Transcript Slide 1

Navigating the ACA: Got Data?
Peter J. Delany, Ph.D., LCSW-C
RADM, U.S. Public Health Service
Director, Center for Behavioral Health Statistics and Quality
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Innovations in Recovery
Coronado, California
March 31, 2015
About SAMHSA
The Substance Abuse and Mental Health
Services Administration (SAMHSA) is the agency
within the U.S. Department of Health and
Human Services (HHS) that leads public health
efforts to advance the behavioral health of the
nation. SAMHSA's mission is to reduce the
impact of substance abuse and mental illness on
America's communities.
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 One morning, a villager decided to walk along
the river on her way to work. As she was
enjoying the view, she noticed a crying infant in
the river. Horrified by the sight of a helpless
child in such a dangerous predicament, the
villager dove into the water, grabbed the baby,
and brought him ashore. The baby, although
afraid and soaking wet, was fine.With a sigh of
relief, the villager wiped the water from her
own eyes and looked out on the river.
As she tried to warm the baby with her jacket,
she heard more crying. She looked out over
the river only to see another baby in the
water. Once again, she dove into the water
and rescued this baby as well. Not a minute
had passed before she heard more crying, and
looking out over the river, she spotted dozens
more babies.
Calling out for help she was soon joined by the entire
community, and together they rescued as many babies
as they could. But the babies kept on coming ....
After half an hour or so, a group of villagers decided to
go upstream to find out why the babies were in the
river in the first place. Upstream, they found an ogre,
tossing babies into the water!
When the villager called her neighbors to the
river, she mobilized community. Going upstream
and confronting the ogre is creating a lasting
change in the condition that causes the problem.
Creating lasting change is what we endeavor to
do. We need to focus on "keeping the babies out
of the river" in the first place. If we don't, we will
be pulling babies out of the river forever.
Only by dealing with the ogre will
the villagers be able to keep the
babies safe.
About CBHSQ
The Center for Behavioral Health and Statistics and Quality
(CBHSQ) is the government’s lead agency for behavioral health
statistics. CBHSQ:
• Provides national leadership in behavioral health statistics and
epidemiology
• Promotes basic and applied research in behavioral health data systems
and statistical methodology
• Designs and carries out special data collection and analytic projects to
examine issues for SAMHSA and other federal agencies
• Participates with other federal agencies in developing national health
statistics policy
• Consults and advises SAMHSA’s Administrator and the HHS Secretary on
statistical matters
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National Survey on Drug Use and
Health (NSDUH)
• NSDUH is an annual data collection that is the primary source of
information on the prevalence, patterns, and consequences of alcohol,
tobacco, and illegal drug use and abuse, as well as mental disorders, in the
U.S. civilian, noninstitutionalized population, aged 12 or older.
• Used to generate national, state, and substate estimates
• Selected data collected include:
• Lifetime, past year, and past
• Past year any mental illness,
month prevalence of alcohol, illicit
serious mental illness, and suicidal
drugs, and tobacco
thoughts/plans for adults aged 18
• Past year substance use disorders
or older
• History of substance use treatment • Past year mental health treatment
• Age at first use of substances
for adults aged 18 or older
• Risk and protective factors for
• Past year Major Depressive
youth substance use
Episode (MDE) for adults and for
youth aged 12 to 17
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SAMHSA Data Collections
National Survey of Substance Abuse Treatment
Services (N-SSATS)
• N-SSATS is an annual, survey of all known substance abuse
treatment facilities, both public and private.
• Selected data collected include :
• Facility operation
• Types of services offered (e.g.,
assessment and testing services)
• Opioid treatment programs
• Medications dispensed or
prescribed
• Counseling and therapeutic
approaches
• Special programs or groups
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•
•
•
•
•
•
Type of treatment provided
Number of clients
Types of payment accepted
Availability of sliding fee scale
Facility accreditation and licensure
Managed care agreements
Facility focus (e.g., substance
abuse, mental health)
• Facility ownership
SAMHSA Data Collections
National Mental Health Services Survey (N-MHSS)
• N-MHSS is an annual survey of all known mental health
treatment facilities in the United States, both public and
private. N-MHSS began in 2010.
