Behavioral Health Needs of the Newly Eligible and Enrollment Assistance Best Practices

Kevin Malone Office of Policy, Planning, and Innovation Substance Abuse and Mental Health Services Administration

THE BEHAVIORAL HEALTH ENROLLMENT CHALLENGE

• • • • • •

Uninsured populations have disproportionate rates of behavioral health conditions Symptoms and income/housing volatility cause challenges for accessing and maintaining coverage Periods of un-insurance lead to increased inpatient and emergency visits, longer lengths of inpatient stays, poorer psychiatric outcomes, and higher healthcare expenditures Behavioral health providers have limited enrollment experience Traditional outreach workers have limited training on working with individuals with behavioral health conditions Behavioral health conditions cross demographic boundaries

DATA SOURCES AND METHODS

•

National Survey of Drug Use and Health

• • Sponsored by SAMHSA National and state estimates on prevalence of • • behavioral health conditions and treatment 2008 – 2010 data 70,000 interviews per year •

American Community Survey from Census

•

Literature Review

THE UNINSURED

•

37.9 million uninsured <400% FPL (2010 NSDUH)

• •

19.9 Million ACA Exchange eligible* 18 Million ACA Medicaid eligible

•

11.019 million (29%) currently uninsured <400% FPL have behavioral health conditions (2010 NSDUH)

*Eligible for premium tax credits and not eligible for Medicaid

PREVALENCE OF BEHAVIORAL HEALTH CONDITIONS AMONG MEDICAID EXPANSION POPULATION

18,0% 16,0% 14,0% 14,9% 12,0% 10,0% 8,0% 6,0% 7,0% 4,0% Percent with a Serious Mental Illness (1,283,000) CI: 6.3%-7.7% Percent with Serious Psychological Distress (2,731,742) CI: 14.0%-15.9% CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey 14,2% Percent with a Substance Use Disorder (2,603,405) CI: 13.2%-15.2%

PREVALENCE OF BEHAVIORAL HEALTH CONDITIONS AMONG EXCHANGE POPULATION

18,0% 16,0% 14,0% 12,0% 13,3% 10,0% 8,0% 6,0% 6,0% 4,0% Percent with a Serious Mental Illness (1,195,600) CI: 5.5%-6.6% Percent with Serious Psychological Distress (2,650,247) CI: 12.4%-14.2% CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey 14,6% Percent with a Substance Use Disorder (2,909,294) CI: 13.7%-15.6%

CHARACTERISTICS OF UNINSURED WITH SMI IN MEDICAID EXPANSION POPULATION Female Age 18-34

64% 53%

Race/Ethnicity

Non-Hispanic White Non-Hispanic Black Non-Hispanic Other Hispanic 67% 12% 4% 17%

EDUCATION

< High School High School Graduate College 31% 39% 30%

Population Density

CBSA: 1 Million + 42% CBSA: < 1 Million Non-CBSA 33% 25%

Overall Health

Excellent 9% Very Good 22% Good 31% Fair/Poor 37% CBSA: Core Based Statistical Area

Typical person with SMI in Medicaid expansion population is:

• Female • White or Hispanic • HS education or less • Living in a metropolitan area • Rating her health as fair or poor

CHARACTERISTICS OF UNINSURED WITH SUD IN MEDICAID EXPANSION POPULATION Male Age 18-34

73% 63%

Race/Ethnicity

Non-Hispanic White Non-Hispanic Black Non-Hispanic Other Hispanic 51% 18% 3% 28%

EDUCATION

< High School 43% High School Graduate College

Population Density

32% 25% CBSA: 1 Million + CBSA: < 1 Million Non-CBSA

Overall Health

47% 32% 20% Excellent Very Good Good Fair/Poor 13% 28% 36% 23% CBSA: Core Based Statistical Area Typical person with SUD in Medicaid expansion population is: • Male • 18-34 years old • White or Hispanic • HS education or less • Living in a metropolitan area • Rating his health as good/very good

CHARACTERISTICS OF UNINSURED WITH SMI IN EXCHANGE POPULATION Female

60%

Age 18-34

59%

Race/Ethnicity

Non-Hispanic White Non-Hispanic Black Non-Hispanic Other Hispanic

EDUCATION

< High School High School Graduate College

Population Density

CBSA: 1 Million + CBSA: < 1 Million Non-CBSA

Overall Health

Excellent Very Good Good Fair/Poor 74% 9% 4% 13% 17% 40% 43% 52% 29% 19% 12% 33% 32% 23% CBSA: Core Based Statistical Area Typical person with SMI in exchange population is: • Female • 18-34 years old • White or Hispanic • HS education or less • Living in a metropolitan area • Rating her health as good or very good

