Health Insurance Reform Possibilities: Shaping the Future of Behavioral Health California Mental Health Policy Forum February 11, 2010

Transcription

1 Health Insurance Reform Possibilities: Shaping the Future of Behavioral Health California Mental Health Policy Forum February 11, 2010 Pamela S. Hyde Administrator Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services

2 Today s Objectives Health Insurance Reform Parity Regulation SAMHSA Strategic Priorities & FY 2011 Budget Proposals 2

3 Why Care About Health Insurance Reform? Rising Cost Last 8 years, average wages increased 20% Average cost of employer-sponsored health coverage doubled Health insurance premiums tripled $1,000 of premium each year is for costs associated with uninsured $28,530 projected health care spending per employee by 2019 Out-of-pocket expenses for Americans w/ insurance will increase by 35% by in 4 Americans live in a family that spent more than 10% of income on health care in 2009; 4 out of 5 of these have health insurance 3

4 United States: Most Expensive Healthcare System in the World America spends nearly twice what next highest spending country spends on health care, but often with uneven quality/poor outcomes Health spending expected to grow at an average annual rate of 6.1% (1.7% points faster than GDP) and climb from $2.5 trillion in 2009 to $4.5 trillion by 2019 In 2009 the health share of gross domestic product (GDP) expected to have increased 1.1% to 17.3% largest single-year increase since 1960; will be 19.3% by end of decade w/o reform Public spending projected to account for more than half of U.S. health care spending by

5 Expenditures Not Producing Acceptable Outcomes 46 million non-elderly Americans lack any form of health coverage; within a decade, million will be uninsured 15,000 more every day last year Americans are living longer than ever, but not as long as people in 48 other countries U.S. ranks 44th among countries for infant mortality rates 5

6 What Reform Gets Us: $2,000 projected reduction in premiums for American families 4,000,000 jobs created as health costs decline $1 trillion potential reduction in deficit in next decade as health savings are realized $36 billion reduced spending on uninsured over next decade 6

7 Disproportionate Impact on Persons with MI/SUDs Uninsured rate among persons with mental disorders = 20.4% SMI and 18.2% other mental disorder, compared to 11.4% w/o mental disorder 111 million Americans covered by group commercial insurance (ERISA); 29 million covered by state/local governments 98% of policies (99% large employers; 95% small employers) cover MI & 92% cover SA (87% not counting detox only) but with unequal coverage and/or processes 22 or so states have some form of parity requirement, leaving many that do not, & most states deal only with quantitative requirements (e.g., deductibles, co-payments, annual or lifetime limits, etc.); few mandate mental health or substance abuse benefits MI/SUD are usually pre-existing conditions when seeking coverage 3 million (16.3%) full-time workers w/o health insurance needed substance use treatment in past year (SAMHSA national survey), particularly among year olds (24.4%) & males (19.2%) 7

8 Disproportionate Cost Implications - 1 Medical costs of persons w/co-morbid physical & BH disorders 5% of population accounted for almost 50% of total costs (AHRQ 2002) due to chronic conditions & multiple comorbidities, severe mental illness, and services that are fragmented among multiple providers Costs for persons w/ these illnesses are disproportionately high and services are increasingly provided in integrated settings 20.3% of MH spending is in general medical settings; 23.2% of mental health spending is for psychotropic drugs (2007) 71% of persons w/ SMI receive SSI/SSDI support; 63% receive SNAP (food stamps) benefits 8

9 Disproportionate Cost Implications 2 Importance of Medicaid as fund source for SA/MI 2003, Medicaid provided 37% of all publicly funded MH/SA dollars; 2005, percentage grew to 42%; projected to be 46.5% by 2014 (over 50% for those w/ MI; as much as 85% for children w/ MI) 16% of SMI on Medicaid; 21.5% on Medicare; compared to 2.3% & 19.7% of those w/o mental disorder 7.1% of those w/ other mental disorders on Medicaid; 14.4% Medicare Medicaid expansion at 133% to 150% of FPL would add million to rolls (CBO) Among uninsured aged w/ family income < 150% of FPL 32.4% had illicit drug or alcohol dependence/abuse, or mental illness 5.0% had illicit drug dependence or abuse 6.9% had SMI Of 1.6 million people treated for substance abuse, 920,000 or well over half reported income at less than 200% FPL 9

