BEHAVIORAL HEALTH: CHALLENGES AND OPPORTUNITIES IN CHANGING TIMES

2012 Alternatives Conference Portland, Oregon • October 10, 2012

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TONIGHT’S DISCUSSION 2

A LOOK BACK: CONSUMER MOVEMENT MILESTONES

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GOAL IS

HEALTH

RICH HISTORY & MANY ACHIEVEMENTSCHALLENGES & OPPORTUNITIES REMAIN

BH affects most Americans; often co-exists with other health conditions – yet still often seen as social/moral issue

Increases risks for other diseases (e.g., HIV/AIDS)

High proportion of pediatric visits and community hospital stays, as well as readmissions

High impact of disparities (race, gender, ethnicity, LGBT, poverty) & social issues (homelessness, jails, child welfare)

High # of BH related deaths; premature death and preventable illnesses

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TODAY IS WORLD MENTAL HEALTH DAY

World Mental Health Survey: conducted in 17 countries found ~1 in 20 people reported having an episode of depression in previous year

Depression affects > 350 million people of all ages, in all communities, and is a significant contributor to global burden of disease

At worst, depression can lead to suicide – ~ 1 million lives lost yearly due to suicide; 3000 suicide deaths every day

Despite the known effectiveness of treatment for depression, majority of people in need do not receive it

• Globally fewer than 50 percent receive treatment; < 30 percent in most regions; < 10 percent in some countries

• In U.S., ~ 45 percent; < 10 percent of those needing treatment for substance abuse receive it

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THE PRESENT

A BUSY FALL

2012 National Recovery Month--first year that included those in recovery from MH problems!

2nd Annual National Wellness WeekRelease of 2011 NSDUH SA dataRelease of Surgeon General’s

National Strategy for Suicide Prevention

SAMHSA celebrated 20th birthday (October 1, 1992)

New CMHS Director appointed

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PAOLO DEL VECCHIO APPOINTED NEW CMHS DIRECTOR

In BH field for over 40 years With SAMHSA for 17 years

• Former CMHS Acting Director• Former CMHS Associate Director for Consumer Affairs• Former Acting Director for Office of External Liaison• First Consumer Affairs Specialist hired by SAMHSA

Promoted consumer participation in all aspects of policy development and operations

Promotes public education in developing evidence-based practices to address needs of people with MH conditions

Initiated historic dialogue meetings between consumers/peers and practitioners, regional peer meetings, social inclusion efforts, training programs, and grant development

A self-identified MH consumer, trauma survivor, and person in recovery from addictions

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SURGEON GENERAL’S NATIONAL STRATEGY FOR SUICIDE PREVENTION

Every year, over 11 million Americans seriously consider taking their own lives; over 38,000 died from suicide in 2010

Almost 2.5 million Americans > 14 yrs are distressed enough to actually attempt it

America loses ~100 people every 24 hours – not to battles of war or acts of terrorism, not to natural disasters, but to incredibly shattering act of suicide

NSSP developed with input from survivors of suicide attempt and suicide loss; released 9/10/12 on World Suicide Prevention Day

DEFINING RECOVERY

• Working common definition of recovery from mental disorders and/or substance use disorders

• A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential

• Incorporating into grants

• Exploring differences between recovery from MH conditions and from addictions

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MAKING RESOURCES AVAILABLE

SAMHSA’S Community Support Program (CSP)• Provides consumers opportunities to come together• Supports state/national consumer organizations• Promotes peer-run programs, shared decision-

making, and person-centered care

Consumer-Operated Services Program (COSP) Multisite Research Initiative• Establish evidence base for alternative programs• Participation in mutual support programs, drop-in

centers, and other consumer-run services significantly boosts consumers’ well-being and empowerment

• More consumers use these, greater their gains

Consumer-Operated Services EBP Kit

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ELEMENTS OF A PUBLIC HEALTH MODEL12

PARTICIPANT-DIRECTED CARE IN A PUBLIC HEALTH MODEL

Goal is HEALTH for Everyone• Identify and address risks (data-driven)• Build capacity and infrastructure to prevent (within

individual or community)• Access treatment when necessary• Maintain and restore to health• Community will override individual where required

for the public’s health– E.g., immunization, flouride, STDs, tuberculosis, child abuse

Community and individual responsibility

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SAMHSA’S QUALITY CONSTRUCT14

National Quality Strategy (from ACA)• Participant-directed care as one goal

National Behavioral Health Quality Framework1. Evidence-based/effective prevention, treatment, recovery

– evidence-based care often rejected by consumers and people in recovery and by courts, by provider systems, and by policy-makers – for different reasons

2. Person/family/community-centered3. Coordinated (within BH; between BH and other health care)4. Promote healthy living5. Safe6. Accessible/affordable

SHARED DECISION-MAKING – 1

Overcomes historical assumption that persons with BH issues cannot possibly know what they need to get and stay well

History of mandated treatment – civil commitment, MH courts – as well as ineffective treatments with unwanted side effects• Assumption – disagreement w/proposed treatment = symptom “lack of

insight” or “denial” of illness• Assumption – medications are bad; treatment professionals don’t know me;

want to “medicalize” my uniqueness or my life experience

Disagreement = may be beginning of recovery; beginning of taking responsibility for own symptoms, health and well-being

Recovery = hope, individually directed process of self-determined wellness and quality of life

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SHARED DECISION-MAKING – 2

SAMHSA’s integrated suite of support tools for BH service users and providers• Example: computer-based, interactive decision aid re “What is the

