Health Care Reform and Its Impact on Substance Use Disorders Treatment

Transcription

1 Health Care Reform and Its Impact on Substance Use Disorders Treatment Richard Rawson, Ph.D. Thomas E. Freese, Ph.D. Darren Urada, Ph.D. UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center

2 In times of change, the learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists. -- Eric Hoffer

3 Affordable Care Act A consolidation of: The Patient Protection and Affordable Care Act (PPACA) and The Health Care and Education Reconciliation Act of 2010

4 4

5 Health Care Reform Implementation Timeline Coverage of preventive services with no co pays Expanded Medicaid eligibility Ends lifetime and certain annual limits Health Insurance Exchanges Dependent coverage <26 Improves student loan access and repayment Ongoing refinement and implementation Requires individuals to get insurance Stop smoking program for pregnant women expands Home and Community Based services Planning and implementation of integrated care Requires business with <50 employees to provide insurance Ongoing implementation Tax on highcost insurance plans

6 2014 Changes New insurance for about 32 million adults. Up to 133% of poverty level (133% is $14,484 in 2011 for an individual): Medicaid (Medi-Cal) Up to 400% of poverty level (400% is $43,560 in 2011 for an individual), sliding subsidies to buy private insurance. State Health Insurance Exchanges (2014): Individual and Small Group Plans. All plans must include Substance Use Disorder treatment. 6

7 Much is Still to be Determined In the House of Representatives version of Health Care Reform alone, the Secretary of Health and Human Services is referenced 3,267 times. The Secretary shall establish The Secretary may develop guidelines The Secretary shall promulgate regulations

8 MediCal Expansion Essential Benefit

9 Essential Health Benefit in CA the largest plan by enrollment in any of the three largest small group insurance products in the State s small group market; any of the largest three State employee health benefit plans by enrollment; any of the largest three national FEHBP plan options by enrollment; or the largest insured commercial non-medicaid Health Maintenance Organization (HMO) operating in the State

10 Essential Health Benefit in CA The benefits are modeled on the Kaiser Foundation Health Plan small group HMO 30 plan, and include autism, acupuncture and tobacco cessation. SB 951 by Ed Hernandez (D-West Covina) and AB 1453 by Bill Monning (D-Carmel) These bills, along with companion legislation by the same authors (SB 961 and AB 1461, which would ban discrimination based on pre-existing conditions) still need concurrence before heading to the governor for approval. "This is the floor. Anyone can buy products that have more, which I'm assuming will cost more," he said. But "everyone will know that if they purchase a product inside or outside the exchange, they will get all the essential benefits and will be covered."

11 Integrated Care for Behavioral Disorders and Medical Comorbidity

12 Mother Nature has no mercy. As a consequence, the presence of one disease usually provides no immunity against others Redelmeier, D. N Engl J Med May 21;338(21):

13 Comorbidity and the Triple Aim Behavioral Disorders may result in reduced quality of medical care Behavioral Disorders may result in elevated costs of medical care Behavioral Disorders may result in worse outcomes of medical care

14 Why is Comorbidity so Common? High prevalence of individual conditions Behavioral and medical comorbidity each risk factors for the other Common factors may pose risks for each of the two types of conditions

15 Prevalence of Comorbid Conditions 1 1. National Comorbidity Survey Replication,

16 Pathways Underlying Comorbidity 1 1. Modified from Katon

17 Prevalence of Psychiatric Diagnoses Among Medicaid Recipients with Chronic Illness 1

18 Comorbidity and Quality Despite more frequent medical contacts, quality of care for persons with behavioral disorders is worse than for those without such disorders 1 This may in part be due to the fact that these patients are treated by lower quality providers. 2 Poor quality may explain as much as half of excess mortality post MI Br J Psychiatry Jun;194(6): Med Care Jul;45(7): Archives of General Psychaitry 2001 Jun;58(6):

19 Comorbidity and Costs 1 1. From Melek and Norris (2005 Marketscan data)

20 Comorbidity and Mortality: Public MH Sector vs. General Population Year AZ MO OK RI TX UT Compared with the general population, persons with major mental illness lose years of normal life span Lutterman, T; Ganju, V; Schacht, L; Monihan, K; et.al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Colton CW, Manderscheid RW. Prev Chronic Dis. Available at: ttp://

21

22 A Solution

23 Collaborative Care PRIMARY CARE PROVIDER AND TEAM PSYCHIATRIC SUPERVISION PATIENT NURSE CASE MANAGER

24 TEAMcare Clinical Trial & Program Multi-Condition Collaborative Care for chronic conditions & depression to address: A1c Blood pressure Cholesterol (LDL) Depression

