Health Reform: Implications and Options Chuck Ingoglia National Council for Community Behavioral...

www.TheNationalCouncil.org

Health Reform:Implications and Options

Chuck IngogliaNational Council for Community Behavioral Healthcare

Sept. 12, 2011


The National Council: Serving & Leading

• Represent community organizations that deliver safety net primary care, mental health and substance abuse services to nearly six million adults, children and families

• National voice for legislation, regulations, policies, and practices that protect and expand access to services that promote recovery

• We educate and advocate…


Membership Driven


National Council Experience - Practice Change and Quality Improvement

Leadership: •Middle Management Academy – 1,500 managers•Psychiatric Leadership Project – 4th class•Health Disparities and Emerging Leaders

Bi-directional Integration: •Primary Care – Behavioral Health Learning Communities (149 pairs of BHOs and FQHCs)•SAMHSA/HRSA Center for Integrated Health Solutions


The SAMHSA/HRSA Center for Integrated Health Solutions (CIHS)

•Purpose: – To serve as a national training and technical assistance

center on the bidirectional integration of primary and behavioral health care and related workforce development (including healthcare homes)

– To provide technical assistance to 56 PBHCI grantees and FQHCs funded through HRSA to address the health care needs of individuals with mental illnesses, substance use and co-occurring disorders

www.CenterforIntegratedHealthSolutions.org


Improvement Initiatives continued…

Quality and Accountability- producing outcomes: •Access and Retention Projects•Transition Age Youth Initiative•Advancing Standards of Care for People with Schizophrenia•Depression Collaborative•Trauma Informed Care Initiatives •September - Online certificate program for practitioners working with veterans (partnership with DoD Center for Deployment Psychology and Essential Learning) •Health Promotion - Mental Health First Aid


A Changing Healthcare Landscape: Ensuring a Role for Behavioral Health• 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 new demands.

• Accountability is the cornerstone of the new healthcare environment.

• All of these initiatives will require investment in new technologies, especially technologies that interface with other systems and also measure outcomes.


Two Hypotheses• Sick Care/Health Care: Federal, State and Local

healthcare reform is in the process of dramatically changing the American healthcare system from a sick care system to a true health care system

• Importance of Behavioral Health: Prevalence and cost studies are showing that this cannot be accomplished without addressing the substance use and mental health needs of all Americans.

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The Affordable Care Act: Four Key Strategies

U.S. health care reform, with or without federal legislation, is moving forward to address key issues

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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


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


State Health Insurance Exchanges • For small employer and individual insurance• Pools risk across more individuals• Parity for SUDs/MH applies• Primary Functions:

– Provides insurance plan info in easy-to-understand format– Monitors insurance plan marketing and competition– Standardizes plan benefits and cost-sharing– Some responsibility to control premium growth– Administration of tax credits for individuals between 134%-400% of

FPL

• Similar to the Massachusetts Connector or Federal Employees Health Benefit Program (FEHBP)


Health Insurance Exchanges

Current World Order:• Employer offers insurance you

select from a few plan choices (or maybe just one).

• Employer doesn’t offer insurance you can get non-group insurance (which is often difficult) or remain uninsured

• You’re unemployed and meet Medicaid disability/income requirements you may get Medicaid

• You’re unemployed and don’t meet Medicaid requirements you can get non-group insurance or remain uninsured

If the ideal is met:• Employer offers insurance Same, but

potential savings to employer via selecting plans through the exchange

• Employer doesn’t offer insurance you can enter the exchange and purchase insurance or remain uninsured (and pay penalty)

• You’re unemployed and have an income up to 133% of FPL you can access Medicaid (inc. childless adults, non-disabled)

• You’re unemployed and don’t meet Medicaid requirements you can get non-group insurance through the exchange, with sliding scale subsidies for people up to 400% FPL, or remain uninsured (and pay penalty)


National Council analysis:$15 to $23 billion more spending for MH/SUDs from insurance expansion potential new revenue sources for BH providers


Medicaid Expansions


Income at Admission (Michigan, 2010)• 133% of Federal Poverty Level in 2011 = approx.