• Selected data collected include in 2010:
• Facility information
• Facility ownership
• Single-day count of clients /
patients by type of service
• Supportive services offered
• Mental health treatment
approaches
• Special programs or groups
• Age categories served
• Languages in which treatment is
provided
• Type of treatment provided
• Types of payment/funding
accepted
• Sliding-fee scale or other types of
payment assistance
SAMHSA Data Collections
Treatment Episode Data Set (TEDS)
• TEDS is an annual data collection that tracks the national flow of
admissions and discharges to specialty providers of substance
abuse treatment. The collection has been ongoing since 1992.
• Selected data collected include:
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•
•
•
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Client demographic characteristics
Health insurance status
Expected source of payment
Employment status
Type of service at
admission/discharge
• Number of prior treatment
episodes
• Number of arrests in past 30 days
• Injection drug use for up to three
substances of abuse
• Age of initiation for up to three
substances of abuse
• Past 30 day use for up to three
substances of abuse
• Principal source of referral
• Presence of co-occurring mental
health disorders
SAMHSA Data Collections
SAMHSA’s Emergency Department Surveillance System
(SEDSS)
• As part of the new National Hospital Care Survey conducted
by the National Center for Health Statistics, SAMHSA will
publish data on drug- and mental health- related visits to
emergency departments as SAMHSA’s Emergency Department
Surveillance System (SEDSS).
• Published data are expected in 2016.
Yes, We Even Threw In…
Substance Abuse and Mental
Health Data Archive
 A resource that our lead statistician for data policy
calls a “health data-palooza”
 CBHSQ contracts with University of Michigan to host
the SAMHDA website
 Access at: http://www.datafiles.samhsa.gov
 More than 400 behavioral health data sets
 Public-use data files, file documentation, online
analysis tools, plus restricted-use and confidential
data file
Substance Abuse and Mental
Health Data Archive
 Drug Abuse Warning Network (DAWN)
 National Survey on Drug Use and Health (NSDUH)
 National Survey of Substance Abuse Treatment
Services (N-SSATS)
 Treatment Episode Data Set—Admissions and
Discharges (TEDS-A & TEDS-D)
 National Mental Health Services Survey (NMHSS)
 Other archived studies available (e.g. NYS)
Substance Abuse and Mental
Health Data Archive
Three No-Cost Avenues of Access
 Public-use files
 No log-in required
 R-DAS (Restricted-use Data Analysis System)
 Log-in account required
 Data Portal (this is changing)
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Log-in account required
Verification of approved IP address
Unique username and password
MToken
Substance Abuse and Mental
Health Data Archive
For assistance with this archive, contact our
“data-palooza” statistician—she has all the
information.
Brooklyn Lupari
[email protected]
(240) 276-0532
And Now…
What you’ve all been waiting for:
Numbers! Graphs! Charts!
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Past Month Use of Selected Illicit Drugs
among Persons Aged 12 or Older: 2002-2013
Percent Using in Past Month
Illicit Drugs
Marijuana
Psychotherapeutics
Cocaine
Hallucinogens
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
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Past Month and Past Year Heroin Use among
Persons Aged 12 or Older: 2002-2013
Numbers in Thousands
Past Year
Past Month
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
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Past Year Perceived Need for and Effort Made to Receive
Specialty Treatment among Persons Aged 12 or Older Needing
but Not Receiving Treatment for Illicit Drug or Alcohol Use: 2013
Did Not Feel They
Needed Treatment
Felt They Needed
Treatment and Did
Not Make an Effort
95.5%
2.9%
1.6%
Felt They Needed
Treatment and Did
Make an Effort
20.2 Million Needing but Not Receiving Treatment
for Illicit Drug or Alcohol Use
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Reasons for Not Receiving Substance Use Treatment among Persons
Aged 12 or Older Who Needed and Made an Effort to Get Treatment
but Did Not Receive Treatment and Felt They Needed Treatment:
2010-2013 Combined
No Health Coverage and
Could Not Afford Cost
Not Ready to Stop Using
Did Not Know Where
to Go for Treatment
Had Health Coverage but Did Not Cover
Treatment or Did Not Cover Cost
No Transportation/Inconvenient
Might Have Negative Effect on Job
Could Handle the Problem
without Treatment
Did Not Feel Need for
Treatment at the Time
Percent Reporting Reason
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Past Year Substance Use Disorders and Serious Mental
Illness among Adults Aged 18 or Older: 2013
SUD and
SMI
SUD,
No SMI
17.9
Million
20.3 Million
Adults Had SUD
SMI = serious mental illness; SUD = substance use disorder.