25 A Mean of HbA1c B Mean of Systolic BP Baseline 6 Months 12 Months Baseline 6 Months 12 Months Control Intervention Control Intervention Mean of LDL Mean of SCL Score C Baseline 6 Months 12 Months Control Intervention D Baseline 6 Months 12 Months Control Intervention

26 The Language That We Use 1. The person receiving services is called 2. The building(s)/place(s) where the person receives services is called 3. The room where the person receives services is called 4. The person who has the ultimate responsibility for the care of the person is called 5. The person who is responsible for care coordination is called

27 The Medical System Primary Care The aims of primary care are to provide broad spectrum of care both preventive and curative; over a period of time; and to coordinate all of the care the patient receives. All family physicians and most pediatricians and internists are in primary care.

28 The Medical System Primary Care Practitioner must possess a wide breadth of knowledge in many areas. Patients consult the same primary care doctor for routine check-ups, and initial consultation about a new complaint. Common chronic illnesses, often treated in primary care, include: Hypertension -- Diabetes Asthma and COPD -- Depression and anxiety Arthritis and other pain

29 Strategies for successful communication It is important to understand the system with which you are working Learn about the medical conditions that bring people to primary care Expand your vocabulary to facilitate communication Stay within your scope of practice in your interactions Make yourself visible and useful

30 A Quick Example Using a Condition Associated with Mental Health and Substance Use Disorders Diabetes

31 Type 2 Diabetes Overview Basic Overview: Metabolic disease. Hyperglycemia (too much sugar) due to insulin resistance and defects in insulin secretion. Diabetes can lead to: blindness heart & blood vessel disease stroke kidney failure amputations nerve damage. 2/how-to-reduce-impact-type-2- diabete.html

32 Sign & Symptoms Often no symptoms at all. Most common symptoms include: Blurred vision Erectile dysfunction Fatigue Frequent or slowhealing infections Increased appetite Increased thirst Increased urination

33 Importance of Hemoglobin A1c Test (HbA1c) The hemoglobin A1c test is used to determine how diabetes is being controlled. HbA1c provides an average of your blood sugar control over a six to 12 week period. When blood sugar is too high, sugar builds up in your blood and combines with your hemoglobin, becoming "glycated." For people without diabetes, the normal range for the HbA1c test is 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than 7%. Retest should occur every three months to determine level of control.

34 Why is it important to know the Hemoglobin A1c for: The Medical Provider The Substance Use Disorders Provider The Mental Health Provider Peers and Family

35 Type 2 Diabetes Relationship with SUD Heavy alcohol consumption can increase risk factors including: body-mass index, low HDL ( good ) cholesterol and cigarette smoking (Tsumura, 1999). A history of substance use is associated with earlier age of onset of diabetes (Johnson, 2001). SUD is associated with increased mortality in diabetics (Jackson, 2007). Societal Significance In 2006, it was the seventh leading cause of death, although likely underestimated (National Diabetes Statistics, 2007). In 2007, diabetes cost the US $174 billion in medical costs, loss of productivity, disability costs (American Diabetes Association, 2007).

36 Type 2 Diabetes & Your Clients Medical services available on-site better link clients in SUD treatment to medical services compared to those with outside referrals (Friedmann, 1999). Social support for abstinence can increase linkage to medical services. (Saitz, 2004). Encourage activities that improve diabetes: Better diet. Reduce simple carbohydrate intake (i.e. potatoes, white bread, corn, soda, candy, sweets). More exercise. Maintain regular appointments with doctor overseeing diabetes treatment.

37 Other factors to consider for successful interdisciplinary collaboration

38 Consumer Improvement Strategies Increase the focus on consumer satisfaction and consumer perception of care Increase the use of behavioral enhancement techniques (use of positive reinforcement techniques). Increase use of strategies to increase consumer access to care and appreciation of care (eg. NIATx) Increase measurement of service effectiveness and greater provider accountability 38

39 Provider/practice barriers Differing practice styles Differing practice cultures and language Difficulty in matching provider skills with patient needs Heavy reliance on physician services Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services 39

40 Provider/practice barriers Lack of recognition of provider limitations Lack of MH knowledge in PC providers and lack of health knowledge in BH providers Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context Differing coding and billing systems Provider resistance 40

41 FINANCIAL BARRIERS Payors have strict requirements of who can bill for what service Increase in Medicaid necessitates provider and workforce capability to bill this payor Payment for health/recovery coaches and use of peers is slow to emerge Allowances for payment for services in new job classifications areas, such as Care Managers 41

42 Behavioral Health Homes The Core Clinical Features

43 Medical Homes The 2010 Patient Protection and Affordable Care Act established a health home option under Medicaid that serves enrollees with chronic conditions. Federal guidance requires a health home to have several provider standards, including quality-driven and cost effective services, comprehensive care plans for each patient, and the involvement of continuing care strategies, to name a few.