$14,483

Income Frequency PercentCumulative

PercentNone 32210 49.4 49.4Under $5,000 8410 12.9 62.3$5,000 to $9,999 11326 17.4 79.7$10,000 to $14,999 6161 9.5 89.1$15,000 to $19,999 3463 5.3 94.4$20,000 to $24,999 1637 2.5 97.0$25,000+ 1981 3.0 100.0Total 65188 100.0


Benefits for the Newly Eligible

• Essential benefits include mental health and substance use treatment

• MH and SUD must be offered at parity with medical/surgical benefits

This means…• …Most members of the safety net will have

coverage, including mental health and substance use disorders

What is the health profile of the newly eligible?


Health Profile of the Newly Eligible

• 16 million new Medicaid enrollees• This group on average is healthier relative to those

who are currently enrolled in Medicaid (due to the fact that many of those with the worst health conditions already receive coverage through SSI or other disability pathways)

• But…• The newly eligible with the most serious health

problems will likely be the first to enroll.


Co-morbidities in the Adult Population

Source: Druss & Walker. “Mental disorders and medical comorbidity.” The Robert Wood Johnson Foundation Synthesis Project, February 2011.


Payment Reform & Service Delivery Design“Follow the Money” (Deep Throat quote from Bob Woodward’s account of Watergate)

• Prevention Activities must be funded and widely deployed

• Primary Care must become a desirable occupation and

• Mental Health and Substance Use Disorder Assessment & Treatment for all must become the Standard of Care

• In order to Decrease Demand in the Specialty and Acute Care Systems

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Prevention, Early Intervention,

Primary Care, and Behavioral Health

Inpatient & Institutional

Needed Resource Allocation

All things Inpatient and Institutional

Prevention, Primary Care, BH

Current Resource Allocation


National Healthcare Reform Strategies and the MH/SU Safety Net

In Treatment: 2.3 millionNot in Treatment:

– Tens of millions (McClellan)– 21% + (Willenbring)

How do we even begin to address these gaps asstates and health plansrealize they have to provide SU servicesat parity?

In Treatment ~2.3 million

“Abuse/Dependence” ~23 million

“Unhealthy Use” ?? million

Little/No Substance Use


A Population Health Approach• Need to think differently about health: move from a

focus on providing services to a single individual… to measurably improving outcomes for the populations in our communities

• Key strategies/elements:– Prevention

– Care management

– Partnerships with primary care providers and others in the healthcare system

– Data collection & continuous quality improvement

– Clinical accountability


Healthcare Models of the Future

• Coverage expansions are ONLY sustainable with delivery system reform– Collaborative Care

– Patient Centered Healthcare Homes

– Accountable Care Organizations

• Accountability and quality improvement are hallmarks of the new healthcare ecosystem


Collaborative Care Approaches to Co-occurring Disorders• >30 randomized controlled trials have found

collaborative care approaches improve quality and outcomes

• Key “active ingredients” = care managers and stepped care

• Collaborative care approaches are highly cost effective

• Variety of models, including:– Fully integrated

– Partnership model

– Facilitated referral model


Core Components of Collaborative Care

Two ProcessesTwo New Team Members

Care Manager Consulting BH Expert

Systematic diagnosis and outcomes tracking(e.g. PHQ-9 to facilitate diagnosis and track depression outcomes)

• Patient education/self-management support

• Close follow-up to make sure pts don’t fall through the cracks

• Caseload consultation for care manager and PCP (population-based)

• Diagnostic consultation on difficult cases

Stepped Care:a)Change treatment according to evidence-based algorithm if patient is not improvingb)Relapse prevention once patient is improved

• Support medication Rx by PCP

• Brief counseling (behavioral activation, PST-PC, CBT, IPT)

• Facilitate treatment change/referral to BH

• Relapse prevention

• Consultation focused on patients not improving as expected

• Recommendations for additional treatment/referral according to evidence-based guidelines


Person-Centered Healthcare Homes: A new paradigm• Picture a world where everyone has...