2.3
Million
7.7
Million
SMI,
No SUD
10.0 Million
Adults Had SMI
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NSDUH Short Reports
• This short report summarized key
state-level mental illness findings
from the 2011 and 2012 NSDUHs.
• Among the key findings:
– The percentage of adults aged
18 or older with serious mental
illness in the past year ranged
from 3.1 percent in New Jersey
to 5.5 percent in West Virginia.
– Nationally, 42.5 million adults
experienced any mental illness
in the past year; the rates ranged
from 14.7 percent in New Jersey
to 22.3 percent in Utah.
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NSDUH Data Spotlights
• Using combined 2011 to 2012
NSDUH data, this Data Spotlight
indicated that 8.5 percent of
pregnant women aged 15 to 44
drank alcohol in the past month;
2.7 percent binge drank.
• Alcohol use was lower during the
second and third trimesters than
during the first (4.2 and 3.7
percent vs. 17.9 percent).
• These findings suggest that many
pregnant women are getting the
message and not drinking alcohol.
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Health Services Research
• Examines how people get access to health care
providers and health care services
• How much care costs
• What happens to patients as a result of this care
• How social factors, financing systems, organizational
structures and processes, technology, and personal
behaviors affect access to treatment, quality and cost
of care, and quantity and quality of life
Health Services Research
How SAMHSA does behavioral health services
research:
• The aim is to perform health services research that
can be applied by providers, policy makers, and
programs to make decisions about behavioral health
prevention and treatment
• The principles of health services research to
behavioral health prevention and treatment
Evaluation
The Quality, Evaluation, and Performance (QEP) Branch
in CBHSQ, composed of 6 evaluation desk officers, has
worked closely with 26 program evaluations with the
potential for providing support to a number of other
evaluations that are being considered or planned. In
addition to program-specific work, Branch staff
coordinate some SAMHSA-wide activities, such as the
evaluation of the diverse portfolio of SAMHSA
behavioral health mobile applications.
PREVALENCE OF BH CONDITIONS AMONG UNINSURED
ADULTS AGES 18-34 WITH INCOMES <400% FPL
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56.0%
44.0%
SMI/
SPD/
SUD
“Behavioral Health Conditions” includes serious mental
illness (SMI), serious psychological distress (SPD) and
substance abuse disorders (SUD)
PREVALENCE OF BH CONDITIONS AMONG UNINSURED
ADULTS AGES 35 AND OVER WITH INCOMES <400% FPL
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23.8%SMI/
SPD/ SUD
76.2%
“Behavioral Health Conditions” includes serious mental illness
(SMI), serious psychological distress (SPD) and substance abuse
disorders (SUD)
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More are Insured than Ever
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Saving Tax Dollars Every Day
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The Impact of Policy on Health
Care Delivery Today
 Many health and health-related policies affect
health care delivery. Some examples:
 Reportable events/conditions, such as animal bites,
interpersonal violence, anthrax exposure, death, etc.
 HIPAA
 Some policies are specifically related to or have
important linkages to behavioral health:
 Parity legislation (MHPAEA)
 Patient Protection and Affordable Care Act (ACA)
Parity Before ACA: The Mental Health
Parity and Addiction Equity Act of 2008
 MHPAEA requires that financial requirements and
treatment limitations for mental health/substance use
disorder benefits be no more restrictive than for
essentially all other benefits
 Applies to plans sponsored by private and public
sector employers with more than 50 employees
 Supplements Mental Health Parity Act of 1996
(MHPA), which required parity on annual and lifetime
coverage costs
MHPAEA Limitations
 Act provides significant new protections
to participants in group plans…but
MHPAEA does not mandate that a plan
provide MH/SUD benefits
 Also…does not apply to policies for
employers with 50 or fewer employees,
or to individual policies
Patient Protection
and Affordable Care Act
 December 24, 2009
 Promotes improved access to health care
coverage and health services
 Many items specific to Medicare and Medicaid
 ACA expected to:
 Improve quality in health care
 Lower costs over time, or at least stabilize costs
Patient Protection
and Affordable Care Act
Key Issues Addressed
 Preventive health
care
 Integrated health
care
 Quality care
 Dependent coverage
 Minimum standards
 Parity
Patient Protection
and Affordable Care Act
Mental Health Parity
 ACA builds on MHPAEA to extend federal parity
protections to 62 million Americans
 Requires MH/SUD benefits for millions of
Americans in individual and small-group markets
 Expands parity to apply to millions whose
coverage did not previously comply with those
requirements.
