Preparing for Health Reform

1. Preparing for Health Reform Kathleen Reynolds LMSW, ACSW kathyr@thenationalcouncil.org May 22, 2012

2. The Presentation 1 - The Basic Elements 2 – Changes Expected 3 – The Implications

3. PURPOSES: • ~ 32 million newly insured • ~ 16 million with Medicaid • ~ 6-10 million new people with mental or substance use disorders • No dropping of individuals with pre-existing conditions • EBPs and technology to improve quality of care

4. COVERAGE TYPES: Private Same benefits – but also …. • No pre-existing condition exclusions • Guaranteed issue and renewal • No lifetime caps on benefits • Required coverage of dependent kids • Portability Benchmark against existing enrolled in CMS Essential Benefits for newly enrolled

5. OTHER ISSUES: • Privacy/Confidentiality HIPAA vs 42 CFR • State variability (for awhile) Covered services Amount of state funding match

6. OTHER ISSUES: • Training Emphasis • Significant grants for provider training • On-line Medicaid billing requirement • Federal/State funding “match” • “Essential services” 100% federal funds • Most prevention is 100% federal funds

7. The Presentation 1 - The Basic Elements 2 – Changes Expected 3 – The Implications

8. ??????????? “Substance Use Disorders”

9. Medicaid Benefit in Diabetes • Physician Visits – 100% • Clinic Visits – 100% • Home Health Visits – 100% • Glucose Tests, Monitors, Supplies – 100% • Insulin and 4 other Meds – 100% • HgA1C, eye, foot exams 4x/yr – 100% • Smoking Cessation – 100% • Personal Care Visits – 100% • Language Interpreter - Negotiated

10. Diabetes Benefits • Virtually all these are in primary care • Most are “visit benefits” not packaged • The term “dual disorder” originated here as diabetes and hypertension • Patients have rights and benefits designed to help them access care and to benefit from it

11. Population Prevalence In Treatment ~ 2,300,000 Addiction ~25,000,000 LOTS Diabetes ~ 24,000,000 “Harmful –60,000,000 Use” Little or No Use LITTLE

12. Current Addiction Benefits • Virtually all these are hospital benefits • Very few are “visit”benefits – almost all are program benefits • Very few care options, little variety within options • Comparatively little acknowledgement of patients’rights, little help with access

13. Future Benefits in Addiction • Virtually all these are in primary care • Most are “visit benefits” not packaged • Note patients have rights and benefits designed to help them access care and to benefit from it

14. The Presentation 1 - The Basic Elements 2 – Changes Expected 3 – The Implications

15. Care Continuum ~ 500,000 Primary Care Physicians + CNPs 1. Prevention Services Screening and Brief Intervention 2. Early Intervention Brief Counseling / Treatment 3. Office-Based Treatment Medications, Monitoring, Management 4. Referral to Specialty Care, And Referral Back for Continuing Care

16. Primary Care • Need “intervention research” with PCPs • Adherence assistance • Tele-health and Tele monitoring • New market for medications • 500,000 PCPs – other “prescribers” • Research on counseling in primary care • “Behavioral Health” focus? Family focus?

17. Primary Care • Adaptation of Health Homes to SUDs • 90% Federal funding for Health Home services • Emphasis on care integration and transition • Addition of case management services • Information exchange and decision support research • New information will be in EMR • Need standards, “performance measures”

18. Specialty Care • Most“treatment” funding will come from Medicaid and private health insurance • New populations – medical referrals • New billing requirements – reporting requirements • Emphasis upon outpatient care integrated into “Medical Home” • Emphasis on “Evidence Based” Practices • What is a profitable outpatient model?

19. Specialty Care • Emphasis/expansion home health services • Will “specialty care” fill this role? • Role of Block Grant could change • Recovery-Oriented services NOT covered in healthcare reform under Medicaid

20. Emphasis on Integrated Care • Substance use disorders are a (generally) chronic health condition as are asthma, hypertension, diabetes, and many mental illnesses • Positive outcomes related to reduced costs and abstinence have been shown for specialty care provided in parallel with primary care • Cost offsets have been shown for individuals and families related to SBI and use of medications in comprehensive treatment

21. What Is Integrated Care? • Comprehensive screening and assessment • Identification of a physical and behavioral health “home” that uses opportunities for collaboration and co-location • Shared development of care plans • Care coordination to provide support for consumers and providers • Engagement of consumers in self-management and care planning

22. What Is Integrated Care? • Standardized protocols, e.g., standardized assessment and protocols for CBT and MI that can be tailored to meet individual needs • Joint, standardized performance measures and feedback mechanisms, e.g., initiation and engagement • Mechanisms for sharing savings from reductions in high cost use • Electronic data systems capable of sharing data

23. Importance of Integration Current Isolation of Substance Use Conditions from Health Care • Only about 10% of those identified with substance use disorders are ever treated • Almost half who try to get help say they are denied treatment because of cost, lack of insurance, or lack of coverage • Access barriers have led to public funding becoming the vast majority – 75% now – of expenditures for treatment (DHHS, 2008)

24. Importance of Integration General Healthcare: • Almost 25% of general healthcare patients report they have a co-morbid substance use conditions likely related to the physical sequelae that result from untreated substance misuse and dependency (NSDUH, 2005) • Substance use conditions often complicate management and treatment of other chronic diseases in primary care such as diabetes, hypertension, asthma and others(PRISM, 2008)

25. Importance of Integration • More than 1.7 million visits to hospital EDs are related to some form of substance misuse or dependency (DAWN, 2006) • Drug and alcohol disorders are associated with about 3% of hospital stays and $12 billion in costs. (HCUP, 2006, 2007)