– An Ongoing Relationship with a responsible healthcare provider

– A Care Team that collectively takes responsibility for ongoing care

• And where... – Quality and Safety are hallmarks

– Enhanced Access to care is available

– Payment appropriately recognizes the Added Value

• What does this look like in practice?


What it’s not:

• A residential facility• Primary care provider

as gatekeeper


Defining the Healthcare Home

Person-Centered Healthcare Home



• Everyone has a health home practitioner and team

• Patients can easily make appointments and select the day and time.

• Waiting times are short.• Email and telephone consultations are

offered.• Off-hour service is available.


Defining the Healthcare Home • Health Home team has a patient-centered,

whole person orientation• Care is tailored to the needs of each patient• Patients are active participants, with the

option of being informed and engaged partners in their care.

• Practices provide information on treatment plans, preventive and follow-up care reminders, access to medical records, assistance with self-care, and counseling.



• Systems support high-quality care, practice-based learning, and quality improvement.

• Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments.

• There is continuous learning and practice improvement.



• The health home team engages in care coordination & management within the team

• The team also coordinates with other healthcare providers/organizations in the community

• Systems are in place to prevent errors that occur when multiple physicians are involved.

• Follow-up and support is provided.


Care Coordination

• The Care Coordination Standard: When I need to see a specialist or get a test, including help for mental health or substance use problems, help me get what I need at your clinic whenever possible and stay involved when I get care in other places.

• Services are supported by electronic health records, registries, and access to lab, x-ray, medical/surgical specialties and hospital care.


Health IT Requires More than an EHR



• Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists).

• Duplication of tests and procedures is avoided.



• Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans.

• Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.


Additional Necessary Components

• The health home is supported by a sustainable business model & appropriately aligned incentives

• The health home is accountable for achieving improved clinical, financial, and patient experience outcomes


Are you ready to be a healthcare home? Do you…

Have a provider team with a range of expertise (including primary care)?

Coordinate consumers’ care with their health providers in other organizations?

Engage patients in shared decision-making?

Collect and use practice data?

Analyze and report on a broad range of outcomes?

Have a sustainable business model for these activities?


Health Homes Serving Individuals with SMI and Substance Use Disorders1. Assure regular health status screening and registry

tracking/outcome measurement

2. Locate medical nurse practitioners/primary care physicians in MH/SU facilities

3. Identify a primary care supervising physician

4. Embed nurse care managers

5. Use evidence-based practices developed to improve health status

6. Create wellness programs


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

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

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

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

Food Mart

CBHOFood MartCBHO

New Paradigm – Primary Care in Behavioral Health Organizations


Primary Care in SU Settings• Many individuals served in specialty MH/SU have no primary

care provider• Health evaluation and linkage to healthcare can improve MH/SU

status• On-site services are stronger than referral to services• Housing First settings can wrap-around MH, SU and primary

care by mobile teams • Person-centered healthcare homes can be developed through

partnerships between MH/SU providers and primary care providers

• Care management is a part of MH/SU specialty treatment and the healthcare home


Providers Need to Rethink their Service Approaches

• Infrastructure development and process improvement are necessary

• Continuing care should link the continuum of services together and support the individual’s change process

• Recovery Oriented Systems of Care support recovery as a process

• Motivational Enhancement Therapy or the Transtheoretical Model are effective, but must be delivered with fidelity

• Other approaches, including medication-assisted therapy are also effective

• Communities must work together to create a continuum of services and agreements about seamless access, stepped care and other transitions

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ResourcesBehavioral Health/Primary Care Integration and The Person-Centered Healthcare

Home, April 2009, The National Council.

Substance Use Disorders and the Person-Centered Healthcare Home, March 2010, The National Council.

http://www.thenationalcouncil.org/cs/resources_services/resource_center_for_healthcare_collaboration/clinical/personcentered_healthcare_homes

California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative. Vols. I, II, and III. September 14, 2009.

