Affordable Care Act Implementation: Opportunities and Challenges For Social Workers

Stacy Collins, MSW National Association of Social Workers Presentation to the New York State Association of Deans of Schools of Social Work August 20, 2012

Presentation Agenda

• Update on ACA implementation, including NASW involvement • Direct and indirect benefits of the ACA for the social work profession • Roles for social work in ACA-supported delivery system models

Benefits of the ACA for Social Workers

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Support for the vulnerable populations served by social workers (i.e. Uninsured/Underinsured)

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Support for the SW Profession

Major outcomes of the June 28 th SCOTUS decision:

     Individual mandate was upheld State Insurance Exchanges will be established Medicaid expansion will go forward w/o penalizing states that don’t comply (i.e., withholding of all Medicaid funds) Absent the penalty, many states now believe that the Medicaid expansion (coverage for all people with incomes up to 133% FPL) is optional.

Implementation of the law goes forward

How do we get to (near) universal coverage?

• • • • People receiving coverage through their employers will continue to receive this coverage Everyone under 133% of the Federal Poverty Line (FPL) - about $15K for an individual - is now covered by Medicaid* Everyone between 133-400% FPL will receive a federal subsidy to purchase coverage on their state “health insurance exchange” – a virtual marketplace for health plans Medicare will continue to cover everyone of the age of 65

Only 15 months away!

Major components of health reform – Medicaid expansion and state insurance exchanges – need to be up and running on January 1, 2014

ACA implementation: Major challenges at the state level

A Patchwork of ACA Compliance

Major ACA benefits for individuals and families

• • • • • • • Dependent coverage to age 26 (2010) No lifetime caps (2010) or annual caps (2014) PCIP insurance plan (2010) (over 75K enrollees; bridge program in advance of exchanges) Guaranteed Issue; aka: No Pre-existing condition exclusions (2014) No coverage rescissions (2010)* Closing the Medicare donut hole (begin 2010) No cost-sharing for preventive services (2010)

The definitive - and most reliable source for all ACA-related information

Resources on Healthcare.gov

Take Action

Find Insurance Options Your Insurance Company & Costs of Coverage Prevention & Wellness Compare Care Providers

Get Help Using Insurance

Managing Your Insurance Understanding Insurance Free or Low-Cost Care Medicare & Long-Term Care Employers & Self-Employed

The Health Care Law and You

Read the Law Key Features of the Law Timeline: What’s Changing & When Implementation Resources

Many states opposed to ACA are stalling implementation until November campaign outcome

Where does NY stand?

• Governor Cuomo signed Executive Order in April 2012, to establish the NY Health Benefit Exchange.

• Governor submitted letter to CMS July 2012 confirming NY’s intent to create an exchange • Donna Frescatore appointed ED of NY State Health Benefit Exchange

All plans operating on the exchanges have to offer a set of “essential health benefits”

Essential Health Benefits

• ambulatory patient services • emergency services • hospitalization • maternity and newborn care • mental health and substance abuse disorder services • prescription drugs • rehabilitative and habiliative services and devices • laboratory services • preventive and wellness services and chronic disease management • pediatric services, including oral and vision care

Essential Health Benefits – Potential New York Benchmark Plans

 Three largest Federal Employees Health Benefits Program (FEHBP) – Government Employees Health Association (GEHA) – – Blue Cross Blue Shield Basic (BCBS Basic) Blue Cross Blue Shield Standard (BCBS Standard)  Three largest New York State Employee Plans (NYSHIP) – – Empire Plan Capital District Physicians Health Plan HMO – Independent Health HMO 

Three largest New York Commercial Small Group Products

– Oxford EPO – Oxford HMO – Oxford Direct 

Largest New York Commercial Group HMO

– HIP Prime (part of Emblem Health) Millman analysis - August 2, 2012

Advocacy that all NY social workers can and should do:

• Advocate for an EHB plan that include robust mental health and substance abuse services – get comments in ASAP: Danielle Holahan at [email protected]

