Health Care Reform and Psychology Katherine C. Nordal, PhD

1. Health Care Reform and Psychology Katherine C. Nordal, PhD Executive Director for Professional Practice American Academy of Clinical Neuropsychology June 22, 2012

2. Compelling Need for Health Care Reform • One of the only developed countries without universal health coverage • About 45 million Americans uninsured • Fragmented system with variable quality • Increased life expectancy but often with chronic illness

3. The Economic Context for Reform 2010 Healthcare expenditure = $2.7T Healthcare is single largest contributor to national debt Federal expenditures 2010: Medicare = 15%; Medicaid = 8%; Social Security = 20%; Defense = 20% By 2020, Fed. Govt. will pay 49% of all health State budgets in worst shape since WWII

4. The Economic Context for Reform • Healthcare costs in 2009: • 1% population = 21.8% of costs • 10% population = 63.6% of costs • 50% of population = only 2.9% of costs • Medicare spending: • 5% beneficiaries = 43% costs • 25% beneficiaries = 85% costs • 50% beneficiaries have >5 chronic illnesses • Medicaid spending: • 15% are disabled and = 43% of costs • 10% are elderly and = 23% of costs • Summary: 25% of population = 66% of costs

5. The Economic Context for Behavioral Health Care • Mental Health Spending • 1986 = 7.5% of all health spending • 2003 = 6% of all health spending • 2014 = 5.9% of all health spending • Psychologists/LCSW/LPCs = only 8% of mental health pending, or 0.047% of mental health $$ • Medications will be 30% of mental health spending by 2014 • Psychologists are approximately 16% of the behavioral healthcare workforce • 58% mental health spending is in public sector

6. Enactment of Health Care Reform After 1½ years of tumult and negotiation, President Obama signed into law both the: • Patient Protection and Affordable Care Act (P.L. 111-148) on March 23, 2010 • Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) on March 30, which includes a package of amendments

7. Key Challenges Facing Health Care Reform

8. Overall Goals of Health Care Reform • To preserve employer-based health insurance • To expand coverage to 32 million more Americans (Medicaid, Insurance Exchanges) • To transform the health care system to address the needs of the whole patient through: • Preventive Services • Primary and Integrated Care • “Triple Aim”: better care experience; better health outcomes; lower cost

9. Insurance Market Reforms in Affordable Care Act • No lifetime or annual dollar limits • No rescissions of coverage except for fraud • Coverage of pre-existing conditions • Guaranteed coverage acceptance and renewal • Requirement of effective appeals process • Establishment of premium rating requirements • Prohibition of participant and provider discrimination • State consumer assistance offices

10. Health Care Reform: Remains a Work in Progress • Many of the law’s key provisions – such as those that establish the state health insurance exchanges – will not go into effect until January 1, 2014 • New law is facing serious challenges by House Republicans in Congress and by governors and state attorneys general through the federal courts

11. Ongoing Congressional Attacks on Health Care Reform • House voted in January 2011 to repeal the health care law, whereas the Senate voted in February against repeal • House voted in April to cut off funding for health care reform for Fiscal Year 2011, which the Senate did not support

12. State Legal Actions Pending Against Health Care Law • To date, 30 states have challenged the constitutionality of the ACA: • Two federal judges upheld the law • One judge invalidated the individual mandate provision • One judge struck down the entire law • Supreme Court Decision 6/2012

13. APA Health Care Reform Priorities • Integrated Health Care • Mental and Behavioral Health Care • Prevention and Wellness • Psychology Workforce Development • Elimination of Health Disparities • Support for Psychological Research

14. Why Focus on Integrated Care? • Aspects of overall health are missed by sole focus on physical or mental health • Behavioral factors are leading causes of chronic illness and mortality • Chronic illness accounts for 75% of nation’s health spending

15. Why Focus on Integrated Care? • At least half of mental health treatment is provided in primary care • High co-existence of physical disorders and behavioral health problems • Adults with SMI in public sector die younger ( by 25 years)due to untreated physical health problems

16. Psychology’s Strengths in Integrated Care • Psychological and neuropsychological assessment • Applying behavioral principles to modify health-risk factors • Promoting patient responsibility and resilience • Attending to interpersonal barriers to behavior change • Understanding environmental determinants of behavior • Designing, monitoring, and evaluating interventions

17. APA and Integrated Health Care APA Implementation Efforts: • Promoted the inclusion of psychology in the new integrated health care initiatives • Arranged meetings to enhance partnerships with primary care organizations representing nurses, physicians, and medical students • Joined the Executive Committee of the Patient-Centered Primary Care Collaborative, a coalition dedicated to promoting the “patient-centered medical home”

18. ACA Impacts Behavioral Health • Eligibility and Service Delivery • Covers persons up to 133% of FLP by 2014 (adds 16-22M folks) • Essential Health Benefits with parity for Medicare Advantage, Medicaid Managed Care, CHIP, and Benchmark Plans • Preventive Care and Wellness • Health Home options for SMI and those with 2 or more chronic illnesses (with significant federal $$ to Mcaid for first 2 years)

