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The Affordable Care Act:Challenges and Opportunities
for Social Workers
Presented By:Christina Andrews, Ph.D., MSW and Teri BrowneUniversity of South Carolina, College of Social Work
Julie Darnell, Ph.D., MHSA, University of Illinois at Chicago, School of Public Health Sarah Gehlert, Ph.D., Washington University, The George Warren Brown School of Social
Work Robyn Golden, LCSW, Rush University Medical Center
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The Affordable Care Act:Challenges and Opportunities
for Social Workers
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mail: P.O. Box 509 Eau Claire, WI 54702-0509 • telephone: 866-352-9539 • fax: 715-833-3953email: [email protected] • website: www.lorman.com • seminar id: 391500
Prepared By:Christina Andrews, Ph.D., MSW and Teri Browne University of South Carolina, College of Social Work
Julie Darnell, Ph.D., MHSA University of Illinois at Chicago, School of Public Health
Sarah Gehlert, Ph.D. Washington University, The George Warren Brown School of Social Work
Robyn Golden, LCSW Rush University Medical Center
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Christina AndrewsTeri BrowneJulie Darnell
Sarah GehlertRobyn Golden
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OutlineI. Strengths of social work that align with the goals
of the ACA (Sarah Gehlert)
II. Social workers’ role in assuring access to health insurance coverage (Julie Darnell)
III. Heightened focus on integration and care coordination: Implications for social workers (Robyn Golden)
IV. Expanded coverage for behavioral health services: Implications for social workers (Christina Andrews)
V. Social work’s role in the ethnical implementation of the ACA for vulnerable populations (Teri Browne)
Sarah Gehlert, PhD
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The Origins of Health Social WorkThe first hospital social worker was hired by
Massachusetts General Hospital (MGH) in 1905, based on:
1. A recent influx of immigrants to the U.S.
2. Changing attitudes about how the sick should be treated
3. Changing attitudes about how social factors affect health
Change in Focus Over Time
Hospital Social Work
Medical Social Work
Health Social Work(1905)
(1990s)
Hospital Community
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Ida Cannon, the Chief of Social Work at MGH, wrote in 1923:
“[B]asically, social work, wherever and wheneverpracticed at its best, is a constantly changing activity,gradually building up guiding principles fromaccumulated knowledge yet changing in techniques.Attitudes change, too, in response to shifting socialphilosophies” (p. 9).
Five Health Social Work Strengthsthat Align with the ACA
Individuals are situated within social contexts
Person
Family & Neighborhood
Community
Society
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Five Health Social Work Strengthsthat Align with the ACAThe systems perspective considers & connects multiple intersecting spheres:
• Health• Education• Employment• Child welfare
Five Health Social Work Strengths that Align with the ACA
Physical & Mental/Behavioral Health are Integrated
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Five Health Social Work Strengthsthat Align with the ACA
All Efforts & Actions are Guided by a Base of Evidence that is Informed by Research within Communities
Five Health Social Work Strengths that Align with the ACA
Social Work Historically has Targeted Services to Disenfranchised Groups
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Five Health Social Work Strengths that Align with the ACA
The Congressional Budget Office estimates that 21 million will be uninsured in 2016
Undocumented immigrants will be prohibited from purchasing insurance through the new exchanges & ineligible for Medicaid (~8 million persons, 1/3 of uninsured by 2019)
They will need assistance
Julie Darnell, PhD, MHSA
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Why is Help in Enrolling in Insurance Programs Needed? Huge numbers of uninsured: ~50 million in 20111
Historically modest rates of participation in Medicaid among eligible populations2
32%‐81% in studies
Many individuals don’t know about insurance coverage3‐4
Unaware or skeptical they would qualify or would find affordable coverage
48% have heard “nothing” and 28% “only a little” about exchange
78% have “not heard enough to say” whether state will expand Medicaid
Sources: 1U.S. Census. (2012). Income, Poverty, and Health Insurance Coverage in the United States: 2011.; 2Sommers, B. et al. (2012). Understanding Participation Rates in Medicaid: Implications for the Affordable Care Act. U.S. Department of Health and Human Services; 3Perry, M. et al. (2012). Faces of the Medicaid Expansion: Experiences of Uninsured Adults Who Could Gain Coverage. Kaiser Commission on Medicaid and the Uninsured; 4Kaiser Family Foundation. Kaiser Health Tracking Poll: March 2013.