Patient Protection
and Affordable Care Act
Payers and Quality
 Providers must be accredited on local performance
 Judged on clinical quality measures such as:
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Healthcare Effectiveness Data and Information Set
Patient experience ratings
Consumer access
Credentialing
Network adequacy
Handling of complaints, etc.
Patient Protection
and Affordable Care Act
Prevention Services and Efforts
 PreSmoking cessation
 Weight management
 Heart disease
prevention
 Stress management
 Healthy lifestyle
support
 Physical fitness
 Diabetes prevention
 Nutrition
Patient Protection
and Affordable Care Act
Chronic Conditions
 Mental health
 Diabetes
 Substance use
disorder
 Heart disease
 Asthma
 Overweight (BMI>25)
Patient Protection
and Affordable Care Act
Important Points
 Does not remove obligation to provide
emergency services
 Still different tiers (Bronze, Silver, Gold) in
levels of insurance—important to remember
in considering access issues
Patient Protection
and Affordable Care Act
What Does This Mean for Clinical Practices?
 Often a clinical context
 Data usually associated with the event, condition, or
activity
 Provides an opportunity to understand
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Events leading up to a health situation
Time-related context of the health situation
Prevalence and incidence
Outcomes
Intervention potential
Patient Protection
and Affordable Care Act
 How does health policy—in particular
ACA—affect clinical care and care
transformation?
 How can research and evaluation improve
and inform the field?
Our Path is Clear
Behavioral Health Care
Those of us in behavioral health
services must seize all opportunities
for translating policy into practice
and research
Behavioral Health Care
Treatment and Cost
How many uninsured (pre-ACA) American
adults received treatment?
 According to the National Survey of Drug Use and
Health (2009-2011), there were 37 million
uninsured Americans between the ages of 18
and 64
Of that group, it is estimated that 3.9 million
received any behavioral health treatment
Behavioral Health Care
Treatment and Cost
How many of the previously uninsured are likely to seek
behavioral health treatment within Medicaid or health insurance
exchanges (ACA)?
 Prior to ACA, estimated that 1.5 million uninsured with incomes at or below
138% of the federal poverty level had behavioral health treatment
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Estimated that an additional 1.2 million will have behavioral health treatment under
Medicaid/ACA
 Prior to ACA, estimated 2.2 million with incomes above 138% of the poverty
level had behavioral treatment
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Estimated that an additional 1 million will have behavioral health treatment under
Medicaid/ACA
Source: National Survey of Drug Use and Health (2009-2011)
Behavioral Health Care
Treatment and Cost
 Income at or below 138% FPL:
 Behavioral health: $2,100
 All health: $9,400
 Income 138-400% FPL:
 Behavioral health: $1,600
 All health: $8,500
 Among those who do not use behavioral health treatment
services, regardless of income, the annual health care cost
is approximately $3,000.
Source: Medical Expenditure Panel Survey (2009-2010)
The Challenges
 Can health systems help to improve what we
know about the cost of care delivery for
patients with psychiatric and other behavioral
health conditions?
 Is there a capacity—given the availability of
billing, claims, EMR, and other data—to more
completely examine cost and expenditure?
