Transcript Slide 1

Health Care Reform
Impact on Primary Care and Behavioral Health
John O’Brien
Senior Advisor on Health Financing, SAMHSA
Statewide Policy Summit on Advancing Bidirectional
Behavioral Health and Primary Care Integration
June 22, 2011 -- Chicago, IL
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“Be
careful about reading health books—you may die of a
misprint”—Mark Twain
Affordable Care Act
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• Major Drivers
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More people will have insurance coverage
Medicaid will play a bigger role in MH/SUD than ever before
Focus on primary care and coordination with specialty care
Major emphasis on home and community based services and
less reliance on institutional care
– Rethink what is offered as a benefit
– Outcomes: improving the experience of care, improving the
health of the population and reducing costs
What Is SAMHSA Concerned About?
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• People Are Dying Younger
• Younger People in our systems are not exempt
from (or at risk of) chronic conditions
• Significant connection between heart
conditions and drug use--Hospitalizations
• About 1/3 of all cigarette smokers have an
MH/SUD
• 30% of all individuals with a MH/SUD may
have 3 chronic conditions
Other Major Drivers
• Primary Care and Specialty Coordination—
Why All the Fuss?
– 20% of Medicare and Medicaid patients are readmitted
within 30 days after a hospital discharge
– Lack of coordination in “handoffs” from hospital is a
particular problem
– More than half of these readmitted patients have not seen
their physician between discharge and readmission
– Most FQHCs and BH Providers don’t have a relationship
So What’s The Response
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• Health Homes—start with folks that have a
variety of chronic conditions
• Accountable Care Organizations—start with
Medicare population
• Patient Safety Initiative—reward hospitals and
other facilities for fewer incidents
• Quality Measures—focus on identifying
people who are at risk of certain conditions
Health Homes—2703
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• New Medicaid State Plan Option
• 2703 Goals:
•Expand upon the traditional and existing
medical home models
•Build linkages to community and social
support
•Enhance the coordination of medical,
behavioral, and long-term care.
Eligibility Criteria
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Medicaid eligible individual having:
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two or more chronic conditions,
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one condition and the risk of developing another,
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or at least one serious and persistent mental
health condition.
The chronic conditions listed in statute include:
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a mental health condition, a substance abuse
disorder, asthma, diabetes, heart disease, and
obesity (as evidenced by a BMI of > 25).
States may add other chronic conditions (e.g.
HIV/AIDs)
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Designated Provider Types
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 There are three distinct types of health home
providers that can provide health home services:
 designated providers,
 a team of health care professionals, and
 a health team.
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Health Home Functions
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• Health home providers are expected to address several
functions including, but not limited to:
• Providing quality-driven, cost-effective, culturally
appropriate, and person- and family-centered health
home services;
• Coordinating and providing access to high-quality
health care services informed by evidence-based
guidelines;
• Coordinating and providing access to mental health
and substance abuse services;
• Coordinating and providing access to long-term care
supports and services.
Health Homes
– Health homes (several new services):
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Comprehensive Care Management
Care Coordination and Health Promotion
Patient and Family Support
Comprehensive Transitional Care
Referral to Community and Social Support Services
– Models
• Still emerging—chronic disease and depression
• Fewer models on chronic disease and alcohol or
substance use
Enhanced Federal Match
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• There is an increased federal matching
percentage for the above health home services of
90 percent for the first eight fiscal quarters that a
State plan amendment is in effect.
• The 90 percent match does not apply to other
Medicaid services a beneficiary may receive.
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Accountable Care Organizations
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• Recently released draft rules on ACOs—responses
due early June
• Initially targets Medicare population—estimated
savings of $960M first three years
• Implications for Medicaid and Commercial plans
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Accountable Care Organizations
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• ACOs have been compared to the
elusive unicorn: everyone seems to
know what it looks like, but no one
has actually seen one.
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Accountable Care Organizations
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• Network of doctors and hospitals that
shares responsibility for providing care to
patients.
• Premise:
• Make providers jointly accountable for the
health of their patients,
• Strong incentives to cooperate and
• Save money by avoiding unnecessary tests and
procedures.
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Accountable Care Organizations
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• Shared Information—for ACOs to work
they’d have to seamlessly share
information.
