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Health Care Reform Impact on Primary Care and Behavioral Health
John O’BrienSenior Advisor on Health Financing, SAMHSA
Statewide Policy Summit on Advancing Bidirectional Behavioral Health and Primary Care IntegrationJune 22, 2011 -- Chicago, IL
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“Be careful about reading health books—you may die of a
misprint”—Mark Twain
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Affordable Care Act
• Major Drivers– 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
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What Is SAMHSA Concerned About?
• 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
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So What’s The Response
• 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
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Health Homes—2703
• 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.
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Eligibility Criteria• Medicaid eligible individual having:
• two or more chronic conditions,
• one condition and the risk of developing another,
• or at least one serious and persistent mental health condition.
• The chronic conditions listed in statute include:
• 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
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 • 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):• 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
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Enhanced Federal Match
• 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
• 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
• 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
• 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
• 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
• 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
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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
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So Why Should You Care?
• 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
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So Why Should You Care?
• 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
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So What Can You Do?
• 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
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So What Can You Do?
• 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
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So What Can You Do?
• 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
