Where Should We Lead? The Role of Psychiatrists in a ‘Reforming’ Public and Private System

2. Where Should We Lead?The Role of Psychiatrists in a ‘Reforming’ Public and Private System Marvin Swartz, MD Professor and Head Social and Community psychiatry Director, Duke AHEC Program Duke University School of Medicine

3. A Brief National and Local Context • Rise then depopulation of the state hospital • Promise and pitfalls of the community mental health center movement • Rise of behavioral health managed care (carve-outs) • NC mental health reforms • Hopes for parity and health care reform

4. Dorothea Dix: Mission to Establish Asylums • Visited nearly every state testifying to state of mentally ill • Spurred establishment of many state hospitals • Convinced Congress to establish land grant for mentally ill

5. Franklin Pierce Veto 1854 • Pierce vetoes a bill sponsored by Dorothea Dix calling for the sale of federal lands to subsidize institutions for indigents with mental disabilities: “[I]f Congress has the power to make provision for the indigent insane. . .it has the same power to provide for the indigent who are not insane, and thus to transfer to the Federal Government the charge of all the poor in all the States.... “

6. President Kennedy’s Message “We must act to bestow the full benefits of our society to those who suffer from mental disabilities; to prevent occurrence of mental illness…wherever and whenever possible; to provide for early diagnosis and continuous care in the community, of those suffering from these disorders; to stimulate improvements in the level of care given the mentally disabled in our State and private institutions, and to reorient those programs to a community-centered approach; to reduce, over a number of years and by hundreds of thousands, the persons confined to these institutions; to retain in and return to, the community the mentally ill… and there to restore and revitalize their lives through better health programs and strengthened educational and rehabilitation services…”Kennedy, J.F., Message from the President of the United States Relative to Mental Illness and Mental Retardation, Washington D.C.: USGPO, 1963.

8. CMHC Movement • Build out and growth in 1960s—serving catchment areas of ~200,000 • Initial direct federal funding • Hampered by lack of clear direction or consensus on target populations • Hopes for dramatic re-vitalization during Carter administration thwarted by Reagan defunding of Mental Health Systems Act of 1980 • Dwindling federal support and transition to Medicaid

9. Advent of Behavioral Health Managed Care • Late 1980s --Mental health care seen as open-ended & discretionary (“worried well”). • Co-incident rise of private psychiatric hospitals led to unnecessary stays • Specialized (carve-out) managed care companies offered employers separately managed behavioral health insurance plans. • Many insurers chose to implement these carve out plans—legally—due to lack of parity

10. Value of Private Behavioral Health Benefits, 1988-1998 (NAPHS/Hays Group) $2527 $2169 $2372 $2099 6.2% 3.2% $155 $70

13. . Source: Substance Abuse and Mental Health Services Administration. (2011). National Expenditures for Mental Health Services & Substance Abuse Treatment 1986-2005. Washington, DC. As cited in Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC.

14. Boyd et al: Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations Center for Health Care Strategies, December, 2010.

15. Boyd et al: Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations Center for Health Care Strategies, December, 2010.

16. Key Elements of State Plan • Per state: Area Programs can not have dual role as manager and provider of care • Area Programs supplanted by Local Management Entity (LME) • Divestiture: privatizes care from public to private providers and directs LME to develop provider networks. • Eliminate 700 state hospital beds by 7/1/06

17. Source: NC Division of MH/DD/SAS

18. Re-investment Strategy—“Medicaid it” • State hospital admissions not Medicaid reimbursable for adults ages 22-64 (IMD Exclusion). • Reduction of State bed dollars can leverage Medicaid community-based services ($1 state $3 Medicaid). • BUT: Need existing community capacity to reduce admissions—bridge funding needed. • Early years--Downsizing savings not realized.

20. Reforming Reform (Perdue) • Perdue administration attempts to restore medical accountability—creates CABHAs (critical access behavioral health agency) • New Legislature very worried about Medicaid shortfalls, potential expansion under ACA • Mandated rapid expansion of Medicaid Managed Carve-out Plan---1915b/c Waiver • New challenges: • Must use substantial state dollars for DOJ settlement • What are implications of Mental Health Parity and Health Reform?

