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Health Reform & The ACA: Promise and Possibility

Health Reform & The ACA: Promise and Possibility. H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services.

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Health Reform & The ACA: Promise and Possibility

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  1. HealthReform & The ACA:Promise and Possibility H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services COMP 10th Annual Training & Educational Symposium September 18, 2013 Los Angeles, CA

  2. “Each day, millions of Americans take courageous steps toward recovery from alcohol and drug addiction…the Affordable Care Act expands mental health and substance use disorder benefits and Federal parity protections for millions of Americans.” President Barack Obama

  3. “For too long we’ve had…really huge barriers to treatment and support for the mentally ill and substance abusers. One is that people have been uninsured and under-insured ...” Secretary Kathleen Sebelius U.S. Department of Health & Human Services

  4. “With 2014 fast approaching, behavioral health providers need to be getting up to speed now to make sure their businesses are prepared to cope with the changes full implementation of health reform will bring.” Pamela S. Hyde, J.D.Administrator, SAMHSA

  5. OTPs: Working to Meet the Need SD US Map: SAMHSA OTP State Profiles March 2010. SD, ND, WY, and total US SAMHSA certified OTPs updated by DPT 9/12/2013.

  6. OTPs: Working to Meet the Need * Examples of states with highest # of SAMHSA certified OTPs. U.S. data includes Guam, PR, and US Virgin Islands. SAMHSA OTP Database. 2010 (SAMHSA 11-4643) & DAMHSA DPT September 2013

  7. OTPs: Working to Meet the Need * Examples of states with highest # of clients served annually U.S. data includes Guam, PR, and US Virgin Islands. SAMHSA OTP Database. 2010 (SAMHSA 11-4643) & http://www.dpt.samhsa.gov/about/about.aspx

  8. OTPs: Working to Meet the Need * Examples of states with highest # of DATA waived clinicians. U.S. data includes Guam, PR, and US Virgin Islands. SAMHSA OTP Database. 2010 (SAMHSA 11-4643) & DAMHSA DPT September 2013

  9. Emergent Patterns and Prognosticators

  10. Substance Dependence or Abuse in the Past Year among Persons >12 years old Numbers in Millions Both Alcoholand Illicit Drugs Illicit Drugs Only Alcohol Only NSDUH 2012 + Difference between this estimate and the 2012 estimate is statistically significant at the .05 level. Note: Due to rounding, the stacked bar totals may not add to the overall total.

  11. Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons >12 years old Percent Using in Past Month Pain Relievers Tranquilizers Stimulants Sedatives NSDUH 2012 + Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.

  12. Specific Illicit Drug Dependence or Abuse in the Past Year among Persons >12 years old 2012 Numbers in Thousands NSDUH 2012

  13. Past Month Illicit Drug Use among Persons > 12 years old by Race/Ethnicity Percent Using in Past Month Black or African American White Hispanic or Latino Asian + Difference between this estimate and the 2012 estimate is statistically significant at the .05 level. Note: Sample sizes for American Indians or Alaska Natives, Native Hawaiians or Other Pacific Islanders, and for persons of two or more races were too small for reliable trend presentation for these groups. NSDUH 2012

  14. Past Month Illicit Drug Use among Persons Aged >12 years old Percent Using in Past Month Age in Years NSDUH 2012 + Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.

  15. Past Month and Past Year Heroin Use among Persons >12 years old Numbers in Thousands Past Year Past Month NSDUH 2012 + Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.

  16. Primary Opiates/Synthetics Admission Rates(Per 100,000 population >12; non-heroin) • Rate for opiates was 400 percent higher in 2010 than in 2000. • Rates increased in every year from 2000 through 2010. TEDS 2012

  17. CA Admissions by Primary Substance of Abuse2000-2010; >12 TEDS 2012

  18. Opioid Related Emergency Department Visits Large increase in the number of ED visits involving nonmedical use of pharmaceuticals observed between 2004 and 2011. Percentage change for opioid involved visits =183% increase. Oxycodone had the largest impact = 263% increase. Short term trend: 15% increase from 2009-2011. Pain relievers were involved in 38.0 % of drug-related suicide attempts. Narcotic pain relievers were involved in over a third of that number (13.9%). DAWN, 2013

