ADVANCING BEHAVIORAL HEALTH IN A CHANGING HEALTH CARE ENVIRONMENT

2. ADVANCING BEHAVIORAL HEALTH IN A CHANGING HEALTH CARE ENVIRONMENT Pamela S. Hyde, J.D. Administrator Substance Abuse and Mental Health Services Administration NAMI of Southwestern Pennsylvania Pittsburgh, PA • June 14, 2013

3. BEHAVIORAL HEALTH PUBLIC HEALTH ISSUE? SOCIAL PROBLEM? or

4. WHY DOES IT MATTER? • Public sees social consequences of behavioral health rather than health consequences • Homelessness, gangs, jails, tragedies (e.g., mass casualty shootings), disability, lost productivity, high government costs • M/SUDs seen as matter of will instead of diseases or conditions to be prevented, treated and recovered from • Compare diabetes • Teach requirements of first aid for health conditions; don’t teach signs, symptoms and how to get help for mental health or substance abuse issues

5. BH AS A SOCIAL PROBLEM LEADS TO INSUFFICIENT RESPONSES

6. ELEMENTS OF A PUBLIC HEALTH MODEL

7. WHY A PUBLIC HEALTH APPROACH? • BH affects most Americans • ~ ½ of Americans will meet criteria for a mental health condition at some point in their lifetime • ~ ½ of all adults know someone in recovery from addiction • BH increases risks for other health conditions • Costs for co-morbid diabetes, hypertension, heart disease higher • Pre-mature death and preventable illnesses • More BH related deaths than HIV, traffic accidents & breast cancer • ½ the deaths from smoking are among those with BH conditions • Persons with M/SUDs die 8 1/2 years earlier

8. WHY PUBLIC HEALTH . . . • High levels of unmet need • Less than 40 percent of adults get treatment for diagnosable mental illness; less than 11 percent for SUDs • Less than 1 in 5 children/adolescents get needed treatment • Longer time between symptoms & treatment than for physical • Inaccurate public perceptions • High proportion of inaccurate assumptions of danger/risk • High levels of social discomfort • High impact of disparities (race, gender, ethnicity, LGBT, poverty) and on social costs (homelessness, jails/prisons, child welfare)

9. SAMHSA – A PUBLIC HEALTH AGENCY Leadership and voice – influencing public policy Data and surveillance Public education and communications Regulation and standard setting Financing and practice improvement Funding - service capacity/system development (esp. to test new approaches)

10. SAMHSA’S STRATEGIC INITIATIVES

11. HEALTH REFORM AND THE CHANGING HEALTH CARE ENVIRONMENT Prevention and wellness rather than illness – a public health approach Role of states increasing, especially in health “care” Integration rather than silo’d care – Parity Access to coverage and care rather than significant parts of America uninsured – Parity Recovery rather than chronicity or disability Quality rather than quantity – cost controls through better care rather than more care

12. PARITY/ACA: PROJECTED REACH NOTE: These estimates include individuals and families who are currently enrolled in grandfathered coverage Source: ASPE Research Brief, February 2013

13. PENNSYLVANIA: STATUS OF DECISIONS ON FFMs, EHBs, AND MEDICAID EXPANSION • December 2012: Governor Tom Corbett notified federal officials that PA would default to a federally-facilitated health insurance marketplace (FFM) in 2014 • EHBs: PA has not put forward a recommendation - state’s benchmark EHB plan will default to the largest small group plan in the state (Perhaps Aetna POS) • Medicaid Expansion: PA still evaluating options and negotiating with CMS, but has not committed to expanding

14. PA: HEALTH INSURANCE COVERAGE TOTAL POPULATION, 2010-2011 Source: Kaiser Family Foundation

15. NATIONALLY: PERSONS WHO ARE UNINSURED <400% FPL 29% with BH conditions 71% withoutBH conditions

16. IN 2014: MILLIONs MORE AMERICANS WILL have health coverage OPPORTUNITIES • Currently, 37.1 Million Are Uninsured <400% FPL* • 18.5 M – Medicaid expansion eligible* • 18.5 M – ACA exchange eligible* • 11 M (29%) – Have BH condition(s)** • *Adults age 18-64, Source: 2011 American Community Survey • **Adults age 18-64, Source: 2010 NSDUH

17. PA: PREVALENCE OF BH CONDITIONS AMONG MEDICAID EXPANSION POP CI = Confidence Interval Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012); 2010 American Community Survey

18. PA: PREVALENCE OF BH CONDITIONS AMONG EXCHANGEPOPULATION CI = Confidence Interval Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012); 2010 American Community Survey

19. AFFORDABLE CARE ACT ENROLLMENT ASSISTANCE ACTIVITIES • Navigator Program (2014) • Include at least one consumer-focused non-profit • Required for and financed by each Exchange • FOA for FFM/SPM Navigators out now • At least 13 states engaged in public planning work (Feb. 27, 2013) AR, WA, WV, CA, CO, CT, DC, HI, MN, NV, OR, VT • In-person assistance personnel • State-based or state-partnership marketplaces only. State-based grants or contracts. Can be funded by marketplace establishment grants • Certified Application Counselors • If state permits, federal training and certification for FFM and SPM. No dedicated funding but can use other Federal grants or Medicaid

20. SAMHSA ENROLLMENT STRATEGY Collaborate with national organizations whose members/constituents interact regularly with individuals who have M/SUDs to create and implement enrollment communication campaigns Promote and encourage use of CMS marketing materials Provide T/TA in developing enrollment communication campaigns using these materials Provide training to design and implement enrollment assistance activities Channel feedback and evaluate success