Types of Consumer Assistance Consumer assistance programs
Navigators
In‐Person Assisters
Certified Application Counselors
Exchange
Medicaid
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Status of State Exchanges
Declared state‐based exchange
Planning for partnership exchange
Default to federal exchange
Consumer Assistance
ProgramState‐BasedExchange
PartnershipExchange
Federally‐Facilitated Exchange
Statewide Consumer Assistance Programs (CAPs)
OPTIONAL OPTIONAL OPTIONAL
Navigator REQUIRED REQUIRED REQUIRED
In‐Person Assister (IPAs) OPTIONAL REQUIRED NONE
Certified Application Counselor (CAC)‐Medicaid
OPTIONAL OPTIONAL OPTIONAL
Certified Application Counselor (CAC)‐Exchange
REQUIRED REQUIRED REQUIRED
Sources: Enroll America. (March 2013). How can Consumers Get Help Enrolling in Health Coverage; Kaiser Family Foundation. (April 2013). Consumer Assistance in Health Reform. Darnell, J.S. (2013). “Navigators and Assisters: Two Case Management Roles for Social Workers in the Affordable Care Act.” Health and Social Work; Robert Wood Johnson Foundation. (March 2013). Navigators and In‐Person Assistors: State Policy and Program Design Considerations; Brooks, T. In‐Person Assistors May Look a Lot Like Navigators. Retrieved from http://ccf.georgetown.edu/all/in‐person‐assistors‐may‐look‐a‐lot‐like‐navigators/.
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Duties of Navigators & Assisters
Duty
Consumer AssistancePrograms Navigator
In‐Person Assister
Certified Application Counselors
Medicaid Exchange
Education/Outreach State option
Enrollment in QHPs State option
Enrollment in Medicaid
State option or Refer
State option or Refer
State option or Refer
State option
Mid‐year changes State option
Culturally/linguistic‐ally appropriate
Grievances and complaints
State option or Refer
Data collection and reporting
State option State option State option To be determined
= Yes; = NoSources: Kaiser Family Foundation. (April 2013). Consumer Assistance in Health Reform; Robert Wood Johnson Foundation. (March 2013). Navigators and In‐Person Assistors: State Policy and Program Design Considerations.
Challenges and Opportunities Opportunity: Consumer assistance roles align closely with social work case management functions
Consumer assistance programs (CAPs)
Navigators
In‐person assisters (IPAs)
Certified application counselors (CACs)
Challenge: Social work is swimming against the tide as other health professionals (nurses) and non‐professionals (lay individuals) have assumed these roles
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How to Get More Involved Advocate for Medicaid
For coverage expansion
Against cuts
Join (or form) oversight bodies (e.g., boards, advisory groups) that oversee exchanges
Become certified/trained as:
Navigators
Ombudsman
Assisters
Application counselors
Robyn Golden, LCSW
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ACA, Social Work, and Care Coordination ACA creates opportunity for new social work roles
Avenues to sustainable care coordination by social workers increasingly available
Provisions include Changing incentives
Changing payment structures
Move away from fee‐for‐service
ACA provisions of note: Penalties for hospital readmissions
Value‐based purchasing
Bundled payments
Patient‐centered medical homes
Accountable care organizations
Second Curve
Adapted from Ian Morrison
First Curve Second CurveOption on the Health Exchange
Direct Contracts with Employers
Medicare Advantage Plan
Accountable Care Organizations
Bundled Payment Pilots
Readmission Rate
Penalties
Traditional Fee‐for‐Service Payment System
Population Health Per Capita Payment System
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Patient Protection and Affordable Care Act of 2010
Reform component What it meansWhat we need to
work on
Readmissions Financial penalties for excess readmissions
Quality and patient safety
Care coordination
Evidence‐based care maps
Clinical documentation
Value Based Purchasing
Payment based on performance on core measures
Hospital Acquired Conditions
1% reduction in payment if in top quartile