• Promote social work appointments to the state health exchange governing board and advisory committees

NASW’s ACA support

• Obama Administration ally • National coalition involvement on all aspects of ACA implementation • Input on all regulation affecting the profession and the populations we serve • Working with NASW state chapters on implementation, esp in “reluctant” states

ACA: Direct Benefits for the Profession

• Loan repayment for mental health providers working in health professional shortage areas • Mental and Behavioral Health Education and Training Grants for SW & psychology schools (apps were due June 2012) • Health care workforce development grant $ available to states

ACA: Indirect Benefits for the Profession

• Support for delivery system models that are pro-social work: • Medical home – micro level • ACO – macro level

ACA: Indirect Support for Social Work

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Payment and Care

– Enhanced primary care $: Medicare and Medicaid – Medicaid “Health Home” for chronically ill – Bundled payment: hospital/sub-acute 30 days – Community based transition program: complex chronic – Community-based Collaborative Networks – ACOs: Medicare Shared Savings program

Innovation Center and Pilots/Demonstrations

– Chronic disease teams for high risk beneficiaries – Innovations to improve outcome/lower costs: Value – In-home care for high-need Medicare patients – Medicare authorized to join multi-payer initiatives

The “New and Improved” Medical Home

Focuses on: •

Coordinated & integrated Care:

• • Care coordination/care management • Integrated Behavioral health Emphasis on patient empowerment/self care Attention to the Social Determinants of Health • Team-based care

AHRQ, 2010

“ The primary care medical home is accountable

for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.”

Department of Veterans Affairs, 2010

• “An essential component of patient-centered

primary care practice is inter-professional teamwork. High-functioning teams require collaboration between physicians, nurses, pharmacists, social workers, clinical psychologists, case managers, medical assistants, and clinical administrators… ”

Who’s on the Team?

Accountable Care Organizations (ACOs)

• • Collection of provider-based organizations that: manage the health care needs of a defined population Reduce costs and improve health care quality and patient experiences by aligning incentives and reducing fragmentation within the care delivery system.

NCQA, 2012

Where do Social workers fit in?

Within Medical Homes and ACOs Social work can and should be a key ingredient

Ample Opportunities for Social Workers in medical homes/ACOs:

• • • • • • Care coordination/case management, esp for those with multiple chronic conditions Patient education & wellness coaching Behavioral health Specialty mental health Outreach specialists CHW supervisors

“It is important to note that patients and families define the “care team” more broadly than the clinicians working in the primary care practice. Care team members also often include pharmacists, physical therapists, social workers, specialists and mental health

providers, among others.”

Medical Home Example: Allegiance Health System, MI

• • • • • Health coach – LMSW – works as part of primary care team Works with PX identified as having depression Has access to EMR Monitors clinical outcomes, supports treatment adherence and provides one-on-one support Reports issues back to MD and team

Quotes from Allegiance Health Clinical Manager

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“Patients often tell physicians what they

want to hear, but they are more likely to confide in a social worker.”

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“This is a prototype, not a pilot. With a few adjustments, you could take out depression and plug in diabetes.”

Small (2 MDs/2 PNPs) pediatric practice – announcement to patient families

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“As part of our interest in providing collaborative care for patients and families in our office, we are excited to announce that we will be launching our Behavioral Health Program in November. Ms. ____, PsyD and Ms. ____,LSW will bring their many years of experience to our office to see patients and

families for a variety of behavioral, developmental, emotional, and school problems. “

The Good News

When the ACA is fully implemented…..

More than 30 million additional people will become insured

That translates into significant job growth potential for social workers

Biggest hurdles

Getting SW students to look at the full range of career opportunities in health social work Demonstrating our Unique value among the other team members (RNs, CHWs, volunteers)

Final Thoughts……

Social workers are a natural fit in the “new” health care delivery models.

But as social workers, if we don’t claim a stake in these models, others will gladly fill the void.

Contact Info:

Stacy Collins, MSW National Association of Social Workers [email protected]