health care reform 2014: implications for professional practice dan abrahamson, phd assistant...
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Health Care Reform 2014: Implications for
Professional Practice
Dan Abrahamson, PhDAssistant Executive Director
Kansas Psychological AssociationApril 5, 2014Wichita, KS
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Compelling Need for U.S. Health Care Reform
About 50 million uninsured Americans
Annual health expenditures of over $2.7 T
Health costs comprise about 17% of GNP
Fragmented system with variable quality
Increased life expectancy but often with chronic illnesses
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The Economic Context for Reform
2010 Healthcare expenditure = $2.7THealthcare is single largest
contributor to national debt: Medicare = 15%; Medicaid = 8%; Social Security = 20%; Defense = 20%
All Health Expenditures, 2009:Private @ 51% (34% Ins. & 13% out of
pocket)Public @ 49% (Fed @ 37%, Mcare @ 22%,
Mcaid @ 16%)
By 2020, Fed. Govt. will pay 49% of all
health
State budgets in worst shape since
WWII
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Economic Context: Mental Health
Largest purchaser of MH/SUD services is the government!
Mental Health Spending, 2009:Private insurance, 26%; Out-of-pocket,
11%; Charity, 3%Public funding, 60%
Medicare, 13%Medicaid, 27%Other federal, 5%Other state/local, 15%
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Economic Context : Mental Health
Mental Health Spending Trends• 1986 = 7.3% of all health spending• 2003 = 6% of all health spending• 2009 = 6.3% of all health spending• 2014 = 5.9% of all health spending
Spending by provider class: Psychiatrists = 6% of all mental health $$ Non-psychiatric physicians = 5% Psychologists/SW/Cs = 5% or 0.315% of total
mental health $$; psychologists only 16% of this provider group
Hospitals = 26% Specialty MH/SUD = 30% Insurance Administration = 7%
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Mental Health: Shifts in Spending
Source: Substance Abuse and Mental Health Services Administration. (2011). National Expenditures for Mental Health Services & Substance Abuse Treatment 1986-2005. Washington, DC. As cited in Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC.
Distribution of Mental Health Expenditures by Type of Service, 1986 and 2005
7% Prescription Drugs
$32 Billion $113 Billion
19%Inpatient
33%Outpatient
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Economic Context: RxP and Mental Health
RxP: 50% of increased MH spending 1998-2004
RxP: 3X growth rate as other services
RxP: 28% of all MH spending in 2009• New drugs/new generics/patents expiring• Fewer side effects• More PCPs comfortable with prescribing• 66% spent on antidepressants and
antipsychotics• 14% spent on ADHD medications
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Treatment Settings for Behavioral Health Care
Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC.
Types of Mental Health Services Used in Past Year, Among Adults Receiving Treatment, 2009
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Economic Context for Reform: Chronic Illness
Healthcare costs in 2009:1% population = 21.8% of costs10% population = 63.6% of costs50% of population = only 2.9% of costs
Medicare spending:• 5% beneficiaries = 43% costs• 25% beneficiaries = 85% costs• 50% beneficiaries have >5 chronic
illnesses
Medicaid spending:• 15% are disabled and = 43% of costs• 10% are elderly and = 23% of costs• Summary: 25% of population = 66% of
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Patient Protection and Affordable Care Act of 2010
Culmination of a 100-year effort that challenged five former presidents
Comparable with passage of the Social Security Act in 1935 and Medicare in 1965
Almost on par with Civil Rights legislation in the 1950s and 1960s
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Controversial Aspects of Health Care Reform
Cost estimate of $180 billion over 10 years (Congressional Budget Office, 2012, prior to Supreme Court ruling)
Individual mandate to purchase health insurance or pay a penalty upheld by Supreme Court ruling, June 2012
Medicaid expansion by states funded mostly by federal government with threatened loss of current funding for noncompliance. Loss of current funding not upheld by Supreme Court
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Key Challenges Facing Health Care Reform
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Overall Goals of Health Care Reform
To preserve employer-based health insurance
To expand coverage to 32 million more Americans (Medicaid, Insurance Exchanges)
To improve quality of care by addressing the needs of the whole patient through:Preventive ServicesPrimary and Integrated Care
Reduce growth rate of healthcare costs13
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ACA Expands Eligibility & Coverage
Medicaid expansion covers persons up to 133% of FPL by 2014 (adds 16-22M)
Health Insurance Exchanges (up to 400% of FPL)
Essential Health Benefits with parity for Medicare Advantage, Medicaid Managed Care, CHIP, and Benchmark Plans
Preventive Care and Wellness
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Insurance Market Reforms in Affordable Care Act
No lifetime or annual dollar limitsNo rescissions of coverage except for
fraudCoverage of pre-existing conditionsGuaranteed coverage acceptance and
renewalRequirement of effective appeals
processEstablishment of premium rating
requirementsProhibition of participant and provider
discriminationState consumer assistance offices
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ACA Impacts Care Delivery
Accountable Care Organizations (ACOs)composed of integrated provider networks with:shared electronic records evidence-based practice protocolsoutcomes measurementperformance incentives
Patient-Centered Medical Homes (PCMH) will have features similar to ACOs
Home and Community Based Services Options
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Why Focus on Integrated Care?
