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Healthcare Reform Impact The Road Ahead. John O’Brien Senior Advisor on Healthcare Financing. What’s Been Done So Far?. Approaching 270 Days Since Affordable Care Act was passed. Changes have focused on: Significant Program Changes and Demonstration Projects for Medicaid Recipients

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healthcare reform impact the road ahead

Healthcare Reform ImpactThe Road Ahead

John O’Brien

Senior Advisor on Healthcare Financing

what s been done so far
What’s Been Done So Far?

Approaching 270 Days Since Affordable Care Act was passed. Changes have focused on:

Significant Program Changes and Demonstration Projects for Medicaid Recipients

Major Insurance Reform

what s been done so far1
What’s Been Done So Far?

What Changes Have Affected Publicly Insured Individuals?

States can receive federal matching funds now for covering low-income individuals and families

1M “donut hole” checks to Medicare individuals

Round 2 of Money Follows the Person—heavy focus on behavioral health

Health Homes for Individuals with Chronic Conditions

what s been done so far2
What’s Been Done So Far?

What Changes Have Affected Publicly Insured Individuals?

Medicaid 1915i Redux—very important changes

Prevention Trust Funds Awarded

Expansion of the number of Community Health Centers—serving 20 million more individuals

Loan forgiveness programs for primary care, nurses and even some behavioral health professionals

Increased payments to rural health providers

what s been done so far3
What’s Been Done So Far?

Major Changes For Individuals Who Are Insured:

Extending coverage to young adults

Providing free preventive care

Ability to appeal coverage determinations

No lifetime limits on benefits

Prohibiting pre-existing coverage for children

Up to 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers

Holding insurance companies accountable for unreasonable rate hikes

affordable care act
Affordable Care Act

Major Drivers

More people will have insurance coverage

Medicaid will play a 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 and less reliance on institutional care

Preventing diseases and promoting wellness is a huge theme

Outcomes: improving the experience of care, improving the health of the population and reducing costs

impact of affordable care act
Impact of Affordable Care Act

Impact on Coverage

61% of the individuals served by SSAs have no insurance

Expect that 90-95% of these individuals will have OPPORTUNITY to be covered

They will be expected to enroll in Medicaid/ Insurance Exchanges

coverage
Coverage

Enrollment

32 million individuals—many are single males

Skepticism—many haven’t been enrolled—historical message that you will never be covered

Penalties for not enrolling may not be a powerful stick

Challenges—doors to enrollment and challenging enrollment processes

Churning

what do we know about the newly covered
What Do We Know About the Newly Covered?

Individuals Near the Federal Poverty Level—More diverse group than we think

40% under the age of 29

56% are employed or living with their families

Conditions are more acute when they present

Care is more costly

Source: Center on Budget and Policy Priorities

what do we know about the newly covered1
What Do We Know About the Newly Covered?

Source: Center on Budget and Policy Priorities

what do we know about service coverage
What Do We Know About Service Coverage?

Timing—Decisions about coverage are not immediate

Some sense of categories (Exchanges)

Mental health and substance abuse services

Rehabilitation and habilitation services

Pharmacy

Preventive and wellness services

This will impact what is purchased through block grant

block grants
Block Grants

2010 Addendum—focus on State’s HCR readiness

2011—Proposed Changes to BG Application and regulations

Proposed needs assessment for uninsured

Planning for FY 2014 Implementation

Joint Planning Efforts with MH

States Enhancing/Beginning Service Management Efforts

Use of technology for service delivery

Greater Accountability—

More specific information on what is purchased through BG dollars

Performance strategies that mirror National Quality Strategies (1/1/2011)

2014 and beyond

Services that are not covered by Medicaid/insurance

Individuals that are not covered by 3rd party insurance

Other (TBD)

provider plumbing
Provider Plumbing

Almost 1/3 of the SAPT do not have experience with 3rd party billing.

Less than 10% of all BH providers have a EHR that is nationally certified

Few have working agreements with health centers

provider plumbing1
Provider Plumbing

National Initiative This Year—Four large trade associations (SAAS, Niatx/NCCBH/NACHC)

Billing

EHRs

Compliance

Access

primary care and coordination
Primary Care And Coordination

Individuals with SUD/SMI have 2 or more chronic health conditions

Barriers include stigma, lack of cross-discipline training, and access to primary care services

Have elevated (and often undiagnosed) rates of:

hypertension,

diabetes,

obesity

cardiovascular disease

Community-based behavioral health providers are unlikely to have formalized partnerships with primary care providers

importance of integrated care
Importance of Integrated Care

Focus on coordination between primary care and specialty care:

Significant enhancements to primary care

Workforce enhancements

Increased funding to SAMHSA, HRSA and IHS

Bi-directional

MH/SUD in primary care

Primary care in MH/SUD settings

Services and technical assistance

Pharmacy opportunities through partnering (340b program

impact of affordable care act1
Impact of Affordable Care Act

Health Homes

Focus on chronic conditions (or at risk)

Start date: 4 months and counting

Medicaid state plan

90% match initially—big incentives for states

Several new services:

Comprehensive Care Management

Care Coordination and Health Promotion

Patient and Family Support

Comprehensive Transitional Care

Referral to Community and Social Support Services

prevention
Prevention

$100 million in grants for public health and prevention priorities

$30 million in new resources to support the National HIV/AIDS Strategy

$26.2 million to expand primary care to individuals with behavioral health disorders

No cost sharing for preventive services for some plans

so what should we do
So What Should We Do?

Many provisions are still needing further clarity (regulations, SMDs, Grants)

Some opportunities now

Three years + until some of the major provisions

Information overload

Economic challenges continue

slide22

Understand The Key Concepts

22

  • Healthcare Exchanges
  • Health Information Exchanges
  • High Risk Pools
  • Benchmark Plans
  • Essential Benefits
what else should we be doing
What Else Should We Be Doing?

Stay Excited

Stay Informed

Get and Stay Involved

Innovate