Patient Protection and Affordable Care Act of 2010
Reform component What it meansWhat we need to
work on
Coverage expansion More patients with insurance
Manage access
Alignment and partnerships
Manage quality and cost
Manage populations
Care coordination
Informatics
Bundled payments Lump sum payments to multiple providers for designated conditions
Accountable Care Organizations
Manage care of specified beneficiaries; quality/cost; share of cost savings
Patient‐centered medical home
Services, structures and access for continuous & comprehensive care
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Avoidable Readmissions Penalty Incentive to improve care transitions and reduce avoidable readmissions
Lost reimbursement to drive performance improvement Penalty for each hospital based on risk adjusted actual 30‐day readmission rate compared to expected readmission rate
Reduced Medicare DRG payments by 1%, rising to 3% in 2015
3 target conditions starting in FY 2012, expanding to 7 in FY 2015
Hospital‐specific readmission rates posted on Hospital Compare website for public viewing
Expand to skilled nursing homes and HH agencies
Community Based Care Transitions Program (3026) Provides funding to hospitals and community‐based entities that furnish evidence‐based transition services to Medicare beneficiaries at high risk for readmission
Preference for medically underserved areas, small communities, rural areas and AoA programs
Services must include at least one of 5 interventions
Arranging post‐discharge services
Providing self‐management support (or caregivers support)
Conducting medication management review
Funding up to $500 million over 5 years started in 2011
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Bundled Payments Bundled payment pilot began January 31, 2013
Single Medicare payment to cover all services for an episode of care to be distributed among care providers: Acute hospital services
Physicians’ services
Care coordination and transitional care services
Post‐acute services Home health care
Skilled nursing facility services
Inpatient rehabilitation services
Pilot testing four variations on bundling model over 3 years to assess efficacy
Medical Homes Change in outpatient care delivery toward coordinated, chronic care, including the following supportive services: Care coordination
Case management
Health promotion
Transitional care
Patient and family support
Referral to community services
Additional funding available for coordination through greater reimbursement
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Accountable Care Organizations Medicare Shared Savings Program (3022) creates incentive for the establishment of Accountable Care Organizations (ACOs) Networks of physicians and other providers
Integrated, cooperative services designed to foster collective accountability
Share savings resulting from the ACO’s coordinated care Reduced Medicare expenditures
Improved beneficiary health outcomes
No consensus on vital components of an ACO Will have to address social issues to see true cost savings
Opportunity for social work to achieve savings and quality improvement
The CMS Innovation Center (CMMI) Test innovative payment and service delivery models
To reduce program expenditures
To preserve or enhance the quality of care furnished to Medicare and Medicaid beneficiaries
Preference given to models that improve health care coordination, quality, and efficiency Authority to expand any model
Funding of $1 billion per year for 10 years Released through ongoing Funding Opportunity Announcements
Targeted distribution within priority areas
Budget neutrality requirement waived during testing
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Thrive Under Reform Key elements to making the ACA successful
Engaging patients
Prevention and wellness
Not transactions but a journey
Transparency of performance
Focus on burden of treatment, not illness
Cost and quality in the same breath
Where does social work fit?
Getting to the Table What can social workers do to get to the table?