Aspects of overall health are missed by sole focus on physical or mental health
Behavioral factors are leading causes of chronic illness and mortality
Chronic illness accounts for 75% of nation’s health spending
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Why Focus on Integrated Care?
Adults with Mental Health Conditions
29% of Adults with Medical Conditions Also Have Mental Health Conditions
68% of Adults with Mental Health Conditions Also Have Medical Conditions
Source: Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.
Percentage of Adults with Mental Health Conditions and/or Medical Conditions, 2001-2003
Adults with Medical Conditions
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Prevalence of Behavioral Health Conditions in US
Percent of US Adults Meeting Diagnostic Behavioral Health Criteria, 2007
Source: Kaiser Commission on Medicaid and the Uninsured. (April 2011). Mental Health Financing in the United States: A Primer. Washington, DC.
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Comorbidities Compound Costs
Monthly Health Care Expenditures per Person for Chronic Conditions, with and without Comorbid Depression, 2005
Source: Melek, S., and Norris, D. (2008). Chronic Conditions and Comorbid Psychological Disorders. Cited in: Druss, B. G., and Walker., E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.
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Interaction Between Medical Disorders and Mental Illness
Model of the Interaction Between Medical Disorders and Mental Illness
Source: Druss, B. G., and Walker., E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.
RISK FACTORS
Childhood Adversity
Stress
SES
- Loss- Abuse and Neglect- Household Dysfunction
- Adverse life events- Chronic stressors
- Poverty- Neighborhood- Social Support- Isolation
Chronic Medical Disorders
Adverse Health Behaviors and Outcomes- Obesity- Sedentary Lifestyle- Smoking- Self care- Symptom Burden- Disability- Quality of Life
Mental Disorders
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Why Focus on Integrated Care?
At least half of mental health treatment is provided in primary care
High co-existence of physical disorders and behavioral health problems
Adults with SMI in public sector die younger ( by 25 years)due to untreated physical health problems
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Psychology’s Contributions to Integrated Care
Conducting thorough psychological assessments Treating more complex, complicated patients
Applying behavioral principles to modify health-risk factors
Promoting patient responsibility and resilience
Attending to interpersonal barriers to behavior change
Understanding environmental determinants of behavior, including impact of families and systems
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Psychology’s Contributions to Integrated Care
Supervision of M.A. level therapists, case managers
Development of programs designed to provide population-based care
Designing, monitoring, and evaluating interventions
Program administration Enhancing health team and
organizational development
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ACA Impacts Payment and Performance
Move will be away from Fee-for-Service
Global, bundled, episode paymentsPay for PerformanceHigher rates for PCPsMedicare Shared Savings & other
modelFQHC investment of $11BQuality Measures (11 of 51 are
behavioral health)
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The Healthcare Environment
Declining reimbursements Increased/incessant demands for cost
containment Increased cost of doing business (rent,
labor, equipment, insurance, etc.) Increasing “competition” in
psychotherapy marketplace Growing regulatory demands (billing,
privacy, confidentiality, patient consent, F-W-A, EHR, retirement planning, occupational safety, etc.)
Lack of negotiation leverage And ever escalating healthcare costs!
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Evolving Healthcare Landscape
Increased regulation of price and volume of psychological services by public/private payers
Rapid and large-scale consolidation of health insurance market leading to more payer power: providers have lower reimbursement and less autonomy and consumers have higher premiums
Professional, market, and regulatory developments encouraging more collaborative care practices
Emergence of new reimbursement mechanisms to replace FFS: P4P, Global payments, Episode of care payments, Shared Savings
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Evolving Healthcare Landscape
Federal/State policies pushing integration:
Quality payment programs with incentives to meet certain quality standards
Health Information Technology (HIT): cost and ability to meet “meaningful use” criteria to be eligible for incentives
Anti-trust Enforcement Policy: allows integrated provider organizations to negotiate with plans re: payment rates but groups without integration (financial and clinical) are prohibited from such negotiation
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Reasons to Integrate
Aggregate capital to finance, develop, implement and maintain infrastructure (HIT & data reporting systems) necessary to collect, track, and report quality information required for performance-based reimbursement mechanisms
Develop collaborative care systems necessary to achieve real quality improvement in patient care
Insurers, employers, consumers demanding data on provider performance: adherence to quality outcome and process measurement, patient satisfaction, cost of care
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Reasons to Integrate
Allows ability to collect your own monitoring and evaluation data that may be needed to correct inaccuracies in tiering or designations imposed on your practice by payers
Share risk as needed in capitated contracts where there will be high-cost patients
Negotiating efficiencies with TPAs by sharing a manager who can analyze and negotiate contracts
Larger integrated groups may be favored by payers due to geographic coverage, mix of services, etc.