  19. “A little less conversation, a little more action…”

  20. SAMHSA’s Strategic Initiatives • Prevention of MH/SUDs • Trauma and Justice • Military Families • Recovery Support • Health Reform • Health Information Technology • Data, Outcomes, and Quality • Public Awareness and Support

  21. Past Year Perceived Need for SUD Treatment >12 years old (2012) 20.6 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use 3.7% felt they neededtreatment but didn’tmake an effort 94.7% did notfeel they needed treatment 94.6% 1.7% felt they neededtreatment and made an effort NSDUH 2012 Fig 7.10

  22. Reasons for Not Receiving SAT among Persons > 12 years old Who Needed and Made an Effort to Get Treatment 2009-2012 Combined No Health Coverage and Could Not Afford Cost Not Ready to Stop Using Had Health Coverage But Did Not Cover Treatment /Cover Cost Might Have Negative Effect on Job Did Not Know Where to Go for Treatment No Transportation/Inconvenient Might Cause Neighbors/Community to Have Negative Opinion Did Not Have Time Percent Reporting Reason NSDUH 2012 Fig 7.11

  23. SAMHSA’s Health Reform Strategic Initiative • Increase access to appropriate high quality prevention, treatment, and recovery services. • Increase parity for MH/SUDs services to put on par with services for other medical conditions. • Support integrated, coordinated care, especially for people with behavioral health and co-occurring PH conditions. • Reduce health disparities.

  24. Health Reform & ACA Medicaid Coverage Expansion (133% FPL) New Insurance Exchanges (subsidies, 400% FPL) Improved service delivery (e.g., integration, coordination) Essential Health Benefits (EHBs): MH/SUD services BH parity Payment models reflecting improved service models & health outcomes as well as cost savings Expanded prevention services

  25. 10 Essential Health Benefits & Parity Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment

  26. OTPs & the ACA • ACA alters the services delivery andthe services reimbursement landscapes. • People have more choices for payment & delivery of BH; and more options for integrated, coordinated, comprehensive care (BH+PH). • All OTP providers need to understand ongoing emergent changes& adapt. OTPs *E.g., Covered California; employer-provided

  27. Snapshot: CA Uninsured • In a U. S. Census August 2013 report, CA ranked 10th highest among states for percentage of uninsured individuals. • Current estimates for the percentage of uninsured Californians typically range from 18-22%. • KFF estimates that the percentage of CA uninsured could decrease by 43.7% via ACA associated expansion.* http://www.census.gov/did/www/sahie/data/2011/SAHIE_Highlights_2011.pdf; http://kff.org/interactive/zooming-in-health-reform-medicaid-uninsured-local-level/

  28. ACA: Continuum of Coverage Insurance Coverage Options for Adults without Medicare or Employer-Based Coverage 0% FPL 133% FPL 400% FPL Adapted from “SAMHSA’s Enrollment Coalition”. David Dickenson

  29. Medicaid Expansion & California MH/SUD Needs • Medi-Cal expansion population beyond 2014 is estimated to be in the range of 1.5 to 2 million additional enrollees. • Between 279,000 and 373,200 individuals within the expansion population are estimated to need (but not necessarily ask for) mental health services. • Between 147,000 and 195,000 of the overall expansion population are expected to need substance use services. • 26% age 18-26 years • 40% age 27-44 years • 18% age 45-54 years http://www.dhcs.ca.gov/provgovpart/Documents/1115%20Waiver%20Behavioral%20Health%20Services%20Needs%20Assessment%203%201%2012.pdf

  30. Medicaid Expansion & California MH/SUD Needs • Early Medi-Cal enrollment of people with higher mental health and substance use needs is expected based on the experiences of other states. • Predicted higher co-morbidity of PH & BH issues for the early enrollees makes it imperative that multi-system approaches and integrated care coordination models be developed and implemented. • In the absence of system re-design for at risk populations (e.g., individuals with SUDs), these populations could continue to experience barriers to service access, poor treatment outcomes, and high utilization of costly services such as EDs and inpatient care. http://www.dhcs.ca.gov/provgovpart/Documents/1115%20Waiver%20Behavioral%20Health%20Services%20Needs%20Assessment%203%201%2012.pdf

