Transcript Document

Behavioral Health
and the
Affordable Care Act
NIHB National Tribal Health Reform Implementation
Summit
April 20, 2011
Dr. Linda Bane Frizzell, Ph.D.
Patient Protection and Affordable Care Act
• Offers significant opportunities to begin to ameliorate the
impact of behavioral health issues upon the lives of
American Indians and Alaska Natives (AI/ANs).
• Has limited, but new language for “parity”.
• Has language specific for:
 Tribes
 Tribal Organizations
 Urban Indian Programs
 Indian Health Service
 Substance Abuse Mental Health Service
Administration
Behavioral Health Issues/Barriers
• Access to and the availability of behavioral health
professionals, such as psychiatrists, psychologists, drug
counselors, and social workers are seriously lacking.
• Poverty, geographic location, and cultural differences
further limit the amount and quality of services available.
• Limited insurance coverage, scarce availability of
services, excessive travel distances, weather hazards,
increased personal monetary costs, and stigma
• Care provided is not intensive enough, not long enough,
and/or lacking in important follow-up health and social
services
“Behavioral” Health
• The Act uses various terms within the context of
Behavioral health including:
 mental illness
 substance related disorders
 substance abuse
 substance abuse prevention
 substance abuse treatment
 behavioral therapies
 behavioral risk
Behavioral Health Sections
 Sec. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS
• With respect to any health plan, coverage that provides
for the essential health benefits
• limits cost-sharing for such coverage
• mental health and substance use disorder services,
including behavioral health treatment
 Sec. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR
ENROLLEES WITH CHRONIC CONDITIONS
• …(e) COORDINATION.—A State shall consult and
coordinate, as appropriate, with the SAMHSA in
addressing issues regarding the prevention and treatment
of mental illness and substance abuse among eligible
individuals with chronic conditions…
 SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC
DEMONSTRATION PROJECT
• shall establish a demonstration project under which an
eligible State shall provide payment under the State
Medicaid plan under title XIX of the Social Security Act to
an institution for mental diseases
 SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR
POSTPARTUM DEPRESSION
• It is the sense of Congress that the Director of the
National Institute of Mental Health may conduct a
nationally representative longitudinal study (during the
period of fiscal years 2010 through 2019)
 SEC. 3012. INTERAGENCY WORKING GROUP ON HEALTH
CARE QUALITY
• The President shall convene a working group to be known
as the Interagency Working Group on Health Care Quality
 Sec. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE
MENTAL HEALTH ADD-ON.
•Section 138(a)(1) of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110–275)
is amended by striking ‘‘December 31, 2009’’ and inserting
‘‘December 31, 2010’’.
 SEC. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR
SPECIAL NEEDS INDIVIDUALS.
• …the Secretary shall evaluate and revise the risk adjustment system
to account for higher medical and care coordination costs associated
with frailty, with multiple, co-morbid chronic conditions, a diagnosis of
mental illness, and costs associated with higher concentrations of
beneficiaries with those conditions…
 SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO
SUPPORT THE PATIENT-CENTERED MEDICAL HOME.
• …Secretary shall establish grants and contracts with eligible entities
to establish community-based interdisciplinary, interprofessional teams
to support primary care practices, including obstetrics and gynecology
practices, within the hospital service areas served by the eligible
entities.
• …(b) ELIGIBLE ENTITIES
• (B) be an Indian tribe or tribal organization, as defined in section 4 of
the Indian Health Care Improvement Act;
 SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION
AND PUBLIC HEALTH COUNCIL.
• The President shall establish, within the Department of Health and
Human Services, a council to be known as the ‘‘National Prevention,
Health Promotion and Public Health Council’’
• …(11) the Assistant Secretary for Indian Affairs;
• …(13) the head of any other Federal agency that the chairperson
determines is appropriate.
• …(5) establish processes for continual public input, including input
from State, regional, and local leadership communities and other
relevant stakeholders, including Indian tribes and tribal organizations;
• … (3) contains a list of national priorities on health promotion and
disease prevention to address lifestyle behavior modification (smoking
cessation, proper nutrition, appropriate exercise, mental health,
behavioral health, substance use disorder, and domestic violence
screenings) and the prevention measures for the 5 leading disease
killers in the United States
 SEC. 4004. EDUCATION AND OUTREACH CAMPAIGN
REGARDING PREVENTIVE BENEFITS.
• The Secretary shall provide for the planning and
implementation of a national public–private partnership for
a prevention and health promotion outreach and education
campaign…
• … (5) preventive care supported by the CDCP, HRSA,
SAMHSA…
• …(e) DISSEMINATION OF INFORMATION
THROUGH PROVIDERS.—
• Secretary, acting through the CDCP, shall develop and
implement a plan… health care providers who participate
in Federal programs, including programs administered by
the IHS, VA, DOD, HRSA, and CMS.
 SEC. 4101. SCHOOL-BASED HEALTH CENTERS.
