Health Care Reform: Implications for Behavioral Health Providers

Uploaded by SAMHSA on 26.10.2010

Rebecca: (inaudible) ...welcome to the National Council Live Webinar,
Healthcare Reform: Implications for Behavioral Health Providers.
My name is Rebecca Farley.
I'm the Policy Associate at the National Council for Community
Behavioral Healthcare and I will serve as your moderator today.
We would like to thank Charlene (LaFove),
(Najay Saleem), Deborah (Stone) and John O'Brien from SAMHSA
for sponsoring this webinar.
Before I introduce the speakers and turn the mic over to John O'Brien
for introductory remarks, I'd like to draw your attention to some
important webinar logistics.
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please call Citrix tech support at 888-259-8414.
And now, on to the topic of today's webinar.
Today's webinar will provide information and guidance to plan and prepare for
clinical and fiscal changes, including those related to Medicaid and discuss
the implications of the Patient Protection and Affordable Care Act
for the behavioral health system.
Our agenda includes introductory remarks from John O'Brien,
Senior Advisor to the Administrator on Health Finance at the
Substance Abuse and Mental Health Service Administration
and then a presentation from our two speakers followed by a
Q & A session with the audience.
Charles Ingoglia has worked as a provider,
advocate and educator for government and public sector organizations for
more than fifteen years.
In his current role, Mr. Ingoglia directs the federal affairs function
of the National Council as well as its policy and technical assistance
outreach to more than one thousand seven hundred member organizations
across the nation.
Most recently, his efforts have centered on key issues such as
parity, healthcare reform and increasing access and retention in
community behavioral healthcare.
Dale Jarvis brings a diverse background as administrator, author and
educator to healthcare organizations throughout the western United States.
He has served as the financial director for healthcare
organizations in Washington and Michigan.
He also taught Healthcare Financial Management at the University of
Washington, School of Public Health.
Before our presenters begin, John O'Brien, Senior Advisor to the
Administrator on Health Finance at the Substance Abuse and Mental Health
Services Administration will provide introductory remarks on the
importance of primary and behavioral health integration.
John has extensive experience in the design and implementation of system
reform initiatives and has provided consultations to more than
thirty-five states and local human services authorities.
He has worked with Medicaid, Child Welfare,
State Behavioral Health and Mental Retardation authorities.
His primary focus is assisting states in developing state plan
amendments for mental health services, federal Medicaid waivers,
managed care vendor procurement and financing mental health,
substance use and child welfare services and the research of
children's behavioral health systems.
And now, it is my pleasure to turn the webinar over to John O'Brien.
John, you may begin.
John: Thank you.
Well, welcome everyone.
I'm a little bit overwhelmed by the number of people that have been interested
in this webinar and right around two o'clock we actually maxxed out
in terms of the number of folks who could present or who could participate.
So, we will -- we welcome the folks that are on and future presentations
we will probably get more lines but let me thank our presenters in advance.
This topic is very interesting to many people and we thought that this
would be our first foray into the SAMHSA sponsored webinars on various
elements of healthcare reform.
I also want to thank AHP for organizing this webinar and
thank all of you who are listening.
This is our first of our Fall learning sessions that SAMHSA
is sponsoring regarding basic concepts on healthcare reform.
Over the past several months, SAMHSA has an environmental scan of our
stakeholders to identify what were some of the concepts that they
wanted more information on.
This first session is focused on the concept of health homes and
accountable care organizations.
Over the next two weeks, SAMHSA will have calls on several other topics,
including one and two days.
On the 23rd at two o'clock Eastern time on health insurance exchanges
and on September 30th at two o'clock on high-risk pools.
So, let me talk a little bit about what we want to accomplish today.
As indicated in the prior conversation, we have some interest in offering some
basic information on health homes and accountable care organizations.
I think that there's lots of interest.
In some respects, there is some misconceptions about what those are
and we thought we would use this webinar, at least,
as a start to hopefully provide some good information and
hopefully, dispel some of the misconceptions around health homes
and accountable care organizations.
We are going to talk a little bit about why these approaches are important.
Why the concepts and maybe the nomenclature seems new.
The concepts and the approaches are not necessarily new and they've been
around for awhile and we want to talk a little bit about not only
their history but why are we doing this,
why is it important now to pay attention to this is.
