Strategies for Improving Health, Well-being and Productivity of Young People, Families and their Communities

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1 Financing Strategies for Improving Health, Well-being and Productivity of Young People, Families and their Communities David Shern, PhD Suzanne Fields, MSW, LICSW Sarah Steverman, MSW August 26, 2013 The National Association of State Mental Health Program Directors

2 General introduction of the emergence of preventive interventions to help assure the health of the population. Federal Initiatives o Affordable Care Act o Other Federal Discretionary Programs o Block Grant Programs State and Local Funding Mechanisms o Traditional o Innovative Funding Strategies Novel Insurance Models Social Impact Bonds Human Performance Bonds

3 Increasing realization that the majority of resources in the health care system are spent on treatment of disorders rather than the prevention on them Chronic illnesses o o o Drive Health Care Expenditures Compromise Population Health Behavioral Health Conditions are arguably the most chronic illnesses Predict the development of other chronic conditions Federal, state and local governments realize the necessity of an increased focus on prevention o o Clinical Preventive Services Primary Preventive Services Expanded role for prevention in Federal initiatives Development of new funding approaches in states and localities

4 Federal Perspective With Guest Presenter: Suzanne Fields, MSW, LICSW Senior Advisor to the Administrator for Health Care Financing SAMHSA NASMHPD August 26, 2013

5 NATIONAL PREVENTION STRATEGY 5

6 NATIONAL PREVENTION STRATEGY Mental and Emotional Well-being Promote positive early childhood development, including positive parenting and violence-free homes. Facilitate social connectedness and community engagement across the lifespan. Provide individuals and families with the support necessary to maintain positive mental well-being. Promote early identification of mental health needs and access to quality services. 6

7 NATIONAL PREVENTION STRATEGY Preventing Drug Abuse and Excessive Alcohol Use Support state, tribal, local, and territorial implementation and enforcement of alcohol control policies. Create environments that empower young people not to drink or use other drugs. Identify alcohol and other drug abuse disorders early and provide brief intervention, referral and treatment. Reduce inappropriate access to and use of prescription drugs. 7

8 ACA PREVENTATIVE HEALTH BENEFITS Coverage of Preventive Benefits Private health plans must Provide coverage for a range of preventive services May not impose cost-sharing on patients receiving these services Coverage for services under four broad categories: Evidence-Based Screenings and Counseling Routine Immunizations Preventive Services for Children and Youth Preventive Services for Women 8

9 ACA PREVENTATIVE HEALTH BENEFITS Medicare Prevention Benefits Provide coverage for a range of preventive services Eliminates cost-sharing for Medicare-covered preventive services Authorizes Medicare coverage for a personalized prevention plan, including a comprehensive health risk assessment Medicaid Coverage of Preventive Services Encourages, but not requires, coverage Provides a one percentage point increase in federal matching payments for preventive services in Medicaid for states that offer Medicaid coverage with no patient cost sharing for services 9

10 ACA PREVENTATIVE HEALTH BENEFITS Chronic Disease Prevention in Medicaid Provides 3-year grants to states to develop programs to provide Medicaid enrollees with incentives to participate in comprehensive health lifestyle programs and meet certain health behavior targets Grants to Establish Wellness Programs Provides grants for up to five years to small employers that establish wellness programs Wellness Programs in Insurance Employees rewards of up to 30%, potentially increasing to 50%, of the cost of coverage for participating in a wellness program and meeting certain health-related standards. 10

11 PREVENTATIVE BENEFITS COVERED U.S. Preventive Services Task Force Centers for Disease Control and Prevention Child preventive services recommended by the Health Resources and Services Administration Requirements do not prohibit A plan or issuer from providing coverage for services in addition to those that are 34 recommended

12 Adults PREVENTIVE SERVICES RELATED TO BH - ADULTS Alcohol misuse screening and counseling Depression screening Tobacco use screening for all adults and cessation interventions for tobacco users Women, including pregnant women Domestic and interpersonal violence screening and counseling for all women Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users Sexually transmitted infections counseling for sexually active women 12

13 PREVENTIVE SERVICES RELATED TO BH - CHILDREN Covered preventive services for children Alcohol and drug use assessments for adolescents Behavioral assessments for children of all ages (0-17 years old) Depression screening for adolescents Developmental screening for children under age 3, and surveillance throughout childhood HIV screening for adolescents at higher risk Sexually transmitted infection prevention counseling and screening for adolescents at higher risk 13

14 Core Concepts of Prevention 1. Prevention requires a paradigm shift 2. Mental health and physical health are inseparable 3. Successful prevention is inherently interdisciplinary 4. Mental, emotional, and behavioral (MEB) disorders are developmental 5. Coordinated community level systems are needed to support young people 6. Developmental perspective is key 14 14

