state behavioral health leadership in a changing health care environment

1

2

STATE BEHAVIORAL HEALTH LEADERSHIP IN A CHANGING HEALTH CARE ENVIRONMENT

Pamela S. Hyde, J.D.SAMHSA Administrator

SAMHSA SSDP Conference Baltimore, MD • July 30, 2012

3

TODAY’S DISCUSSION

4

A PUBLIC HEALTH MODEL FOCUSES ON PEOPLE & COMMUNITIES

People – NOT money, diseases, programs, or authorities• People come with multiple diseases/conditions, social determinants,

cultural backgrounds and beliefs• People come to multiple settings – primary or specialty care, schools,

courts, places of worship, through social media• Healthy productive satisfying lives without disorder or in recovery are the

outcomes we seek

Communities – People w/ common geography, culture, language, beliefs, or characteristics focusing together on common good• Health and disease/disorder occurs and is promoted or prevented in

communities• State/Territorial/Tribal governments can help or be a barrier• Requires collaboration

5

PUBLIC HEALTH MODEL FOR BEHAVIORAL HEALTH

6

MISUNDERSTANDING LEADS TO INSUFFICIENT RESPONSES

7

BEHAVIORAL HEALTH IS NOT A MORAL OR SOCIAL PROBLEM

Social/moral problem context focuses on problems:– Homelessness– Crime/jails– Child welfare problems– School performance or youth behavior problems– Provider/system/institutional/government needs or failures– Public tragedies

Public (and public officials) often misunderstand, blame, discriminate, make moral judgments, exclude• Ambivalence about worth of individuals affected and investment

in prevention/treatment/recovery• Ambivalence about ability to impact “problems” “caused” by

persons with behavioral health needs

8

INTEGRATING INTO HEALTH CARE & COMMUNITY SETTINGS

9

BUDGET - CHALLENGES

10

SAMHSA’S BUDGET FY 2008 – FY 2013

$3,234$3,335

$3,431$3,379 $3,348

$3,152

$3,343

$3,153

$122

$132

$132$132

$129

$165

$129

$20 $88$88

$105

$88

$2,500

$2,700

$2,900

$3,100

$3,300

$3,500

$3,700

FY 2008 Actual

FY 2009 Actual

FY 2010 Actual

FY 2011 Actual

FY 2012 Enacted

FY 2013 President's

Budget

FY 2013 Senate

Committee Mark

FY 2013 House

SubCommittee Mark

Do

llars

in

Mill

ion

s

SAMHSA FY 2008 - FY 2013 Total Program Level$

$3,356 M

$3,466 M

$3,583 M $3, 565 M$3,599 M

$3, 423 M*

#$3,560 M*

$3,153 M

Total Program Level Includes: Budget Authority, PHS Evaluation Funds, and ACA Prevention Funds. FY2012 Enacted amount incorporates the 0.189% recession. *FY2013 also includes $1.5 M estimated for user fees for Extraordinary Data and Publication Requests.

ACA

PHS

BA

11

FY 2013 LIKELY SCENARIOS

President’s Budget, Senate Committee Mark, and House Subcommittee Mark• All signal positions, not decisions

CR Through December or March• How long and how much depends . . .• Likely equal to or less than FY 2012

Sequester Jan 2013 = ~ 7.8 percent ↓ from FY12 • Applied to FY 2013 (enacted or CR)• Exec’s/OMB’s role by September

12

SAMHSA’S FY 2014 PRINCIPLES(IF POSSIBLE . . .)

Maintain ~ Ratio of BG to Discretionary Dollars (~65/35)• Assumptions re health reform impacting need

Maintain Ratio of SA and MH Funding (~ 70/30)

Avoid Terminations/Reductions of Existing Awards

Continue Holistic Approach through Joint Funding

Build Off Innovations from Previous Funding Cycles

Maintain Support for SAMHSA’s Strategic Initiatives; Target Available Funding for Top Priorities

13

HEALTH REFORM - OPPORTUNITIES

14

CHANGING HEALTH CARE ENVIRONMENT

Role of States Increasing

Integration Rather than Silo’d Care – Parity

Prevention and Wellness Rather than Illness

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

15

SAMHSA’S HEALTH REFORM PRIORITIES – FY 2012 AND FY 2013Uniform Block Grant Application FYs 2014 & FY 2015

• In Fed Reg for 60-day public comment as of 7-13-12Enrollment PreparationExchanges and Qualified Health PlansParity in Medicaid and Essential BenefitsProvider Capacity Development and WorkforceWork with States and Medicaid

• Health homes, rules/regs, service definitions and evidence, screening, prevention, duals, PBHCI, payment issues

• Parity – MHPAEA/ACA Implementation & CommunicationQuality (NBHQF) and Data (including HIT)