#1 reason: Market a valuable/competitive product that you cannot produce acting independently
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Implications for Professional Practice
New care delivery models/systems: PCMHs, ACOs
New skills and training models for integrated, inter- professional team-based care
Implementing advances in telehealth, HIT, and electronic health records
Increasing demand for the use of EBPs (Evidence-based practices) and quality measures
Payment reforms: P4P, Global payments, Bundled payments, Shared-savings models
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Primary Work Setting of APA Practicing Psychologists
Independent solopractice
Institution-basedPractice
Independent Group practice
Academic: teaching and/or research
Other
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APA’s Health Care Reform Team
Staff Working Group:CEO, Deputy CEO, and Senior Policy
AdvisorGovernment Relations Offices: Practice,
Public Interest, Education, and SciencePublic & Member Communications Office
Involvement of APA Leadership and Members, as well as other organizations
Collaboration with the APA Practice Organization (APAPO) – APA’s affiliated 501(c)(6) entity that works to advance the interests of practitioners 33
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The APA Center for Psychology and
Health
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APA Center for Psychology and Health
Organizational Chart
*The APA Practice Health Care Team and the State Implementation Advisory Group are combined APA Practice Directorate (c3) and APA Practice Organization (c6) activities.
Ellen Garrison, PhD Coordinator
APA Practice
Health Care Team
State Implementatio
n Advisory Group
Collaborating Units*
Health Leadership Team
Working Groupof APA Member
Primary Care Experts(TBD)
Director ofIntegrated Health
Care (TBD)Assistant
Coordinator
Health Team
Norman Anderson, PhDDirector
Randy Phelps, PhDOffice of
Health Care Financing
*The APA Practice Health Care Team and the State Implementation Advisory Group are combined APA Practice Directorate (c3) and APA Practice Organization (c6) activities.
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APAPO is dedicated to serving theinterests and needs of its members: APA members
who pay the annual Practice Assessment to APAPO.
The mission of the APAPO isto advance, protect and defend
the professional practiceof psychology.
APAPO Mission
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501(c)(6) Business/Trade Association
As a 501(c)(6) organization, APAPO can:
Focus on advancing a particular trade – professional psychology
Engage in unrestricted lobbying Work with a political action committee to facilitate
political giving
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Top Priorities for 2014• Medicare and Medicaid
reimbursement• “Physician” definition in
Medicare• HITECH incentive payments for
electronic health records
Legislative Advocacy
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Medicaid: H&B Codes
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Serving SPTAs: 2013 CAPP Grant Examples
Minnesota•Pursuing funding for the development of electronic health records; ensuring psychologists role in behavioral health homes.
Vermont•Supporting the inclusion of psychologists in legislative process during Vermont’s restructure to a Single Payer Plan.
Kentucky•Ensuring parity in private insurance and Medicaid; addressing workforce capacity challenges with Medicaid expansion.
Georgia•Pursuing efforts to defend scope of practice regarding psychological assessments.
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HEALTHCARE REFORM AT THE STATE LEVEL
Established in fall 2011 in response to the passage of the Affordable Care Act
Composed of the Practice Health Care Team and the State Implementation Advisory Group
Facilitated administratively through the State Advocacy Office
State Implementation Updates
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State Implementation Initiative & APA Communities
Launched by the association in April 2012. Designed as a professional network that enables users
to connect and work collaboratively online, in real time. Securely accessed via MyAPA ID. The APA Practice Initiative: State Implementation of
Health Care Reform is now using APA Communities to link leaders to resources and state efforts on health care reform.
www.apacommuniti es.org
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State Health Care Reform Group on APA Communities
A Document Library
Tools for State Leaders
A Discussion Forum
Categorization of Resources:Mental Health Priority Areas in ACA1. Accountable Care Organizations2. Health Care Financing3. Health Care Medical Homes4. Health IT5. Insurance Exchanges6. Integrated Care7. Medicaid Redesign8. Primary Care
Additional Categories:9. SPTA Health Care Summits10. Updates: APA State Implementation
of Health Care Reform
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SPTAs and Health Care Reform Education 2011New York State Psychological AssociationMassachusetts Psychological AssociationMaryland Psychological Association
2012North Carolina Psychological AssociationIdaho Psychological AssociationMaine Psychological AssociationCalifornia Psychological AssociationIndiana Psychological AssociationOregon Psychological AssociationWashington State Psychological Association
2013Connecticut Psychological AssociationWisconsin Psychological AssociationNevada Psychological AssociationMinnesota Psychological AssociationSouth Carolina Psychological AssociationRhode Island Psychological AssociationOhio Psychological AssociationOklahoma Psychological AssociationVermont Psychological Association
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Funding level maintained for 2014Organizational development,
legislative, emergency and Canadian$250,000 awarded in
organizational developmentgrants to 25 states andDC in 2014
$185,000 awarded inlegislative grants to 13 states in 2013 (for 2014)
Serving SPTAs: CAPP Grants
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Contact Information
Phone: 1-800-374-2723
Web: www.apa.org
www.apapracticecentral.org
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