44 Medical Homes Hence, becoming a health home requires multiple changes in practice, in workflow, in billing operations, and other practical areas. Behavioral health providers can anticipate that these changes will be difficult and they will need to manage these necessary changes well to become a behavioral health

45 Medical Homes Health Homes do not need to provide all services themselves but must provide access and care coordination. Program must target patients with 2 or more chronic health conditions (and must address MH and SUD). MH and SUD treatment providers can become a health home for the people they serve; behavioral health based health home.

46 Medical Homes Chronic Care Models Self-Management Support: patients selfmanage their care, collaborate with providers to maintain their health. Use MI to get patients activated in their health. Delivery System Design: formation of multidisciplinary practice teams (clear roles, single care plan, effective communication, coordinate care). Decision Support: Ensure clinical care is provided in line with best practices by involving specialists, embedding evidence-based guidelines in routine care (example placing standing orders in an EMR).

47 Medical Homes Chronic Care Models Clinical Information Systems: Support the organization of data; must be able to look at population level data to help maximize outcomes for defined groups as well as at the individual level. These systems can organize data and deliver reminders to providers and consumers. Community Linkages: Develop an understanding of the contextual factors (eg poverty) that may underpin consumers poor health. Support consumers connections to resources in the community.

48 Three Structures for the Behavioral Health Home: In House Model: Provides and owns the complete array of primary care and specialty behavioral health services. Co-Located Partnerships: BH agency arranges for healthcare providers to provide primary care services onsite and must involve case coordination. Facilitated Referral Model: Most PC services are not provided on-site but the agency ensures coordination of care. They may conduct screenings and link clients to PCPs and facilities and must also include case coordination.

49 Electronic Health Records will be required

50 The Certified HIT Product List (CHPL) provides the authoritative, comprehensive listing of Complete EHRs and EHR Modules that have been tested and certified under the Temporary Certification Program maintained by the Office of the National Coordinator for Health IT (ONC). Each Complete EHR and EHR Module listed below has been certified by an ONC-Authorized Testing and Certification Body (ONC-ATCB) and reported to ONC.

51 Ambulatory Products = 2,583 Inpatient Products = 855

52 Sharing Information Issues of Confidentiality

53 42 CFR Part 2 The regulations governing confidentiality of alcohol and drug abuse patient records

54 42 U.S. Code 290dd 42 CFR Part 2 First issued 1975, revised 1987 Designed to help deal with the stigma of addiction. Requires notification of confidentiality, consent forms, prohibition of redisclosure

55 Intent of 42 CFR Part 2 Imposes restrictions upon the disclosure and use of patient records that are maintained in connection with the performance of any federally assisted alcohol and drug abuse program

56 Applicability Any information (including referral and intake) about alcohol and drug abuse patients obtained by a program Includes (not limited to): Treatment or rehab programs EAP Programs within a general hospital School-based programs Private practitioners who provide alcohol or drug abuse diagnosis, treatment or referral

57 42 CFR Part 2 Allowable Disclosures Written authorization Internal communication ( need to know ) No patient-identifying information Medical emergency Qualified Service Organization Audit and evaluation Crimes (or threats of) on program premises or against program personnel Initial reports of suspected child abuse or neglect Court order meeting specifications of 42 Research

58 More interesting 42 CFR Part 2 facts Applies to law enforcement or other official, even with a subpoena Disclosing the presence of a patient at a facility which is identified as a place where only drug/alcohol services are provided requires written authorization A payer or funding source that maintains records of a recipient of drug/alcohol treatment becomes subject to 42 CFR Part 2 to the same extent as the program from which the information came.

