Transcript Slide 1

A National View:
Healthcare 2008
CBHC Annual Training Conference
October 5, 2008
Charles Ingoglia, MSW
Vice President, National Council for Community
Behavioral Healthcare
Today…talk about
 Opportunities
and Challenges
 2008 National Healthcare Debate
 National Council Public Policy and
The State of Medicaid
 Taking Charge – relationships,
quality and communications
www.nccbh.org
The National Council
 Not
for profit association of 1500 +
mental health/addiction treatment
and rehabilitation organizations
 Member organizations employ
250,000 staff and provide services to
6 million adults and children in
communities across the country
www.nccbh.org
Membership
1400
1196
1200
1007
1000
800 732
1277
1398
1075
752
600
400
200
0
FY02
FY03
FY04
FY05
FY06
FY07
FY08
YTD
www.nccbh.org
Our Vision – the big picture
A nation where there is prevention
and early detection of mental
illnesses and addictions; and
everyone has access to the effective
treatments and supports essential
to live, work, learn and participate
fully in their communities.
www.nccbh.org
Our Job
The National Council is the interface
between practice and policy.
We are the national voice for legislation,
regulations and policies that protect,
strengthen and expand access to
mental health and addictions services.
Your job is to support others, our job is to
support you.
www.nccbh.org
Members – Top Issues
Funding, Medicaid, Medicare
 Reform – privatization, competition,
managed care
 Workforce
 Health Integration
 Technology
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www.nccbh.org
Time of opportunity
Surgeon General Satcher, President Bush’s
New Freedom Commission, and The
Institute of Medicine all agree that:
mental health and freedom from
addictions are vital to overall health
 effective treatments exist and recovery
is possible
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www.nccbh.org
Opportunity
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Up to 90% of people with a mental illness
that are treated with a combination of
medication and therapy experience
substantially reduced symptoms, enhanced
quality of life & increased productivity
Science has revolutionized our
understanding of addictions – treatment has
been shown to cut drug use in half, reduce
crime by 80% & reduce arrests up to 64%.
www.nccbh.org
Challenges
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Each year 100,000 + Americans die from
alcohol and drug abuse.
50% jail/prison inmates have mental health
problem, 75% substance abuse.
2/3 homeless - chronic alcoholism, drug
addiction, mental illness or combination.
25% of all hospital admissions have mental
illness or addictions disorder.
25% social security payments are for mental
illnesses.
www.nccbh.org
Challenges
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Staffing crisis - low prestige and salaries/
high turnover
Limited use of outcome data to refine
treatment/research based practices
Limited use of knowledge based
technology/neuroscience and biological
advances
Low rates of access, retention & adherence
www.nccbh.org
Challenges
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Ambivalence about healthcare: chronic
illnesses v. recovery; integration?
Complexity of serious mental illnesses –
early mortality – poverty
Protecting individuals with mental illness
from harm v. protecting society
Late detection – complex U.S. system
www.nccbh.org
Challenges
No uniform standards of care and
layers of regulation and oversight
 Multiple hospital and community
providers with fierce competition for
Medicaid
 Dependence on Medicaid and limited
to no access for non – Medicaid
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www.nccbh.org
The Healthcare Debate
www.nccbh.org
www.nccbh.org
U.S. Healthcare System
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The financing system is
 Inefficient
 Inequitable, and
 Fiscally unsustainable.
The delivery system is
 Fragmented
 Not designed to care for chronic diseases
 Haphazard and poor quality
 High use of unproven, marginal therapies.
www.nccbh.org
Costs
 In
2006, the U.S. spent
$2,100,000,000,000 --$2.1 trillion –on
health care.
 $1
out of every $6 spent in the U.S.
www.nccbh.org
Costs
How Big is a Trillion?
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1 million seconds
Last week
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1 billion seconds
Richard Nixon’s
resignation
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1 trillion seconds
30,000 BCE
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Costs
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47 million without health insurance
16% of GDP – no other country above 10%
Fragmented array of insurers and providers
drive high administrative costs: 25-35%
compared to 15%
$5,711 per person, Switzerland $3,847; 31st in
life expectancy
Insurance premiums doubled since 2000
www.nccbh.org
Costs
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We pay hospitals and doctors more
Rely on specialists, using high cost
diagnostics & interventions offering
possibility of improvement
Little to no use of comparative
effectiveness/No budget
75% of costs by 4-5% with chronic illnesses
and at end of life.
www.nccbh.org
Costs
Extremely wealthy country; most like their
providers – change for everyone else, but
 By 2028, health care will consume 28% of
GDP. This is as much as all federal, state
and local governments currently spend.
