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Meeting the Needs of the People We Serve: SAMHSA and CMS Partnerships

Substance Abuse and Mental Health Services Administration

National Association of State Mental Health Program Directors

2015 Commissioners Meeting July 20, 2015

Leading Change 2.0:

Advancing the Behavioral Health of the Nation 2015–2018• To increase awareness and understanding

about mental and substance use disorders, promote emotional health and wellness, prevent substance abuse and mental illness, increase access to effective treatment, and support recovery

Leading Change 2.0 - Six Strategic Initiatives

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Theory of Change

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FY 2016 BUDGET HIGHLIGHTS

• Strengthening Crisis Systems $10 M ($5 M in MH↑; $ 5 M in SAP)

• Tribal Behavioral Health Grants (TBHG): $30 M ($15 M in MH; $15 M in SAP) ($25 M ↑)

• Mental Health First Aid: $15 M (4 M ↑ in MH)

• Grants for Adult Trauma Screening and Brief Response: (+$2.9 M)

• National Strategy for Suicide Prevention (NSSP): $4 M ($2 M ↑ in MH)

• Science of Changing Social Norms ($ 2 M ↑ in PAS)

• PBHCI: $28 M ($24 M ↓ in MH)

Setting the Context

• Designed Focus of SAMHSA and HHS

• Importance of Collaboration with Payers and Providers

• System Redesigns Under ACA

• Meeting in the Middle

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Federal Initiatives and Efforts to Support Integration

• OASH: Co-morbidity working group

• SAMHSA’S Primary/Behavioral Health Integration (PBHCI): Physical health of adults w/ SMI and technical assistance for bi-directional integration (Center for Integrated Health Solutions, w/ HRSA)

• Primary Care/Addiction Services Integration (PCASI): Proposed for FY 2015

• HRSA FQHCs: Integrating behavioral health screening, brief intervention, and treatment into primary care settings

• Million Hearts: Wrapping behavioral health into efforts to address ABCS

• AHRQ Center for Integration Models: Developing models of integrated behavioral health care in primary care settings

• CMMI Innovative Financing Models for Integration: Grants to test models using SAMHSA and AHRQ indicators and technical assistance

• Medicare Accountable Care Organizations (ACOs): Payment for integrated care & outcomes (ASPE tracking impacts for behavioral health)

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Service Models, Payment Structures, and Demos to Achieve Better Care and Value

• State Innovation Models: Support for development and testing of state-based models for multi-payer payment and health care delivery system transformation

• Health Homes (Section 2703): Whole person care for Medicaid recipients w/specific characteristics or conditions (50 SAMHSA consultations with 25+ states)

• Accountable Care Organizations: Coordinating high quality care for Medicare recipients, including behavioral health care

• Duals Demo: Ensuring Medicare-Medicaid enrollees have full access to seamless, high quality health care that is cost effective

• Transforming Clinical Practice Initiative: designed to help clinicians achieve large-scale health transformation through sharing, adapting and further developing their comprehensive quality improvement strategies.

• Medicaid Innovation Accelerator Program: Focusing on payment and service delivery reforms to improve health and quality of care for Medicaid beneficiaries; Priority Area SUDs

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Increasing Costs

Boyd, C., Clark, R., Leff, B., Richards, T., Weiss, C., Wolff, J. (2011, August). Clarifying Multimorbidity for Medicaid Programs to Improve Targeting and Delivering Clinical Services. Presented to SAMHSA, Rockville, MD.

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Impacts on Physical Health

MH problems increase risk for physical health problems & SUDs increase risk for chronic disease, sexually transmitted diseases, HIV/AIDS, and mental illness

Cost of treating common diseases is higher when a patient has untreated BH problems, mostly preventable or treatable

24 percent of pediatric primary care office visits and ¼ of all adult stays in community hospitals involve M/SUDs

M/SUDs rank among top 5 diagnoses associated with 30-day readmission, accounting for about one in five of all Medicaid readmissions (12.4 percent for MD and 9.3 percent for SUD)

Half of Americans will experience M/SUD; half know someone in recovery from SUD

$0$50,000,000

$100,000,000$150,000,000$200,000,000$250,000,000$300,000,000

With behavioral health problems and

diabetes

With diabetes alone

Individual Costs of Diabetes Treatment for Patients Per Year

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Cost of Care Post ACA

M/SUD and All-Health Medicaid and Private Insurance Spending ↓M/SUD and All-Health Out-of-Pocket and Medicare Spending

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SAMHSA and CMS Interaction

Domains of Work that Intersect

• Laws, regulations, sub-regulatory guidance• Grant Making and Convening• Communications• Agency and emerging HHS health priorities

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• Informational Bulletins: Medication Assisted Treatment (MAT); coverage/service design of BH services for youth with serious emotional disturbance (SED); trauma-focused services; prevention and early identification of mental health and substance use conditions; and strengthening management of psychotropic medications for vulnerable populations; others in process

• Ongoing Interactions: Payment rules; waiver consultation; state plan amendments; regulation review; quality measures; same day billing guidance; and parity

• Section 223 of the Protecting Access to Medicare Act of 2014: SAMHSA developed criteria for Certified Community Behavioral Health Clinics (CCBHCs) and managing state planning grants; CMS developed prospective payment system; ASPE to evaluate outcomes

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Selected SAMHSA/CMS Collaborations

Main Mechanism – Health Care and Health System Integration Strategic Initiative

• Foster integration between behavioral health and prevention, health care, and social supports – “behavioral health is essential to health”

• Develop and implement new provisions under Medicaid and Medicare to assure treatment available, provide and evidence-based

• Influence and support efficient use of financing models and mechanisms to address behavioral health behavioral health treatment, services, and activities

• Finalize and implement parity provisions in MHPAEA & ACA, disseminate information

• Implementation of quality indicators to advance behavioral health outcomes – NBHQF; Delivery System Reform

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Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help

provide better care at lower cost across the health care system.