10 Health Insurance Reform Goals President s Principles: More stability & security for those who have insurance Affordable coverage options for those who do not Lower costs for families, businesses, and governments 10

11 Reform Possibilities for BH 1 Parity Parity required in essential benefits plans offered through exchanges Employer mandate requires parity in private health plans Grandfathered employer plans required to meet minimum essential benefits, including M/SUDs, w/in 5 years Coverage Medicaid expansion to 133 or 150% FPL and low-income subsidies to support significant treatment expansion, especially persons with BH issues Free up block grant dollars for recovery support services not paid for through insurance benefit plans Changes in Medicaid to assist youth to maintain coverage in times of transition, and expand dependent coverage to age 26 Elimination of pre-existing condition exclusions & policy terminations; guaranteed renewability Medication Costs Expansion of 340b drug discount programs to clinics treating M/SUDs Begin closing of Medicare doughnut hole 11

12 Reform Possibilities for BH 2 Prevention Prevention research programs and national prevention plans Eliminate cost-sharing on recommended preventive services delivered by Medicaid, Medicare and Health Insurance Exchange plans Coverage of preventive services in benefits packages, esp., screening for depression in adolescents & screening for SA in adults (SBIRT) Services New home visiting programs for young children Programs to expand medical homes & school-based health clinics Specialty Care Federally Qualified Behavioral Health Centers (FQBHCs) 12

13 Reform Possibilities for BH 3 Involvement At least one representative on benefit determination commission to have background/expertise in behavioral health SAMHSA consultation on regs, demonstrations, implementation Demonstrations Initiatives w/in HHS at discretion of Secretary to allow for MH/SA inclusion Training and Research Increased patient-centered health research Training grants for BH workforce 13

14 Opportunities for States Expansion of Medicaid for persons with SA, SUDs, MI Grant opportunities in legislation Public education on parity & insurance reforms importance of including behavioral health care Build linkages between primary care and specialty care for both mental and substance use disorders Help providers move to claims-based environment, esp. substance abuse providers use to block grant funding Implement grant project on recovery support services outside of insurance model to identify critical factors in fidelity; infuse them in block grant programs Address the interface of federal health insurance reform and state treatment mandates/parity laws 14

15 Status of Reform Efforts President Obama has not given up on health insurance reform & has made it clear that America s leaders cannot walk away from their responsibility to protect our citizens from: Insurance companies that deny coverage to people when they get sick Skyrocketing health care costs crushing families, businesses, economy and government Rising premiums forcing small businesses to drop coverage Unaffordable prescription drug bills causing seniors to forgo needed medicine Insecurity of knowing that in next decade nearly half of Americans under age 65 will find themselves without health coverage President Obama has called for half-day of public bipartisan discussion of all ideas 2/25 Secretary Sebelius calling on Anthem BC to justify it's 39% rate increase 15

16 Negotiations before; Negotiations now Every worthwhile accomplishment... has its stages of drudgery and triumph; a beginning, a struggle, and a victory. - Mahatma Gandhi 16

17 Actions in the Meantime Celebrate CHIPRA One-Year Mark 2.6 million more children served by Medicaid or the Children s Health Insurance Program (CHIP) at some point over the past year The Secretary s Challenge: Connecting Kids to Coverage fiveyr campaign challenging federal officials, governors, mayors, community organizations, tribal leaders and faith-based organizations to enroll nearly 5 million uninsured children who are eligible for Medicaid or CHIP but are not enrolled Moving agenda to cover more people, increase quality and lower costs, wherever resources and authority allows 17

18 President s HHS Budget FY 2011 Foundation for Health Insurance Reform $25.5 B new for 2 more Qs of FMAP enhancement to June 2011 $995 M ($33 M new) to address shortage of health care providers in underserved areas, esp. physicians, nurses, dentists $290 M new to increase funding for 25 new community health centers (FQHCs) and to increase behavioral health capacity $78 M ($17 M new) for adoption and use of health information technology (HIT) $5.4 B ($354 M new) for Indian Health Service (IHS) $250 M new to generate $9.9 billion in savings from increased fraud recoveries and prevention efforts $110 M new to move CMS data system from claims processing to data analysis and information sharing with stakeholders 18