59 Clarifying 42 CFR Part 2 The restrictions on disclosure in these regulations do not apply to communications between a program and a qualified service organization of information needed by the organization to provide services to the program. Source: 42 CFR 2.12 (c)(4)

60 Qualified Service Organization (QSO) Provides services to a program, such as data processing, bill collecting, dosage preparation, laboratory analyses, or legal, medical, accounting, or other professional services, or services to prevent or treat child abuse or neglect, including training on nutrition and child care and individual and group therapy, and Source: 42 CFR 2.11

61 QSO Written Agreement A written agreement with a program under which that person: (1) Acknowledges that in receiving, storing, processing or otherwise dealing with any patient records from the programs, it is fully bound by these regulations; and (2) If necessary, will resist in judicial proceedings any efforts to obtain access to patient records except as permitted by these regulations. Source: 42 CFR 2.11

62 HIPAA

63 HIPAA Health Insurance Portability and Accountability Act of 1996 Designed to ensure maintenance of health insurance coverage when you change jobs. Administrative simplification Healthcare processes becoming very complex look to standardize information make it easier. Protect confidentiality and security of patient information

64 Protected Health Information 2 Components Identifies the client Health Information Any information that is oral, written, electronic, created or received by health care provider, health plan, public health authority, employer, insurer, or others Relating to past, present or future physical or mental health status, health care, and payment for such services

65 HIPAA ISSUES Confidentiality of client PHI assured through secure transmissions ( secure or fax). Program must determine the identity and authority of person requesting PHI before it is released

66 HIPAA ISSUES DOCUMENTATION OF RELEASES When entity releases information to: EMT in medical emergency Police in case of crime on premises Child abuse/neglect report Prevent harm Court Order ALL MUST BE DOCUMENTED IN CHART!

67 General Rule of Disclosure Treatment Programs may only release information or records that will directly or indirectly identify a client as a substance abuser or treatment patient: With a knowing and written consent from the participant, AND Other exceptions (explained earlier)

68 PRACTICAL SAFEGUARDS Do not leave papers containing PHI lying around where others can see them At end of workday clear desk or other exposed areas of PHI and place I secure location (file, cabinet, desk drawer). Do not talk about patient PHI in public areas If you take work home don t leave it in a place accessible to people not agency employees, keep locked in a briefcase or in car/trunk.

69 HIPAA vs. 42 CFR Part 2

70 HIPAA vs. 42 CFR Part 2 (1) The laws cover a lot of the same material. Some points of difference more specific or more recent rule usually applies. For the CD Treatment providers, in most cases the rules of 42 CFR Part 2 are more stringent In some cases HIPAA wins.

71 HIPAA vs. 42 CFR Part 2 (2) Many HIPAA provisions PERMIT something but don t mandate it. 42 CFR Part 2 PROHIBITS all disclosures unless specifically allowed by the regulation.

72 Disclosure for Payment HIPAA PERMITS disclosure with out patient consent for the purpose of payments. 42 CFR Part 2 PROHIBITS these disclosures with out patient consent. SUD/AOD providers must follow 42 CFR Part 2.

73 Patient Rights & Administrative Requirements HIPAA imposes several new administrative requirements and establishes new patient rights. These are not included in 42 CFR Part 2. SUD/AOD providers must follow HIPAA.

74 Re-disclosure of Information HIPAA is silent on this topic. 42 CFR Part 2 requires that a statement prohibiting re-disclosure accompanies the patient information that is disclosed. SUD/AOD providers must follow 42 CFR Part 2.

75 Disclosures to Other Providers HIPAA allows, but does not require, programs to make disclosures to other healthcare providers without authorization. 42 CFR Part 2 limits this to medical emergencies. SUD/AOD providers must follow 42 CFR Part 2.

76 Medical Emergencies HIPAA allows health care providers to inform family members of the individual s location and condition without consent in emergency circumstances or if a person is incapacitated. 42 CFR Part 2 limits this disclosure to medical personnel ONLY. SUD/AOD providers must follow 42 CFR Part 2.

77 Disclosure to Public Health HIPAA permits disclosure to a public health authority for disease prevention or control, or to a person who may have been exposed to or at risk of spreading a disease or condition. 42 CFR Part 2 prohibits these disclosures unless there is an authorization, court order, or the disclosure is done with out revealing patient information. SUD/AOD providers must follow 42 CFR Part 2; some state laws compel notification.

78 Right to Access Records HIPAA REQUIRES a covered program to give an individual access to his/her own health information (with few exceptions). 42 CFR Part 2 gives programs DISCRETION to decide whether to permit patients to view or obtain copies of their records, unless they are governed by a state law that gives right to access. SUD/AOD providers must follow HIPAA.

79 Contact Information Thomas Freese Richard Rawson Darren Urada