Delivery Systems Reform

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Pay Providers

Deliver Care

Distribute Information

FOCUS AREAS

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Encourage the integration and coordination of clinical care services Improve individual and population health Support innovation including for access

INCENTIVES

Bring electronic health information to the point of care for meaningful use Create transparency on cost and quality information Support consumer and clinician decision making

Focus Areas Description

CARE DELIVERY

INFORMATION

Promote value-based payment systems – Test new alternative payment models– Increase linkage of Medicaid, Medicare FFS, and other payments to value

Bring proven payment models to scale Align quality measures

A health system that provides better care, spends dollars more wisely, and has healthier people

Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.

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Delivery System Reform – Focus Area 1 (Incentives)

• Incentives: Improve the ways providers are paid, now looking to reward value and care coordination – rather than volume and care duplication

• Pay providers for what works, whether something as complex as preventing or treating disease, or something as straightforward as making sure patients have more than one way to communicate w/ the team of clinicians taking care of them o Example: New Medicare payment goals to drive quality and value; many

new payment models being testing at the CMS Innovation Center (such as Accountable Care Organizations)

o BH Example: Section 223 Demonstration – Improving Quality of Community Behavioral Health Services

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Section 223

• Elementso Criteria for CCBHCs (SAMHSA)o Prospective Payment System (PPS) to pay costs + quality

incentive (CMS)o Evaluation to see what difference it makes (ASPE)

• Timelines/Processo Planning grant RFA issued – May 2015o Planning grant states awarded – October 2015o Demonstration states selected – Dec 2017o Annual Report to Congress re outcomes and

recommendations – Dec 2018

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Delivery System Reform – Focus Area 2 (Care Delivery)

• Care Delivery: Drive progress on how care is delivered, focused on improving coordination and integration of health care; engaging patients more deeply in decision-making, and improving health of patients – priority on prevention and wellness

o Examples: Transforming Clinical Practice Initiative (CMMI) to provide $840 M + to ~ 150,000 providers to help redesign their practices; Partnership for Patients (PfP) to improve patient safety in hospitals& reduce readmissions

o BH Examples: Primary BH Care Integration (PBHCI) grants; Primary Care and Addiction Services Initiative (PCASI) budget proposal; Medication Assisted Treatment (MAT) work plan and budget proposals; Million Hearts protocols in SAMHSA RFAs; shared decision-making tools; suicide prevention clinical guidelines and “zero suicide” efforts

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Delivery System Reform – Focus Area 3 (Information)

• Information: Improve the way information is distributed, working to create more transparency on cost and quality information, to bring electronic health information to more places, and to bring most recent scientific evidence to point of care to bolster clinical decision-making

o Examples: ONC interoperability roadmap, improvements to EHR meaningful use program; getting more cost and quality data into patients’ hands for informed decision-making

o BH Examples: NBHQF measures and electronic specifications; standards for BH vendors; Consent2Share; HL7 work on electronic care coordination document; electronic health records (EHRs) language in SAMHSA RFAs; proposed revision to 42 CFR Part 2

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Strategy for Delivery System Reform

• More services and dollars under budget or quasi-budget

• Clinical organizations with capacity to manage continuum of care increasingly delegated responsibility for budgets and populations

• Accountability and rewards for performance– Savings – Quality indicators

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High Powered Budget Incentives

• Consolidates funding across service lines; moves accountability towards population focus

• Can reward integration of primary care and specialty behavioral health care

• Can favor prevention and early intervention approaches– Especially for clinical preventive services

• Challenges– Business case relies on savings subject to meeting quality

thresholds– Behavioral health quality measures are under-developed

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IMD Payment Exclusion

• CMS is proposing to allow states to purchase inpatient acute care services for MI/SUD offered by IMDs that are freestanding inpatient psychiatric facilities that provide the same level of care provided by distinct part psychiatric units in general hospitals so long as certain conditions are met.

• The recently published managed care NPRM allows states to authorize capitation payments for an enrollee aged 22 to 64 who is in an IMD and the stay in the IMD is for less than 15 days.

• Payment will only be allowed in capitated arrangements in which the managed care plans are at-risk for services provided in inpatient settings.

• Managed care plans will be required to publicly report on quality measures for their enrollees who receive services in IMDs to assess the quality of care received in these facilities and efforts by these IMDs to transition individuals to community-based services.

• Comment period is now closed and CMS is currently reviewing and preparing to respond.

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SAMHSA and IMD

• Have worked closely with CMS on the proposed regulation on:– Appropriate lengths of stay– Commitment to a continuum– Maintained investment in community based services– Quality reporting and performance metrics– Impact of covering IMDs on overall emergency department

utilization, inpatient utilization, successful transitions to outpatient care, and overall costs

• Much interest from constituents, states and current political hotpoint

• SAMHSA recognizes there is a need, but…

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