I did want to mention that this session is not about the specifics
of the health home provisions and the Affordable Care Act.
I'm actually getting some feedback.
Female: Yes, we can hear her.
Female2: Is that who that was?
Female: Yeah.
John: Anyway, the session is not about the specifics of the health home provisions
in the Affordable Care Act, which is Section 2703, as you know.
SAMHSA and CMS is partnering on that particular part
of the affordable care act.
We are in the process of working together on providing some
additional guidance to states on that provision and hope to have this
out to states soon.
We know that there is a lot of interest in this so we won't be discussing
this provision on this call or we won't be able to answer questions
on this call related to that section.
We will offer that opportunity later on after we can get
some guidance out about it.
So, why is integration of primary care and behavior health important?
Some context that we at SAMHSA have been using as we've been
talking about primary care and behavioral health integration is
some of the important statistics.
We know that a few years ago in 2007,
almost twelve million of the ninety million visits annually to emergency
rooms were by people with a mental illness or substance use disorder.
We also know that forty-four percent of all the cigarette consumption
that is in the United States are done by individuals with mental
health and substance use disorder.
And in a number of places, there have been studies,
which have shown that seventy percent of the individuals with
significant mental health and substance use disorder have either
one or more chronic conditions.
And so, those statistics and as well as many other statistics underline
the need to have a connection between primary care and
behavior health integration.
If we go to the next slide, I just want to talk a little bit about
SAMHSA's primary care behavioral health initiative project.
We had launched the project last fall and really the project represents
SAMHSA's approach to primary care and behavioral health integration.
SAMHSA believes that it is important to have a bi-directional approach to
primary care and behavioral health integration which means both
behavioral health professionals, behavioral health services in
primary care settings like federally qualified health centers,
community health centers as well as large practices but also,
the importance of being able to have primary care in behavioral health
settings, community mental health centers,
substance abuse treatment providers, other behavioral health providers
whom individuals with serious mental illness and/or significant substance
use disorders have often seen those organizations as their health home,
as the organization that's accountable for their care.
So, we wanted to make sure that we framed it as really
a bi-directional approach.
The Primary Care Behavioral Health Initiative Project has thirteen sites.
More sites will be awarded.
They are going to be awarded this week.
We are actually waiting towards the end of the week where the secretary
will announce these sites.
And in addition, she will announce a technical assistance center that
SAMHSA and HRSA is co-funding in order to provide mental health and
substance abuse providers with primary care integration strategies.
So, we're really excited not only about this webinar but about our
efforts as it relates to primary care behavioral health integration.
They're expanding.
They're expanding quickly and we felt that regardless of what was in
the Affordable Care Act that this is something that we needed to pay
attention to because it was certainly the wave of the future and
therefore, wanted to get this information out to folks
sooner rather than later.
So, I'll stop there and I'll turn it over to the National Council who
will walk through some important questions and really take you
through the rest of the presentation.
Male: Chuck, if I could interrupt just for a second.
Dale, are you on the line?
Dale: Yes, I am. Can you hear me?
Male: Yes, thank you.
Okay, go ahead, Chuck.
Chuck: Well, John, thank you so much for that introduction and we're so
grateful to SAMHSA for all the leadership that the agency has
provided in this area, the area of integration.
And obviously, your new grant program that pays for the
co-location of primary care capacity within mental health -- within
behavioral health organizations is critically important both for the
people who need those services as well as I think,
the message that it sends to the broader field about the importance
of bi-directional care and the fact that mental health and substance
abuse really are part of healthcare and need to be connected.
So, we're very greatful to administrator Hyde for all of her leadership
and the great work that you do, John, at SAMHSA
setting a course for the field as we move into our future.
As John indicated, today's webinar is trying to kind of get at some
basics of the affordable care act and what we're hoping to do in the
course of today's webinar is answer two questions which we think are
really important to understanding the design implementation and
implications of healthcare reform.
So the first question really is
will healthcare reform really change the healthcare system.
What do we have -- you know, kind of -- what is in there that holds implications
for consumers or families or providers for authorities as they
think about their future as part of the larger healthcare system.
The second question really has to do with how does the answer to the
first questions affect the lives of people with mental health and
substance use disorders and the organizations that serve them.