Find cross‐institutional ways to collaborate
Learn to communicate and market social work
Frame social work from other perspectives
Speak the language of other professions
Vary the message to fit the mission of the team
Find ways to partner with other disciplines
Example: Delegating tasks to community health workers so social worker can focus on skilled activities
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Christina Andrews, PhD
Impact on Behavioral Health Insurance coverage for behavioral health will expand significantly under the ACA through two key provisions:
Medicaid expansion
Creation of state Health Insurance Exchanges (HIEs)
Overall rate of uninsured residents in the United States is expected to decrease by 50% (Congressional Budget Office, 2012)
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Impact on Behavioral Health The ACA requires that behavioral health be included in “essential benefits” offered by all private insurers
All state Medicaid programs will also be required to provide behavioral health coverage
However, public and private insurers will have some discretion in the types and volume of behavioral health services covered
Impact on Behavioral Health The ACA also aims to enhance the quality of coverage by extending the reach of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008
Medicaid and newly‐established HIEs will be required to offer behavioral health benefits that are no more restrictive than benefits for medical services
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Behavioral Health Workforce Increase in coverage for behavioral health services is expected to lead to increased demand for behavioral health services
Demand for Medicaid‐covered behavioral health services is expected to increase most, as a higher proportion of low‐income individuals have untreated behavioral health disorders
Behavioral Health Workforce ACA also emphasizes integration of physical and behavioral health through ACOs and PCMHs
Great overlap among behavioral health disorders and chronic and acute medical conditions
Many ACOs and PCMHs are emphasizing identification and treatment of these “high risk” populations
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Behavioral Health Workforce Bureau of Labor Statistics estimates significant increase in demand for behavioral health services providers
Increase in demand of 34% for healthcare social workers and 31% increase for behavioral health social workers between 2010 and 2020 (16% for other SWs)
Implementation Challenges Service systems may not be ready to address rapid growth in demand for behavioral health services
At present, only 50% of substance abuse treatment providers accept Medicaid
Immediate access to truly integrated services may be limited to health care “innovators” engaged in early ACO/PCMH efforts
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Implementation Challenges Case of Massachusetts: Enrollment difficulties; co‐pays as deterrents to help seeking; loss of presumptive eligibility clause (Capoccia et al., 2012)
Some left out of ACA coverage expansions, including undocumented residents
Among those with coverage, great variation across states in the generosity and scope of coverage for behavioral health services
Opportunities for Social Workers Assume leadership roles in systems expansions of behavioral health services
Demonstrate capacity to contribute to integrated care models by assisting patients with co‐occurring behavioral health conditions
Advocate for Medicaid expansion and push for extensions of ACA to encompass excluded populations
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Teri Browne, PhD
How Social Work Ethics Informs the Implementation of the ACA Social work mission: To enhance human well‐being and help meet the basic needs of all people, with particular attention to the needs and empowerment of people who are oppressed, vulnerable and living in poverty.
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How Social Work Ethics Informs the Implementation of the ACA NASW Code of Ethics
“Professional ethics are at the core of social work. The profession has an obligation to articulate its basic values, ethical principles, and ethical standards. The NASW Code of Ethics sets forth these values, principles, and standards to guide social workers’ conduct. The Code is relevant to all social workers and social work students, regardless of their professional functions, the settings in which they work, or the populations they serve.”
Value: Service
Ethical Principle: Social workers’ primary goal is to help people in need and to address social problems.Social workers elevate service to others above self‐interest. Social workers draw on their knowledge, values, and skills to help people in need and to address social problems.
People in need of medical care
• Health care• Health care coverage
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Social Work Practice, Administration and Research Implications of the ACA
SOCIAL WORKERS’ ETHICAL RESPONSIBILITIES TO CLIENTS
SOCIAL WORKERS’ ETHICAL RESPONSIBILITIES TO THE BROADER SOCIETY
Commitment to Clients: Social workers’ primary responsibility is to promote the wellbeing of clients.
Social workers should advocate for living conditions conducive to the fulfillment of basic human needs
How Social Workers Can Help Advance the Goals of the ACA Value: Social Justice
Ethical Principle: Social workers challenge social injustice.
Social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people. Social workers’ social change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice.
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6.04 Social and Political Action Social workers should engage in social and political action that seeks to ensure that all people have equal access to the resources, employment, services, and opportunities they require to meet their basic human needs and to develop fully. Social workers should be aware of the impact of the political arena on practice and should advocate for changes in policy and legislation to improve social conditions in order to meet basic human needs and promote social justice.
Social workers should act to expand choice and opportunity for all people, with special regard for vulnerable, disadvantaged, oppressed, and exploited people and groups.
Challenges and Opportunities
ACA implementation
States choosing to opt out of Medicaid expansion
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Christina AndrewsTeri BrowneJulie DarnellSarah GehlertRobyn Golden
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Notes
