Healthcare Reform ImpactThe Road Ahead

Steven RandazzoSAMHSA

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What’s Been Done So Far?

• Approaching One Year Since Affordable Care Act was passed. Changes have focused on:– Significant Program Changes and

Demonstration Projects for Medicaid Recipients

– Major Insurance Reform

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What’s Been Done So Far?

• What Changes Have Affected Publicly Insured Individuals?– States can receive federal matching funds now for

covering low-income individuals and families– 3M “donut hole” checks to Medicare individuals – Round 2 of Money Follows the Person—heavy

focus on behavioral health– Health Homes for Individuals with Chronic

Conditions

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What’s Been Done So Far?

• What Changes Have Affected Publicly Insured Individuals?– Medicaid 1915i Redux—very important changes– Prevention and Public Health Funds Awarded– Expansion of the number of Community Health Centers—

serving 20 million more individuals– Loan forgiveness programs for primary care, nurses and

even some behavioral health professionals– Increased payments to rural health providers

–

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What’s Been Done So Far?

– Major Changes For Individuals Who Are Insured:• Extending coverage to young adults• Providing free preventive care• Ability to appeal coverage determinations• No lifetime limits on benefits• Prohibiting pre-existing coverage for children• Up to 4 million small businesses are eligible for tax

credits to help them provide insurance benefits to their workers

• Holding insurance companies accountable for unreasonable rate hikes

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Affordable Care Act

• Major Drivers– More people will have insurance coverage– Medicaid will play a bigger role in MH/SUD than ever before– Focus on primary care and coordination with specialty care– Major emphasis on home and community based services and

less reliance on institutional care– Preventing diseases and promoting wellness is a huge theme– Outcomes: improving the experience of care, improving the

health of the population and reducing costs

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Impact of Affordable Care Act

Impact on Coverage• 61% of the individuals served by SSAs have no

insurance• 39% of the individuals served by MHAs have no

insurance• Expect that 90-95% of these individuals will have

OPPORTUNITY to be covered• They will be expected to enroll in Medicaid/

Insurance Exchanges

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Coverage

Enrollment• 32 million individuals—many are single males• Skepticism—many haven’t been enrolled—

historical message that you will never be covered• Penalties for not enrolling may not be a powerful

stick• Challenges—doors to enrollment and challenging

enrollment processes• Churning

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What Do We Know About the Newly Covered?

• Individuals Near the Federal Poverty Level—More diverse group than we think– 40% under the age of 29– 56% are employed or living with their families– Conditions are more acute when they present– Care is more costly

Source: Center on Budget and Policy Priorities

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What Do We Know About the Newly Covered?

Traits >100%

100-200% 200% + FPL

Poor or fair physical health

25% 18% 11%

Poor or fair mental health

16% 11% 6%

Source: Center on Budget and Policy Priorities

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What Do We Know About Service Coverage?

• Timing—Decisions about coverage are not immediate– IOM recommendations– Department of Labor Survey

• Some sense of categories (essential services)• Mental health and substance abuse services• Rehabilitation and habilitation services• Pharmacy• Preventive and wellness services

• This will impact what is purchased through block grant

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Block Grants

• 2010 Addendum—focus on State’s HCR readiness• 2011—Proposed Changes to BG Application and regulations

– Proposed needs assessment for uninsured– Planning for FY 2014 Implementation– Joint Planning Efforts between MH and SA– States Enhancing/Beginning Service Management Efforts– Use of technology for service delivery– Greater Accountability—

• More specific information on what is purchased through BG dollars• Performance strategies that mirror National Quality Strategies

– 2014 and beyond• Services that are not covered by Medicaid/Medicare/insurance• Individuals that are not covered by 3rd party insurance• Experience indicated that 20% in our systems remained uninsured at some

point in year

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Provider Plumbing

• Almost 1/3 of the SA providers and 20% of MH providers do not have experience with 3rd party billing.

• Less than 10% of all BH providers have a EHR that is nationally certified

• Few have working agreements with health centers• Many staff don’t have credentials required

through practice acts MCOs

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Provider Plumbing

• National Initiative This Year—Four large trade associations (SAAS, Niatx/NCCBH/NACHC)– Billing– EHRs– Compliance– Access

• Work with HRSA on several key workforce initiatives

Primary Care And Coordination

• Individuals with SUD/SMI have 2 or more chronic health conditions

• Barriers include stigma, lack of cross-discipline training, and access to primary care services

• Have elevated (and often undiagnosed) rates of: – hypertension, – diabetes, – obesity – cardiovascular disease

• Community-based behavioral health providers are unlikely to have formalized partnerships with primary care providers

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Importance of Integrated Care

• Focus on coordination between primary care and specialty care:– Significant enhancements to primary care

• Workforce enhancements• Increased funding to SAMHSA, HRSA and IHS• Bi-directional

– MH/SUD in primary care– Primary care in MH/SUD settings– Services and technical assistance– Pharmacy opportunities through partnering (340b program

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Impact of Affordable Care Act

• Health Homes – Focus on chronic conditions (or at risk)– Medicaid state plan– 90% match initially—big incentives for states

• Several new services:– Comprehensive Care Management– Care Coordination and Health Promotion– Patient and Family Support– Comprehensive Transitional Care– Referral to Community and Social Support Services

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Impact of Affordable Care Act

• Other Coordination Initiatives– Accountable Care Organizations—focus on dual

eligibles– Other Dual Eligible Coordination Demonstrations

(yet to be determined)

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Impact of the Affordable Care Act

• Exchanges– Timeframes

• Planning Grants 9/2010• Establishment Grants 2/2011• Operational 1/2013• Enrollment 7/2013

– Public Participation– Consumer Assistance Strategies

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Home and Community Services

• State long term care systems still unbalanced– Some states still have more than 75% of LTC

spending in “institutions”– Access to HCB services is limited—historical issues

(limited Waiver slots)– Continued concerns about the quality of these

services

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Implications

• Home Visiting Program—co-drafted RFA• HHS and DOJ work on Olmstead • Expansion of Medicaid to additional

HCBS services and for individuals in institutional care (PRTFs/IMD 65+)

• 1915i Redux • Developing HCBS Policies re: quality

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Prevention

• $100 million in grants for public health and prevention priorities

• $30 million in new resources to support the National HIV/AIDS Strategy

• $26.2 million to expand primary care to individuals with behavioral health disorders

• No cost sharing for preventive services for some plans

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SAMHSA Work

• Ongoing Communications – Website http://www.samhsa.gov/healthReform– Tip Sheets– Webinars

• Parity– Coordinating expert panel on various treatment

limitations– Assist DOL/Treasury re: Enforcement Issues– CMS and MCO Regulaitons

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What Else Should We Be Doing?

• Stay Excited

• Stay Informed

• Get and Stay Involved • Innovate