• (a) GRANTS FOR THE ESTABLISHMENT OF SCHOOL-BASED
HEALTH CENTERS
•…‘‘(B) MENTAL HEALTH.—Mental health and substance use
disorder assessments, crisis intervention, counseling, treatment, and
referral to a continuum of services including emergency psychiatric
care, community support programs, inpatient care, and outpatient
programs…
 SEC. 4103. MEDICARE COVERAGE OF ANNUAL WELLNESS
VISIT PROVIDING A PERSONALIZED PREVENTION PLAN.
• (a) COVERAGE OF PERSONALIZED PREVENTION PLAN
SERVICES
• … ‘‘(ii) A list of risk factors and conditions for which
primary, secondary, or tertiary prevention interventions are
recommended or are underway, including any mental
health conditions or any such risk factors or conditions…
 SEC. 4106. IMPROVING ACCESS TO PREVENTIVE SERVICES
FOR ELIGIBLE ADULTS IN MEDICAID.
• “(C) any medical or remedial services (provided in a facility, a home,
or other setting) recommended by a physician or other licensed
practitioner of the healing arts within the scope of their practice under
State law, for the maximum reduction of physical or mental disability
and restoration of an individual to the best possible functional
level;’’….
 SEC. 4201. COMMUNITY TRANSFORMATION GRANTS.
• The Secretary acting through the CDCP, shall award competitive
grants to State and local governmental agencies…
• ..(b) ELIGIBILITY…
• …(E) an Indian tribe…
• …(v) changes in emotional well-being and overall mental health
 SEC. 4202. HEALTHY AGING, LIVING WELL; EVALUATION
OF COMMUNITY- BASED PREVENTION AND WELLNESS
PROGRAMS FOR MEDICARE BENEFICIARIES.
• The Secretary, acting through the CDCP, shall award grants to State
or local health departments and Indian tribes to carry out 5-year pilot
programs to provide public health community interventions,
screenings, and where necessary, clinical referrals for individuals who
are between 55 and 64 years of age.
• …(ii) TYPES OF INTERVENTION ACTIVITIES.—
Intervention activities conducted under this subparagraph may
include efforts to improve nutrition, increase physical activity,
reduce tobacco use and substance abuse, improve mental health,
and promote healthy lifestyles among the target population.
• … (C) COMMUNITY PREVENTIVE SCREENINGS
• (I) mental health/behavioral health and substance use disorders…
• (i) EVIDENCE REVIEW
• (IV) mental health.
 SEC. 5101. NATIONAL HEALTH CARE WORKFORCE
COMMISSION.
• It is the purpose of this section to establish a National Health Care
Workforce Commission
• … (III) Mental and behavioral health care workforce capacity at all
levels.
• The Commission shall consult with Federal agencies, Congress, the
Medicare Payment Advisory Commission, the Medicaid and CHIP
Payment and Access Commission, and, to the extent practicable, with
State and local agencies, Indian tribes…
 SEC. 5203. HEALTH CARE WORKFORCE LOAN REPAYMENT
PROGRAMS.
• The Secretary shall establish and carry out a pediatric specialty loan
repayment …in providing pediatric medical subspecialty, pediatric
surgical specialty, or child and adolescent mental and behavioral health
care, including substance abuse prevention and treatment services.
 SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL
INTERNAL MEDICINE, GENERAL PEDIATRICS, AND PHYSICIAN
ASSISTANTSHIP.
• … ‘‘(B) proposes innovative approaches to clinical teaching using
models of primary care, such as the patient centered medical home,
team management of chronic disease, and interprofessional integrated
models of health care that incorporate transitions in health care settings
and integration physical and mental health provision;…
 SEC. 5306. MENTAL AND BEHAVIORAL HEALTH EDUCATION
AND TRAINING GRANTS.
• The Secretary may award grants to eligible institutions of higher
education to support the recruitment of students for, and education and
clinical experience of the students…
• … ‘‘(c) INSTITUTIONAL REQUIREMENT.—For grants authorized
under subsection (a)(1), at least 4 of the grant recipients shall be
historically black colleges or universities or other minority serving
institutions.
 SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES
TRACK.
• … established a United States Public Health Sciences Track, sites to
be selected by the Secretary, with authority to grant appropriate
advanced degrees…uniquely emphasizes team-based service, public
health, epidemiology, and emergency preparedness and response.
• It shall be so organized as to graduate not less than—
• ‘‘(E) 100 behavioral and mental health professional students annually
 SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED
LINKAGES.
• (a) AREA HEALTH EDUCATION CENTERS (grants)
• ‘‘(A) Develop and implement innovative curricula in collaboration
with community-based accredited primary care residency training
programs, FQHCs, RHCs, behavioral and mental health facilities,
…goal of increasing the number of primary care physicians and other
primary care providers prepared to serve in underserved areas and
health disparity populations.
 SEC. 5405. PRIMARY CARE EXTENSION PROGRAM.
• The Secretary, acting through the AHRQ, shall establish a Primary Care
Extension Program.
•‘‘(2) PURPOSE - provide support and assistance to primary care providers
about preventive medicine, health promotion, chronic disease management,
mental and behavioral health services (including substance abuse
prevention and treatment services), …working with community-based
health connectors (referred to in this section as ‘Health Extension Agents’).