 By 2050, Medicare and Medicaid will
consume all federal taxes.
“Even in fantasy, no one has yet come up with
a way to pay for Medicare.”
www.nccbh.org
Solutions?
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Managed care: largely unable to reform
care delivery/hated by all
Control drug costs, allow Medicare to
negotiate: small piece of the pie
Pay for Performance: more to providers
already doing the right thing, others won’t
change for additional 2% or 5%
IT: long term can reduce paperwork
burden, errors and repeated tests
www.nccbh.org
Solutions?
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Prevention/Disease management/Medical
homes: not clear if or when get savings:
Skin in the game: 1974 to 1982 Rand study 30% saving when people paid with same
outcomes, exception low income people in
poor health
Close hospital beds: match lower spending
regions save 20% to 30%
www.nccbh.org
Healthcare Reform
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True health care reform must fix both
the financial and delivery systems.
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Unfortunately, most public discussions
focus exclusively on the financing
system and getting to (or close to)
universal coverage. They ignore
delivery system reform.
www.nccbh.org
Incremental Reform
Incremental reform is business as
usual.
 If you like the current system, you like
incremental reform.
 Builds on a broken system.
 Fails to achieve universal coverage, no
cost control, no improved delivery
system.
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www.nccbh.org
Political Feasibility
Many barriers to change:
1) Rule of Satisfaction—85% of Americans
have health insurance and many are
satisfied.
2) James Madison Rule of Government—
American government was designed with
many places for special interests to kill
legislation. With 16% of the GDP, health
care has many special interests.
www.nccbh.org
Political Feasibility
A majority of Americans are for
health care reform. But they are
divided among many different
plans. After their preferred
reform, their second choice is the
status quo.
www.nccbh.org
2007 Lobbying Leaders
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US Chamber of Commerce $52,750,000
General Electric $23,660,000
Pharmaceutical Rsrch & Mfrs of America
$22,733,400
American Medical Assn $22,132,000
American Hospital Assn $19,734,545
AARP $19,540,000
Exxon Mobil $16,940,000
www.nccbh.org
Healthcare Lobbying in 2007
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Pharmaceuticals/Health Products
$226,757,501
Hospitals/Nursing Homes $91,208,297
Health Professionals $70,378,540
Health Services/HMOs $52,990,044
Misc Health $4,985,719
Total spending: $446,320,101
www.nccbh.org
What we must do…
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Broad, strong, engaged membership.
Assertive/focused policy agenda.
Strategic alliances - industry leadership.
Reputation for quality - expert education &
practice improvement initiatives.
Effective communications with members,
media, advocates, policymakers & public.
www.nccbh.org
The National Council
An assertive, focused policy
agenda
www.nccbh.org
Assertive, focused policy agenda
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Understanding and Defending Medicaid
Parity/ Medicare
Veterans
Criminal Justice: Mentally Ill Offender
Treatment and Crime Reduction
Act/Second Chance Act
Community Mental Health Services
Improvement Act - Primary care in
behavioral sites
www.nccbh.org
Assertive, focused policy agenda
The State of Medicaid
www.nccbh.org
In 2007, Over 2/3 of States Offered New
Proposals
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Governors in 34 states offered plans to
reduce uninsured children, parents, adults,
aged and disabled in their state through
 Medicaid expansions
 SCHIP expansions
 DRA waivers
 Comprehensive Section 1115 waivers
 Prevention and better management of
chronic conditions
www.nccbh.org
2008 Response:
 Expansion
plans in jeopardy or
delayed
 States once again freezing or
cutting rates
www.nccbh.org
Illustrative Medicaid Dynamics; Ohio Department of Mental Health
State General Fund and Medicaid
FY 1990 – FY 2007
millions
$200
$150
millions
$200
Medicaid FFP
Medicaid Match
Remaining GRF
$150
$100
$100
$50
$50
$0
$0
-$50
-$50
-$100
-$100
-$150
The Squeeze
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
-$150
www.nccbh.org
Federal Regulations Reflect Federal
Goals
Make Medicaid look like commercial
health insurance.”
 “Medicaid should not be a financing
option for other public systems for nonMedicaid purposes.”
 “Rein in federal health spending.”
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www.nccbh.org
It’s Raining Regulations!