  31. Health Reform & ACA: Integrated & Coordinated Health Care Services • Focus on holistic health, including prevention and recovery • Cross-disciplinary knowledge and understanding • Shared priorities/initiatives • Improved management and continuity of care • Coordinated and/or co-located service delivery • Consolidated reporting of client outcomes • Braided/blended funding streams • Linkage of health records

  32. Benefits of Integrated Care Research has found that individuals with co-occurring substance abuse/mental health disorders randomized into integrated care had significantly lower total medical costs than those in independent care.¹ By integrating substance abuse treatment and mental health services into primary care, the quality of health care available to these populations will improve – along with their health status. ¹ Parthasarathy, S. et al. (2001) J Stud Alcohol. 62(1): 89-97 ² Parthasarathy, S. et al. (2003) Med Care. 41(3): 357-367

  33. ACA: Integrated Care Models Primary care in MH/SUD settings through community health centers (CHCs) & other agencies MH/SUD services in primary care through Federally-Qualified Health Centers (FQHCs) Health Homes SBIRT Accountable Care Organizations

  34. Community Health Centers • Approximately 1,200 CHCs operate at nearly 9,000 service delivery sites nationwide and serve 21 million patients each year. • 36% Uninsured • 72% < 100% FPL • 93% < 200% FPL • 1.1 M homeless individuals • May 2013 HHS provided $150 million to CHC to enable them to give in-person enrollment assistance to uninsured individuals across the nation. http://www.hhs.gov/news/press/2013pres/05/20130509a.html & http://bphc.hrsa.gov/healthcenterdatastatistics/index.html

  35. Health Homes • Health Homes are a strategy for helping individuals with chronic conditions manage those conditions better. • Eligible individuals select a provider or a team of health care professionals to comprise their “health home.” • Health homes then become accountable for the individual’s care, including: • Manage/coordinate all services the person receives from multiple providers or programs • Promote good health • Help with transitions from one kind of setting to another. • Provide support to the individual and family members • Offer referrals to community and social support services.

  36. SBIRT • Embedding screening, brief intervention, referral & treatment of substance abuse problems within primary care settings such as emergency centers, community health care clinics, and trauma centers helps to: • Identify patients who don’t perceive a need for treatment, • Provide them with a solid strategy to reduce or eliminate substance abuse, and • Move them into appropriate services. 37

  37. Clients Receiving Buprenorphine at OTPs or non-OTPs ACA Rollout: Where will clients go for their BH & PH services? N-SSATS Report, April 23, 2013

  38. OTP Care Offered by Facility: Outpatient Only OR Overnight N-SSATS OTP Draft Report

  39. Are All Patients in the Facility in the Opioid Treatment Program? N-SSATS OTP Draft Report

  40. Is OTP Normally Scheduled to be Open 365 Days a Year?

  41. Does OTP Have a Formal Agreement for Medical Referral Purposes with…? N-SSATS OTP Draft Report

  42. Does OTP Have a Written Agreement to Permit Other Providers Access to Patient Records? N-SSATS OTP Draft Report

  43. Does OTP Provide Vaccinations for Hepatitis B or Influenza? N-SSATS OTP Draft Report

  44. Percentage of OTPs that Routinely Screen or Perform Diagnostic Tests for Diabetes N-SSATS OTP Draft Report

  45. Percentage of OTPs that Routinely Screen or Perform Diagnostic Tests for HIV/AIDS N-SSATS OTP Draft Report

  46. Percentage of OTPs that Routinely Screen for … N-SSATS OTP Draft Report

  47. Percentage of OTPs that Screen and Treat Depression N-SSATS OTP Draft Report

  48. Does This Facility Offer Payment Assistance? N-SSATS OTP Draft Report

  49. What Types of Client Payments or Insurance Are Accepted by This Facility? N-SSATS OTP Draft Report

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