16

IN 2014: MILLIONS MORE AMERICANS WILL HAVE HEALTH COVERAGE OPPORTUNITIES

Currently, 37.9 million are uninsured <400% FPL*

• 18.0 M – Medicaid expansion eligible

• 19.9 M – ACA exchange eligible**

• 11.019 M (29%) – Have BH condition(s) * Source: 2010 NSDUH**Eligible for premium tax credits and not eligible for Medicaid

17

PREVALENCE OF BH CONDITIONS AMONG MEDICAID EXPANSION POP

CI = Confidence IntervalSources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

18

PREVALENCE OF BH CONDITIONS AMONG EXCHANGE POPULATION

CI = Confidence IntervalSources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

19

FOCUS: ENROLLMENT – PREPARATION

Consumer Enrollment Assistance (AZ, NM, MO, CA, NY, VT, ME, MD)• Outreach/public education• Enrollment/re-determination assistance• Plan comparison and selection• Grievance procedures• Eligibility/enrollment communication materials

Enrollment Data, Best Practices TA, and Toolkits – with CMS & ASPE• Testing new common application• SAMHSA learning collaborative with 7 state stakeholder coalitions

Communication Strategy – Message Testing, Outreach to Stakeholder Groups, Webinars/Training Opportunities

Incorporating Enrollment Requirements into RFAs

SOAR Changes to Address New Environment

20

ESSENTIAL HEALTH BENEFITS (EHB) 10 BENEFIT CATEGORIES

1. Ambulatory patient services

2. Emergency services3. Hospitalization4. Maternity and newborn

care5. Mental health and

substance use disorder services, including behavioral health treatment

6. Prescription drugs7. Rehabilitative and

habilitative services and devices

8. Laboratory services9. Preventive and wellness

services and chronic disease management

10. Pediatric services, including oral and vision care

21

FOCUS: BENCHMARK PLANS

Serves as Reference Plan • Reflecting scope of services and limits offered by a

“typical employer plan” in that state• Parity applies

States Allowed to Select a Single Benchmark Plan:• 1 of 3 largest small group market plans (default), or• 1 of 3 largest state employee plans, or• 1 of 3 largest federal employee plans, or• Largest HMO plan in a state

EHB Mini Rule – Thru 9/30/12 Critical

22

BENCHMARK PLANS

If State Does Not Select, Default To Largest Plan By Enrollment In Largest Product in Small Group Market

Must Include All 10 Essential Health Benefit Categories Regardless What Selected Benchmark Plan Covers/Excludes• Supplement from other plans if category not sufficiently covered• Substitution within categories

Parity Applies in Individual, Small & Large Group Markets• Both MHPAEA and ACA parity requirements• Parity work within HHS and with DOL and Treasury

23

BENCHMARK AND EHB REVIEW

HHS Will Assess Benchmark Process for 2016• State choices in 2012 will remain for two years (2014 & 2015)

Periodically Review and Update EHBs• Difficulties with access due to coverage or cost • Changes in medical evidence or scientific advancement • Market changes • Coverage affordability

SAMHA’s Good and Modern Service Definitions & Assessing the Evidence Process Will Inform

24

QUALIFIED HEALTH PLANS – NETWORK ADEQUACY

Qualified Health Plans (QHPs) • Offered through affordable health exchanges (marketplaces)• State choice to set up exchange or use federally facilitated

exchange (FFE)

QHPs’ Networks – Providers Sufficient In Number/Types To Assure Services Accessible w/o Unreasonable Delay• Encourages QHPs to provide sufficient access to broad range

of MH/SUD services, particularly in low-income & underserved communities

• Highlights MH/SUD providers – must be sufficient providers available to deliver!

25

PROVIDERS ACCEPTING HEALTH INSURANCE PAYMENTS*

Inpatient – 95 percent

Outpatient – 68 percent• Primary MH plus some SA – 85 percent

• Primary SA (w/ none or some MH) – 56 percent

• Residential SA – 54 percent

• Other (e.g., Homeless Shelters, Social Services Agencies) – 37 percent

*Source: NSATSS

26

SOURCE OF FUNDS FOR CMHCs*

State/County Indigent Funds – 43 percent• NOTE: State MH ↓$5 B in last 5 years; SA ↓$2-3 B

Medicaid – 37 percent

Private health insurance – 6 percent

Self-pay – 6 percent

*Source: 2011 National Council Survey

27

HEALTH REFORM RESOURCES

http://www.samhsa.gov/HealthReform/• General information about health reform and BH

http://www.healthcare.gov/news/factsheets/2011/05/exchanges05232011a.html• Information re state-by-state exchange funding & plans

http://cciio.cms.gov/resources/other/index.html#hie • State Exchange Blueprint

http://cciio.cms.gov/resources/regulations/index.html#hie• States three largest small group plans

28

NEW KIND OF LEADERSHIP – CHALLENGES & OPPORTUNITIESNew PartnersDifferent PoliciesCollaborative PracticeMultiple Party StructuresInfluence v DirectionFunding Capacity v Funding Integrated Service DeliveryBG – State MH & SA Authorities Roles

• Changing not declining