“Healthcare Reform” Preparing for the Change Mental Health Association of New York State

1. “Healthcare Reform” Preparing for the Change Mental Health Association of New York State October 26, 2011

2. Ps & Qs “To mind one's P's and Q's; to be attentive to the main chance.” The Dictionary of the Vulgar Tongue Francis Grose, 1785 ed.

3. Ps & Qs Pillars People Players & Plans Promotion Questions

4. Healthcare Reform Why Now? 1. Pillars of Healthcare

5. Cost --Contain costs Quality -- focused on outcomes Access -- timely, right service at the right time Pillars of Healthcare

6. Cost Spending on mental illness grew faster than for heart disease, cancer, trauma-linked disorders & asthma Americans seeking treatment for mental health conditions almost doubled, from 19M to 36M Treatment cost for mental disorders rose from $35B to nearly $58B between 1996 and 2006 Antidepressant use among U.S residents almost doubled from 1996 to 2005. AHRQ data (HHS Agency for Healthcare Research and Quality-August 2009. August 6, 2009 — Anne Ziegler (Fierce Health)

7. Cost of Health & Mental Health Among the most expensive 1% of Medicaid beneficiaries (acute care only) Almost 83% have three or more chronic conditions Over 60% have five or more chronic conditions And most of them are in unmanaged fee-for-service Source: Kronick RG, Bella M, Gilmer TP, Somers SA, “The Faces of Medicaid II: Recognizing the Care Needs of People with Multiple Chronic Conditions.” Center for Health Care Strategies, Inc. October 2007 7

8. Purchasers (employers or government) seek value for health care expenditure & managed care companies to deliver: Member satisfaction Positive clinical outcomes and recovery Timely access to needed services Controlling the rate of cost increases Targeting scare health care dollars to the High Risk/High Cost/High Need members. Quality

9. Timely Culturally responsive Right service, right time, right LOS, right reason Access

10. Quality 18 Months: Technology Change (Data) 20 Years: Research to Practice

11. Cost, Quality & Access Practice Models: what types of interventions work — and for whom “ …knowing which treatments work won’t matter unless we know how to target the interventions to the people who will benefit most….In the absence of such knowledge we risk treatment decisions guided by accessibility to resources rather than patient needs.” Psychological scientists Varda Shoham, Ph.D., and Thomas R. Insel, M.D. Perspectives on Psychological Science. Source: Association for Psychological Science http://psychcentral.com/news/2011/09/14/mental-health-care-reform-urged-by-top-scientists/29412.html

12. 2. People Healthcare Reform Why Now?

13. Incidence of Mental Illness & Medical Conditions 1 in 4 Americans has a diagnosable mental disorder 6% of Americans have a serious mental illness, e.g. Bi-polar disorder or schizophrenia 50 million children and adults in this country are diagnosed every year with mental illness People with diabetes, heart disease, asthma & cancer are at greater risk of becoming depressed. http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_862051.html

14. The Case for Health Homes If you are depressed & have asthma, diabetes, heart disease or cancer your are: 2X as likely to develop cardiovascular disease and stroke, 4X more likely to die within six months of a heart attack 3X more likely to be non-compliant with your treatment. http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_862051.html

15. 3. Players & Plans Healthcare Reform Why Now?

16. Who Are They DOB & DOH OMH & OASAS Managed Care Companies Providers Counties Peers/Recipients All are advocates

17. Managing State Medicaid Costs The Economist-April 2011 In challenging economic times States move more aggressively to manage costs. States have 3 ways to manage costs Restrict eligibility, which is prohibited under the federal health care reform initiative Cut benefits-vision, dental, pharmacy, etc. Cut provider payments

18. Addressing System Stressors Managed Care Health Homes ACOs Service Limits Regulatory Reform

19. Future of Medicaid The Economist-October 2012 CA & NY are moving the elderly and disabled into a managed care system Second step in Managed Care - integrate the dual eligibles into MC Dual eligibles account for 40% of Medicaid’s cost and just 15% of the population.

20. Future of Medicaid The Economist-October 2012 If the managed care system works as designed, doctors (health care professionals) can monitor all aspects of care, in contrast to the fragmented fee for service system. If states do not draft their contracts properly or fail to be vigilant in monitoring patient’s health, their experiment in managed care could be a disaster.

21. Why States Use Managed Care To limit the financial exposure of the state Design and manage systems of care To bring together health care financing and health care service delivery into one operating system Manages data for quality monitoring, to track & trend utilization, etc. Use of clinical outcome measures and use of standardized measures to track progress

22. Health Homes & ACOsNCCBH -http://www.thenationalcouncil.org/galleries/default-file/ACOs%20and%20Health%20Homes%20Exec%20Summary.pdf Health Homes & ACOs are responsible for providing the full range of healthcare services needed by the populations they serve Goals are to improve quality, patient experience, & reduce costs MH/SU providers are urged to prepare for participation in the larger healthcare field Ensure IT readiness of providers

23. ACOs Final Federal Regulations published Oct 20 Decreased quality measures from 65 to33 Re: ACO regulations, "But fundamentally, most health systems continue to struggle with the fact that their present operations are oriented toward billing per service, and not taking on risk and responsibility for quality." Dan Mendelson, CEO Washington-based consulting firm Avalere Health Oct 20, 2011

24. Life improvements, e.g. community tenure, education, jobs, housing, etc. Services in least restrictive settings Decreased use of ER & avoidable inpatient and residential stays Customer satisfaction with personal goal achievement Quality Outcomes

25. Healthcare Reform Why Now? 4. Promotion

26. Components of Managed Care Benefits designed by the purchaser, e.g. the state in Medicaid or the insurance company with approval by the employer group Networks are built for Access & to: Meet geo-access requirements Provide timely access to ambulatory services, e.g. medication management Provide the “right” level of care to support recovery & build on strengths

27. Services Individual Therapy Group Therapy Medication Therapy Detox Case Management Care Coordination Peer Support Interventions Assessment Treatment Planning Discharge Planning Medication Therapy/Education/Monitoring Verbal Therapies Assistance with ADLs Safety Planning Services not Programs Services & Interventions vary by: frequency, duration & location of care--in other words, the program 27

28. Members: Who is in Adults Adults with SMI Children Dual Eligibles Who gets served Money: What is in Medicaid Grant Dollars Other State & Local Money Preserve the base funding Members & Money in Managed Care Less about the Models: Carve In or Carve Out 28

29. People Pillars: Cost, Quality & Access Players & Plans Services not Programs Evidence based practices Measurable outcomes Care coordination Recovery Follow the Money not the Model Opportunities

30. What MHA knows….

31. Questions Ann Boughtin 615-498-4398 boughtin@boughtinandorndoff.com www.boughtinandorndoff.com Thank You