Transcript Health Care Reform 2014 - Kansas Psychological Association

Health Care Reform 2014:
Implications for Professional Practice
Dan Abrahamson, PhD
Assistant Executive Director
Kansas Psychological Association
April 5, 2014
Wichita, KS
Compelling Need for U.S. Health Care Reform
 About 50 million uninsured Americans
 Annual health expenditures of over $2.7 T
 Health costs comprise about 17% of GNP
 Fragmented system with variable quality
 Increased life expectancy but often with
chronic illnesses
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The Economic Context for Reform
 2010 Healthcare expenditure = $2.7T
 Healthcare is single largest contributor to
national debt: Medicare = 15%; Medicaid = 8%;
Social Security = 20%; Defense = 20%
 All Health Expenditures, 2009:
 Private @ 51% (34% Ins. & 13% out of pocket)
 Public @ 49% (Fed @ 37%, Mcare @ 22%,
Mcaid @ 16%)
 By 2020, Fed. Govt. will pay 49% of all health
 State budgets in worst shape since WWII
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Economic Context: Mental Health
 Largest purchaser of MH/SUD services is the
government!
 Mental Health Spending, 2009:
 Private insurance, 26%; Out-of-pocket, 11%;
Charity, 3%
 Public funding, 60%
 Medicare, 13%
 Medicaid, 27%
 Other federal, 5%
 Other state/local, 15%
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Economic Context : Mental Health
 Mental Health Spending Trends
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1986 = 7.3% of all health spending
2003 = 6% of all health spending
2009 = 6.3% of all health spending
2014 = 5.9% of all health spending
 Spending by provider class:
 Psychiatrists = 6% of all mental health $$
 Non-psychiatric physicians = 5%
 Psychologists/SW/Cs = 5% or 0.315% of total mental health $$;
psychologists only 16% of this provider group
 Hospitals = 26%
 Specialty MH/SUD = 30%
 Insurance Administration = 7%
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Mental Health: Shifts in Spending
Distribution of Mental Health Expenditures by Type of Service, 1986 and
2005
$32 Billion
$113 Billion
7%
Prescription Drugs
33%
Outpatient
19%
Inpatient
Source: Substance Abuse and Mental Health Services Administration. (2011). National Expenditures for Mental Health
Services & Substance Abuse Treatment 1986-2005. Washington, DC. As cited in Kaiser Commission on Medicaid and
the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC.
Economic Context: RxP and Mental Health
RxP: 50% of increased MH spending 1998-2004
RxP: 3X growth rate as other services
RxP: 28% of all MH spending in 2009
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New drugs/new generics/patents expiring
Fewer side effects
More PCPs comfortable with prescribing
66% spent on antidepressants and antipsychotics
14% spent on ADHD medications
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Treatment Settings for Behavioral Health Care
Types of Mental Health Services Used in Past Year, Among Adults
Receiving Treatment, 2009
Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the
United States: A Primer. Washington, DC.
Economic Context for Reform: Chronic Illness
 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
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Patient Protection and Affordable Care Act of 2010
 Culmination of a 100-year effort that
challenged five former presidents
 Comparable with passage of the
Social Security Act in 1935 and
Medicare in 1965
 Almost on par with Civil Rights
legislation in the 1950s and 1960s
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Controversial Aspects of Health Care Reform
 Cost estimate of $180 billion over 10 years (Congressional
Budget Office, 2012, prior to Supreme Court ruling)
 Individual mandate to purchase health insurance or pay a
penalty upheld by Supreme Court ruling, June 2012
 Medicaid expansion by states funded mostly by federal
government with threatened loss of current funding for
noncompliance. Loss of current funding not upheld by
Supreme Court
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Key Challenges Facing Health Care Reform
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Overall Goals of Health Care Reform
 To preserve employer-based health insurance
 To expand coverage to 32 million more
Americans (Medicaid, Insurance Exchanges)
 To improve quality of care by addressing the
needs of the whole patient through:
Preventive Services
Primary and Integrated Care
 Reduce growth rate of healthcare costs
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ACA Expands Eligibility & Coverage
 Medicaid expansion covers persons up to 133% of
FPL by 2014 (adds 16-22M)
 Health Insurance Exchanges (up to 400% of FPL)
 Essential Health Benefits with parity for Medicare
Advantage, Medicaid Managed Care, CHIP, and
Benchmark Plans
 Preventive Care and Wellness
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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
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ACA Impacts Care Delivery
 Accountable Care Organizations (ACOs)composed
of integrated provider networks with:
shared electronic records
evidence-based practice protocols
outcomes measurement
performance incentives
 Patient-Centered Medical Homes (PCMH) will have
features similar to ACOs
 Home and Community Based Services Options
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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
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Why Focus on Integrated Care?