19 Foundation for Health Insurance Reform (continued) Legislative and administrative changes that will save $14.7 B in Medicare and Medicaid over ten years Level physician payment rates for Medicare $261 M new in AHRQ to develop and disseminate patientcentered health research to improve quality & outcomes $222 M ($16 M new) for NIH Autism Spectrum Disorders research; CDC awareness & monitoring; and HRSA screening & support Chronic disease prevention at CDC & reduction of tobacco use and prevention & treatment of HIV/AIDS New investments in prevention, treatment and surveillance of substance abuse, children's mental health, suicide prevention, SBIRT, ATR, Drug Courts, and other SAMHSA programs 19

20 AS HEALTH INSURANCE REFORM DISCUSSIONS CONTINUE... Implementing MHPAEA - The Mental Health Parity and Addiction Equity Act of 2008

21 Who is Covered by MHPAEA Insurance plans sponsored by private and public sector employers with more than 50 employees Plans that choose to offer a mental health and/or substance use benefit Employers/plans can choose to not cover specified diagnoses Medicaid Managed Care Programs (through separate regulations to be released) Children's Health Insurance Reauthorization Act (CHIPRA) In total approximately 150 million Americans 21

22 Who is Not Covered by MHPAEA Employer groups 50 and under in size Individual insurance plans Medicaid plans not covered by managed care Medicare State & local government plans that request to be exempted Covered employer group plans that can prove after implementing that their costs have increased by>2% for 1 year 22

23 What Does MHPAEA Do? Prohibits applying more restrictive financial requirements (e.g., deductibles, co-payments, coinsurance) to mental health and substance use benefits than are applied to the predominant (defined by reg as 2/3) and substantial (defined by reg as 1/2) medical and surgical benefits offered Prohibits applying more restrictive treatment limitations to mental health and substance use benefits than are applied to the predominant and substantial medical and surgical benefits offered Requires that the standards for determining medical necessity and the reasons for denials be available to consumers and providers 23

24 Regulations are Interim Final Regulations go into effect April 4, 2010 for new and renewal plans beginning July 1, 2010 Good Faith compliance from 10/3/09 (effective date of law) until new regulations are effective Regulations outline process for getting answers to questions and to identify need for enforcement Comments and questions through May 4,

25 Requesting Comments On: Whether additional examples would be helpful to illustrate the application of non-quantitative treatment limitation rule to other features of medical management or general plan design Whether and to what extent MHPAEA addresses the scope of services or continuum of care provided by a group health plan or health insurance coverage What additional clarifications might be helpful to facilitate compliance with disclosure requirement for medical necessity criteria or denials of mental & substance use disorder benefits Implementing the new statutory requirements for the increased cost exemption under MHPAEA, as well as information on how many plans expect to use the exemption 25

26 What Next For SAMHSA? Mission: To reduce the impact of substance abuse and mental illness on America s communities Roles: Voice & Leadership Funding Information 26

27 SAMHSA S Key Messages Behavioral Health is Part of Health Prevention Works Treatment is Effective People Recover 27

28 Fast Facts 1 : Behavioral Health is Part of Health 64% of antidepressants prescribed by primary-care offices, hospitals, outpatient programs or surgical offices Almost ¼ of all adult stays in U.S. community hospitals involved mental or substance use disorders 5 Conditions: mood disorders, diabetes, heart disease, hypertension and asthma 49% of total health care costs 42% of illness-related lost wages Mood disorders rank: 1st in work loss costs, 2nd total costs & 3rd in health care costs Medicaid spending on mental health and substance abuse treatment expected to double between 2003 and 2014 ($239 billion) with increasing share of expenditures falling to the States Up to 83% of people with serious mental illness are overweight or obese People with serious mental illness have shortened life-spans, on average living only until 53 years of age 28