26. Reduced Costs • A study of SBI in family physician health clinics vs. usual care estimated an intervention cost of $205 that resulted in an average benefit per patient of $1,151 in reduced ER and hospital use and costs (Fleming, 2000) • Studies show a decrease of 50% in PMPM medical costs following outpatient addiction treatment. (Parthasaraty, Meretns et al., 2003)

27. There are new medications for treatment of addictions that are administered in primary care settings, e.g., buprenorphine and injection naltrexone. • Detoxification and induction for patients receiving new medications are receiving attention; new models for induction/medical education centers are emerging. • In integrated care we also need to focus on medication management that includes psychotropic medications for co-occurring mental disorders as well as medications for other chronic health conditions. Medications

28. Costs and Use: • Patients treated with medications in healthcare settings for either alcohol or opioid dependence have reduced inpatient hospitalizations and use of EDs and increased use of psychotherapy (Chalk et al. 2010, Aetna, 2009). • Yet, pharmacotherapy for substance use disorders was offered in <25% of specialty treatment programs (Knudsen et al, 2007), even though cost of medication treatment was very low (<1% of total treatment costs (Mark et al, 2009). • Low adherence with oral medications: 50% of patients fail to obtain their first refill compared to injection medications (Kranzler et al, 2008). Medications

29. Patients have identified a preference for office-based treatment in healthcare settings based on: • convenience (combining healthcare and medication management), • greater patient-focused orientation and increased role in decision-making about treatment, • a more supportive environment (including being “safer” for sobriety) compared with outpatient addiction treatment settings (Korthius, T., Gregg, J. et al., 2010) Medications

30. Integrated Care Models • Many different models of integration and enhanced coordination can be successfully implemented with a variety of patient populations • Models need to be a “fit” with the settings and the environment in which they are implemented

32. Health Homes • Upper end of integration continuum • Incorporate the concept of person-centered care delivery by MD lead team. • Team provides continuous and comprehensive care across all elements of complex health system • Team also has responsibility to improve the health status of its patient populations

33. The Role of Prevention in Integrated Care • How/where will substance abuse prevention land in the health home? • Funding is provided in Section 2703 for prevention services. Are we prepared to advocate for our prevention services as a part of that?

34. In Summary • Clinical models differ but are strategic for each State’s policy environment and historical treatment approaches • Goals are similar -- to provide seamlessly integrated care -- environment determines what approaches can be used initially

35. Financing Challenges Categorical Funding, the “Rehab Option,” and Billing: • Prohibitions re: “mixing” categorical funding prevent FQHCs and CHCs from using multiple funding streams even when they were available • Difficulty of disassembling “bundled” charges for billing purposes • Assuring that substance use treatment is supported as an “Optional Rehab” service by Medicaid is a state-by-state issue.

36. Financing Challenges (con’t) Coding, Preauthorization, and Denials: • Inflexible or inaccurate billing and coding systems • Multiple UM and preauthorization rules, and performance requirements • Providers lack knowledge or motivation to use reimbursable codes for procedures which are confusing (CPT vs. HCPC codes) and have different reimbursement levels

37. Financing Challenges (con’t) Co-pays, Reimbursement Rates, and Regulations: • Patient access is impeded by new or existing co-pays for these often indigent or low-income clients with multiple health issues • Public payer reimbursement rates vary by state and may be set very low, discouraging clinicians providers from offering services • State-by-State regulations re: Medicare/Medicaid “same day” billing for health and behavioral health visits is a barrier

38. Workforce Challenges Credentialing, Recruitment, and Retention: • Credentialing/staffing requirements of clinics reimbursed by Medicaid and addiction treatment specialties differ and are a barrier to hiring in integrated settings • Salary levels are low; counselors’ salaries nationally are below those of entry level workers at Burger King

39. New Types of Staff: • New types of staff are needed: behavior change coaches, care coordinators, patient “navigators”, “boundary spanners,” and behavioral health specialist/health educators • Training issues: new paradigms and emerging techniques for online training, on-the-job training and supervision seem not to be getting sufficient attention Workforce Challenges (con’t)

40. “Turf” and Attitudes: • Many providers are not willing to consider integrated substance use/health services because they view new models of care as threatening existing paradigms, organizational designs, and “turf.” • Negative attitudes about including patients with substance use disorders and the services they need in community health centers continue to be an issue. Workforce Challenges (con’t)

41. “Turf” and Attitudes: • Many providers are not willing to consider integrated substance use/health services because new models of care threaten existing paradigms, organizational designs/arrangements, and “turf.” • Negative attitudes about including patients with substance use disorders and the services they need in community health centers continue to be an issue. Workforce Challenges (con’t)

42. Information Systems and Technology • IT systems, electronic health records and electronic medical record investments are now significantly below what is needed by specialty treatment and primary care organizations to implement integrated care. • Few specialty and primary care settings use data to track outcomes and costs that are needed to support integrated care. • Patient consent, access to information, and consumer transparency are increasingly issues that will need to be addressed.

43. Health Reform and SUDs Public and private purchasers and providers are about to discover what it is like to work with people who are Insuredand who: • Want to make choices about their treatment and recovery services • Want treatment that is in compliance with standards of care • Want treatment and recovery services that are integrated with primary and other healthcare

44. Issues We Need to Address Performance, Quality, and Accountability Organization of Treatment Services Health Homes Primary Care Integration New Workforce Roles Consumer Choice • New Payer Sources and New Enrollees • Medical Needs and Care of Patients • Financing • Use of Funding Streams • Integration of Funding • Medicaid Eligibility and Benefit Design

45. THANK YOU For additional information and for questions Contact: Kathleen Reynolds LMSW ACSW kathyr@thenationalcouncil.org or Mady Chalk, Ph.D. at mchalk40@gmail.com