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Mark Covall, President/CEO National Association of Psychiatric Health Systems Presentation to Alaska State Hospital and Nursing Home Association September 2014 Mental and substance use disorders National Association of Psychiatric Health Systems - September 2014 Millions of Americans Affected BY MENTAL ILLNESS One in every five adults (45.9 million Americans aged 18 or older) experienced mental illness in the past year. Some 5% of the adult population (11.4 million adults) suffered from serious mental illness in past year (defined as one that resulted in serious functional impairment that substantially interfered with or limited one or more major life activities) SOURCE: SAMHSA. January 2012. See http://www.samhsa.gov/data/NSDUH/2k10MH_Findings/. National Association of Psychiatric Health Systems - September 2014 Yet Need Is Only Partially Met Only about 4 in 10 people (39.2%) experiencing any mental illness in the past year – and only 60.8% of those experiencing serious mental illness – received any mental health services during that period. SOURCE: SAMHSA. 2010 National Survey on Drug Use and Health. January 2012. www.samhsa.gov/data/NSDUH/2k10MH_Findings/. Some 23.1 million Americans aged 12 or older (9.1%) needed specialized treatment for a substance abuse problem, but only 2.6 million (or roughly 11.2%) received it. SOURCE: SAMHSA. 2010 National Survey on Drug Use and Health. September 8, 2011. Release at www.samhsa.gov/newsroom/advisories/1109075503.aspx. National Association of Psychiatric Health Systems - September 2014 Mental Health and Substance Abuse National Association of Psychiatric Health Systems - September 2014 Total Mental Health & Substance Use Spending (2014-2020) 2014: $210.6 billion In Billions 280.5 300.0 250.0 2020: $280.5 billion (projected) 210.6 Includes all treatment spending for mental health and substance use disorders (including prescription 200.0 150.0 drugs, hospitals, and all other treatment settings) 100.0 50.0 0.0 2014 2020 SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use disorders…” August 2014. National Association of Psychiatric Health Systems - September 2014 Mental Health/Substance Use Spending Projected Growth (vs. All Health Spending) Average annual growth in spending 19982009 20092020 Mental health / substance use 6.7% 4.6% All health 6.8% 5.8% 1998-2009: 2.9% of mental health increase directly related to increase in prescription drug spending 2009-2020: major driver of mental health decrease is expiration of pharmaceutical drug patents SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use disorders…” August 2014. National Association of Psychiatric Health Systems - September 2014 Projected Mental Health/Substance Use Spending, to 2020(as a Proportion of Overall Health Spending) Behavioral Health 9.3% 10.0% 8.1% 9.0% 7.3% 8.0% 7.5% 7.3% SOURCES: Mechanic D. Health Affairs. 33(8): 14161424.August 2014 Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use disorders…” August 2014. 7.3% 6.5% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 1986 1992 1998 2002 2005 2009 2020 National Association of Psychiatric Health Systems - September 2014 Mental Health/Substance Use as a Proportion of Overall Health Spending (by category) 10.0% 9.0% 8.0% Addiction 2.1% 1.7% 7.0% 1.3% 1.3% 1.2% 1.0% 6.0% 6.2% 6.1% 6.3% Mental health 6.0% 5.0% 4.0% 7.2% 6.4% 3.0% 2.0% 1.0% 0.0% 1986 1992 1998 2002 2005 2009 National Association of Psychiatric Health Systems - September 2014 SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use disorders…” August 2014. Reasons Behind Slower Overall Growth 2007-2009: Recession 2009-2012: State hospital closures and reductions in beds 2011: Medicare payment rate changes in the Affordable Care Act and Budget Control Act of 2011 2014-2016: Decline in prescription drug prices due to loss of patent protection SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use disorders…” August 2014. National Association of Psychiatric Health Systems - September 2014 • Macro Trends • Health System Trends National Association of Psychiatric Health Systems - September 2014 National Association of Psychiatric Health Systems - September 2014 Macro Trends More / improved coverage Different payment structures (e.g., case rates/ bundled payments) More managed Medicaid More outpatient / community-based More emphasis on quality and accountability Stigma reduced Shortage of psychiatrists / therapists National Association of Psychiatric Health Systems - September 2014 National Association of Psychiatric