15 Promotion and Prevention as Two Major Public Health Goals NRC/IOM 2009 recommended national priorities: 1) assurance that individuals who are at risk receive the best available evidence-based [preventive] interventions prior to the onset of a disorder and 2) promotion of positive MEB development for all children, youth and young adults. SAMHSA s First Strategic Initiative = Creating communities where individuals, families, schools, faith-based organizations, and workplaces take action to promote emotional health and reduce the likelihood of mental illness, substance abuse including tobacco, and suicide. National Prevention Strategy = The National Prevention Strategy s vision is Working together to improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on prevention and wellness. One of the seven priorities is mental and emotional well-being. Slide 15

16 Grantee Locations 16

17 Project LAUNCH: Core Components Infrastructure Development: Federal, state, tribal and local level coordination, policy change and data integration Prevention & Wellness Promotion Practices (5 core strategies): Use of developmental assessments in a range of child-serving settings Integration of behavioral health into primary care Mental health consultation in early care and education Enhanced home visiting through increased focus on social and emotional wellbeing Family strengthening and parent skills training Cross-cutting activities: interdisciplinary workforce development public education/social marketing 17

18 Project LAUNCH Cumulative in FY12: 7,866 individuals in the mental health or related workforce trained. 390 organizations collaborating or sharing resources as a result of the grant program. 14,281 individuals have received evidence-based mental health-related services. 16,514 individuals were screened for mental health or related interventions. 4,610 of these individuals were referred for services.

19 Elements of Safe Schools/Healthy Students Create safe school environment and prevent violence Deliver alcohol, tobacco and drug prevention programs and early intervention programs Provide and promote student behavioral, social and emotional supports Promote school and community mental health services Provide early childhood social and emotional learning programs 19

20 Safe Schools / Healthy Students 365 grants Decreases in violent incidences and fewer students reported that they had experienced violence. Ninety-six percent of school staff said that SS/HS had improved school safety. The number of students receiving school-based mental health services increased 263 percent. The number of students receiving community-based mental health services increased 519 percent. Almost 70 percent of school staff said early childhood development had improved.

21 Reach of Safe Schools/Healthy Students Over 365 Grantees Since

22 The future of mental health promotion Theory of Change: Safe Schools/Healthy Students to move from community level to state level Continuing the national dialogue New cohort of LAUNCH IOM: Promoting Children's Cognitive, Affective, and Behavioral Health Forum Now is The Time preparing for Project AWARE Bullying Prevention App

23 Now Is The Time Project AWARE: $40 million to help school districts work with law enforcement, mental health agencies, and other local organizations to assure students with mental health issues or other behavioral issues are referred to the services they need. $15 million for training for teachers and other adults who interact with youth to detect and respond to mental illness in children and young adults; including how to encourage adolescents and families to seek treatment.

24 Health.gov Identify and talk about mental health challenges Assist individuals in finding help if needed Connect people with local conversations about mental health Link to the conversation taking place on social media Engage "real people" stories and some famous individuals in telling their stories some

25 Partners can link to MentalHealth.gov from their own websites using downloadable badges and can link to MentalHealth.gov social media sites Partners can use content on MentalHealght.gov for talking points and general information about mental health Partners can download the Toolkit for Community Conversations About Mental Health

26 Contact Information Suzanne Fields, MSW, LICSW Senior Advisor to the Administrator for Health Care Financing SAMHSA Slide 26

27 State and Local Programs for Primary Prevention

28 A substantial science base exists that demonstrates the value of primary prevention and mental health promotion interventions on o Pro-social Behaviors o Reduction of Risk Factors o Educational and Occupational Achievement o Psychosocial and Interpersonal Functioning o Prevention of Mental Health and Substance Use Conditions Over the lifetime

29 This value is reflected in improved human capital with savings in both direct and indirect public expenditures in o Education o Health o Criminal Justice o Social Welfare Programs As well as improved human capital contributing to increased productivity and broadly distributed societal good. o Business and employer benefits o Increased community and civic engagement o Improved family and individual health and well-being

30 Every child should have the opportunity to live, learn, work and play in safe, nurturing and caring environments that support healthy development. Every child should have access to evidence based primary MEB prevention and promotion programs, just as they have access to preventive vaccinations and other public health goods and services.

31 Developing ongoing, sustainable and coordinated funding for universal, selective and indicated prevention programming. o With programs available for every child Developing an organizing conceptual framework to understand and manage broad scale investments in this area. Requires infrastructure and operational funding

32 Public benefit funding (like current public health funding) in which all contribute through tax revenue to secure the general public good. Entitlement funding in which every child is provided access to the preventive services o Less subject to state/federal budgetary cycles o Predictable funding for program planners

33 Given the broadly distributed areas of well being impacted by preventive programming, current programs and funding are spread across: o o Various human service departments of federal, state and local government Various payers, including insurers, government, philanthropic and voluntary sectors Many of these funding sources have categorical outcome targets that o o Are not well coordinated with one another May offer time limited funding but are not amenable to long term sustained funding Separate programs lead to fragmented surveillance data and uncoordinated goals.