Percentage of Adults with Mental Health Conditions and/or Medical Conditions, 2001-2003
Adults with Mental
Health Conditions
29% of Adults with
Medical Conditions
Also Have Mental
Health Conditions
Adults with
Medical
Conditions
68% of Adults with
Mental Health
Conditions Also Have
Medical Conditions
Source: Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research
Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.
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Prevalence of Behavioral Health Conditions in US
Percent of US Adults Meeting Diagnostic Behavioral Health Criteria, 2007
Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the
United States: A Primer. Washington, DC.
Comorbidities Compound Costs
Monthly Health Care Expenditures per Person for Chronic Conditions,
with and without Comorbid Depression, 2005
Source: Melek, S., and Norris, D. (2008). Chronic Conditions and Comorbid Psychological Disorders. Cited in:
Druss, B. G., and Walker., E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis
Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.
Interaction Between Medical Disorders and Mental Illness
Model of the Interaction Between Medical Disorders and Mental Illness
RISK FACTORS
Childhood Adversity
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Loss
Abuse and Neglect
Household Dysfunction
Stress
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Adverse life events
Chronic stressors
SES
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Poverty
Neighborhood
Social Support
Isolation
Chronic Medical Disorders
Adverse Health Behaviors
and Outcomes
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Obesity
Sedentary Lifestyle
Smoking
Self care
Symptom Burden
Disability
Quality of Life
Mental Disorders
Source: Druss, B. G., and Walker., E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research
Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.
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
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Psychology’s Contributions to Integrated Care
 Conducting thorough psychological assessments
 Treating more complex, complicated patients
 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, including impact of families and systems
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Psychology’s Contributions to Integrated Care
 Supervision of M.A. level therapists, case
managers
 Development of programs designed to provide
population-based care
 Designing, monitoring, and evaluating
interventions
 Program administration
 Enhancing health team and organizational
development
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ACA Impacts Payment and Performance
 Move will be away from Fee-for-Service
 Global, bundled, episode payments
 Pay for Performance
 Higher rates for PCPs
 Medicare Shared Savings & other model
 FQHC investment of $11B
 Quality Measures (11 of 51 are behavioral
health)
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The Healthcare Environment
 Declining reimbursements
 Increased/incessant demands for cost containment
 Increased cost of doing business (rent, labor,
equipment, insurance, etc.)
 Increasing “competition” in psychotherapy
marketplace
 Growing regulatory demands (billing, privacy,
confidentiality, patient consent, F-W-A, EHR,
retirement planning, occupational safety, etc.)
 Lack of negotiation leverage
 And ever escalating healthcare costs!
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Evolving Healthcare Landscape
 Increased regulation of price and volume of
psychological services by public/private payers
 Rapid and large-scale consolidation of health
insurance market leading to more payer power:
providers have lower reimbursement and less
autonomy and consumers have higher premiums
 Professional, market, and regulatory developments
encouraging more collaborative care practices
 Emergence of new reimbursement mechanisms to
replace FFS: P4P, Global payments, Episode of care
payments, Shared Savings
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Evolving Healthcare Landscape
 Federal/State policies pushing integration:
 Quality payment programs with incentives to meet
certain quality standards
 Health Information Technology (HIT): cost and
ability to meet “meaningful use” criteria to be
eligible for incentives
 Anti-trust Enforcement Policy: allows integrated
provider organizations to negotiate with plans re:
payment rates but groups without integration
(financial and clinical) are prohibited from such
negotiation
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Reasons to Integrate
 Aggregate capital to finance, develop, implement
and maintain infrastructure (HIT & data reporting
systems) necessary to collect, track, and report
quality information required for performancebased reimbursement mechanisms
 Develop collaborative care systems necessary to
achieve real quality improvement in patient care
 Insurers, employers, consumers demanding data
on provider performance: adherence to quality
outcome and process measurement, patient
satisfaction, cost of care
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Reasons to Integrate
 Allows ability to collect your own monitoring and
evaluation data that may be needed to correct
inaccuracies in tiering or designations imposed on
your practice by payers
 Share risk as needed in capitated contracts where
there will be high-cost patients
 Negotiating efficiencies with TPAs by sharing a
manager who can analyze and negotiate contracts
 Larger integrated groups may be favored by payers
due to geographic coverage, mix of services, etc.