29 Fast Facts 2: Substance Use and Mental Disorders can be Prevented $1 investment in substance abuse prevention saves up to $10 in treatment and other costs By 8th Grade Communities That Care students were: 32% percent less likely to begin using alcohol 33% percent less likely to begin smoking, and 33% less likely to begin using smokeless tobacco 25% less likely to initiate delinquent behavior Safe School/Healthy Students Program: Bullying Down 5% Fighting Down 8% Verbal Abuse Down 11% Alcohol Use (past 30 days) Down 11% Cigarette Use at School Down 19% Feeling Unsafe at School Down 7% Childhood traumas/difficulties potentially explain 32.4% of psychiatric disorders in adulthood. 29

30 Fast Facts 3: Treatment Works Average cost of substance abuse treatment = $1,583 - Investment returns a $11,487 benefit to society Federally funded substance abuse treatment programs Reduced illicit drug use by half (48%) Improved physical and mental health Alcohol/drug related medical visits declined by 53% after treatment Inpatient mental health visits declined by 28% Reduced criminal activity by as much as 80% SBIRT 50% increase in abstinence at 6-month post intake 30

31 Fast Facts 4: People Recover Early treatment reduces disability/recurrences Recovery rates for mental illness with treatment and medication: Bipolar disorder 80% Major depression 65-80% Schizophrenia 60% Addiction 70% Pathways are highly personal Recovering people work, pay taxes, have homes and relationships, volunteer, contribute 31

32 10 Strategic Initiatives 1. Prevention of Substance Abuse and Mental Illness 2. Violence and Trauma 3. Military Families Active, Guard, Reserve, and Veteran 4. Housing and Homelessness 5. Jobs and Economy 6. Health Insurance Reform Implementation 7. Health Information Technology for Behavioral Health Providers 8. Behavioral Health Workforce In Primary and Specialty Care Settings 9. Data and Outcomes Demonstrating Results 10. Public Awareness and Support 32

33 Initiative 1 - Prevention of Substance Abuse and Mental Illness By 2020, as a major cause of disability, behavioral health disorders will surpass all physical diseases world-wide 12.4 percent (30.9 million) of persons aged 12 or older drove under the influence of alcohol at least once in the past year 2.9 million persons aged 12 or older used an illicit drug for the first time; almost 8,000 initiates per day ½ of all lifetime cases of mental illness begin by age 14 and ¾ by age 24 Young people with major depressive episode are twice as likely to take 1st drink or use drugs for the 1st time Approximately 90% of individuals who die by suicide had a mental disorder and 40% had visited their primary care doctor within the month - the question of suicide was seldom raised 33

34 Prevention Highlights in FY 2011 Budget Project LAUNCH (Kids 0-8) $12 million to $37 million Prevention Prepared Communities (Young people 9-25) $23 million for this new initiative Strategic Prevention Framework/Partners for Success $7 million to $103.5 million Preventing Suicide $6 million to $54 million SBIRT $8 million to $37 million Prescription Drug Monitoring $2 million Stop Act (Sober Truth on Preventing Underage Drinking) $8 million 34

35 Initiative 2 - Violence & Trauma Youth violence 2nd leading cause of death for young people Among America s youth: 60% exposed to violence within last year 8% reported a lifetime prevalence of sexual assault 17% reported physical assault 39% reported witnessing violence 26% of adolescent girls involved in serious physical violence Youth in juvenile justice have high rates of substance use and mental disorders - with prevalence rates as high as 66% - with the vast majority (95%) experiencing functional impairment 43% to 80% of men and women in psychiatric hospitals have experienced physical or sexual abuse, most of them as children Between 16 and 50 percent of all incarcerated individuals have mental illnesses, and up to 80 percent have a substance use problem 35

36 Violence & Trauma Highlights in FY 2011 Budget Children s Mental Health Initiative (CMHI) $5 million to $126 million Safe Schools/Healthy Students $95 million Drug Courts $13 million to $56 million 36

