Workshop: Mental Health Care and Reform: Into the Weeds!

1. Workshop: Mental Health Care and Reform: Into the Weeds! Objective: Dive into the new federal laws defining the environment for mental health care benefits and delivery. Toni P Miles, M.D., Ph.D. Health and Aging Policy Fellow, 2008 - 2010 & Professor, Kent School of Social Work University of Louisville April 15, 2011 Ms. Freedom

2. Related Publications: Miles TP, 2009, Health care reform and health disparities: Reason for hope? In Annual Review of Gerontology and Geriatrics, Volume 31, Springer NY. Miles TP, Washington, Karla Physical Problems Shaping Transitions of Care, Chapter 4 In Annual Review of Gerontology and Geriatrics, Volume 31, Springer NY. Forthcoming November 2011. Miles TP. Health Reform and Disparities: History, Hype, and Hope. Praeger Publisher. Forthcoming Fall 2012. Where did I learn all this stuff? Health and Aging Policy Fellowship ( http://www.healthandagingpolicy.org; Sponsor - Atlantic Philanthropies )

3. Today’s Strategy 50,000 foot view: Two landmark pieces of federal legislation to increase access to mental health and substance abuse care. 5,000 foot view: Insurance market reforms opening the door to care. 5 foot view: Delivery system reforms and changes in provider behavior.

4. At the end of this day you will: Have a source for finding additional information when you need it about the new laws. Have resources to explain details of health insurance markets. Feel empowered rather than blindsided by the healthcare changes.

5. Time for fun and games… Policy Bingo!

6. Online Resources for your further study www.hhs.gov; ‘The Mental Health Parity and Addiction Act of 2008’ www.hhs.gov; ‘The Patient Protection and Accountable Care Act of 2010’ www.samsha.gov; ‘Change: A plan for Samsha’s role and action 2011- 2014. Samsha’s Webinars: 3/28/11: Commonly used terms in health reform, Quick Facts, Immediate Changes. 4/8/11: Mental Health and Substance Abuse Parity. Plus several pdf files from the Center for Medicare and Medicaid Services will be available on the association website. Bruce Scott promised !!!

7. 50,000 foot view: Legislation directly targeting mental health and substance abuse care. Source: www.kff.org

8. Why do the laws emphasize employer-sponsored plans? The 5,000 foot view. Market segregated by work history and economic resources. Not all employers offer insurance. Not all insurance plans offer Mental illness benefit. Not all plans offer comprehensive Mental illness benefit. Public Plans / Private Plans Public Plans: Provider of last resort. Cover severely ill patients. Private Plans: Anything goes. 2.4 million (U.S. BLS for KY, 2010) 800,000 (KY Medicaid Task Force, 2010) Public plans include Medicaid, Indian Health Service, and Medicare as well as the Department of Defense plans.

9. What about public plans? A 5,000 foot view of Medicaid • Financial eligibility NOT medical need determines access. Mandated groups: Children aged 0 to 19 years in households < 150% FPL, Blind, Disabled, Elders, Dual Eligibles • Most states manage Medicaid budgets by: • Moving the line that defines financial eligibility. i.e. %FPL • Changing types of services • Managed care contracts Expansion of Medicaid under ACA challenges the states to preserve services while covering more people. Bottom line: Medicaid Managed Care Organizations (like Passport) increase the number of persons under a parity requirement.

10. Summary of the 50,000 and 5,000 foot view. • Domenici-Wellstone created parity in large group plans and managed Medicaid starting in October 2009. • Accountable Care Act extends parity to all insurance plans sold via the exchange in 2014. • Accountable Care Act makes Mental Health and Substance Abuse Care an Essential Benefit. What else is there to know? What else is in ACA relevant to mental health and substance abuse?

11. The 5 foot view: Delivery system Reform!!!!

12. The 5 foot view: What does delivery system reform look like? How do we get there? Quality, Quality, Quality

13. Norton Healthcare wins national quality award Business First - by Steve Ivey, Staff Writer ; March 28, 2011, 12:04pm EDT Norton Healthcare Inc. has received the 2011 National Quality Healthcare Award from the National Quality Forum, the organizations announced Monday. NQF presents the award annually to a health care organization that achieves goals in quality improvement, performance measurement, transparency and accountability, care management and public reporting. Norton is the 18th recipient of the annual award and the first Kentucky organization to win. To learn more about the Quality movement in U.S. healthcare go to: http://www.qualityforum.org/Home.aspx

14. What is the Norton Healthcare Quality Report? The hospitals of Norton Healthcare show their patient satisfaction scores and their performance on almost 600 nationally recognized quality indicators and practices. Where available, performance is also displayed for the average hospital in Kentucky and in the United States. To read the full report go to: http://www.nortonhealthcare.com/body.cfm?id=157

15. Quality Report Principles We do not decide what to make public based on how it makes us look. We give equal prominence to good and bad results. We do not choose which indicators to display. These are a nationally endorsed list. We display every indicator on the list. We are not the indicator owner. We do not modify indicator definitions or inclusion/exclusion criteria. We correct our internal data only for objective errors. We do not correct data submitted or billed externally unless we also resubmit or re-bill the data. We display our results even when we disagree with the indicator definition. Unused data never become valid.  We recognize that we must display and make decisions based upon imperfect data, because until the data are used, no resources will be spent making the data valid.