21. Federal Parity Legislation: Background • Wellstone and Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) enacted 10/3/2008 as part of ARRA • Creates “Equal rights in health insurance”—ends insurance discrimination • Federal predecessor—Mental Health Parity Act of 1996 • Eliminated differential annual or lifetime limits • Covered large group market, but not small groups or self-insured plans • Excluded substance use disorders • No prescription benefit

22. MHPAEA Features • Continues existing legal provisions—annual and lifetime limits • Applies to large group market and insurers • Including ERISA groups • State and local govt. • Medicaid managed care organizations (?) • Adds substance use disorders to disorders protected • Adds special rule for prescription drug benefits • Does NOT cover: plans under 50 people, the individual market and Medicare

23. Other MHPAEA Features • Does not mandate mental health benefit coverage • If MH covered, plan must comply for those benefits • Opt out for state and local government self insured plans • Generally effective January 1, 2011

24. Federal Parity Rules issued 11/13 • Prohibit plans from imposing any different: • Financial requirements (eg. Co-pays, deductibles) • Treatment limitations • Quantitative Treatment Limitations (eg. 30 day hospitalization) • Non-quantitative Treatment Limitations (eg. utilization review standards and processes, definitions of medical necessity) • “Requirements and limitations can not be any more restrictive than the predominant ones applied to substantially all the med/surg benefits within the same benefits classification”

25. Health Care Reform (ACA) Features • Integrates MH into reforming health system • Adds preventive services/screening (eg. depression) • Makes MH/SA treatment an essential benefit in health exchange plans • Increases access • Medicaid expansion up to 133% of poverty • Affordable private coverage through HI Exchanges • Adds coverage through age 26 for dependents • Eliminates pre-existing conditions • BUT: eliminates Disproportionate Share Funding

28. Where Should We Focus? • Staying at the table at policy forums • Resisting marginalization in MCO and provider organizations • Fighting for Parity • Advocating for Medicaid Expansion and sensible system reform • Leading on MCO performance and quality metrics • Addressing Psychiatry workforce shortages and solutions • Leading clinical care redesign • Leading the efforts on Integrated care • Finding efficiencies—Medicaid formulary example

29. Will the MH/SA Workforce be Adequate to Benefit and Enrollment Expansion? “It is difficult to overstate the magnitude of the workforce crisis in behavioral health.” --SAMHSA /Annapolis COALITION

32. The Nation’s Behavioral Health Workforce Crisis (Annapolis Coalition) • “Across the nation there is a high degree of concern about the state of the behavioral health workforce and pessimism about its future. • There is equally compelling evidence of an anemic pipeline of new recruits to meet the complex behavioral health needs of the growing and increasingly diverse population in this country. • It is difficult to overstate the magnitude of the workforce crisis in behavioral health. The vast majority of resources dedicated to helping individuals with mental health and substance use problems are human resources, estimated at over 80% of all expenditures. “

33. Workforce Training (Annapolis Coalition) • “There is overwhelming evidence that the behavioral health workforce is not equipped in skills or in numbers to respond adequately to the changing needs of the American population. • Most of the workforce lacks the array of skills needed to assess and treat persons with co-occurring conditions. • Training and education programs largely have ignored the need to alter their curricula … and, thus, the nation continues to prepare new members of the workforce who simply are underprepared from the moment they complete their training.”

34. A Behavioral Health Workforce in Crisis • The workforce issues encompass difficulties in: • recruiting and retaining staff, • the absence of career ladders for employees, • marginal wages and benefits, • limited access to relevant and effective training, • the erosion of supervision, • a vacuum with respect to future leaders, • financing systems that place enormous burdens on the workforce to meet high levels of demand with inadequate resources. How will NC respond to the workforce shortages?

35. Can NC Grow it’s Way Out of Psychiatry Shortages? • GME (Residency) slots are capped at 1996 level—can’t grow more • Most of the counties with psychiatry shortages are also primary care shortages! • Need different models of care • Calls for task-shifting and collaborative care type models.

36. Provider Shortages, Care Re-design and Psychiatry • In every health care reform scenario there is a shortage of psychiatrists • If we can not grow our way out of psychiatry manpower shortages—what remedies do we propose? • What is our strategy for primary care? • Specialty mental health care? • What is the role of collaborative and team-based care?