CHARACTERISTICS OF UNINSURED WITH SUD IN EXCHANGE POPULATION Male Age 18-34

73% 71%

Race/Ethnicity

Non-Hispanic White Non-Hispanic Black Non-Hispanic Other Hispanic

EDUCATION

< High School 60% 12% 4% 23% 24% High School Graduate College 40% 36%

Population Density

CBSA: 1 Million + CBSA: < 1 Million Non-CBSA 56% 28% 15%

Overall Health

Excellent 15% Very Good 40% Good Area 31% Fair/Poor 13% CBSA: Core Based Statistical Typical person with SUD in exchange population is: • Male • 18-34 years old • White or Hispanic • HS education or less • Living in a metropolitan area • Rating his health as good or very good

15% 10% 5% 0% 40% 35% 30% 25% 20%

STATE PREVALENCE OF SMI AMONG MEDICAID EXPANSION POPULATION

* l Line indicates 95% confidence interval * Suppressed for imprecision

STATE PREVALENCE OF SUD AMONG MEDICAID EXPANSION POPULATION

60% 50% 40% 30% 20% 10% 0% l Line indicates 95% confidence interval

20% 15% 10% 5%

STATE PREVALENCE OF SMI AMONG EXCHANGE POPULATION

25% 0% l Line indicates 95% confidence interval

STATE PREVALENCE OF SUD AMONG EXCHANGE POPULATION

40% 35% 30% 25% 20% 15% 10% 5% 0% l Line indicates 95% confidence interval

STATE-PROFILES

• • • •

State-by-state profiles of prevalence of behavioral health conditions among newly eligible vs. current Medicaid enrollees Demographic profiles National comparisons For profiles and more, please visit:

http://www.samhsa.gov/healthReform/

EFFECTIVE PRACTICES TO ENCOURAGE ENROLLMENT/REENROLLMENT

• • • • • • •

Key research findings Types of organizations with demonstrated success Specific core competencies of successful outreach workers Effective messages/mechanisms Key eligibility/enrollment process fail points Practices to minimize adverse impact of churn Role of providers

KEY RESEARCH FINDINGS

• • •

Individuals require the same types of outreach and enrollment services as “hard to reach populations” but need more intensity and a longer duration of services Behavioral health providers have unique access to uninsured consumers with behavioral health conditions States can identify those likely to be at risk of administrative disenrollment/ reenrollment and target enrollment assistance effectively

ORGANIZATIONS WITH DEMONSTRATED SUCCESS RE: ENROLLMENT

• • • • • •

Health providers, including behavioral health providers Legal Services/Justice Centers Shelter and Homeless Outreach Groups Minority Interest Groups Advocacy Groups (health & behavioral health) Family/Peer Support Groups

CORE COMPETENCIES OF SUCCESSFUL OUTREACH WORKERS

• • • • •

Solid understanding of eligibility requirements, forms, and appeal mechanisms (ongoing training/technical assistance) Comfort in working in non-traditional settings (clinics, shelters, etc.) and non-traditional hours (nights/weekends) Cultural/linguistic competence reflective of those to be reached Easily accessible for follow-up – in person, by phone, email Ability to connect folks with other needed services (housing and primary care identified as two critical services)

EFFECTIVE MESSAGES/MECHANISMS

• • • • •

Messages must be simple and clear – “Open this Envelope, Stay Covered” Consistent messages across populations adapted for particular audiences (e.g. messages that appeal to woman with children won’t reach single males) Messaging must be done over a prolonged period of time to be effective Think outside the box – use of pizza boxes as a way to reach 19-26 yr. olds Use of broad based “access” coalitions to agree on key messages and hone outreach strategies

ELIGIBILITY/ENROLLMENT PROCESS FAIL POINTS

• • • •

Limited hours of operations Poor customer service Complexity of communications Comprehension difficulties especially about the consequences of changes in enrollment status

ELIGIBILITY/ENROLLMENT PROCESS FAIL POINTS

• • • • •

Housing instability (failure to receive notices) Income volatility Difficulty assembling support documents Repeated hospitalizations or program changes Lack of a consistent primary care provider/medical home

REDUCING AND ADDRESSING CHURN

• • • •

Housing instability: Provide recertification forms to social service staff in housing systems Proactive: Identifying heavy users and targeted outreach work prior to disenrollment Used “eligibility representative designees” to help monitor coverage status and to help rapid re enrollment Provider involvement in monitoring enrollment status and assisting in recertification

ROLE OF BEHAVIORAL HEALTH PROVIDERS

• • •

Providers need training on eligibility determination, enrollment and recertification assistance Effective provider assisted enrollment can help mitigate impact of churn when it happens Behavioral health providers have unique access to behavioral health consumers

SAMHSA STRATEGY

• • • • •

Consumer Enrollment Assistance Subcontracts

•

Consumer Assistance

• • • • •

Outreach/public education Enrollment/re-determination assistance Plan comparison and selection Grievance procedures Develop eligibility/enrollment communication materials Challenge.gov Projects

•

Enrollment marketing campaign for uninsured18-34 yr men

•

Innovative eligibility redetermination communication strategies for population at high risk for churn

Communication strategy Enrollment assistance best practices TA for State BH Leaders Provider-assisted enrollment TA

Thank you!

www.samhsa.gov

Kevin Malone [email protected]

240-276-2239