I think an interesting -- we find ourselves at an interesting point as
a field that for years we've been asking to be part of healthcare.
That we wanted the broader healthcare community to recognize the
importance of the provision of mental health and substance use treatment.
And I think with the passage of the Affordable Care Act and its many
provisions, I think that we got what we always had been asking for.
Where we are seen as part of healthcare and now the question
really comes down to how will this impact our system?
So I just want to -- we're going to use some words and/or some
abbreviations in the course of the Webinar and I just wanted to kind of
go over those to make sure that we're all on the same page.
So you might see the initials SMI and we're using that as an
abbreviation for serious mental illness.
The kind of -- current term being used.
Substance use describes the broadest context of alcohol and other drug
(services) and disorders so we tend to use that.
We use the term behavioral health to describe services that are for --
or mental health and substance use disorders and you might see a
reference to co-occurring disorders.
And we use the definition for that as a presence of both a mental
disorder and a substance related disorder.
So let's turn then, to our first question.
Will health care reform really change the healthcare system?
And this is not an insignificant question and it's not insignificant
because of the fact that in the United States right now,
we really have a story of the best and the worst healthcare system.
Obviously, we spend a significant amount of money in the provision of
healthcare and yet, if you look at the rate of preventable deaths in
industrialized nations, it's almost counterintuitive that the country
that spends the most on healthcare also has the highest rates of
avoidable deaths compared to other industrialized nations.
That then takes us right to the question about healthcare spending
and the serious problem confronting us as a nation which is if
healthcare expenditures continue to increase at the rate they have been,
they will continue to consume an ever larger amount of gross domestic
-- represent a consistently larger amount of our domestic --
gross domestic product and will really make the United States
non-competitive in the rest of the world that as -- the healthcare will
consume so much of our spending that it really will present -- put
businesses in an awful position.
And also, from a -- the position of the amount of money available.
If you think about the role of the Federal government and states have
in paying for healthcare that as those expenditures continue to
increase, the amount of money available for other programs
decreases at the same time.
In his introductory remarks, John touched on this.
There is -- then this question becomes what do we need to do
to deal with the first problem, which is the number of avoidable deaths,
and the second problem, the amount of money that is spent
in the United States' healthcare system.
And folks, health policy leaders have really focused on the fact that
it's really a small percentage of people,
those with chronic conditions who account for a disproportionate
amount of spending in the US healthcare system.
So people with chronic conditions account -- which is about forty
percent of people, account for eighty percent of the spending.
And if we look within that cluster, we also see that there are very high
rates of mental disorder and substance use in that population
who also has a chronic illness.
And certainly, there is some relationship factors there that
people living with chronic -- with heart disease or diabetes -- tend to
have high rates of depression, etc.
And if this is a study looking at data from Washington State,
that if you look at the fact that all of these illnesses terribly overlap.
So the question becomes -- there is an -- there is a link between these illnesses,
that they tend to be co-occurring and we need to do something holistically
if we're going to address the rate of spending related to chronic illnesses.
The next slide also just talks about the need to address this holistically.
Not only do people with chronic health conditions have high rates of
substance use and mental illness but conversely,
people with mental illness and substance use in co-occurring
disorders have high rates of chronic -- other chronic health conditions
and that that combination of factors is very deadly for this population.
So the research prepared by the National Association of State Mental
Health Program Directors based on data from eight public mental health
systems showed an average life span of fifty-three for people with
serious mental illness.
The State of Oregon did some further research and they looked at what
were the death rates for people with serious mental illness,
what were the death rates for people with -- being treated for substance
use disorders and what was it for people with co-occurring disorders.
And in Oregon, they found that people with co-occurring disorders
actually have an average age of death of forty-five.
So if you kind of put that -- that's comparable to life expectancy
in sub-Saharan Africa.
So obviously, there's this huge issue here of how do we improve the
life trajectory for this population?
If we think then, about the relationship of these illnesses
and why it's important to think holistically,
this data from California is also interesting.
And it shows that the -- not only is the overall cost of care in the
mental health system higher than other people who are enrolled in
Medicaid but that the rate of chronic illnesses is also
substantially higher for this population.
So if you look at the Medicaid -- (medic) health fee for service
population total and then you then just look at the population that has
serious mental illness, you see huge disparities in the amount of monies
spent on that population as well as the rates of chronic illnesses.