National Behavioral Health
Quality Framework
http://www.samhsa.gov/data/NBHQF/index.html#exhibit1
Payer/System/Plan
(e.g., SAMHSA, HRSA,
Provider/Practitioner
Patient/Population
Medicaid/Medicare, State Govt)
BHQF Goal 1: Promote the most effective prevention, treatment, and recovery practices for behavioral health disorders (Recommended Measures)
LINKED TO AND
REFLECTIVE OF
MEASURECONCEPTS
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Relevant EBPs in
preventive, clinical,
and recovery support
settings tracked,
summarized, and
publicly available
Outcomes reflecting
recovery
Social connectedness
of persons with
behavioral health
issues
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NQF #0418: Screening for Clinical
Depression
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NQF #0104: Major Depressive
Disorder: Suicide Risk Assessment
In NQF review: Screening, brief
intervention, and referral for
treatment for alcohol misuse
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NQF#0710-0711-0712:
Depression Utilization of PHQ-9
and Remission at 6 and 12 months
NQF #0576: Follow-up After
Hospitalization for Mental
Illness
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NQF #0105: Anti-depressant
Medication Management: (a)
Effective Acute Phase Treatment
and (b) Effective Continuation
Phase Treatment
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NQF #1364/1365:
Child/Adolescent Depressive
Disorder: Diagnostic Evaluation
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NQF #1401: Maternal Depression
Screening
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NQF #0028: Preventive Care and
Screening Measure Pair: (a)
Tobacco Use Assessment and (b)
Tobacco Cessation Intervention
NQF #0004: Initiation and
Engagement of Alcohol and
other Drug Dependence
Treatment
Consumer Evaluation of Care:
Reporting Positively About
Outcomes (adult and child)
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NQF #0110: Bipolar Disorder and
Major Depression: Appraisal for
Alcohol or Chemical Substance Use
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Emergency Department Alcohol
Use Screening and Follow-up
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Employment/Education:
Changes in employment status
(increased/no change) or in
school status at a date of last
service compared to first
service
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Abstinence: ATOD-related
suspensions and expulsions
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Housing: Increase in stable
housing status from date of
first service to date of last
service
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Abstinence: Family
communication around drug
use
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Percentage of patients with
annual encounter data with a
primary care physician OR
pediatrician OR
obstetrician/gynecologist
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MU2 Screening for Intimate
Partner Violence
Translational Research: Questions to Face
on Behavioral Health Care Integration
 What is the right model?
 What other health issues should be considered?
 Outcomes? (BH vs. physical)
 What are the evidence-based metrics that matter?
 How do the models translate across systems and settings?
 Are there cost savings?
 How are the patterns of utilization affected by these
strategies?
 What are the barriers to implementation? How sustainable?
Some Congressional Issues:
“Dual-eligibles” and ACA
 Improve quality of care and long term services
 Increase patient literacy of and satisfaction with coverage
 Eliminate regulatory conflict
 Improve continuity of care; safe and effective care transitions
 Eliminate cost-shifting
 Improve quality of performance
 Study provision of drug coverage for new full-benefit, dualeligible people, monitor total expenditures, health outcomes,
and access to benefits
Other Topics that Might
Emerge Under ACA
 Integrated care delivery
 Who got covered? Who didn’t? Why?
 Health literacy—how does it affect behavioral health care delivery
and choice of care settings?
 Health care costs—what are the right questions in behavioral health?
 Behavioral health care quality—what matters at the clinical level?
 Health care workforce—is capacity sufficient?
 Who is still not covered?
 What kind of care are people accessing and using?
 Impacts on chronic disease management and health care costs
Other Topics that Might
Emerge Under ACA
 How to engage behavioral health population in prevention
programming
 Religious sects may be exempt
 Vulnerable populations
 Re-admissions
 Development of recommendations for additional task force activities
 School-based behavioral health services
 Tobacco cessation, particularly among pregnant women
 Strengthening public health surveillance
 Contribution of private health care providers to surveillance of
behavioral health
Data Resources for Translational
and Policy-Relevant Research
 “Big Data”
 Mini-Sentinel…a $116-million government pilot project
 Pro-actively seeks adverse events linked to marketed drugs
 Mines huge databases of medical records (privacy protected)
 A five-year experiment coming to an end
 FDA deciding what to do next
 General agreement that the ability to sift through huge amounts
of patient data is the way of the future—but what’s the best way
to do that sifting?
Data Resources for Translational
and Policy-Relevant Research
 Electronic health records and health
information exchanges (EMR, HIE, HIT)
 Claims data
 Evaluation data
 Local and internal surveys
 SAMHSA health data information
Conclusion
 As our nation continues to move toward the full roll-out
of a health policy that is expected to reach most
citizens, questions still remain
 Organizations delivering health care have opportunities
to develop and test new models that can improve care
delivery, outcomes, and potentially reduce costs
 Use your evidence. We won’t know the impact of policy
until we know how to use data to tell our story—data
will prove the value of your innovations
Resources
• For more about NSDUH data, visit:
http://www.samhsa.gov/data/population-datansduh
• For more about SAMHSA, visit:
http://www.samhsa.gov/
• For more about CBHSQ, visit:
http://www.samhsa.gov/about-us/who-weare/offices-centers/cbhsq
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Questions?
Navigating the ACA: Got Data?
Peter J. Delany, Ph.D., LCSW-C
RADM, U.S. Public Health Service
Director, Center for Behavioral Health Statistics and Quality
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
[email protected]
Dee S. Owens, Special Assistant to the Director
[email protected]