Transcript Challenges Facing Behavioral Health Care

Mark Covall, President/CEO
National Association of Psychiatric Health Systems
Presentation to Alaska State Hospital and Nursing Home Association
September 2014
Mental and substance use disorders
National Association of Psychiatric Health Systems - September 2014
Millions of Americans Affected
BY MENTAL ILLNESS
 One in every five adults (45.9 million Americans
aged 18 or older) experienced mental illness in the
past year.
 Some 5% of the adult population (11.4 million
adults) suffered from serious mental illness in past
year (defined as one that resulted in serious
functional impairment that substantially
interfered with or limited one or more major life
activities)
SOURCE: SAMHSA. January 2012. See http://www.samhsa.gov/data/NSDUH/2k10MH_Findings/.
National Association of Psychiatric Health Systems - September 2014
Yet Need Is Only Partially Met
 Only about 4 in 10 people (39.2%) experiencing any mental
illness in the past year – and only 60.8% of those
experiencing serious mental illness – received any mental
health services during that period. SOURCE: SAMHSA. 2010 National Survey on
Drug Use and Health. January 2012. www.samhsa.gov/data/NSDUH/2k10MH_Findings/.
 Some 23.1 million Americans aged 12 or older (9.1%) needed
specialized treatment for a substance abuse problem, but
only 2.6 million (or roughly 11.2%) received it. SOURCE: SAMHSA. 2010
National Survey on Drug Use and Health. September 8, 2011. Release at
www.samhsa.gov/newsroom/advisories/1109075503.aspx.
National Association of Psychiatric Health Systems - September 2014
Mental Health and Substance Abuse
National Association of Psychiatric Health Systems - September 2014
Total Mental Health & Substance
Use Spending (2014-2020)
 2014: $210.6 billion
In Billions
280.5
300.0
250.0
 2020: $280.5 billion
(projected)
210.6
 Includes all treatment spending for
mental health and substance use
disorders (including prescription
200.0
150.0
drugs, hospitals, and all other
treatment settings)
100.0
50.0
0.0
2014
2020
SOURCE: Mark TL, et al. Health Affairs, 33(8):
1407-1415. “Spending on mental and substance use
disorders…” August 2014.
National Association of Psychiatric Health Systems - September 2014
Mental Health/Substance Use Spending
Projected Growth (vs. All Health Spending)
Average annual
growth in spending
19982009
20092020
Mental health /
substance use
 6.7%
 4.6%
All health
 6.8%
 5.8%
 1998-2009:
 2.9% of mental health
increase directly related to
increase in prescription
drug spending
 2009-2020:
 major driver of mental
health decrease is
expiration of
pharmaceutical drug
patents
SOURCE: Mark TL, et al. Health Affairs,
33(8): 1407-1415. “Spending on mental and
substance use disorders…” August 2014.
National Association of Psychiatric Health Systems - September 2014
Projected Mental Health/Substance Use
Spending, to 2020(as a Proportion of Overall Health Spending)
Behavioral Health
9.3%
10.0%
8.1%
9.0%
7.3%
8.0%
7.5%
7.3%
SOURCES:

Mechanic D.
Health Affairs.
33(8): 14161424.August 2014

Mark TL, et al.
Health Affairs,
33(8): 1407-1415.
“Spending on
mental and
substance use
disorders…”
August 2014.
7.3%
6.5%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
1986
1992
1998
2002
2005
2009
2020
National Association of Psychiatric Health Systems - September 2014
Mental Health/Substance Use as a Proportion of
Overall Health Spending (by category)
10.0%
9.0%
8.0%
Addiction
2.1%
1.7%
7.0%
1.3%
1.3%
1.2%
1.0%
6.0%
6.2%
6.1%
6.3%
Mental
health
6.0%
5.0%
4.0%
7.2%
6.4%
3.0%
2.0%
1.0%
0.0%
1986
1992
1998
2002
2005
2009
National Association of Psychiatric Health Systems - September 2014
SOURCE: Mark
TL, et al. Health
Affairs, 33(8):
1407-1415.
“Spending on
mental and
substance use
disorders…”
August 2014.
Reasons Behind
Slower Overall Growth
 2007-2009:
 Recession
 2009-2012:
 State hospital closures and reductions in beds
 2011:
 Medicare payment rate changes in the Affordable Care
Act and Budget Control Act of 2011
 2014-2016:
 Decline in prescription drug prices due to loss of patent
protection
SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use
disorders…” August 2014.