34 Medical care system focuses on remediating illness not preventing it. Health insurance programs are o Limited by definitions of medical necessity o Limited to reimbursing services to identified insurance program enrollees o Not available to all - Lack of universal insurance leads to less than full coverage for the population. Public health funding has traditionally underemphasized behavioral health concerns

35 Cost savings from prevention programs often do not occur until years following the interventions o Funders often focus on short term vs. long term processes or outcomes o Capitalizing these programs has been difficult since cost savings aren t realized in the short term and are broadly spread across health, education and human welfare sectors. o Undercapitalized programs are difficult to implement with model fidelity

36 Relatively stable sources of funding both for o Population based protective factors o Risk factor reduction Emphasis on areas related to human development o Reducing behavioral health disorders/strengthening mental health o Reducing child maltreatment/strengthening families o Improved childcare o School readiness o Violence/trauma reduction o Reducing anti-social behaviors o Ameliorating the effects of poverty o Economic development

37 Variety of Federal Sources o HHS ACF HRSA SAMHSA CMS CDC o OJJDP o SSA o DOE o HUD Among Others Share Common Distal Goals

38 Challenges o Categorical funding limitations o Housed in different departments of federal and state governments o General lack of an integrative framework Opportunities o Shared efficiencies with common goals and integrative leadership framework. o Stable, ongoing funding

39 Overview State revenue (general revenue or dedicated taxes) or passthrough from federal grants Allocated to counties, localities, school districts, schools, CBOs State funds for prevention from various state budgets/agencies BH, Ed, JJ, PH, CW, etc. Funds can be combined with foundation, Medicaid, local dollars Types of Prevention: Universal, Selective, Indicated

40 Must be renewed each year, not guaranteed State budget deficits impact available funds Agency silos both for funding and tracking data/outcomes Varied use of terminology/language across agencies, although common mission of youth MEB health Funds can be combined in innovative ways Focus on 0-5/school readiness one common area of concern

41 Overview Federal, state, local taxes levied on a particular good (alcohol, tobacco, gambling, soda) Can be used for general revenue or for dedicated purposes like primary prevention Reduce alcohol consumption, especially among youth Types of Prevention: Universal, Selective, Indicated

42 Must be enacted by legislation or referendum Revenue generated must be designated for prevention Even if revenue is not used for intended purpose, communities benefit from reduced alcohol/smoking Taxes provide predictable revenue without yearly reauthorization

43 Overview 76,600 total operating in the U.S. Various foci o Domestic and global o Health, social issues, the arts, environment, poverty 2011 giving - $46.9 billion 2011 assets - $646.1 billion Types Large family/corporate, small community, health conversion

44 Time limited, not necessarily sustainable Specific issue priorities, must meet criteria May only fund innovation, not ongoing expansion of established programs Outcomes driven Often willing to fund what government and insurance cannot Types of Prevention: Universal, Selective, Indicated

45 Formed when a not-for-profit hospital or health system converts to a for-profit entity Approx. 200 conversion foundations in U.S. Assets range from $2.4 million to $3.5 billion Most prioritize well-being/population level health, attempting to solve problems not easily addressed by the health care system.

46 Overview UW Worldwide: 2011 revenue of $5.14 billion, 1800 affiliates UW U.S. Impact: 2011 revenue of $4.14 billion, 1300 affiliates Priorities: Education (readiness, reading, and attainment), Income (job readiness and financial stability), and Health (nutrition, childhood obesity, and exercise) Types of Prevention: Universal, Selective, Indicated

47 UW Chapters are diverse in capacity and interests Funding relies on individual and corporate giving Education and health focus aligns with primary prevention Integral part of the community - stakeholders and partners in prevention work in addition to potential funder

48 Challenges to Prevention Coverage: Medical necessity criteria Service rendered only to beneficiary Potential for Coverage: 2014 move toward universal coverage Evidence prevention is in payers best interest

49 Type: Per member fee levied on insurers Overview: 3 private insurers, Medicaid, Medicare pay per member/per month fee to common fund Fund supports 100 FTEs on community health teams deployed to support primary care Teams are program grant funded and can provide flexible services Activities based on needs of PCP practices for integrated care, individuals and community

50 Potential for Prevention Does not currently provide primary prevention Teams could use flexibility to provide population level interventions Teams can provide services anywhere in the community and to anyone, regardless of insurance status Types of Prevention: Universal, Selective, Indicated

51 Considerations and Challenges Insurers volunteered to contribute because a pilot showed such benefits. Health teams/pooled fund activities must show a benefit to insurers, policy makers, providers, and the community. This model would not work well for states with high rates of persons who are uninsured. Vermont is implementing reforms to provide universal coverage for the population.