10 new regs in first six months of
federal fiscal year (15+ in last 2 years)
 Most issued as either “interim final”
regulations or with shortened public
comment periods
 Fighting new regs – Congressional
moratoriums
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www.nccbh.org
Council Leadership - Rehab
Option/Case Management
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In DRA, Congress rejected Bush efforts to
legislate changes - President uses
administrative measures for $6.1 billion
savings over next 10 years
Council – member political heat, member
testimony, rallying partners
Achieved moratorium
Working with Congress on legislation to
address rehab and case management regs
www.nccbh.org
Assertive, focused policy agenda
Parity
www.nccbh.org
Commercial Parity
Senator Paul Wellstone Mental Health Parity
Act of 2007 – parity for both mental health and
addictions treatment services
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Senate - introduced by Senators Edward Kennedy (D-MA),
Michael Enzi (D-WY), and Pete Domenici (R-NM)/House
- introduced by Representatives Patrick Kennedy (D-RI)
and Jim Ramstad (R-MN)
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Rally on 9/17; ad campaign
Agreement on content, added to rescue/tax bill
(AMT)
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www.nccbh.org
Parity
Use The Toll-Free Parity Hotline: 1-866-parity4
(1-866-727-4894, the Parity Hotline reaches the U.S.
Capitol switchboard, which connects you to your
Senators' offices.)
"I'm calling to ask that the Senator vote YES on the
energy and tax package that includes parity for
mental health and addiction services. This
legislation must pass this month before Congress
adjourns."
www.nccbh.org
Medicare
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Historic milestone – Congress ( HR 6331)
ending discrimination of outpt. mental
health benefits between 2010 and 2014
Re-authorization of SCHIP - 2 provisions
related to Medicare:
1.marriage&family therapists and licensed
professional counselors as providers
2. additional covered services including
case management, ACT, rehab
Vetoed by President but passage by
Congress is important legislative record
moving forward
www.nccbh.org
Assertive, focused policy agenda
Veterans
www.nccbh.org
Veterans authorization
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S. 38 calls for the VA to contract with
community providers to meet needs of
reserves and National Guard
Recent VA directive to all VISN'S that
describes expectations for access and
services and calls for individual medical
centers to contract with community
providers
www.nccbh.org
Veterans appropriations
$100 million to be allocated to community
mental health organizations in the Veterans
Administration’s health care budget lineitem to increase mental health care for
National Guard members, reservists, and
family members of veterans with service
connected mental disorders
www.nccbh.org
Assertive, focused policy agenda
Community Mental Health
Services Improvement Act
www.nccbh.org
Community Mental Health Services
Improvement Act
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Primary care in behavioral sites ***
Co-occurring disorders funding demo
Workforce improvements, salary study
Paperwork reduction - elimination of
regulatory redundancy
Advancing tech. & electronic health record
Rural behavioral health treatment incentives
www.nccbh.org
Assertive, focused policy agenda
 Coming
soon
www.nccbh.org
Coming Soon
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Federal funding stream to cover the mental
health treatment costs of the uninsured
Restore eligibility for social security
disability for people with addictive disorders
Cost based re-imbursement that supports
salaries that can attract and retain skilled
staff
Chronic disease management project –
medical home
www.nccbh.org
Strategic relationships
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Chronic Disease, Healthcare, Medicaid
Coalitions, Medicaid Directors
Addiction Treatment Advocacy and
Criminal Justice Leadership
Mental Health Groups – Campaign, NAMI,
MHA, Consumers, NASMHPD, Guilds
Feds – SAMHSA, HRSA, CMS
Presidential Election – Whole Health
www.nccbh.org
Reputation for quality – Member
Benefits
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Promoting Wellness - Saving Lives
 Survey on medical services
 Health & Wellness Roundtables
 Primary Care and Behavioral Health
Learning Community - 23
organizations ***
 Primary Care/Behavioral Health
Collaborative Project ***
 Medical/healthcare homes ***
www.nccbh.org
Primary Care/Behavioral Health
Collaborative Project
Objectives:
 Safety net population in every community has
seamless access to both mental health/addiction
and physical healthcare services.
 Strong working partnership among mental
health/addiction and physical healthcare
providers, with roles defined, referral protocols in
place, and cross-placement of clinical staff.