National Association of Psychiatric Health Systems - September 2014
• Macro Trends
• Health System Trends
National Association of Psychiatric Health Systems - September 2014
National Association of Psychiatric Health Systems - September 2014
Macro Trends
 More / improved coverage
 Different payment structures (e.g., case rates/ bundled





payments)
More managed Medicaid
More outpatient / community-based
More emphasis on quality and accountability
Stigma reduced
Shortage of psychiatrists / therapists
National Association of Psychiatric Health Systems - September 2014
National Association of Psychiatric Health Systems - September 2014
Health System Trends
 New delivery models / ACOs
 Health systems expanding behavioral health
services…especially those in risk-sharing contracts
 Increased awareness of mental health/substance use
comorbidities and impact on chronic disease management
 Integration of mental health and primary care
-continuedNational Association of Psychiatric Health Systems - September 2014
Health System Trends (continued)
 Telemedicine growing
 More use of mid-levels, nurse practitioners
 Specialty programs
 Eating disorder
 Dual diagnosis
 Women’s programs
 Gay/lesbian
 Military
National Association of Psychiatric Health Systems - September 2014
• Parity
• Affordable Care Act
National Association of Psychiatric Health Systems - September 2014
“Game – changer”
National Association of Psychiatric Health Systems - September 2014
The Parity Law
 The Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act signed into law on
October 3, 2008.
 Basically, became effective January 1, 2010.
National Association of Psychiatric Health Systems - September 2014
Key Provisions
 Applies to 113 million employed Americans, including
individuals in ERISA plans (self-insured companies)
 Requires equity in financial requirements
 Requires equity in treatment limits
-continued-
National Association of Psychiatric Health Systems - September 2014
Key Provisions
(continued)
 Does not mandate mental health benefits
 Exempts certain businesses
 With 50 or fewer employees
 Posting an overall cost increase due to parity
requirements (2%+ in first year; 1% in subsequent
years)
 Exemption only lasts one year; need to reapply
the following year (or comply)
National Association of Psychiatric Health Systems - September 2014
Interim Final Regulations
 Published in the February 2, 2010, Federal Register at
http://edocket.access.gpo.gov/2010/pdf/2010-2167.pdf
Department of Health and Human Services
 Treasury Department
 Labor Department

 Went into effect for health plan years beginning on or
after July 1, 2010.
 Means that most health plans were not subject to the
regulations until January 1, 2011.
National Association of Psychiatric Health Systems - September 2014
Treatment Limitations
 The regulations go further with respect to treatment
limitations.
 The regulations define treatment limitations as
quantitative and non-quantitative.
-continued-
National Association of Psychiatric Health Systems - September 2014
Definitions
 Quantitative limits:
 Are numerical (e.g., 30 inpatient days).
 Non-quantitative treatment limitations:
 are such things as (NOTE: This list is not exhaustive):
 medical management standards, including standards for
admission to participate in a network;
 determination of usual, customary, and reasonable charges,
 requirement for using lower cost therapies before the plan will
cover more expensive therapies (also known as fail-first policies or
step therapy protocols),
 conditioning benefits on the completion of a course of treatment.
National Association of Psychiatric Health Systems - September 2014
Comparison of Med/Surg and
Psychiatric Benefits
 Plans are only permitted to compare medical/surgical
and mental health benefits for purposes of applying
parity requirements using six specified categories:
1.
2.
3.
4.
5.
6.
inpatient, in-network
inpatient, out-of-network
outpatient in-network
outpatient out of network
emergency care
prescription drugs
National Association of Psychiatric Health Systems - September 2014
Final Rule
 Issued November 8, 2013
 Includes an intermediate classification to clarify the law
is intended to include coverage for a full range of
services (inpatient – intermediate –outpatient).
 Makes clear that insurers must have comparability in
management practices
 Health plan transparency
 Removes exception to NQTLs
National Association of Psychiatric Health Systems - September 2014
Mental Health Parity
• Final rule applies to plan years beginning on or after
July 1, 2014.
• Until the rules take effect, plans must continue to
comply with parity provisions of the interim final
regulations.