52 Type: Geographically-based Capitated Medicaid Model Overview: $1.9 billion CMS experiment - Oregon must show 2% reduction in Medicaid expenditures Coordinated Care Organizations (CCOs) serve as single financial entity for the Medicaid population in a given area All Medicaid providers are part of the CCO The CCO manages a per beneficiary capitated rate to provide all care

53 Potential for Prevention Cost-benefit of many primary prevention interventions has been proven If CCOs have financial risk and must show cost savings, the model could be structured for long-term savings from primary prevention One coordinated group of financial entity and providers can view Medicaid beneficiaries from a population level Community stakeholders involved in CCO leadership Types of Prevention: Selective, Indicated

54 Considerations and Challenges: CCOs are struggling to provide services with capitated rate focused on care coordination for high cost beneficiaries Primary prevention may not yield enough savings in the near term Currently operating under current CMS billing rules limiting flexibility in services provided

55 Type: Medicaid Primary Care Based Selective and Indicated Prevention Overview: Utilized Block Grant funding to train PCPs on Triple P s Level 2 and 3 interventions Obtained a CPT code for the service that can only be used by trained providers PCPs that encounter a family in need of parenting/bh support can authorize a schedule of Level 2 or 3 interventions

56 Potential for Prevention Triple P is a well-studied, evidence-based preventive intervention The setting can be any Medicaid provider PCP, CMHC, school clinic with trained staff Allows providers to give needed care without child needing to wait until they have a diagnosable MH condition Types of Prevention: Selective, Indicated

57 Considerations and Challenges CPT code for Triple P must be authorized Up-front costs of training must be obtained foundation, block grant, state general funds, Medicaid administrative funds Providers must see the benefit of the service

58 Challenges Developing up-front capital for long-term benefits Garnering support from private companies and individuals that is sustainable New Models Social Impact Bonds (SIBs) Human Capital Performance Bond

59 Overview They aren t traditional bonds but performance-based contracts Shifts risk from government to private investors Private investors put up funding to address a social problem intermediary is hired to work with government to handle contract, determine intervention, hire service provider, set desired outcomes Outside evaluator measures outcomes of intervention -investors are only paid back if they meet certain outcomes which provide a cost benefit to the government The better the outcomes, the more ROI for investors, up to a specified cap Long-term investment projects last 4-10 years Types of Prevention: Universal, Selective, Indicated

60 Conditions for a SIB Are the current costs of the social problem sufficient for meaningful potential savings? Do the following exist: o proven preventive interventions to address the problem for this particular population? o Service providers with capacity to bring the intervention(s) to scale? o A meaningful number of constituents to be served?

61 Considerations and Challenges Only interventions with sound evidence should be used o must have demonstrated financial benefits to governments and human capital Strong emphasis on evaluation, clear outcomes If outcomes are not obtained, investors recoup none of their investment Investors can be driven by ROI and/or desire for social good SIBs may be backed by foundations, guaranteeing part of the loan SIBs currently have high administrative costs to design contracts, perform rigorous evaluations, etc. higher than traditional funding

62 New model relatively untested First SIB in world UK s Peterborough Prison First SIB in US NYC JJ Diversion program at Riker s Island MA SIB Addressing homelessness NYS and several other states in planning for use of SIB

63 Annual appropriations bond - sold by the state, the state pays the principle and the interest. Bond funds are used to support proven service providers to expand already established programs Benefits to the state from expanded programs o Increased tax revenue and o Costs avoided in CJ, JJ, BH, etc. are used to repay bonds and pay performance bonuses to providers Focus on bringing programs to scale Types of Prevention: Universal, Selective, Indicated

64 Considerations and Challenges Must have providers to meet requirements o Willingness to participate o Ability to provide accurate data o Likelihood of providing positive ROI o Geographic diversity Entire repayment of bond must come from program savings to the government Still relatively untested

65 Minnesota Experiment First HCPB bond in the country Will provide 20-30% added revenue to providers over 3-4 year period saving accrue in out years Repaid within 10 years Pilot project underway legislatively authorized

66 Credibly monetizing the large scale social benefits associated with primary prevention activities. o Categorical versus full social cost perspectives o Categorical organization of government Re-investing savings into sustainable models Funding appropriate state/local and national leadership to assess the overall effectiveness of prevention activities o Like CDC surveillance system o Monitoring the status of our human capital

67 Thank you for joining us today!