Health Systems - September 2014 Health System Trends New delivery models / ACOs Health systems expanding behavioral health services…especially those in risk-sharing contracts Increased awareness of mental health/substance use comorbidities and impact on chronic disease management Integration of mental health and primary care -continuedNational Association of Psychiatric Health Systems - September 2014 Health System Trends (continued) Telemedicine growing More use of mid-levels, nurse practitioners Specialty programs Eating disorder Dual diagnosis Women’s programs Gay/lesbian Military National Association of Psychiatric Health Systems - September 2014 • Parity • Affordable Care Act National Association of Psychiatric Health Systems - September 2014 “Game – changer” National Association of Psychiatric Health Systems - September 2014 The Parity Law The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act signed into law on October 3, 2008. Basically, became effective January 1, 2010. National Association of Psychiatric Health Systems - September 2014 Key Provisions Applies to 113 million employed Americans, including individuals in ERISA plans (self-insured companies) Requires equity in financial requirements Requires equity in treatment limits -continued- National Association of Psychiatric Health Systems - September 2014 Key Provisions (continued) Does not mandate mental health benefits Exempts certain businesses With 50 or fewer employees Posting an overall cost increase due to parity requirements (2%+ in first year; 1% in subsequent years) Exemption only lasts one year; need to reapply the following year (or comply) National Association of Psychiatric Health Systems - September 2014 Interim Final Regulations Published in the February 2, 2010, Federal Register at http://edocket.access.gpo.gov/2010/pdf/2010-2167.pdf Department of Health and Human Services Treasury Department Labor Department Went into effect for health plan years beginning on or after July 1, 2010. Means that most health plans were not subject to the regulations until January 1, 2011. National Association of Psychiatric Health Systems - September 2014 Treatment Limitations The regulations go further with respect to treatment limitations. The regulations define treatment limitations as quantitative and non-quantitative. -continued- National Association of Psychiatric Health Systems - September 2014 Definitions Quantitative limits: Are numerical (e.g., 30 inpatient days). Non-quantitative treatment limitations: are such things as (NOTE: This list is not exhaustive): medical management standards, including standards for admission to participate in a network; determination of usual, customary, and reasonable charges, requirement for using lower cost therapies before the plan will cover more expensive therapies (also known as fail-first policies or step therapy protocols), conditioning benefits on the completion of a course of treatment. National Association of Psychiatric Health Systems - September 2014 Comparison of Med/Surg and Psychiatric Benefits Plans are only permitted to compare medical/surgical and mental health benefits for purposes of applying parity requirements using six specified categories: 1. 2. 3. 4. 5. 6. inpatient, in-network inpatient, out-of-network outpatient in-network outpatient out of network emergency care prescription drugs National Association of Psychiatric Health Systems - September 2014 Final Rule Issued November 8, 2013 Includes an intermediate classification to clarify the law is intended to include coverage for a full range of services (inpatient – intermediate –outpatient). Makes clear that insurers must have comparability in management practices Health plan transparency Removes exception to NQTLs National Association of Psychiatric Health Systems - September 2014 Mental Health Parity • Final rule applies to plan years beginning on or after July 1, 2014. • Until the rules take effect, plans must continue to comply with parity provisions of the interim final regulations. National Association of Psychiatric Health Systems - September 2014 Mental Health Parity Rule applies to: • • 113 million employed Americans, including individuals in self-insured companies (large employers with more than 50 employees). Parity is also now embedded in the Affordable Care Act and extends federal parity protections to those Americans obtaining small group and individual health plan coverage under the ACA. National Association of Psychiatric Health Systems - September 2014 Mental Health Parity Rule does NOT apply to: • Medicaid managed care organizations • Children’s Health Insurance Program (CHIP) • Alternative Benefit Plans (i.e., Medicaid expansion plans under the ACA) Further clarification is needed because the rule states the statute applies to these entities. National Association of Psychiatric Health Systems - September 2014 Key Provisions and Clarifications in Final Parity Rule • Includes an intermediate care classification to clarify the law is intended to include the full continuum of services for behavioral health care which includes (inpatientintermediate-outpatient). This provision clarifies that the interim rule never intended to exclude outpatient, partial hospitalization and residential care. • Makes clear that insurers must have comparability in management practice (removes loophole that allowed behavioral health benefits to be managed differently). -continued- National Association of Psychiatric Health Systems - September 2014 Key Provisions and Clarifications in Final Parity Rule (continued) New disclosure requirements are included to require more transparency from health plans in the areas of medical necessity determinations and management practices. States will have primary enforcement authority over health insurance issuers. As such, states will be the primary means of effectuating mental health parity implementation. Government will continue to issue more guidance on final rule. National Association of Psychiatric Health Systems - September 2014 Next Steps Medicaid / parity rule Enforcement National Association of Psychiatric Health Systems - September 2014 Signed into law March 23, 2010, by President Obama National Association of Psychiatric Health Systems - September 2014 Key Provisions of the ACA Individual mandate requires almost everyone to obtain coverage or face a penalty Employers with 50 or more employees must provide coverage or face a penalty (delayed for 1 year until 2015) Covers people regardless of any preexisting conditions Young people up to age 26 gain insurance through their parents’ plan (3.1 million) National Association of Psychiatric Health Systems - September 2014 Affordable Care Act (ACA) Will expand coverage to 32 million Americans through either: the health insurance exchanges or Medicaid expansion National Association of Psychiatric Health Systems - September 2014 ACA extends parity to two key groups (continued) Group 1 Individuals People who will gain MH/SA (or both) benefits under the ACA, including federal parity protections Currently in individual plans 3.9 million Currently in small-group plans 1.2 million Currently uninsured 27 million Subtotal 32.1 million National Association of Psychiatric Health Systems - September 2014 ACA extends parity to two key groups (continued) Group 2 Individuals People with existing MH/SA benefits who will benefit from federal parity protections Currently in individual plans 7.1 million Currently in small-group plans 23.3 million Subtotal 30.4 million National Association of Psychiatric Health Systems - September 2014 ACA extends parity to two key groups (continued) By building on the structure of the MHPAEA, the ACA will extend federal parity protections to 62.5 million Americans. Individuals Total # of people who will benefit from federal parity protections Currently in individual plans 11 million Currently in small-group plans 24.5 million Currently uninsured 27 million Total 62.5 million National Association of Psychiatric Health Systems - September 2014 Affordable Care Act (ACA) States are mandated to participate in the insurance exchanges States can: Run their own exchange, Let the feds run the exchange, or Establish a partnership with the feds National Association of Psychiatric Health Systems - September 2014 State Health Insurance Exchanges As of 8/6/13, Center on Budget & Policy Priorities (http://www.cbpp.org/files/CBPP-Analysis-on-the-Status-of-State-Exchange-Implementation.pdf) National Association of Psychiatric Health Systems - September 2014 Health Insurance Exchanges Approximately 23 million people will purchase individual or small group private health insurance through the exchanges. ACA created health insurance subsidies (in the form of premium tax credits and cost-sharing reductions) to help eligible individuals and families purchase health insurance through an exchange. National Association of Psychiatric Health Systems - September 2014 State Health Insurance Exchanges October 1, 2013: Exchanges open enrollment period started Federal on-line health Insurance exchange marketplace is live at www.HealthCare.gov Coverage begins January 1, 2014 Subsidies available beginning in 2014 Open enrollment ends March 31, 2014 National Association of Psychiatric Health Systems - September 2014 Essential Benefit Requirements Mental health and addiction services are one of the 10 essential benefit requirements in the plans offered through the insurance exchanges and in the Medicaid expansion. The federal parity law applies to the mental health/ addiction essential benefit. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Hospitalization Mental health/addiction Ambulatory Emergency Maternity Pediatric services Laboratory services Prescription drugs Rehabilitative and habilitative services Preventive and wellness services National Association of Psychiatric Health Systems - September 2014 Medicaid Expansion States – at their option – can choose to expand Medicaid with the feds paying 100% of the cost in the first three years and no less than 90% going forward National Association of Psychiatric Health Systems - September 2014 Medicaid Expansion Expands eligibility to adults ages 19-64 with income at or below 133% of the federal poverty level No deadline for state in Medicaid expansion decision; however, coverage begins January 1, 2014 States that want to take advantage of the three-year window for 100% federal match have already made their decision to take the Medicaid expansion option National Association of Psychiatric Health Systems - September 2014 Status of State Medicaid Expansion As of 7/18/13, Center on Budget & Policy Priorities http://www.cbpp.org/cms/index.cfm?fa=view&id=3819 National Association of Psychiatric Health Systems - September 2014 Medicaid Expansion Arkansas Model Arkansas’ “Private Option” model uses the federal funding for Medicaid expansion to buy private health insurance coverage through the state exchange Numerous Republican governors considering Arkansas model for Medicaid expansion It’s a way to take Medicaid money without being branded as “Obamacare” supporters National Association of Psychiatric Health Systems - September 2014 Estimated Impact of ACA on Mental Health In 2020: Will increase mental health spending (overall) by 1.9% ($4.4 billion) in 2020. Will also alter mental health financing, primarily from Medicaid and private insurers. Medicaid spending in states that did not decline to expand enrollment is expected to be 7.8% ($5.2 billion) higher (than without the ACA) Private insurance is expected to be 3.4% ($2 billion) higher (than without the ACA) SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use disorders…” August 2014. National Association of Psychiatric Health Systems - September 2014 Estimated Impact of ACA and Parity on Substance Use Spending In 2020 substance use spending (overall) will increase by 7.2% ($2.8 billion) (vs. 1.9% in mental health). Substance use disorders are prevalent among young adults, who are over-represented among those who are currently uninsured and who may gain insurance. Many young people with severe mental illnesses are already insured by Medicaid or Medicare by virtue of disability (which lowers potential increase in spending under ACA expansions). Prescription patent expirations are not expected to have a significant impact on substance abuse spending. SOURCE: Mark TL, et al. Health Affairs, 33(8): 1407-1415. “Spending on mental and substance use disorders…” August 2014. National Association of Psychiatric Health Systems - September 2014 H.R.3717 introduced by Rep. Tim Murphy (R-PA) National Association of Psychiatric Health Systems - September 2014 H.R.3717 would: Create a pathway under Medicaid for people to get access to short- term acute psychiatric care. Give behavioral health organizations funding for health information technology Elevate mental health in the federal government by creating an Assistant Secretary for Mental Health and Substance Use Disorders in the U.S. Department of Health & Human Services Promote primary care integration Support suicide prevention for children and youth -continuedNational Association of Psychiatric Health Systems - September 2014 H.R.3717 would: (continued) Encourage research on serious mental illness and self- or other- directed violence Improve communication between families and mental health providers. Apply quality standards for a new class of Federally Qualified Community Behavioral Health Clinics (FQCBHC), requiring them to provide a range of mental health and primary care services Promote justice system reforms Establish national standards for both inpatient and outpatient commitment to reduce barriers to timely access to treatment National Association of Psychiatric Health Systems - September 2014 H.R.3717 Introduced by Rep. Tim Murphy Chair, House Oversight Subcommittee of the Energy & Commerce Committee. Co-chair, Congressional Mental Health Caucus Has 89 cosponsors (as of 6/6/14): 57 Republicans 32 Democrats National Association of Psychiatric Health Systems - September 2014 Performance Measurement National Association of Psychiatric Health Systems - September 2014 Quality Initiatives HBIPS Core Measures – Joint Commission IPF Quality Reporting Program – CMS National Quality Forum National Association of Psychiatric Health Systems - September 2014 HBIPS Measures The assessment process The use of antipsychotic medications Seclusion and restraint Discharge summary / aftercare National Association of Psychiatric Health Systems - September 2014 Centers for Medicare and Medicaid Services National Association of Psychiatric Health Systems - September 2014 IPF Quality Reporting / CMS The ACA requires that, as of rate year 2014 (starting October 1, 2013), all facilities reimbursed under the inpatient psychiatric facility prospective payment system (IPF PPS) must report data on at least six measures to CMS for the purpose of public reporting, payment updates, and pilot pay-for-performance programs. CMS approved six measures to meet the requirements of the Affordable Care Act’s (ACA) mandate for both psychiatric hospitals and psychiatric units to begin reporting inpatient quality measures. National Association of Psychiatric Health Systems - September 2014 IPF Quality Reporting / CMS CMS measures are six of the seven Hospital-Based Inpatient Psychiatric Services (HBIPS) core measures (already required of psychiatric hospitals by The Joint Commission and available for use by psychiatric units to meet ORYX reporting requirements): HBIPS-2 Hours of physical restraint use (patient safety); HBIPS-3 Hours of seclusion use (patient safety); HBIPS-4 Patients discharged on multiple antipsychotic medications (pharmacotherapy); HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification (pharmacotherapy); HBIPS-6 Post discharge continuing care plan created (care coordination); and HBIPS-7 Post discharge continuing care plan transmitted to next level of care provider upon discharge (care coordination). National Association of Psychiatric Health Systems - September 2014 IPF Quality Reporting – Next Steps 8/19/13 -- CMS issued final rule on FY2014 quality reporting requirements for inpatient psychiatric facilities (see pages 50887-50901) National Association of Psychiatric Health Systems - September 2014 Quality Reporting—Next Steps No additional measures required by CMS for rate year 2015. Substance abuse assessment (SUB-1) and Medicare data on follow-up after discharge added for rate year 2016. Currently testing potential measures for rate year 2017. NAPHS and partners constantly work to keep measures aligned and harmonized to decrease burden and to increase benefit to the field. National Association of Psychiatric Health Systems - September 2014 Final Rule (Update for FY15) In 8/6/14 Federal Register final rule: For FY16 & subsequent years (in addition to those already previously adopted): “Assessment of Patient Experience of Care” (attestation that an organization routinely assesses patient experience of care using a standardized collection protocol and a structured instrument) 2. “Use of an Electronic Health Record” (attestation to the facility’s highest level use of an EHR for transfer of health information). 1. National Association of Psychiatric Health Systems - September 2014 Final Rule (Update for FY15) (continued) For FY17 and subsequent years: Influenza Immunization (IMM-2); 2. Influenza Vaccination Coverage Among Healthcare Personnel; 3. Tobacco Use Screening (TOB-1); and 4. Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-2a). 1. National Association of Psychiatric Health Systems - September 2014 November 2014 National Association of Psychiatric Health Systems - September 2014 2014 Mid-Term Elections HOUSE: Republicans will retain control SENATE: Leaning toward Republicans regaining control of Senate Republicans need to pick up 6 seats National Association of Psychiatric Health Systems - September 2014 Key Senate Races Democratic incumbents: Alaska / Begich Arkansas / Pryor North Carolina / Hagan Louisiana / Landrieu Republican incumbents: Kentucky / McConnell Open Democratic seats: Montana South Dakota West Virginia National Association of Psychiatric Health Systems - September 2014 www.naphs.org