The Business Case for Bidirectional Integrated Care: Mental Health and Substance Use Services in Primary Care Settings and Primary Care Services in Specialty Mental Health and Substance Use Settings. June 30, 2010. http://www.cimh.org/Initiatives/Primary-Care-BH-Integration.aspx

Oregon Standards and Measures for Patient Centered Primary Care Homes. February 2010. Office for Oregon Health Policy and Research. http://courts.oregon.gov/OHPPR/HEALTHREFORM/PCPCH/docs/FinalReport_PCPCH.pdf



http://www.cimh.org/Initiatives/Primary-Care-BH-Integration.aspx

http://courts.oregon.gov/OHPPR/HEALTHREFORM/PCPCH/docs/FinalReport_PCPCH.pdf

http://courts.oregon.gov/OHPPR/HEALTHREFORM/PCPCH/docs/FinalReport_PCPCH.pdf


What does it mean to provide primary care?• It’s more than having a nurse on staff• Primary care is the provision of integrated,

accessible health care services by clinicians who are accountable for addressing a range of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

• Partnerships with primary care providers/FQHCs


New Medicaid State Option for Healthcare Homes• State plan option allowing Medicaid beneficiaries with

or at risk of two or more chronic conditions (including mental illness or substance abuse) to designate a “health home”

• Community behavioral health organizations are included as eligible providers

• Effective Jan. 2011• Additional guidance forthcoming from HHS


Eligibility Criteria

• To be eligible, individuals must have:– Two or more chronic conditions, OR– One condition and the risk of developing another, OR– At least one serious and persistent mental health

condition

• The chronic conditions listed in statute include a mental health condition, a substance abuse disorder, asthma, diabetes, heart disease, and obesity (as evidenced by a BMI of > 25).

• States may add other conditions subject to approval by CMS


Designated Provider Types/Functions

• Provider organizations may work alone or as part of a team

• Functions include (but are not limited to):– Providing quality-driven, cost-effective, culturally

appropriate, and person-centered care;– Coordinating and providing access to high-quality

services informed by evidence-based guidelines;– Coordinating and providing access to mental health

and substance abuse services;– Coordinating and providing access to long-term care

supports and services.


Health Home Services• 90% Federal match rate for the following services

during the first 8 fiscal year quarters when the program is in effect:– Comprehensive care management

– Care coordination and health promotion

– Comprehensive transitional care from inpatient to other settings

– Patient and family support

– Referral to community and social support services

– Use of health IT to link services (as feasible/appropriate)


Thoughts on the Implications for Behavioral Health

• We guarantee we are all moving into a period of disruption

• This is going to be hard stuff

• Behavioral Health won’t automatically be included

• BH stakeholders need to develop the value proposition

• And we will likely have to ask to be involved

• This will require thinking and acting differently

• And what unfolds will depend, to a large degree, on what the people in this room do over the next 18 months

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Be Efficient

Do you have the ability to identify patients with MH/SUD who represent the top 5% to 10% of high cost consumers of health care and provide effective care management services to help them manage their MH/SU disorders AND their chronic health conditions?

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Care Management: Missouri Example• Identified the cohort of MO HealthNet participants for

whom care management offers the greatest opportunity• Program components:

– Outreach and engagement (door-to-door outreach, collaboration with other health providers)

– Care coordination by mental health case manager

– Nurse training

– Chronic disease training

– Evaluating outcomes: both process indicators and clinical outcomes


Connect with Other Providers

• Do you use a collaborative care approach to clinical services?

• Are you actively pursuing bi-directional involvement in your community as a person-centered healthcare home?

• Can you electronically collect and share both demographic and clinical-level data with your partners in the healthcare community?


Focus on Episodic Care NeedsDo you have well defined assessment processes and defined levels of care based on clinical pathways, functionality in daily living activities, symptom severity indicators, service volumes, etc. to match client need with the type, location, and duration of evidence-based care that increases the likelihood that consumers will get their needs met in a timely and effective manner?

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Stepped Care

Is your clinical delivery process consumer-centered and supportive of “stepped care”?•The ability to rapidly step care up to a greater level of intensity when needed?•The ability to step care down so that a consumer’s MH/SU care is provided in primary care with appropriate supports?•The ability to offer “back porch” services for consumers who graduate from planned care?•All offered from a client-centered, recovery-oriented perspective?


Questions?

• Chuck IngogliaVice President, Public [email protected]

mailto:[email protected]

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