 Phases
I and II : 12 sites in 10 states
 Phase III – 4 additional sites
www.nccbh.org
roject Goals Diagram
Current Referral Chasm
 Only 50% get to MH upon referral
 Little information flows between PCP and MH
 Patients get pushed back and forth, rather
than jointly served
Primary Care Clinic
 Screen all patients for depression
 Screen all depressed patients for bipolar,
suicide, substance use
 Refer per protocols for specialty MH,
referral includes medical co-morbidity
information
 Provide depression care and care
management for those not referred
 Use PHQ – 9 for proactive follow-up and
management of depression
 Access to psychiatry to support PCP and
care management and assure stepped
care
 Provide primary care services
 Support/information from PCPs to MH
regarding health status, joint planning for
patients with medical co-morbidities
 Data tracking regarding care processes
and patient status
Community Mental Health Provider
 Expedited support for referrals and
engagement
 Psychiatry training and support for PCPs
 Psychiatric evaluation and treatment for
referrals
 Track weight, lipids, glycemia for patients
on SGAs
 Support/information from PCPs regarding
health status, joint planning for patients
with medical co-morbidities
 Evidence based MH services and case
management
 Transition stable patients back to PCP per
protocols
 Data tracking regarding care processes
and patient status
Improved Referral Process
 Agree on who needs specialty MH and 100% of
them get there and get engaged
 Information flows between PCP and MH
 Patients are collaboratively cared for, with attention
to medical co-morbidities exacerbated by SGAs
www.nccbh.org
Reputation for quality – Member
Benefits
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Continuity of Care -Access, Engagement
and Adherence Project
Six Sigma Initiative ***
Recruitment and Retention
Psychiatric Leadership Project ***
Middle Management and Leadership
Development – Culture diversity
National Benchmarking Project ***
www.nccbh.org
Access and Engagement
Executive Staff Walkthrough
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Objectives: Experience Intake, Assessment,
and First Appointment Process from Client’s
Perspective; Identify Barriers; and Identify
Strategies for Improvement
Requirements: Site Teams Work in Pairs
(One Client, One Observer/Recorder); and
Mock Clients Complete All Paperwork/
Processes Client Completes
www.nccbh.org
Access and Engagement
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Number of data elements collected in the
process = 1,854
Number of redundant elements = 564
Number required = 957
Staff time required to administer original
flow process = Four hours ten minutes
Staff time required to administer revised
flow process = One hours twenty minutes
www.nccbh.org
Quality – Member Benefits
Criminal Justice Leadership Forum
 Project Helping Hands***
 Awards of Excellence***
 JoBank
 International Community and
“Passport” program ***
 Mental Health First Aid ***
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www.nccbh.org
Few are bigger, none are better
National Council Conference
The Hyatt RiverWalk
San Antonio, Texas
April 5 - 8, 2009
www.nccbh.org
Conference Attendance
2500
2100
2000
1832
1500
1032
1000
607
1013
1179
697
500
0
2002
2003
2004
2005
2006
2007
2008
www.nccbh.org
Effective Communications
Electronic and Print
 Public Policy Update
 Technical Assistance Newsletter
 State Policy Focus
 National Council Magazine
 Letter from Linda
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Journal of Behavioral Health Services & Research
Addictions/Co-occurring Disorders Newsletter
www.nccbh.org
Communications – messaging and
marketing
National Council Live
 Marketing - Message piece/ Policy Guide/Annual
Report
 Print Media – member stories and voices: news,
letters, op-eds and magazine articles in trade and
mainstream press
Redesigned website, www.nationalcouncil.org
 Offering stories of recovery
 Sharing member writings
 National Council resources
 Special interactive sections
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www.nccbh.org
How do we move our agenda…
Change requires 4 things to coalesce:
1) A problem attracts widespread public and
political attention.
2) A proposal to solve the problem is agreed on by
the major actors.
3) There is a major actor or set of actors who
vigorously champion the policy proposal.
4) A transforming political event creates an open
policy window to enact the agreed upon proposal.
Political opportunity is unpredictable. We must be
ready when the policy window opens.
www.nccbh.org
What do we need to succeed?
 An
organized and effective
grassroots
 Congressional champions
www.nccbh.org
What we must do politically…
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Be informed, www.thenationalcouncil.org understand and influence the national
dialogue: mental health and freedom from
addictions are vital to overall health and
effective treatments exist
Tell our story - commit to using our
influence: Congress doesn’t know us very
well and CMS doesn’t always like us
www.nccbh.org
Build relationships with policymakers
•
•
•
•
Meet them in Washington or the District
Get to know their staff
Help them — contribute to their
campaign, attend a fundraiser, put up
yard signs, serve as a content expert etc.
Maintain contact
www.nccbh.org

Political action
is the highest
responsibility
of a citizen.”
“Political action
“
is the highest
responsibility
of a citizen.”
John F. Kennedy
John F. Kennedy
Hill Day: June 9 and 10
www.nccbh.org