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A Policy Conversation on Primary and Behavioral Healthcare Integration Kathleen Reynolds, LMSW ACSW National Council for Community Behavioral Healthcare
A Changing Healthcare Landscape: Ensuring a Role for Behavioral Health • With new policy changes and more people with access to care, we will have to think creatively about how to increase capacity, reach out to underserved populations, and provide services in a way to meet new demands. • Accountability is the cornerstone of the new healthcare environment. • All of these initiatives will require investment in new technologies, especially technologies that interface with other systems and also measure outcomes.
Affordable Care Act Supported Goal: enhanced integration and coordination of primary, acute, behavioral health (mental health and substance use), and long-term services and supports for persons across the lifespan with chronic illness CMS expects that use of the health home service delivery model will result in • lowered rates of emergency room use, • reduction in hospital admissions and re-admissions, • reduction in health care costs, • less reliance on long-term care facilities, and • improved experience of care and quality of care outcomes for the individual
Benefits for the Newly Eligible • Essential benefits include mental health and substance use treatment • MH and SUD must be offered at parity with medical/surgical benefits This means… • …Most members of the safety net will have coverage, including mental health and substance use disorders
Essential Benefits – 10 Core Areas • 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, and • Pediatric services, including oral and vision care
State Options for Determining Benchmarks • States would choose one of the following benchmark health insurance plans: • One of the three largest small group plans in the state by enrollment; • One of the three largest state employee health plans by enrollment; • One of the three largest federal employee health plan options by enrollment; • The largest HMO plan offered in the state’s commercial market by enrollment. • If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state
Affordable Care Act: Health Home • To be eligible, individuals must have: • Two or more chronic conditions, OR • 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 amental health condition, a substance abuse disorder, asthma, diabetes, heart disease, and obesity (as evidenced by a BMI of > 25). • States may add other conditions subject to approval by CMS
Status of Health Home Statewide Work • 6 State Plans have been approved: • Missouri (2) – Behavioral Health and Primary Care • Rhode Island (2) – adults and children with SMI • New York – chronic behavioral and physical health • Oregon • North Carolina • Iowa • 3 states have submitted State Plans and await approval: • Washington • 15 States with Planning Grants: • Alabama, Arizona, Arkansas, California, District of Columbia, Idaho, Maine, Michigan, Nevada, New Jersey, New Mexico, North Carolina, Washington, West Virginia, and Wisconsin
New Service Paradigm – Bi-Directional Integration of Primary Care and Behavioral Health Funding starting to open up for embedding primary medical care into CBHOs, a critical component of meeting the needs of adults with serious mental illness
Initial Approved ACOs for Medicare -1.Allina Hospitals & Clinics Minnesota and Western Wisconsin • 2. Atrius Health Services Eastern and Central Massachusetts • 3. Banner Health Network Phoenix, Arizona Metropolitan Area (Maricopa and Pinal Counties) • 4. Bellin-Thedacare Healthcare Partners Northeast Wisconsin • 5. Beth Israel Deaconess Physician Eastern Massachusetts • 6. Bronx Accountable Healthcare Network (BAHN) New York City (the Bronx) and lower Westchester County, NY • 7. Brown & Toland Physicians San Francisco Bay Area, CA • 8. Dartmouth-Hitchcock ACO New Hampshire and Eastern Vermont • 9. Eastern Maine Healthcare System Central, Eastern, and Northern Maine • 10. Fairview Health Systems Minneapolis, MN Metropolitan Area • 11. Franciscan Health System Indianapolis and Central Indiana • 12. Genesys PHO Southeastern Michigan • 13. Healthcare Partners Medical Group Los Angeles and Orange Counties, CA • 14. Healthcare Partners of Nevada Clark and Nye Counties, NV • 15. Heritage California ACO Southern, Central, and Costal California • 16. JSA Medical Group, a division of HealthCare Partners Orlando, Tampa Bay, and surrounding South Florida • 17. Michigan Pioneer ACO Southeastern Michigan • 18. Monarch Healthcare Orange County, CA • 19. Mount Auburn Cambridge Independent Practice Association (MACIPA) Eastern Massachusetts • 20. North Texas Specialty Physicians Tarrant, Johnson and Parker counties in North Texas • 21. OSF Healthcare System Central Illinois • 22. Park Nicollet Health Services Minneapolis, MN Metropolitan Area • 23. Partners Healthcare Eastern Massachusetts • 24. Physician Health Partners Denver, CO Metropolitan Area4 • 25. Presbyterian Healthcare Services -Central New Mexico Pioneer Accountable Care Organization Central New Mexico • 26. Primecare Medical Network Southern California (San Bernardino and Riverside Counties) • 27. Renaissance Medical Management Company Southeastern Pennsylvania • 28. Seton Health Alliance Central Texas (11 county area including Austin) • 29. Sharp Healthcare System San Diego County • 30. Steward Health Care System Eastern Massachusetts • 31. TriHealth, Inc. Northwest Central Iowa • 32. University of Michigan Southeastern Michigan
Parity • Managed care • Accountable Care Organizations • New MH/SUD coverage under qualified health plans • New parity requirements
Questions? Kathleen Reynolds LMSW ACSW firstname.lastname@example.org 734.476.9879