37 Initiative 3 - Military Families Active, Guard, Reserve, & Veteran 17% of service members deployed to Iraq show signs of PTSD 9.3% percent of veterans experienced at least one major depressive episode Over ½ with major depressive episode reported severe impairment with home management, work, close relationships with others and social life Over ½ with major depressive episode received treatment in the past year 194,000 homeless veterans Associated treatment costs for veterans: $184.6 billion for alcohol abuse treatment $143 billion for drug abuse treatment FY 2011 Budget highlights which could focus on military families: Prevention, Housing, Children s MH, Suicide Prevention, Block Grant Increases ATR $10 million to $109 million 37

38 Initiative 4 - Housing & Homelessness 700,000 Americans are homeless on any given night About ½ of the people who experience homelessness are single adults About one-fifth have a serious mental illness with ½ of this sub-group Also having an alcohol or drug problem 5% to 7% of youth experience homelessness each year Approximately 150,000 to 200,000 chronically homeless individuals nationwide A person with a mental illness relying on SSI would have to pay 113% of monthly income to rent a modest one bedroom apartment FY 2011 Budget: PATH $5 million to $70 million silo-busting" HUD/HHS demo $16 million provision of 10,000 new homeless and special needs vouchers, 4,000 of which are targeted for persons with mental illness/substance abuse disorders eligible for Medicaid through states 1115 waivers 38

39 Initiative 5 - Jobs and Economy Money and the economy topped the American Psychological Association s list of sources of stress for 8 of 10 Americans Economic downturns/financial distress increase mental and substance use disorders Economy down binge drinking up 5% increase in unemployment = 8% increase in probability of binge drinking 25% of calls to the suicide prevention lifeline related to financial difficulties FY 2011 Budget: Community Mental Health Block Grant at $421 million Substance Abuse Prevention & Treatment Block Grant at $1.8 billion Community Resilience & Recovery Initiative (CRRI) $5 million 39

40 Initiative 6 - Health Insurance Reform As urgent today as it ever was Discussions are active about the way forward Legislation will have tremendous benefits for all Americans including people with mental and substance use disorders 20 million people meet the criteria for needing substance abuse treatment do not receive it 10.6 million adults report an unmet need for mental health care Of those who sought care lack of insurance coverage or ability to pay was the top reason for not receiving needed help Parity is only the beginning 40

41 Initiative 7 - Health Information Technology (HIT) & Electronic Health Records (EHR) 20% of 175 counseling centers surveyed had no information systems, or even voic Although 50% of treatment programs had an information technology system they were used for billing not monitoring care 1.8% total information technology spending for behavioral health vs. 3.5% for general health care Only 8.2% of behavioral health organizations have an EHR compared to 10% -12% for primary care physicians FY 2011 Budget: $4 million new in the Office of the National Coordinator (ONC) for Behavioral Health HIT 41

42 Initiative 8 - Workforce 2000 Study: 94% of primary care physicians failed to diagnose substance use disorders properly More than ½ of workforce over age 50 Over 85% of 1,669 federally designated mental health treatment shortage areas are rural 1/2 of Counties in the U.S. do not have a single mental health professional 2020 Projected need of child and adolescent psychiatrists = 12,624 projected supply = 8,312 FY 2011 Budget In Health Resources and Services Administration (HRSA) $25 million new for behavioral health in FQHCs 42

43 Initiative 9 - Data and Outcomes Demonstrating Results Fragmented data systems reinforce the historical separateness of systems of care Discrete approaches to treatment Distinct funding streams for state mental health, substance abuse, and Medicaid agencies Data requirements are not consistent across programs Separate treatment systems create access barriers, uneven quality, disjointed coordination, and information silos across agencies and providers FY 2011 Budget: National data collection $33 million to $136 million DAWN & New C-EMS Internal work regarding common data elements and approaches 43

44 Initiative 10 - Public Awareness and Support 66% of Americans believe addiction can be prevented 75% of Americans believe recovery from addiction is possible 66% of Americans believe that treatment and support can help people with mental illnesses lead normal lives 20% of Americans say they would think less of a friend or relative if they discovered that person is in recovery from an addiction 30% of Americans say they would think less of a person with a current addiction 20% of Americans feel that persons with mental illness are dangerous to others 44

45 The Only Failure is Failure to Aim High Not failure, but low aim is sin. Benjamin E. Mays Not failure, but low aim, is crime. James Russell Lowell