Role of Antipsychotic Medication in my Recovery Plan?” Scientific data on range of medication, other treatment options; outcomes, risks,

benefits Weighing side effect protocols of every anti-psychotic medication on market Opportunities to identify/consider personal values/preferences in relation to options Printable personalized report, video & multi-media tools, tip/worksheets To date: 15,630 visitors to the decision aid on website

Reflect standards by International Patient Decision Aid Standards Collaboration• Global researchers, practitioners, stakeholders

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EXPANDING INVENTORY OF DECISION SUPPORT RESOURCES/AIDS

Wider topics and broader audiences; e.g.:• Medication Assisted Treatment (MAT) for Recovery

from Opioid Dependence

• Antidepressant medications (AHRQ has created one for primary care setting)

• Psychoactive medications prescribed for children and youth with behavioral/emotional problems

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THE PATH FORWARD: MHPAEA/PARITY AND AFFORDABLE CARE ACT (ACA)

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UNDERSTANDING MHPAEA & PARITY

October 3, 2008: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)

HHS, DOL and Treasury Federal regulations issued to implement are now effective (as of 2010) for all plans covered by MHPAEA

MHPAEA does not require group health plans to cover M/SUDsRequires group health insurance plans that do offer coverage for

M/SUDs to provide those benefits in a way that is no more restrictive than all other medical and surgical (Med/Surg) procedures covered by the plan• Covered at levels no lower than the levels of other Med/Surg benefits

offered by the plan• Treatment limitations no more restrictive than other offered benefits

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WHO IS COVERED BY MHPAEA?

Insurance plans sponsored by private and public sector employers with more than 50 employees (large groups)

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

Children's Health Insurance Reauthorization Act (CHIPRA)

In total, approximately 150 million Americans

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WHO IS NOT COVERED BY MHPAEA?

Employer groups 50 and under in size (small groups)

Individual insurance plans (individual market)

Medicaid plans not covered by managed care

Medicare

State and local government plans requesting exemption

Covered employer group plans that can prove after implementing their costs have increased by >2% for 1 yr

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PARITY IN AFFORDABLE CARE ACT

Affordable Care Act (ACA) embraces and goes beyond MHPAEA to create broader parity

Identified services that must be included • In non-grandfathered plans; • In individual and small group markets; • Inside and outside of insurance exchanges (qualified health

plans or QHPs); and • In benchmark and benchmark-equivalent plans in Medicaid

expansion• Beginning in 2014

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ESSENTIAL HEALTH BENEFITS (EHBs)

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

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GOALS FOR DEFINING EHBs

Encompass the 10 categories of servicesReflect typical employer health benefit plans (“benchmark” plan)Reflect balance among the categoriesAccount for diverse health needs across many populationsEnsure there are no incentives for coverage decisions, cost sharing

or reimbursement rates to discriminate by age, disability, or expected length of life

Ensure compliance with MHPAEABalance comprehensiveness and affordabilityProvide states a role in defining essential health benefits

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YOUR ROLE IN MHPAEA/PARITY

Learn• Take advantage of opportunities; ask!

Participate• With each other and with other stakeholders

Advocate• Collectively and individually• Give SAMHSA information and feedback

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

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PREVALENCE OF BH CONDITIONS AMONG MEDICAID EXPANSION POP

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

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PREVALENCE OF BH CONDITIONS AMONG EXCHANGE POPULATION

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

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HEALTH COVERAGE IN 2014

Income as a percent of the federal poverty level

0 133 400+

Coverage Options for Adults without Medicare or Employer-Based Coverage

A Continuum of Coverage – Everyone Fits Somewhere!

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States must choose to expand

States must create or let feds do it (FFE)

Individuals must act

2014 ENROLLMENT CHALLENGE

Source: March 2012 CBO estimates

Enroll at least 21 million people in new coverage options(another 11 million must take up employer or other coverage)

}8 million in Exchange coverage

13 million in Medicaid or CHIP}

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A NEW WAY TO ENROLL IN COVERAGE 31

SIMPLE STREAMLINED APPLICATION PROCESS

NowDifferent applications for

different programs

Denied? Back to the drawing board

Applications often only available on paper or as PDFs if online

In-person interview requirements

2014A single application as

gateway to all coverage programs

Must be available online, by telephone through a call center, by mail, and in person

Interview requirements prohibited

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CONSUMER ENROLLMENT ASSISTANCE IN ACA

Navigator Functions• Include at least one consumer-focused non-profit• Maintain expertise in eligibility and enrollment and

facilitate enrollment in QHPs• Conduct public education activities to raise

awareness about the state’s exchange• Provide referrals to any applicable office of health

insurance consumer assistance or health insurance ombudsman

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SAMHSA ENROLLMENT ACTIVITIES

Consumer enrollment assistance subcontracts (BRSS TACS)• Outreach/public education• Enrollment/re-determination assistance• Plan comparison and selection• Grievance procedures• Eligibility/enrollment communication materials

Learning collaboratives in AZ, CA, ME, MD, MO, NM, NY, VTEnrollment assistance best practices TA – ToolkitsCommunication strategy – message testing, outreach to

stakeholder groups, webinars/training opportunitiesData work with ASPE and CMS

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ENROLLMENT ASSISTANCE OPPORTUNITIES

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HEALTH REFORMROLE OF ADVOCATES

Learn• Educate yourself and others on implications of HR – ask!• http://www.samhsa.gov/HealthReform/

Participate• Work with states and with local advocacy groups – behavioral

health and other stakeholders

Advocate• Make your voice heard to further shape HR• Speak out and motivate America to better understand how

behavioral health is essential to health

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MOVING FORWARD TOGETHER

Goal is lives healthy and meaningful rather than lives managed

Focus is on people’s lives – prevention, treatment, and services are means to that end

Safe, healthy, supportive communities and people

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