 #1 reason: Market a valuable/competitive product
that you cannot produce acting independently
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Implications for Professional Practice
 New care delivery models/systems: PCMHs, ACOs
 New skills and training models for integrated, interprofessional team-based care
 Implementing advances in telehealth, HIT, and
electronic health records
 Increasing demand for the use of EBPs (Evidencebased practices) and quality measures
 Payment reforms: P4P, Global payments, Bundled
payments, Shared-savings models
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Primary Work Setting of APA Practicing Psychologists
Other
Academic: teaching
and/or research
Institution-based
Practice
Independent solo
practice
Independent
Group practice
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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 interests of practitioners
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The APA Center for
Psychology and Health
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APA Center for Psychology and Health
Organizational Chart
Norman Anderson, PhD
Director
Randy Phelps, PhD
Office of
Health Care Financing
Ellen Garrison, PhD
Coordinator
Collaborating Units*
APA Practice
Health Care
Team
State
Implementation
Advisory Group
Director of
Integrated Health Care
(TBD)
Assistant Coordinator
Health Leadership Team
Working Group
of APA Member
Primary Care Experts
(TBD)
Health Team
*The APA Practice Health Care Team and the State Implementation Advisory Group are combined
APA
Practice
Directorate
APA
Practice Organization
(c6)Group
activities.
*The APA Practice
Health
Care
Team and(c3)
theand
State
Implementation
Advisory
are combined
APA Practice Directorate (c3) and APA Practice Organization (c6) activities.
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APAPO Mission
The mission of the APAPO is
to advance, protect and defend
the professional practice
of psychology.
APAPO is dedicated to serving the
interests and needs of its members: APA members
who pay the annual Practice Assessment to
APAPO.
501(c)(6) Business/Trade Association
As a 501(c)(6) organization, APAPO can:
 Focus on advancing a particular trade – professional
psychology
 Engage in unrestricted lobbying
 Work with a political action committee to facilitate
political giving
Legislative Advocacy
Top Priorities for 2014
• Medicare and Medicaid
reimbursement
• “Physician” definition in Medicare
• HITECH incentive payments for
electronic health records
Medicaid: H&B Codes
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Serving SPTAs: 2013 CAPP Grant Examples
Georgia
• Pursuing efforts to defend scope of practice regarding
psychological assessments.
Kentucky
• Ensuring parity in private insurance and Medicaid; addressing
workforce capacity challenges with Medicaid expansion.
Minnesota
• Pursuing funding for the development of electronic health
records; ensuring psychologists role in behavioral health homes.
Vermont
• Supporting the inclusion of psychologists in legislative process
during Vermont’s restructure to a Single Payer Plan.
HEALTHCARE REFORM AT THE STATE LEVEL
 Established in fall 2011 in
response to the passage of
the Affordable Care Act
 Composed of the Practice Health
Care Team and the State
Implementation Advisory Group
 Facilitated administratively
through the State Advocacy
Office
 State Implementation Updates
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State Implementation Initiative & APA Communities
w w w.apacommunities.org
 Launched by the association in April 2012.
 Designed as a professional network that enables users
to connect and work collaboratively online, in real time.
 Securely accessed via MyAPA ID.
 The APA Practice Initiative: State Implementation of
Health Care Reform is
now using APA Communities to link leaders to
resources and state efforts on health care reform.
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State Health Care Reform Group on APA Communities
A Discussion Forum
A Document Library
Categorization of Resources:
Mental Health Priority Areas in ACA
1.
2.
3.
4.
5.
6.
7.
8.
Accountable Care Organizations
Health Care Financing
Health Care Medical Homes
Health IT
Insurance Exchanges
Integrated Care
Medicaid Redesign
Primary Care
Additional Categories:
9. SPTA Health Care Summits
10. Updates: APA State Implementation
of Health Care Reform
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SPTAs and Health Care Reform Education
 2011
New York State Psychological Association
Massachusetts Psychological Association
Maryland Psychological Association
 2012
North Carolina Psychological Association
Idaho Psychological Association
Maine Psychological Association
California Psychological Association
Indiana Psychological Association
Oregon Psychological Association
Washington State Psychological Association
 2013
Connecticut Psychological Association
Wisconsin Psychological Association
Nevada Psychological Association
Minnesota Psychological Association
South Carolina Psychological Association
Rhode Island Psychological Association
Ohio Psychological Association
Oklahoma Psychological Association
Vermont Psychological Association
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Serving SPTAs: CAPP Grants
Funding level maintained for 2014
Organizational development, legislative,
emergency and Canadian
$250,000 awarded in
organizational development
grants to 25 states and
DC in 2014
$185,000 awarded in
legislative grants to
13 states in 2013 (for 2014)
Contact Information
Phone: 1-800-374-2723
Web: www.apa.org
www.apapracticecentral.org
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