37. Gov. McCrory: Partnership for a Healthy NC • New Legislature and Governor want Medicaid budget predictability--“write a check for Medicaid” • Propose a new wave of Medicaid reforms to control costs and integrate general and behavioral health • Proposes 1115 Medicaid Waiver and 6(?)Regional Comprehensive Care Entities • Three key issues: • Carve-in vs. carve-out • Privatization • Risk assumption

38. Whither “Reform?” • Arguably—National trend is toward “carving-in” behavioral health and strengthening primary care homes. • Community Care of NC—prime example of Enhanced PCMH • Few states are currently moving ahead with pure carve-out models for Medicaid Managed Care • How does “carving out” mental health care affect other parts of the Medicaid program? • How does “carving in” address the highly specialized needs of severely mentally ill patients? • Privatization can also be a failure—how are contracts structured and effectively monitored by the state?

39. Source: Bob Atlas NC DHHS Consultant, November , 2013

40. Source: Bob Atlas NC DHHS Consultant, November ,2013

41. CAUTION: Tennessee's Failed Managed Care Program for Mental Health and Substance Abuse Services In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs. Source: Chang et al, JAMA. 1998;279(11):864-869.

42. Adequate Administrative Capacity is Key to Realizing the Goal of Running a High Performing Medicaid Program. A state’s ability to make the most of the opportunities currently available to it depends on its ability to effectively and efficiently manage its program. Administrative capacity includes at least three key elements: resources, skills and systems. During an economic downturn, when the need for a balanced budget requires significant cuts, the Medicaid program can be an obvious target, as a major portion of the state budget. Often state legislatures will resist cutting services and the administrative budget takes the deepest cut, with the impact of that cut magnified by the reduced federal match: a $1 cut in state dollars results in a $2 cut in the Medicaid agency’s administrative budget .

43. Adequate Administrative Capacity is Key to Realizing the Goal of Running a High Performing Medicaid Program. In the midst of the most recent recession, staff furloughs have been a common strategy for managing administrative funding reductions. While these reductions have leveled off in recent years, increased investment in funding and staffing Medicaid agencies has been limited. As a result of budget cuts fewer staff members are available to carry a heavier burden. Timelines for implementing ACA reforms has also increased demands on Medicaid program staff Within the level of resources provided, state personnel and contracting requirements can either support or impede the effective deployment of resources Whether fulfilling its basic responsibilities for administering a Medicaid program or retooling its operations to respond to new demands, a Medicaid agency does not always have the discretion to hire needed staff .

44. Adequate Administrative Capacity is Key to Realizing the Goal of Running a High Performing Medicaid Program. With these restrictions on hiring and procurement decisions, state Medicaid programs must compete for sophisticated clinical, financial and analytic expertise that can match that of the managed care organizations and providers they are negotiating with yet they can rarely pay what the private sector does. In some cases, the state will opt to contract out for expertise, but the lack of investment in in-house expertise can limit access and leave that expertise vulnerable to contract renewals and negotiations. However, even when a state contracts out for expertise, the state needs the staff capacity to oversee those contracts and consultants. .

45. Adequate Administrative Capacity is Key to Realizing the Goal of Running a High Performing Medicaid Program. Unfortunately, the natural forces of the state budgeting process often work against state investment in a Medicaid program’s administrative capacity, at the same time that the complexity of managing a Medicaid program has only increased over time. Inadequate investment in Medicaid administrative capacity could undermine a state’s ability to fulfill its responsibilities under federal and state law, as well as its ability to achieve the most from this important program. .

46. Critical Issues for Medicaid Managed Care Implementation in NC • DHHS and DMA will be very hard pressed to oversee and monitor a new Managed Medicaid program. • DHHS and DMA need resources, skills and systems on staff—not among consultants to monitor new vendors. • Will need well developed contract/performance management measurement. • Should pilot approach in one region as we did with PBH and 1915b/c waiver.

47. What is Psychiatry’s Role in Performance and Outcomes Measurement? Psychiatry’s Role in priority setting in Public and private managed Care

48. Purpose of measurement Classifications of indicators Accountability Measure for Summative presentation and comparison Structure Setting of care delivery Process Activities between practitioner and patient Outcome Effectiveness and efficacy Quality improvement Measure for improvement Performance measurement Performance management Measure to predict effect of management interventions Source: Baars et al, Int J Health PalnnMgmt2012; 25: 200. DOI: 10.1002/hpm

49. Stewardship of the Formulary Opportunities For psychiatrists to Offer Value to Public and Private Health Plans

50. . Source: Substance Abuse and Mental Health Services Administration. (2011). National Expenditures for Mental Health Services & Substance Abuse Treatment 1986-2005. Washington, DC. As cited in Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC.