Healthcare Implementation A New Day for Virginia Behavioral Health Services

1. Healthcare ImplementationA New Day for VirginiaBehavioral Health Services Substance Abuse Services Council Glen Allen May 10, 2012 Enzo Pastore, MSS, MLSP Director of Health Policy State Associations of Addiction Services www.saasnet.org

2. SAAS Mission Ensure the availability and accessibility of quality BH/SUD treatment, prevention, education and related services throughout the country • SAAS serves as an information broker and advocate linking state associations with national developments such as evidence-based practices • Through our member associations, SAAS has a direct link to thousands of treatment programs and services

3. SAAS Moving the Field Forward Project • Virginia-- one of 6 states selected to receive specialized and intensive technical assistance GOALS • Ensure that addiction and BH services receive the necessary attention and focus at the state level • Provide training, TA, guidance and resources to state association and service providers for advocacy, outreach, education, and monitoring of legislative and regulatory compliance

4. Moving the Field Forward Project • Identify and outreach to potential partners in primary care followed by advocacy around integration of services with primary care • Develop policies to ensure that current and future regulations support the intent of federal and state legislation to make health care accessible to all in need • Development of Advocacy toolkits • Partner with Indiana Association of SA Providers

5. IMPACT OF HEALTH CARE REFORM • SAMHSA National Survey of Drug Use and Health - National and state estimates on prevalence of behavioral health conditions and treatment - 2008 – 2010 data - 70,000 interviews each year • American Community Survey from Census

6. IMPACT OF HEALTH CARE REFORM Among Adults 18 – 64 • VA Current Medicaid Pop 285,665 • VA Medicaid Expansion Pop 345,173 • VA Health Ins Exchange Pop 437,805

7. IMPACT OF HEALTH CARE REFORM Prevalence of Serious Mental Illness Among Adults Ages 18 – 64 • VA Medicaid Current 285,665 7.8% 22,282 • VA Medicaid Expansion 345,173 11.5% 39,695 • VA Exchange 437,805 7.5% 32,835

8. IMPACT OF HEALTH CARE REFORM Prevalence of Serious Psychological Distress Among Adults Ages 18 – 64 • VA Medicaid Current 285,665 21.4% 61,132 • VA Medicaid Expansion 345,173 22.3% 76,974 • VA Exchange 437,805 20.9% 91,501

9. IMPACT OF HEALTH CARE REFORM Prevalence of Substance Use Disorders Among Adults Ages 18 – 64 • VA Medicaid Current 285,665 5.9% 16,854 • VA Medicaid Expansion 345,173 20.8%71,796 • VA Exchange 437,805 23.0% 100,695

10. IMPACT OF HEALTH CARE REFORM Major Drivers • More people will have insurance coverage • Medicaid 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 with less reliance on institutional care • Preventing disease and promoting wellness is a HUGE theme • Outcomes: improving health of the population, the experience of care and reducing costs

11. IMPACT OF HEALTH CARE REFORM Key Elements • Individuals will take advantage of the OPPORTUNITY to be insured • Services reflect the health and behavioral health needs of the population • Services are accessible • Focus on affordability • Development of a quality framework • Critical dashboard indicators

12. IMPACT OF HEALTH CARE REFORM Key Elements • Program standards, including common service definitions, system performance expectations, and consumer/family outcomes • Adequate number and distribution of appropriately credentialed and competent primary care and BH providers • Funding strategies sufficiently flexible to promote a more efficient system of services and supports

13. IMPACT OF HEALTH CARE REFORM How Will We Identify Service Needs • What services do BH/SUD need? – need more than a “I will read the tea leaves” exercise • What modality or modalities will work? • What does the evidence say about what works for these populations? • How much will these individuals need? • What will it cost? • What are the cost offsets to the healthcare system?

14. IMPACT OF HEALTH CARE REFORM Delivery of Behavioral Health Services • Health Homes • Prevention and Wellness Services • Engagement services • Outpatient and Medication Services • Community Supports and Recovery Services • Other Supports • Out of Home Residential Services • Acute Intensive Services

15. IMPACT OF HEALTH CARE REFORM What will drive access? • Availability of workforce in new settings which require partnerships • Credentials required by the payers in the settings that plan to deliver the service • Infrastructure to deliver services • The math that works for all parties Payers Providers Patients

16. IMPACT OF HEALTH CARE REFORM Provider Issues • Almost 1/3 of SAPT Block Grant programs have NO experience with 3rd party billing – new partners needed? • Less than 10% of BH providers have an EHR system that is electronically certified • Few have working agreements with community health centers

17. IMPACT OF HEALTH CARE REFORM Provider Issues • More and New Payment Strategies • More documentation of individual treatment plans & separate service “episodes” to claim reimbursement • Exchanges may have multiple plans • Authorizations, Compliance, Billing rules • Payment may be based on “successful” episode of care --- what is it and how will it be “priced?”

18. IMPACT OF HEALTH CARE REFORM Integration • Individuals with SUD/SMI have 2 or more chronic health conditions • SUD providers and many MH providers unlikely to have formalized partnerships with primary care providers • States are being offered greater incentives to innovate coordination of services • Need evidence/promising practices and models for integration

19. IMPACT OF HEALTH CARE REFORM Integration Next Steps • Begin to explore your community for new and necessary partners for collaboration • Identify what you do BEST/the value you can bring • What you want partners to do so you will be able to increase access and reduce costs • Budget constrains, cuts, and realignments will require new partnerships • States and counties will have to make very, very tough choices

20. IMPACT OF HEALTH CARE REFORM Integration Next Steps • What are the service needs of people in VA and local community, including the newly enrolled with benefits? • What are the outcomes that are important to your system? • What do you need --- including new partners to meet service needs? • How much do you need in $ for a good system, and eventually an ideal system

21. HEALTH REFORM AND CRIMINAL JUSTICE Extent of the Problem • Since the mid-1970s scientific research shows that drug abuse treatment can help many offenders change their attitudes, beliefs, behaviors towards drug abuse, avoid relapse, and successfully remove themselves from a life of substance use and crime • Untreated substance abuse adds significant costs to communities, violent and property crimes, prison expenses, court/criminal costs, emergency rooms, child abuse and neglect, lost child support, foster care, reduced productivity, unemployment and victimization • In 2002, cost to society of drug abuse estimated at $181 billion, $107 billion of which was associated with drug-related crime

22. HEALTH REFORM AND CRIMINAL JUSTICE Extent of the Problem • Successful drug abuse treatment in CJS can help reduce crime, reduce spread of HIV/AIDS, hepatitis, other infectious. Estimated for every $1 spent on addiction treatment programs, $4 -$7 reduction in cost of drug-related crimes. With some outpatient programs, total savings can exceed costs by ratio of 12:1 • 2008 statistics from DOJ’s Bureau of Justice Statistics, correctional population estimated at 7.3 million, with more than 5 million on probation or under parole supervision. Drug law violations most common type of criminal offense • Juvenile justice pop - in 2008, 10 percent of estimated 2.1 million juvenile arrests were for drug abuse or underage drinking violations with 2/3 of detained juveniles have a substance use disorder (SUD)

23. HEALTH REFORM AND CRIMINAL JUSTICE Extent of the Problem • Studies show treatment can cut drug abuse in half, reduce criminal activity up to 80 %, reduce arrests up to 64 % • Variety of approaches for incorporation of drug abuse treatment into criminal justice settings • As condition of probation, drug courts that blend judicial monitoring, sanctions with treatment, treatment in prison followed by community-based care, treatment under parole or probation supervision • Outcomes for substance abusing individuals can be improved by cross-agency coordination and collaboration of criminal justice professionals, substance use treatment providers, and other social service agencies

24. HEALTH REFORM AND CRIMINAL JUSTICE NOW COMES • National health reform, ACA, creates opportunities to re-examine how we connect health care provided in our nation’s jails with care provided in local communities • In 2014, Medicaid expansion extends prospect of health care coverage to estimated 15 - 18 million newly eligible individuals • Substantial pop of non-violent offenders with MI or chemical addiction cycling in/out of local jails. Individuals have costly, complex health problems frequently contribute to criminal behavior • For the first time, Medicaid expansion support delivery of community-based medical and behavioral health care • Enormous potential to reduce the use of jail beds as well as other costs to society

25. HEALTH REFORM AND CRIMINAL JUSTICE • Need to rethink priorities of CJS in order to develop sound policies and regulations -- state legislators, county administrators, criminal justice leaders, the judiciary, and community advocates, all CJS stakeholders • Because the vast majority of this group is poor, most will qualify for Medicaid • 2014, Federal government will pay 100 % of billable Medicaid charges for newly eligible enrollees through 2017, decreasing to 90 % by 2020 • States and localities bear almost all health care costs incurred within CJS. Medicaid expansion shifts large share of such costs to the Feds • Counties and jails must be prepared to bill Medicaid

26. HEALTH REFORM AND CRIMINAL JUSTICE • State Medicaid authorities will need to define Medicaid benefit packages • New approach under HCR gives States, counties opportunity to save $$ with comprehensive health care services available to justice-involved populations • Medicaid expansion support delivery of community-based medi­cal, MH care, reducing use of jail beds and other government costs • Another important aspect of Medicaid expansion is establishment of parity for MH and chemical dependency treatment if provided by a managed care organization • Parity means that benefits for MI and chemical dependency—defined in terms of lifetime or annual dol­lar limits—must be equivalent to those for physical ill­ness

27. HEALTH REFORM AND CRIMINAL JUSTICE • Implications are potentially ENORMOUS • 2006 study by the Bureau of Justice Statistics, 64 % of people in jail have some form of mental illness • For the first time, local jurisdictions will have resources and motivation to connect this population with appropriate treatment to manage their conditions in the community • Access to mental health services could keep some people from reoffending, thereby lowering costs to CJS • What kinds of results can local jurisdictions expect to see under Medicaid expansion?

28. HEALTH REFORM AND CRIMINAL JUSTICE Washington State’s experience providing treatment to chemi­cally dependent, very-low-income childless adults dem­onstrated important benefits • Emergency room use among those who received Tx was 35 % lower than among not. Resulting savings almost completely offset the average costs of chemical dependency Tx • Chemical dependency Tx associated with average medical cost savings on order of $2,500/year per person treated • Rates of re-arrest were 21 to 33 % lower in three groups treated for chemical dependency compared with other adults not in treatment • Reduction in arrests saved local law enforcement, jails, courts, and State correction agen­cies an additional estimated $5,000 to $10,000 for each person treated

29. HEALTH REFORM AND CRIMINAL JUSTICE ISSUES FOR IMPLEMENTATION • Medicaid expansion creates major incentives for addi­tional partnershipsbetween criminal justice and com­munity health providers • States and counties must address the follow­ing questions: - How should a benefit package be designed to address the needs of justice-involved pops and maxi­mize positive effects of Medicaid expansion for local jurisdictions? - How can local jurisdictions help in the development of Medicaid benefit packages? - How can we ensure eligible detainees and offenders are enrolled ? Where and when should enrollment take place?

30. HEALTH REFORM AND CRIMINAL JUSTICE - What role can jails play in enrolling offenders in Medicaid? - How can we design and implement more effective diversion programs that place detainees into appro­priate MH & chemical dependency treatment? - Does the local provider community have the capac­ity to meet the needs of the newly expanded service population? If not, how can it be strengthened? - How can local criminal justice and health care sys­tems create effective mechanisms for sustained coor­dination and collaboration? - What protocols are needed to achieve seamless continuity of care - How will organizations exchange health information?

31. HEALTH REFORM AND CRIMINAL JUSTICE KEY POINTS TO TAKEAWAY • Medicaid expansion offers jails and counties unique opportyto improve access to health care for CJ pop while reducing costs in CJ & public health care sectors • A well-designed pack­age of Medicaid services that addresses the needs of CJ population can more than pay for itself ----improved public safety and reduced public expense. • Ongoing dialogue and strong collabora­tion will be required to address challenges and take advantage of this opportunity • Will you stand still and let others make the choices for you?

32. Essential Health Benefits • Design of the Essential Health Benefits (EHB) will have a direct impact on the health and well-being of over 70 million Americans • EHB critically important - opportunity to address health needs of 25 million Americans with untreated MI and/or SUD, prevent these diseases in millions more and provide necessary services to those seeking care for or in recovery from MI or SUD • Essential Health Benefits Bulletin (“the Bulletin”) released by the Center for Consumer Information and Insurance Oversight on December 16, 2011

33. Essential Health Benefits • Bulletin’s explicit recognition of the ACA requirement for the EHB to include MH and SUD services, and in a manner consistent with the requirements of the MHPAEA • The ACA requires coverage of MH and SUD benefits as one of the EHB categories thereby extending MHPAEA to those plans • In the ACA, Congress mandated all public & private plans subject to the EHB, inside/outside Exchanges, be required to offer MH and SUD benefits, at parity with the medical/surgical benefits offered by the plan

34. Essential Health Benefits Section 1302(b)(1) of the ACA provides that EHB include items and services within the following 10 benefit categories -- • ambulatory patient services • emergency services • Hospitalization • maternity and newborn care • mental health and substance use disorder services, including behavioral health treatment • prescription drugs • rehabilitative and habilitative services • laboratory services • preventive and wellness services and chronic disease mgt. • pediatric services, including oral and vision care

35. Essential Health Benefits • Two statutory goals – how do we reconcile? • Benefit package (within available resources) that supports recovery • Ensuring there is NO discrimination by illness • How should the EBP distinguish medical vs. non-medical services? • How should a medical service be defined? • Should the package contain any non-medical services?

36. Essential Health Benefits Four Benchmark Plan Types • the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market 2. any of the largest three State employee health benefit plans by enrollment 3. any of the largest three national FEHBP plan options by enrollment, or • the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State. • HHS intends to assess the benchmark process in 2016 and beyond based on evaluation and feedback

37. CHANGE IS COMING BRACE YOURSELVES FOR 2014 THANK YOU FOR YOUR ATTENTION QUESTIONS?? www.SAMHSA.gov/healthreform www.kff.org/healthreform www.healthcare.gov www.saasnet.org