19. ACA Impacts Behavioral Health • Eligibility and service delivery: • Accountable Care Organizations (ACOs): composed of integrated provider networks with shared electronic records, practice protocols, performance incentives • Patient-Centered Medical Homes (PCMH) • Home and Community Based Services Options • Co-location grants for behavioral health and primary care—training grants for co-located care • Dual Eligible Care Management

20. ACA Impacts Behavioral Health • Payment and Performance: • Global, bundled, episode payments • Pay for Performance • Higher rates for PCPs • Medicare Shared Savings • Integrated care grants and training grants (like GPE) • FQHC investment of $11B • Quality Measures (11 of 51 are behavioral health) • Clinical Effectiveness Research

21. Implications of Health Care Reform for Psychology • Psychology’s expanded role: primary care, integrated delivery systems, assessment and care planning, behavior change for wellness and treatment of chronic disease, prescribing and medication management • Increasing demand for the use of EBPs and clinical outcome measures • Implementing advances in telehealth, HIT, and electronic health records • Addressing health disparities and increased emphasis on cultural competencies

22. Implications of Health Care Reform for Psychology • Need to adapt to new models and systems of health care delivery • New skills and training models needed for integrated, interdisciplinary and team-based care • Payment reforms: bundled payments, shared-savings models, ACOs, etc. How will psychologists in both public and private sector be paid?

23. Opportunities for Psychologists Prevention and Health Promotion: • Elimination of cost sharing for eligible preventive services • Depression screening for adolescents and adults • Screening and counseling for child and adult obesity • Counseling for alcohol misuse and tobacco use for adults • New initiatives funded under the Prevention and Public Health Fund • New incentives for corporations to promote employee health and reduce workplace stress

24. Opportunities for Psychologists Client Populations and Clinical Settings: • Increased client access due to insurance reforms and new state health exchanges at parity • New grant program to establish community-based, interdisciplinary health teams to support primary care • New Medicaid state option for health teams and health homes to treat persons with at least two chronic conditions (including serious mental disorders)

25. Challenges to Psychology Practice • Difficult economic times • Stigma surrounding seeking mental health care • Pressures from public and private payers to reduce costs • Psychologists are a small part of the pool of mental health providers and psychotherapy has become a commodity to be purchased at the lowest possible cost

26. Challenges to Psychology Practice Accessing capital to meet health information technology demands Adjustment from FFS to other payment mechanisms that may be required for participation in ACOs Provider reimbursement if global rates are not risk adjusted and performance payments do not take into account disparities in outcomes for individuals with SMI and substance use disorders

27. APA Practice Organization at Work • Coordinated over 300 Capitol Hill visits for the 2012 State Leadership Conference: • SGR • Medicare Physician Definition (HR.831, S.483) • BHIT (5.539) • Advocated successfully for law enacted in December that halted the threatened 25% cut in the Medicare Sustainable Growth Rate (SGR) through 2012

28. APA Practice Organization at Work Medical Economic Index (MEI): Objected to revisions that would negatively impact psychologists due to their low practice expense. 22 MOCs wrote to CMS on our behalf. Advocacy for additional protection of psychological test data under HITECH Letter to Secretary Sibelius to urge inclusion of psychologists as participants in ACOs, thereby ensuring better access of Medicare beneficiaries to mental health, substance abuse, and behavioral health services

29. APA Practice Organization at Work Supported repeal of Medicare Independent Payment Advisory Board whose cost-cutting measures prior to 2020 would impact only health professionals and drug manufacturers Continuously monitor proposed Medicare reimbursement policies as they might impact psychological practice. Urged CMS to include psychologists as providers of behavioral services for obesity. Unsuccessful to date.

30. APA Practice Organization at Work Supporting S. 539, The Behavioral Health Information Technology Act of 2011 which would allow mental health facilities and practitioners to receive reimbursement for purchasing electronic health record keeping systems Closely monitoring parity implementation at the state level and successful in working with SPTAs to addressing violations State Implementation of Health Care Reform Initiative involving staff and governance: 2012 State Leadership Conference programming focused on this initiative

31. APA Practice Organization at Work Medicare Physician Definition Bills: • H.R. 831 (Rep. Jan Schakowsky + 34) • S. 483 (Sen. Olympia Snowe + 7) Also Supported by: • National Council for Community Behavioral Healthcare • Association for Ambulatory Behavioral Healthcare • Bazelon Center for Mental Health Law

32. APA’s Health Care Reform Team • Staff Working Group: • CEO, Deputy CEO, and Senior Policy Advisor • Government Relations Offices: Practice, Public Interest, Education, and Science • Public & Member Communications Office • Involvement of APA Leadership and Members, as well as other organizations • Collaboration with the APA Practice Organization (APAPO) – APA’s affiliated 501(c)(6) entity that works to advance the professional and business interests of practitioners

33. For Updates on APA Health Care Reform Initiatives http://www.apa.org/health-reform/

34. Contact Information Email: knordal@apa.org Phone: 1-800-374-2723 Web: www.apa.org www.apapracticecentral.org