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A National View: Healthcare 2008

A National View: Healthcare 2008. CBHC Annual Training Conference October 5, 2008 Charles Ingoglia, MSW Vice President, National Council for Community Behavioral Healthcare. Today…talk about. Opportunities and Challenges 2008 National Healthcare Debate

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A National View: Healthcare 2008

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  1. A National View: Healthcare 2008 CBHC Annual Training Conference October 5, 2008 Charles Ingoglia, MSW Vice President, National Council for Community Behavioral Healthcare

  2. Today…talk about • Opportunities and Challenges • 2008 National Healthcare Debate • National Council Public Policy and The State of Medicaid • Taking Charge – relationships, quality and communications

  3. The National Council • Not for profit association of 1500 + mental health/addiction treatment and rehabilitation organizations • Member organizations employ 250,000 staff and provide services to 6 million adults and children in communities across the country

  4. Membership

  5. Our Vision – the big picture A nation where there is prevention and early detection of mental illnesses and addictions; and everyone has access to the effective treatments and supports essential to live, work, learn and participate fully in their communities.

  6. Our Job The National Council is the interface between practice and policy. We are the national voice for legislation, regulations and policies that protect, strengthen and expand access to mental health and addictions services. Your job is to support others, our job is to support you.

  7. Members – Top Issues • Funding, Medicaid, Medicare • Reform – privatization, competition, managed care • Workforce • Health Integration • Technology

  8. Time of opportunity Surgeon General Satcher, President Bush’s New Freedom Commission, and The Institute of Medicine all agree that: • mental health and freedom from addictions are vital to overall health • effective treatments exist and recovery is possible

  9. Opportunity • Up to 90% of people with a mental illness that are treated with a combination of medication and therapy experience substantially reduced symptoms, enhanced quality of life & increased productivity • Science has revolutionized our understanding of addictions – treatment has been shown to cut drug use in half, reduce crime by 80% & reduce arrests up to 64%.

  10. Challenges • Each year 100,000 + Americans die from alcohol and drug abuse. • 50% jail/prison inmates have mental health problem, 75% substance abuse. • 2/3 homeless - chronic alcoholism, drug addiction, mental illness or combination. • 25% of all hospital admissions have mental illness or addictions disorder. • 25% social security payments are for mental illnesses.

  11. Challenges • Staffing crisis - low prestige and salaries/ high turnover • Limited use of outcome data to refine treatment/research based practices • Limited use of knowledge based technology/neuroscience and biological advances • Low rates of access, retention & adherence

  12. Challenges • Ambivalence about healthcare: chronic illnesses v. recovery; integration? • Complexity of serious mental illnesses – early mortality – poverty • Protecting individuals with mental illness from harm v. protecting society • Late detection – complex U.S. system

  13. Challenges • No uniform standards of care and layers of regulation and oversight • Multiple hospital and community providers with fierce competition for Medicaid • Dependence on Medicaid and limited to no access for non – Medicaid

  14. The Healthcare Debate

  15. U.S. Healthcare System • The financing system is • Inefficient • Inequitable, and • Fiscally unsustainable. • The delivery system is • Fragmented • Not designed to care for chronic diseases • Haphazard and poor quality • High use of unproven, marginal therapies.

  16. Costs • In 2006, the U.S. spent $2,100,000,000,000 --$2.1 trillion –on health care. • $1 out of every $6 spent in the U.S.

  17. Costs How Big is a Trillion? • 1 million seconds Last week • 1 billion seconds Richard Nixon’s resignation • 1 trillion seconds 30,000 BCE

  18. Costs • 47 million without health insurance • 16% of GDP – no other country above 10% • Fragmented array of insurers and providers drive high administrative costs: 25-35% compared to 15% • $5,711 per person, Switzerland $3,847; 31st in life expectancy • Insurance premiums doubled since 2000

  19. Costs • We pay hospitals and doctors more • Rely on specialists, using high cost diagnostics & interventions offering possibility of improvement • Little to no use of comparative effectiveness/No budget • 75% of costs by 4-5% with chronic illnesses and at end of life.

  20. Costs Extremely wealthy country; most like their providers – change for everyone else, but • By 2028, health care will consume 28% of GDP. This is as much as all federal, state and local governments currently spend. • By 2050, Medicare and Medicaid will consume all federal taxes. “Even in fantasy, no one has yet come up with a way to pay for Medicare.”

  21. Solutions? • Managed care: largely unable to reform care delivery/hated by all • Control drug costs, allow Medicare to negotiate: small piece of the pie • Pay for Performance: more to providers already doing the right thing, others won’t change for additional 2% or 5% • IT: long term can reduce paperwork burden, errors and repeated tests

  22. Solutions? • Prevention/Disease management/Medical homes: not clear if or when get savings: • Skin in the game: 1974 to 1982 Rand study - 30% saving when people paid with same outcomes, exception low income people in poor health • Close hospital beds: match lower spending regions save 20% to 30%

  23. Healthcare Reform • True health care reform must fix both the financial and delivery systems. • Unfortunately, most public discussions focus exclusively on the financing system and getting to (or close to) universal coverage. They ignore delivery system reform.

  24. Incremental Reform • Incremental reform is business as usual. • If you like the current system, you like incremental reform. • Builds on a broken system. • Fails to achieve universal coverage, no cost control, no improved delivery system.