‘‘(ii) collect data and provision of primary care provider feedback from
standardized measurements of processes and outcomes to aid in continuous
performance improvement;
‘‘(iii) collaborate with local health departments, community health centers,
tribes and tribal entities, and other community agencies to identify
community health priorities and local health workforce needs, and
participate in community-based efforts to address the social and primary
determinants of health, strengthen the local primary care workforce, and
eliminate health disparities;…
 SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS
HEALTH PROFESSIONS WORKFORCE NEEDS; EXTENSION OF
FAMILY-TOFAMILY HEALTH INFORMATION CENTERS.
• … ‘‘(C) ASSURANCE OF OPPORTUNITIES FOR INDIAN
POPULATIONS.—
The Secretary shall award at least 3 grants to an eligible entity that is an
Indian tribe, tribal organization, or Tribal College or University.
• ‘‘(3) REPORTS AND EVALUATION.—
•… ‘‘(A) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a
State, an Indian tribe or tribal organization, an institution of higher
education, a local workforce investment board established under
section 117 of the Workforce Investment Act of 1998, a sponsor of an
apprenticeship program registered under the National Apprenticeship
Act or a community- based organization.
• …‘(G) TRIBAL COLLEGE OR UNIVERSITY.—The term ‘Tribal
College or University’ has the meaning given that term in section
316(b) of the Higher Education Act of 1965 (20 U.S.C. 1059c(b)).
 (Continued)
SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS
HEALTH PROFESSIONS WORKFORCE NEEDS; EXTENSION OF
FAMILY-TOFAMILY HEALTH INFORMATION CENTERS
• …‘‘(3) TEACHING HEALTH CENTER.—
• ‘‘(B) INCLUSION OF CERTAIN ENTITIES.—Such term
includes the following:
• ‘‘(i) A FQHC
• ‘‘(ii) A community mental health center (as defined in section
1861(ff)(3)(B) of the Social Security Act).
• ‘‘(iii) RHC
• ‘‘(iv) A health center operated by the Indian Health Service,
an Indian tribe or tribal organization, or an urban Indian
organization (as defined in section 4 of the Indian Health Care
Improvement Act).
 SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE
IN COMMUNITY-BASED MENTAL HEALTH SETTINGS.
• ‘‘(1) ELIGIBLE ENTITY. - qualified community mental health
program defined under section 1913(b)(1).
• ‘‘(2) SPECIAL POPULATIONS. - adults with mental illnesses who
have co-occurring primary care conditions and chronic diseases.
• ‘‘(b) PROGRAM AUTHORIZED. - demonstration projects for
coordinated and integrated services to special populations through
community co-location of primary and specialty care services
 SEC. 10306. IMPROVEMENTS UNDER THE CENTER
FOR MEDICARE AND MEDICAID INNOVATION.
• For purposes of testing payment and service delivery
models
• ‘‘(xix) Utilizing entities located in medically underserved
areas and facilities of the Indian Health Service (whether
operated by such Service or by an Indian tribe or tribal
organization, telehealth services—
• ‘‘(I) in treating behavioral health issues (such as posttraumatic stress disorder) and stroke; and
•‘‘(II) to improve the capacity of non-medical providers
and non-specialized medical providers to provide health
services for patients with chronic complex conditions…
 SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE
COMPREHENSIVE WORKPLACE WELLNESS PROGRAMS.
• The Secretary shall award grants to eligible employers to provide
their employees with access to comprehensive workplace wellness
programs
• … (D) Supportive environment efforts (including workplace policies
to encourage healthy lifestyles, healthy eating, increased physical
activity, and improved mental health).
 SEC. 10410. CENTERS OF EXCELLENCE FOR DEPRESSION.
•(a) SHORT TITLE.—‘‘Establishing a Network of Health-Advancing
National Centers of Excellence for Depression Act of 2009’’ or the
‘‘ENHANCED Act of 2009’’.
• … ‘‘(5) ELIGIBLE ENTITIES.—
• ‘‘(A) REQUIREMENTS.—To be eligible to receive a grant under this
section, an entity shall—
• ‘‘(i) be an institution of higher education or a public or private
nonprofit research institution
Summary
American Indian/Alaska Native aspects. There are specific
provisions that specifically name tribes: Sections 3502, 4001,
4201, 4202, 5101, 5405, 5507, and 10306; and one (1) Section
5507 that names urban Indian programs.
American Indian/Alaska Native impact. At this time the
impact is unclear, but there is potential for innovative, far
reaching treatment and prevention programs, an emergency
demonstration project, education and trainings, school based
centers, leadership development, work force development,
research, data base development, loan repayment, and
reimbursement improvement for behavioral health services.
Thoughts?
The behavioral health features of the PPACA are numerous and
complex. There are a variety of different opportunities that can
impact or begin to impact the tremendous needs of Indian
Country.
Contact Information:
Dr. Linda Bane Frizzell, Ph.D.
Northwest Portland Area Indian Health Board
2121 SW Broadway, Suite 300
Portland, OR 97201
[email protected]
www.npaihb.org