Health Reform, and Integration Challenges and Opportunities

1. Health Reform, and Integration Challenges and Opportunities WVAADAC Conference Center for Integrated Health Solutions Oct. 4, 2011

2. Agenda • Health Reform/overview • What is Integration? • Why Do it? • Challenges • Opportunities

3. A Changing Healthcare Landscape: Ensuring a Role for Behavioral Health • Affordable Care Act • Substance Use/Mental Health Parity • Merged Block Grant Submissions

4. 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.

5. 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

6. Health Care Reform

7. 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.

8. The Affordable Care Act: Four Key Strategies U.S. health care reform, with or without federal legislation, is moving forward to address key issues 8

9. 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

10. 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

12. Medicaid Expansions

13. 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?

14. 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.

15. 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

16. National Healthcare Reform Strategies and the MH/SU Safety Net In Treatment: 2.3 million Not 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?

17. Mental Health/ Substance Abuse Block Grant

18. In recent SAMHSA block grant application States were allowed to submit a combine MH/SA block grant application • Data was collected about state integration efforts

19. If ACA is implemented, changes to the block grant could be made, as Medicaid will become primary payer of services • Whether ACA is fully implemented or not Integration is on the minds of policy makers and payers

20. What does integration mean?

21. Substance Use & Mental Health Disorders • Behavioral Health (SU & MH) and Primary Care • Whole health approach for individuals with mental health and substance use problems • Considerations: Clinical, operations, financing

22. Bi-Directional Integration • Placing mental health and substance abuse services in primary care • Placing primary care services in mental health and substance abuse settings • Health Homes assume integration

23. Why Integrate Behavioral Health and Primary Care?

24. Surgeon General’s 1999 Report • This hallmark report was the first major emphasis on Integrated Care • Dr. David Satcher, former US Surgeon General (1998 – 2002), declared: • “There is no Health without Mental Health.”

25. 45 percent of Americans have one or more chronic conditions • Over half of these people receive their care from 3 or more physicians • Treating these conditions accounts for 75% of direct medical care in the U.S. • In large part due to the fact that money doesn’t start flowing in the U.S. healthcare system until after you become sick

26. Co-morbidities in the Adult Population Source: Druss & Walker. “Mental disorders and medical comorbidity.” The Robert Wood Johnson Foundation Synthesis Project, February 2011.

27. Supporting Data • People with mental illness die, on average, at age 53 (Colton & Manderscheid, 2006) • One in fourteen stays in U.S. community hospitals involved SU disorders (AHRQ, 2007) • 70% of primary care visits stem from psychosocial issues (Robinson & Reiter, 2007) • Nearly 60% of individuals with bipolar disorder and 52% of persons with schizophrenia have a co-occurring SU disorder (Verduin et al, 2005) • Approximately 41% of individuals with an alcohol use disorder and 60% of individuals with a drug use disorder have a co-occurring mood disorder (Verduin et al, 2005)

28. Causes of Premature Death in the General Population1 1. Schroeder S. New England Journal of Medicine 2007 Sep 20;357(12):1221-8

29. Ideal for treatment of the whole person • Reducing health disparities of people who live with serious behavioral health conditions • Bi-directional integration allows for individual choice in determining the Healthcare Home • More efficient and effective use of healthcare dollars

30. Many individuals served in specialty SU have no PCP Health evaluation and linkage to healthcare can improve 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 SU providers and primary care providers Care management is a part of SU specialty treatment and the healthcare home Primary Care in SU Settings

32. Doherty, McDaniel & Baird Integration Scale

34. 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

35. 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?

36. 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?

37. Primary Care and SU Services Diffusion of screening and brief intervention (SBI) is underway Motivational interviewing with fidelity should be a consistent component of SBI Repeated BI in primary care is a promising practice Medication-assisted therapies in primary care can be expanded

38. Challenges to Integration

39. Integration Discussion Points at the Clinical Level • Traditional separation of Substance abuse and Mental health issues from general medical issues • Lack of awareness of Substance Abuse/Mental Health screening tools in the primary care setting • Limited options for referrals and consultation with specialty Substance Abuse providers including psychiatrists, especially in rural settings

40. Integration Discussion Points at the Administrative Level • There is an absolute need for trust between the organizations for any collaboration to be successful • Administrative • Operations • Clinical • The partners must deal with issues like: • Fears of one org. entering the other org.’s turf • One org. taking over the other org., or learning how to do so

41. Cultural Integration at the Policy Level • Separation of physical health and Mental Haelth funding streams • Restrictions on allowable activities and services for community health centers and community substance use providers • Limitations on the population eligible for public mental health services • Statutory or regulatory restrictions of public organizations

42. Integration Discussion Points at the Financial Level • Provision of multiple services on the same day • Delivery of co-occurring services • Reimbursement of services which are currently not being reimbursed • Medication Administration (i.e. methadone) • Crisis Intervention • Peer Counseling • Medical visits that are distinct from the substance abuse service billed separately

43. Opportunities

44. Models of Integration?

45. Healthcare Models of the Future • Collaborative Care • Patient Centered Healthcare Homes • Accountable Care Organizations • Accountability and quality improvement are hallmarks of the new healthcare ecosystem

46. 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

47. Core Components of Collaborative Care

48. Person-Centered Healthcare Homes: • A new paradigm

49. 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?

50. 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