National Association of Psychiatric Health Systems - September 2014
Mental Health Parity
 Rule applies to:
•
•
113 million employed Americans, including
individuals in self-insured companies (large
employers with more than 50 employees).
Parity is also now embedded in the Affordable
Care Act and extends federal parity protections to
those Americans obtaining small group and
individual health plan coverage under the ACA.
National Association of Psychiatric Health Systems - September 2014
Mental Health Parity
 Rule does NOT apply to:
• Medicaid managed care organizations
• Children’s Health Insurance Program
(CHIP)
• Alternative Benefit Plans (i.e., Medicaid
expansion plans under the ACA)
Further clarification is needed because the rule states the
statute applies to these entities.
National Association of Psychiatric Health Systems - September 2014
Key Provisions and Clarifications
in Final Parity Rule
• Includes an intermediate care classification to clarify the
law is intended to include the full continuum of services
for behavioral health care which includes (inpatientintermediate-outpatient). This provision clarifies that
the interim rule never intended to exclude outpatient,
partial hospitalization and residential care.
• Makes clear that insurers must have comparability in
management practice (removes loophole that allowed
behavioral health benefits to be managed differently).
-continued-
National Association of Psychiatric Health Systems - September 2014
Key Provisions and Clarifications
in Final Parity Rule (continued)
 New disclosure requirements are included to require
more transparency from health plans in the areas of
medical necessity determinations and management
practices.
 States will have primary enforcement authority over
health insurance issuers. As such, states will be the
primary means of effectuating mental health parity
implementation.
 Government will continue to issue more guidance on
final rule.
National Association of Psychiatric Health Systems - September 2014
Next Steps
 Medicaid / parity rule
 Enforcement
National Association of Psychiatric Health Systems - September 2014
Signed into law March 23, 2010, by President Obama
National Association of Psychiatric Health Systems - September 2014
Key Provisions of the ACA
 Individual mandate requires almost everyone to obtain
coverage or face a penalty
 Employers with 50 or more employees must provide
coverage or face a penalty (delayed for 1 year until 2015)
 Covers people regardless of any preexisting conditions
 Young people up to age 26 gain insurance through
their parents’ plan (3.1 million)
National Association of Psychiatric Health Systems - September 2014
Affordable Care Act (ACA)
 Will expand coverage to 32 million Americans
through either:
 the health insurance exchanges or
 Medicaid expansion
National Association of Psychiatric Health Systems - September 2014
ACA extends parity to two key groups (continued)
Group 1
Individuals
People who will gain MH/SA (or both)
benefits under the ACA, including
federal parity protections
Currently in individual plans
3.9 million
Currently in small-group plans
1.2 million
Currently uninsured
27 million
Subtotal
32.1 million
National Association of Psychiatric Health Systems - September 2014
ACA extends parity to two key groups (continued)
Group 2
Individuals
People with existing MH/SA benefits
who will benefit from federal parity
protections
Currently in individual plans
7.1 million
Currently in small-group plans
23.3 million
Subtotal
30.4 million
National Association of Psychiatric Health Systems - September 2014
ACA extends parity to two key groups (continued)
By building on the structure of the MHPAEA, the ACA will extend
federal parity protections to 62.5 million Americans.
Individuals
Total # of people who will benefit from
federal parity protections
Currently in individual plans
11 million
Currently in small-group plans
24.5 million
Currently uninsured
27 million
Total
62.5 million
National Association of Psychiatric Health Systems - September 2014
Affordable Care Act (ACA)
 States are mandated to participate in the insurance
exchanges
 States can:
 Run their own exchange,
 Let the feds run the exchange, or
 Establish a partnership with the feds
National Association of Psychiatric Health Systems - September 2014
State Health Insurance Exchanges

As of 8/6/13, Center on Budget & Policy Priorities
(http://www.cbpp.org/files/CBPP-Analysis-on-the-Status-of-State-Exchange-Implementation.pdf)
National Association of Psychiatric Health Systems - September 2014
Health Insurance Exchanges
 Approximately 23 million people will purchase
individual or small group private health insurance
through the exchanges.
 ACA created health insurance subsidies (in the form of
premium tax credits and cost-sharing reductions)
to help eligible individuals and families purchase
health insurance through an exchange.