  25. Political Feasibility Many barriers to change: 1) Rule ofSatisfaction—85% of Americans have health insurance and many are satisfied. 2) James Madison Rule ofGovernment—American government was designed with many places for special interests to kill legislation. With 16% of the GDP, health care has many special interests.

  26. Political Feasibility A majority of Americans are for health care reform. But they are divided among many different plans. After their preferred reform, their second choice is the status quo.

  27. 2007 Lobbying Leaders • US Chamber of Commerce $52,750,000 • General Electric $23,660,000 • Pharmaceutical Rsrch & Mfrs of America $22,733,400 • American Medical Assn $22,132,000 • American Hospital Assn $19,734,545 • AARP $19,540,000 • Exxon Mobil $16,940,000

  28. Healthcare Lobbying in 2007 • Pharmaceuticals/Health Products $226,757,501 • Hospitals/Nursing Homes $91,208,297 • Health Professionals $70,378,540 • Health Services/HMOs $52,990,044 • Misc Health $4,985,719 Total spending: $446,320,101

  29. What we must do… • Broad, strong, engaged membership. • Assertive/focused policy agenda. • Strategic alliances - industry leadership. • Reputation for quality - expert education & practice improvement initiatives. • Effective communications with members, media, advocates, policymakers & public.

  30. The National Council An assertive, focused policy agenda

  31. Assertive, focused policy agenda • Understanding and Defending Medicaid • Parity/ Medicare • Veterans • Criminal Justice: Mentally Ill Offender Treatment and Crime Reduction Act/Second Chance Act • Community Mental Health Services Improvement Act - Primary care in behavioral sites

  32. Assertive, focused policy agenda The State of Medicaid

  33. In 2007, Over 2/3 of States Offered New Proposals • Governors in 34 states offered plans to reduce uninsured children, parents, adults, aged and disabled in their state through • Medicaid expansions • SCHIP expansions • DRA waivers • Comprehensive Section 1115 waivers • Prevention and better management of chronic conditions

  34. 2008 Response: • Expansion plans in jeopardy or delayed • States once again freezing or cutting rates

  35. Illustrative Medicaid Dynamics; Ohio Department of Mental Health State General Fund and Medicaid FY 1990 – FY 2007 millions millions $200 $200 Medicaid FFPMedicaid MatchRemaining GRF $150 $150 $100 $100 $50 $50 $0 $0 -$50 -$50 -$100 -$100 The Squeeze -$150 -$150 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

  36. Federal Regulations Reflect Federal Goals • Make Medicaid look like commercial health insurance.” • “Medicaid should not be a financing option for other public systems for non-Medicaid purposes.” • “Rein in federal health spending.”

  37. It’s Raining Regulations! • 10 new regs in first six months of federal fiscal year (15+ in last 2 years) • Most issued as either “interim final” regulations or with shortened public comment periods • Fighting new regs – Congressional moratoriums

  38. Council Leadership - Rehab Option/Case Management • In DRA, Congress rejected Bush efforts to legislate changes - President uses administrative measures for $6.1 billion savings over next 10 years • Council – member political heat, member testimony, rallying partners • Achieved moratorium • Working with Congress on legislation to address rehab and case management regs  

  39. Assertive, focused policy agenda Parity

  40. Commercial Parity Senator Paul Wellstone Mental Health Parity Act of 2007 – parity for both mental health and addictions treatment services • Senate - introduced by Senators Edward Kennedy (D-MA), Michael Enzi (D-WY), and Pete Domenici (R-NM)/House - introduced by Representatives Patrick Kennedy (D-RI) and Jim Ramstad (R-MN) • Rally on 9/17; ad campaign • Agreement on content, added to rescue/tax bill (AMT)

  41. Parity Use The Toll-Free Parity Hotline: 1-866-parity4(1-866-727-4894, the Parity Hotline reaches the U.S. Capitol switchboard, which connects you to your Senators' offices.) "I'm calling to ask that the Senator vote YES on the energy and tax package that includes parity for mental health and addiction services. This legislation must pass this month before Congress adjourns."

  42. Medicare • Historic milestone – Congress ( HR 6331) ending discrimination of outpt. mental health benefits between 2010 and 2014 • Re-authorization of SCHIP - 2 provisions related to Medicare:1.marriage&family therapists and licensed professional counselors as providers 2. additional covered services including case management, ACT, rehab • Vetoed by President but passage by Congress is important legislative record moving forward

  43. Assertive, focused policy agenda Veterans

  44. Veterans authorization • S. 38 calls for the VA to contract with community providers to meet needs of reserves and National Guard • Recent VA directive to all VISN'S that describes expectations for access and services and calls for individual medical centers to contract with community providers

  45. Veterans appropriations $100 million to be allocated to community mental health organizations in the Veterans Administration’s health care budget line-item to increase mental health care for National Guard members, reservists, and family members of veterans with service connected mental disorders

  46. Assertive, focused policy agenda Community Mental Health Services Improvement Act

  47. Community Mental Health Services Improvement Act • Primary care in behavioral sites *** • Co-occurring disorders funding demo • Workforce improvements, salary study • Paperwork reduction - elimination of regulatory redundancy • Advancing tech. & electronic health record • Rural behavioral health treatment incentives

  48. Assertive, focused policy agenda • Coming soon

  49. Coming Soon • Federal funding stream to cover the mental health treatment costs of the uninsured • Restore eligibility for social security disability for people with addictive disorders • Cost based re-imbursement that supports salaries that can attract and retain skilled staff • Chronic disease management project – medical home

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