• Shared savings—ACOs that save money
while also meeting quality targets would
keep a portion of the savings.
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Accountable Care Organizations
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• Better Screening—focus on “red flag”
conditions that may indicate higher risk
clients
• Care coordination especially between
hospitals and primary care
• Specialty care has a role—not well
articulated yet
• Minimum of 5,000 Medicare beneficiaries
for at least three years 18
Partnership for Patients
• National partnership that will help save
60,000 lives
• Goal is to stop millions of preventable injuries
and complications in patient care over the
next three years.
• Focus on nine types of medical errors and
complications: preventing adverse drug
reactions, pressure ulcers, childbirth
complications and surgical site infections.
Partnership for Patients
• HHS has committed $500 million to
community-based organizations partnering
with eligible hospitals to help patients safely
transition between settings of care.
Other Implications
• There will be more and new payment strategies
– Quite a contrast from 3 years ago
• Widgets versus bundling
• Overly accounted rates versus add ons or tiered rates
• Prescriptive versus creative definitions of services
– Shared savings:
• Need upfront $ to play
• May not see the returns immediately—do you (or board) have the
stomach for that
– Payment on “successful” episode of care
• Will have to define successful and episode
• Price it out based on what will be needed to be successful
Implications
• What’s old is new—lots of discussion about
capitation (again)
• Lessons learned from the 90’s
– Although many providers signed capitation contracts, most of
these efforts ultimately failed
– Providers were not organized to coordinate care efficiently.
– Providers did not change their practice
– Many large payers continued to pay through grants or FFS
– As providers began losing money on capitation contracts,
patients became fearful that clinical decisions were affected by
financial considerations.
– Providers largely not have data to prove value to payers, so
ever at risk of services being eliminated from benefits when
dollars tight
Compliance and Payment
• Providers and managed care organizations must
report/repay any overpayment from Medicare or
Medicaid within 60 days .
• More rigorous screening procedures for providers
seeking Medicare’s approval to bill
• Require providers as a condition of participation in
Medicare, to adopt compliance programs that meet
federal
• Soon all claims submitted online
• Bundling should not be mechanism to “hide” the
services rendered
Implications
• Changes in Mission of Block Grant
– The “who” changes—more people are covered by
insurance. Who is left uninsured:
• Individuals that dont enroll or lapse coverage
• Individuals not eligible for exchanges—too much
income but cant afford private pay
– The “what” what changes
• We need to buy what is “good and modern” - ACA
requires “essential” MH/SUD
• Need to make sure we don’t duplicate payment for
same services
So Why Should You Care?
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• Feast or Famine
• Health homes—lots of opportunities for SUD providers to
participate
• Clear focus on SUD as a chronic condition
• Health homes for other chronic conditions are being encouraged
to screen for MH/SUD
• Provider descriptions specifically cite behavioral health providers
as a possible HH provider
• ACOs—Not as clear of a role
• Initial focus on Medicare—not out clients
• Proposed rules lean on behavioral health conditions
• Sharing information is daunting
So Why Should You Care?
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Feast or Famine
• Patient Safety Initiative—
• No mention of BH conditions
• But—SUD patients have high rates of
hospitalization
• SUD patients may actually be more susceptible
to medical errors and complications
• $500 million available now for local initiatives
So What Can You Do?
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• Mandatory Requirements:
– Do outreach to primary care—start with larger
organizations (FQHCs, CHCs)
• Business Case
• Recommend screening tools and processes
• Help them with concerns regarding 42 CFR—decipher
myth from reality
• Develop a workable hand off/referral strategy
So What Can You Do?
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• Mandatory Requirements:
– Make recommendations regarding ACOs
regulations and SUD conditions (SAAS)
• Screening tools
• Measures
– Find out who is forming ACOs
• Hospital executives
• Local foundations
• Large consulting firms
So What Can You Do?
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• Mandatory Requirements:
– Assess how prevalent hospital errors and illnesses
are among newly discharged patients
– Lead or form the partnerships re: Patient Safety
now
– Develop plan and make investment for sharing
information—most challenging
– Assess your compliance strategies
Additional Information
• http://www.healthcare.gov
• John O’Brien— [email protected]