National Association of Psychiatric Health Systems - September 2014
State Health Insurance Exchanges
 October 1, 2013:
 Exchanges open enrollment period started
 Federal on-line health Insurance exchange marketplace
is live at www.HealthCare.gov
 Coverage begins January 1, 2014
 Subsidies available beginning in 2014
 Open enrollment ends March 31, 2014
National Association of Psychiatric Health Systems - September 2014
Essential Benefit Requirements
 Mental health and addiction services are one of the 10
essential benefit requirements in the plans offered through
the insurance exchanges and in the Medicaid expansion.
 The federal parity law applies to the mental health/
addiction essential benefit.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Hospitalization
Mental health/addiction
Ambulatory
Emergency
Maternity
Pediatric services
Laboratory services
Prescription drugs
Rehabilitative and habilitative services
Preventive and wellness services
National Association of Psychiatric Health Systems - September 2014
Medicaid Expansion
 States – at their option – can choose to expand
Medicaid with the feds paying 100% of the cost in
the first three years and no less than 90% going
forward
National Association of Psychiatric Health Systems - September 2014
Medicaid Expansion
 Expands eligibility to adults ages 19-64 with income at
or below 133% of the federal poverty level
 No deadline for state in Medicaid expansion decision;
however, coverage begins January 1, 2014
 States that want to take advantage of the three-year
window for 100% federal match have already made
their decision to take the Medicaid expansion option
National Association of Psychiatric Health Systems - September 2014
Status of State Medicaid Expansion
 As of 7/18/13, Center on Budget & Policy Priorities
http://www.cbpp.org/cms/index.cfm?fa=view&id=3819
National Association of Psychiatric Health Systems - September 2014
Medicaid Expansion
 Arkansas Model
 Arkansas’ “Private Option” model uses the federal
funding for Medicaid expansion to buy private health
insurance coverage through the state exchange
 Numerous Republican governors considering Arkansas
model for Medicaid expansion
 It’s a way to take Medicaid money without being
branded as “Obamacare” supporters
National Association of Psychiatric Health Systems - September 2014
Estimated Impact of ACA
on Mental Health
 In 2020:
 Will increase mental health spending (overall) by 1.9%
($4.4 billion) in 2020.
 Will also alter mental health financing, primarily from
Medicaid and private insurers.


Medicaid spending in states that did not decline to expand
enrollment is expected to be 7.8% ($5.2 billion) higher (than
without the ACA)
Private insurance is expected to be 3.4% ($2 billion) higher
(than without the ACA)
SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use disorders…” August 2014.
National Association of Psychiatric Health Systems - September 2014
Estimated Impact of ACA and Parity
on Substance Use Spending
 In 2020 substance use spending (overall) will increase
by 7.2% ($2.8 billion) (vs. 1.9% in mental health).
 Substance use disorders are prevalent among young adults, who are
over-represented among those who are currently uninsured and
who may gain insurance.
 Many young people with severe mental illnesses are already insured
by Medicaid or Medicare by virtue of disability (which lowers
potential increase in spending under ACA expansions).
 Prescription patent expirations are not expected to have a
significant impact on substance abuse spending.
SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use
disorders…” August 2014.
National Association of Psychiatric Health Systems - September 2014
H.R.3717 introduced by Rep. Tim Murphy (R-PA)
National Association of Psychiatric Health Systems - September 2014
H.R.3717 would:
 Create a pathway under Medicaid for people to get access to short-
term acute psychiatric care.
 Give behavioral health organizations funding for health information
technology
 Elevate mental health in the federal government by creating an
Assistant Secretary for Mental Health and Substance Use Disorders in
the U.S. Department of Health & Human Services
 Promote primary care integration
 Support suicide prevention for children and youth
-continuedNational Association of Psychiatric Health Systems - September 2014
H.R.3717 would:
(continued)
 Encourage research on serious mental illness and self- or other-
directed violence
 Improve communication between families and mental health
providers.
 Apply quality standards for a new class of Federally Qualified
Community Behavioral Health Clinics (FQCBHC), requiring them to
provide a range of mental health and primary care services
 Promote justice system reforms
 Establish national standards for both inpatient and outpatient
commitment to reduce barriers to timely access to treatment
National Association of Psychiatric Health Systems - September 2014
H.R.3717
 Introduced by Rep. Tim Murphy
 Chair, House Oversight Subcommittee of the Energy &
Commerce Committee.