16. Title III of ACA links performance to payment! • Implications: • Patients and their families have a voice! • Advocates have a tool. • Health care delivery systems have a reason to listen.

17. Other sources of ground-level perspective: www.medicalnews.md

18. Summary: Mental Health Care and the Weeds of health care reform • Mental health care is now on par with physical health care in employer-sponsored plans and in Medicaid Managed Care plans. • If someone says its not, then advocates need to work for enforcement of existing statutes. • Statutes in Title III of ACA link patient satisfaction with payment reform. • Advocates can use these data to advance the quality of mental health and substance abuse care. Patient satisfaction with inpatient care can be found for other hospitals at: http://www.hospitalcompare.gov

19. Q& A 2009-2010 American Political Science Fellows On the steps of the Canadian Parliament, Ottawa.

20. Wellstone-Domenici (W-D)/Accountable Care Act (ACA): Policies to improve access Medicaid eligibility for unemployed adult single men remains a problem.

21. To study health disparities, understand Medicaid: • Covers 40% of all births in the U.S. (Source: Kaiser Family Foundation, KFF.org) • Mandatory groups include: (Source: Kentucky Cabinet for Health and Family Services) • Children aged 0 to 19 years in households < 150% FPL • Blind, Disabled • Elders, Dual Eligibles • The number one payer for long term care services. The Accountable Care Act and Medicaid

22. What is Medicaid / Passport? Medicaid is the insurance for 800,000 persons in Kentucky. In the 16 counties around Jefferson County Medicaid = Passport. It is a partnership between Federal and State government. The feds match state dollars. It is not Medicare. Medicare is a federal health insurance program for the elderly and persons with end stage renal disease. Medicare does not cover long term care services. • Two policies in ACA focus on Medicaid Long Term Services: • Money Follows the Person (MFTP) • Community First Option

23. Medicaid Long term care services in ACA: • Money Follows the Person: • Provides in-home services to individuals moving out of an institutional setting back to the community. • The required 6 month stay for eligibility is reduced to 90 days. • Community First Choice: • Provides in-home services to individuals who require institutional level care. • The ACA gives states an enhanced federal matching rate of six percentage points. This rate will sunset after five years.

24. Public insurance programs and ACA: Medicare Cost Reduction Policies: Quality measures Bundled payments Anti-fraud measures Adjustments to Medicare Advantage Medicaid Expansion: By January 1, 2014, the program expands eligibility to nearly all low-income people under age 65 with income below 133 percent of the federal poverty line. For more details visit: http://www.kff.org/healthreform

25. New dimensions for Health Disparities and access to care research: Working poor ineligible for Medicaid. Newly unemployed mid-life adults. Young adults aged 19 to 34 years. Male health and longevity issues before age 65 years. Before ACA, these persons were ineligible for Medicaid. In 2014, Medicaid expansion and Health Insurance Exchanges will create a pathway to health insurance. Will these groups see improved access to health care?

27. Department of Insurance on Health Reform: Individual Responsibility When will I be required to buy insurance and what happens if I don't? Effective January 1, 2014, all U.S. citizens and legal residents. Those who do not obtain coverage will pay a tax penalty. The tax penalty will be the greater of either a flat dollar amount or a percentage of taxable income: $95 per person or 1 percent of taxable income in 2014, $326 per person or 2 percent of taxable income in 2015, and $695 per person or 2.5 percent of taxable income in 2016. After 2016, the tax penalty increase annually based on a cost-of-living adjustment. Exceptions for: • individuals and families below a certain income, • people who cannot afford coverage that is available, • individuals who have been uninsured for less than three months, • members of Indian tribes, and • people who do not obtain coverage because of religious objections. See: http://insurance.ky.gov/

28. Policy basis for the individual responsibility?Everybody into the pool! Individual responsibility means that everyone shares the cost of health care by pooling premium dollars. The larger the pool of dollars, the lower the per capita cost to all members. This is the reason large companies are more likely to offer benefits than small ones. For more details visit http://insurance.ky.gov/

29. Employer responsibility: A U.S. tradition changes with health reform… Small businesses (< 50 employees): Not subject to employer insurance provisions. Can enroll your employees in coverage through the Exchanges beginning in 2014. 75+ employees: An employer must offer minimum essential coverage. Failure to do so results in a penalty of $2,000 for each of their employees beyond the first 30. Self-employed: Individual mandate requires coverage. Beginning Jan. 1, 2014, self-employed individuals and their families will have the option of purchasing coverage through the Exchange. For more details visit http://insurance.ky.gov/