21. SIMPLE STREAMLINED APPLICATION PROCESS Now 2014 (beginning Oct 1, 2013) Regulations require a single application as gateway to all coverage programs Must be available online, by telephone through a call center, by mail, and in person (www.healthcare.gov) Interview requirements prohibited • Different applications for different programs • Denied? Back to the drawing board • Applications often only available on paper or as PDFs if online • In-person interview requirements

22. ENROLLMENT RESOURCES • SAMHSA Enrollment Webpage • http://www.samhsa.gov/enrollment/ • Healthcare.gov • http://www.healthcare.gov/marketplace/index.html • HHS Partners Resources • http://www.cms.gov/Outreach-and-Education/Outreach/HIMarketplace/index.html • Different types of ACA consumer assistance • http://www.cms.gov/CCIIO/Resources/Files/Downloads/marketplace-ways-to-help.pdf

23. PARITY IN AFFORDABLE CARE ACT • Affordable Care Act (ACA) embraces and goes beyond MHPAEA to create broader parity • Final MHPAEA reg this year • Essential health benefits must be included • In non-grandfathered plans; • In individual and small group markets; • Inside and outside of insurance exchanges (qualified health plans or QHPs); and • In benchmark and benchmark-equivalent plans in Medicaid expansion • States oversee and enforce

24. ESSENTIAL HEALTH BENEFITS (EHBs) • 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 and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care

25. PROVIDERS ACCEPTING HEALTH INSURANCE PAYMENTS SOURCE OF FUNDS FOR CMHCS** SA TREATMENT FACILITIES ACCEPTANCE OF INSURANCE PAYMENTS * *Source: NSATSS **Source: 2011 NCCBH BH Salary Survey

26. FOCUS: PROVIDER READINESSBHbusiness Networks • TA to help 900+ provider orgs/year in 5 areas of practice • Strategic business planning in an era of health reform • 3rd-party contract negotiations • 3rd-party billing and compliance • Health insurance eligibility determinations and enrollment • Health information technology adoption • Special focus on providers of peer and recovery support services and providers serving racial/ethnic minority and other vulnerable populations • http://bhbusiness.org/

27. NATIONAL CONFERENCE ON MENTAL HEALTHJUNE 3, 2013 • EAST WING, WHITE HOUSE • President Obama opened; Vice President Biden closed – focus on young people • HHS Secretary Sebelius, Education Secretary Duncan, VA Secretary Shinseki • Panels of those with mental health experience, survivors, and young people with social media approaches • Advocates, educators, health care providers, faith leaders, members of Congress and representatives from all levels of government • From all over the country to talk about ways to increase understanding and awareness of MH issues

28. THE PRESIDENT’S PLAN: MENTAL HEALTH AS A PUBLIC HEALTH ISSUE “We are going to need to work on making access to mental health care as easy as access to a gun.” --President Obama • Less than half of people w/BH conditions receive the care they need • President’s plan Launch a national dialogue • Engages everyone – general public, elected officials, schools, parents, community coalitions, churches, health professionals, researchers, persons directly affected by mental illness and/or addiction & their families • Committed to health of everyone (social inclusion/universal) • Based on facts, science, common understandings/messages • Focused on prevention (healthy communities) and earlier intervention

29. PRESIDENT’S FY 2014 BUDGET: $235M IN NEW PROGRAMS • Department of Education -- $75 M • Safer School Climates: $50M to help 8,000 schools implement evidence-based behavioral practices to improve school climate and behavioral outcomes for all students, and to ↓ problem behaviors, ↓ bullying and peer victimization, ↑ the perception of school as a safe setting, and ↑ academic performance • Address Pervasive Violence: $25M for grants to schools in communities with pervasive violence to address the trauma of children who are exposed to or victims of violence, and implement conflict resolution and other school-based violence prevention strategies • Health & Human Services – $160 M CDC – $30M • Gun Violence Research: $10M to understand causes and impacts, including relationship between video games, media images, and gun violence • Nationwide Violent Deaths Surveillance System: $20M to increase reporting system to all states

30. FY 2014 PROPOSED NEW MENTAL HEALTH PROGRAMS: SAMHSA $130M SAMHSA -- $130 M • Project AWARE (Advancing Wellness and Resilience in Education): $55M to reach 750,000 young people through programs to identify mental illness early and refer to treatment • Project AWARE State Grants: $40M to ensure students with signs of mental illness get a critical first referral to treatment, and toward ensuring local organizations are all coordinating appropriately • Mental Health First Aid: $15M to train teachers and other adults who interact with youth to detect and respond to mental illness in children and young adults, including how to seek treatment

31. FY 2014 PROPOSED NEW MENTAL HEALTH PROGRAMS: SAMHSA – cont’d • Healthy Transitions: $25M for states to help 16-25 year olds get treatment and to help communities develop an integrated network to support schools working w/ law enforcement, MH agencies, and other local organizations • Behavioral Health Workforce: $50M (w/HRSA) to train 5,000 additional MH professionals to serve students and young adults • Masters level clinical and paraprofessionals: $35M co-administered with HRSA’s Mental and Behavioral Health Education Training (MBHET) program • Peer professionals: $10M with community colleges and peer organizations • Minority Fellowship Program – Youth: $5M new aspect of SAMHSA’s Minority Fellowship Program, focusing on preparing masters level behavioral health professionals serving youth/young adults

32. BH AS PUBLIC HEALTH OUT OF THE SHADOWS… Keeping Americans safe from lost hope is as critical a public health issue as keeping them safe from bad drinking water, tainted food, and infectious diseases