1. ACA and Mental Health Care: Closing the Gaps NAMI Delaware Conference: January 24, 2013Rita Landgraf, Secretary, Department of Health and Social Services

2. Health Care Spending vs. Outcomes Source: United Nations Development Programme Report 2007-2008. Retrieved from www.unnatuaralcauses.org 2

3. ACA: Challenge and Opportunity Delawareans benefit from health care reform by: • Increased access to health insurance and quality health care, including mental health services. • Being supported in community-based settings. • Promoting healthy lifestyles.

4. Need for Increased Access • More than 45 million adults had a mental illness in 2011, according to a federal Substance Abuse and Mental Health Services Administration survey. • About 11 million had a serious illness. • More than 40% did not get care.

5. ACA’s Effect on Providers • Primary care re-established as gateway to medical care, including those in need of mental health services. • Systems and reimbursements will focus on patient outcomes and measurable standards. • Must transition from what Gov. Markell calls a “sick care system” to one that encourages positive outcomes and healthy behavior.

6. ACA’s Effect on Providers • Concern about geographic distribution of primary care providers, especially in underserved and rural areas, including Sussex. • For each member, the MCO must have a PCP available within 30 minutes or 30 miles of residence. • Every 2,000 patients = 1 PCP

7. Data on Primary Care Physicians The 2011 Primary Care Physicians in Delaware report found: • 888 active PCPs (FTE = 707 physicians; that’s down from 736 in 2008) • Population to provider ratio = 1,274 to 1 (up from 1,187 to 1 in 2008; capacity = 2,000) • 86% accept new patients, but only 69%-70% accept new Medicare & Medicaid clients

8. Patient-Centered Medical Homes • Transforms the organization and delivery of primary care.  • The practice treats the “whole” patient, including physical and mental health needs, coordinating care with specialists, hospitals, and home- and community-based care. • Convenient hours and secure communication organized around patient.

9. Health Benefit Exchange • Delaware’s HBE must go live by Jan. 1, 2014; enrolling clients by October 2013. • Pursuing a state-federal exchange partnership option rather than create a state exchange. • Partnership option permits Delaware to maintain control of plan management and consumer assistance functions.   

10. ACA: Medicaid Expansion • In January 2014, Delaware will widen eligibility up to 138% of the federal poverty level ($15,415 for an individual; $31,809 for a family of four). • State expects to cover anadditional 20,000 to 30,000 Delawareans. Federal government will pay 100% of the cost for newly eligible clients from 2014-2017; phased down to 90% of costs by 2020.

11. Why Medicaid Is Important • Medicaid is the largest payer for mental health services in the U.S. • It accounts for 27% of all expenditures for mental health services. • Individuals with mental health disorders represent 11% of the individuals enrolled in Medicaid. • And they represent almost 30% of all Medicaid expenditures.

12. Use of Health Care Services • Almost 12 million ER visits in 2007 involved people with a mental disorder, substance abuse problem or both. • Almost one-fourth of hospital admissions are associated with a mental or substance abuse disorder. • Medicaid coverage can help with access.

13. Among Goals for Coverage • Be able to identify and treat mental illness and substance abuse disorders in order to improve overall health. • Services and programs should be person-centered and support health, recovery and resilence of individuals. • Individuals and families should have choice. • Services should be of high quality and consistent with clinical guidelines or evidence-based practices. • Services should maximize community integration.

14. Mental Health Goals of ACA • Screen for mental and substance abuse disorders, including those in children. • Increase access to behavioral health services for people with serious and/or chronic disorders. • Improve integration of primary care and behavioral health.

15. Mental Health Parity Act • The 2008 act ended differences for benefits for people dealing with mental illness or substance abuse. • Health plans could not charge higher co-pays or deductibles for mental health services or place tighter limits on the number of therapy visits. • Protections applied only to health plans offered by large employers. • In 2014, ACA extends benefits to plans offered by small employers and those that individuals buy. Medicaid and CHIP will have to offer equivalent mental health benefits.

16. Delaware’s Workforce Needs • Delaware’s aging population, health care reform, and additional insured clients under Medicaid expansion and health benefit exchange will increase demands on health professionals. • To deal with shortage: Encourage nurse practitioners to practice to top of licenses, using prescriptive authority. • Electronic medical records: As of July, 95% of providers enrolled in the DHIN.

17. Delaware’s Workforce Needs • Delaware experiencing shortages among mental health providers, especially in Kent and Sussex. • Use State Loan Repayment Program to attract professionals. • Telehealth will help extend resources, especially for specialty care, including telepsychiatry. As of July 1, Medicaid now reimburses for telehealth-delivered care.

18. Community-Based Services • The right care in the right place at the right time. For mental health care, it means: • Receiving care in the most integrated and least restrictive setting possible. • 24/7 mobile crisis and mental health screeners. • Drop-in centers and peer support services. • State Rental Assistance Program to help with housing and increased employment opportunities. • HB311, reforming Delaware’s emergency mental health detainment law. • HJR17, creating a study group to review the state’s civil mental health laws.

19. YOUR TURN • What is important to you relative to mental health care, state government and the next term?