 Co-chair, Congressional Mental Health Caucus
 Has 89 cosponsors (as of 6/6/14):
 57 Republicans
 32 Democrats
National Association of Psychiatric Health Systems - September 2014
Performance Measurement
National Association of Psychiatric Health Systems - September 2014
Quality Initiatives
 HBIPS Core Measures – Joint Commission
 IPF Quality Reporting Program – CMS
 National Quality Forum
National Association of Psychiatric Health Systems - September 2014
HBIPS Measures
 The assessment process
 The use of antipsychotic medications
 Seclusion and restraint
 Discharge summary / aftercare
National Association of Psychiatric Health Systems - September 2014
Centers for Medicare and Medicaid Services
National Association of Psychiatric Health Systems - September 2014
IPF Quality Reporting / CMS
 The ACA requires that, as of rate year 2014 (starting
October 1, 2013), all facilities reimbursed under the
inpatient psychiatric facility prospective payment system
(IPF PPS) must report data on at least six measures to CMS
for the purpose of public reporting, payment updates, and
pilot pay-for-performance programs.
 CMS approved six measures to meet the requirements of
the Affordable Care Act’s (ACA) mandate for both
psychiatric hospitals and psychiatric units to begin
reporting inpatient quality measures.
National Association of Psychiatric Health Systems - September 2014
IPF Quality Reporting / CMS
 CMS measures are six of the seven Hospital-Based
Inpatient Psychiatric Services (HBIPS) core measures
(already required of psychiatric hospitals by The Joint Commission and available for use by psychiatric units to meet
ORYX reporting requirements):






HBIPS-2 Hours of physical restraint use (patient safety);
HBIPS-3 Hours of seclusion use (patient safety);
HBIPS-4 Patients discharged on multiple antipsychotic medications
(pharmacotherapy);
HBIPS-5 Patients discharged on multiple antipsychotic medications
with appropriate justification (pharmacotherapy);
HBIPS-6 Post discharge continuing care plan created (care
coordination); and
HBIPS-7 Post discharge continuing care plan transmitted to next
level of care provider upon discharge (care coordination).
National Association of Psychiatric Health Systems - September 2014
IPF Quality Reporting – Next Steps
 8/19/13 -- CMS issued final rule on FY2014 quality
reporting requirements for inpatient psychiatric
facilities (see pages 50887-50901)
National Association of Psychiatric Health Systems - September 2014
Quality Reporting—Next Steps
 No additional measures required by CMS for rate year 2015.
 Substance abuse assessment (SUB-1) and Medicare data on
follow-up after discharge added for rate year 2016.
 Currently testing potential measures for rate year 2017.
 NAPHS and partners constantly work to keep measures
aligned and harmonized to decrease burden and to
increase benefit to the field.
National Association of Psychiatric Health Systems - September 2014
Final Rule (Update for FY15)
In 8/6/14 Federal Register final rule:
 For FY16 & subsequent years (in addition to those
already previously adopted):
“Assessment of Patient Experience of Care”
(attestation that an organization routinely assesses
patient experience of care using a standardized
collection protocol and a structured instrument)
2. “Use of an Electronic Health Record” (attestation to
the facility’s highest level use of an EHR for transfer of
health information).
1.
National Association of Psychiatric Health Systems - September 2014
Final Rule (Update for FY15)
(continued)
 For FY17 and subsequent years:
Influenza Immunization (IMM-2);
2. Influenza Vaccination Coverage Among Healthcare Personnel;
3. Tobacco Use Screening (TOB-1); and
4. Tobacco Use Treatment Provided or Offered (TOB-2) and
Tobacco Use Treatment (TOB-2a).
1.
National Association of Psychiatric Health Systems - September 2014
November 2014
National Association of Psychiatric Health Systems - September 2014
2014 Mid-Term Elections
 HOUSE:
 Republicans will retain control
 SENATE:
 Leaning toward Republicans regaining control of Senate
 Republicans need to pick up 6 seats
National Association of Psychiatric Health Systems - September 2014
Key Senate Races
 Democratic incumbents:
 Alaska / Begich
 Arkansas / Pryor
 North Carolina / Hagan
 Louisiana / Landrieu
 Republican incumbents:
 Kentucky / McConnell
 Open Democratic seats:
 Montana
 South Dakota
 West Virginia
National Association of Psychiatric Health Systems - September 2014
www.naphs.org