So I think -- all of these statistics have -- point then,
to a couple of conclusions.
One, that there is a growing awareness of the prevalence of
mental health and substance use disorders and the costs,
the true costs of not providing effective treatment and supports
to address those disorders.
Now obviously, those are costs in terms of spending as well as
loss of life.
And that awareness is happening at the same time that there is broad
recognition that the services we provide are essential,
that prevention works, that treatment is effective,
people can recover.
So, it's kind of this interesting confluence of understandings occurring.
Those of you who follow the healthcare reform debate have heard a phrase
that was coined by the then director of the Office of Management and Budget
that one of the goals of healthcare reform was to bend the cost curve.
And of all of this data that we have examined so far today,
if we're going to achieve that, if we're actually going to reduce the
amount of money that is being spent by the healthcare system,
there is no way that we can accomplish that without addressing
adequately the healthcare needs of persons with serious mental illness,
the co-occurring disorders and the mental health and substance use
needs of the population that has chronic illnesses.
And we'll come back to this later in our presentation.
So then as we entered into the healthcare reform process,
there were really kind of several goals driving policymakers.
If you would talk to people in the White House,
people on Capitol Hill that really the goal here is two-fold: how do we
improve quality of care while managing costs.
And there were a couple of ideas that were then included in
healthcare reform to try to achieve that.
The first is this notion of moving from a sick care system to a
healthcare system or another way to say that how do we move further
upstream with prevention and early intervention services to prevent
health conditions from becoming chronic health conditions.
If we think about to some of the points that I made earlier about the
amount of money that is spent by our healthcare system on persons who
have chronic health conditions, that it makes a lot of sense that we want
to try to avoid those chronic health conditions from ever occurring.
Secondly then, related to that is we also wanted to dramatically improve
the management of chronic health conditions for Americans who have
one or more of those conditions.
So then, there are then particular interventions and ways of organizing
services to better manage care and we'll talk about and I think John
talked about the fact that we are going to talk about healthcare homes
and accountable care organizations today.
Those are two of the ways that are being talked about to try to improve
that management of chronic health conditions.
And then a third goal always is,
A: how do we reduce errors and waste in the system and reduce incentives for
high cost low value procedure based care.
So every system is perfectly designed to achieve the result that
it achieves.
So the idea here is that if things aren't going right in our system
it's because it's -- has a design flaw and part of then,
what we are going to be talking about are ways to re-engineer the
system to produce different outputs.
I'd also say that even before healthcare reform legislation was
being considered in Congress that the President and the Congress
realized that there was another first step that they had to take in
order to achieve this vision.
And that was in the passage of the High Tech Act which was part of the
Recovery Act that was -- were the first pieces of legislation -- one
of the first pieces of legislation passed in the hundred and tenth
Congress and that really envisioned a future where healthcare providers,
hospitals could be connected to each other electronically to share
patient information to reduce unnecessary and duplicative tests
and to improve care quality.
So a lot of what we're going to be talking about -- a lot of the vision
for how the healthcare system will change is really built on that
electronic infrastructure.
That the ability of healthcare providers to share information electronically
about common patients becomes very important as we go into the future.
Whenever I describe the Healthcare Reform Law,
I really say that there are four pillars underlying the law.
There are four things that it was trying to achieve.
The first is insurance reform.
Second, coverage expansion.
Third, delivery system redesign and fourth, payment reform.
I think it would be fair to say that the law did a lot more on the first
two pillars, insurance reform and coverage expansion.
It laid important groundwork for the second two but I think the
difference is also reflected in -- is a product of what we're being --
kind of what's envisioned here is that things will have to change in
order to achieve payment reform and delivery system redesign.
And I often reflect that the most important thing I learned in social
work school was the notion that all organisms tend toward homeostasis.
That none of us likes to change and the prospect of change is scary.
It conjures up images of winners and losers and I think what we --
in order for payment reform and delivery system redesign to be
effective we've got to be smart going into that and not be afraid of
what the future might hold.
So the notion of insurance reform, kind of why is that important?
You think about it, every country that has approached healthcare
reform has done it from the foundation in which it found itself.
No country just took whatever healthcare system they had,
threw it out the window and started from scratch as attractive an idea
as that is to some people.
So, in our country, private health -- since World War II, private health
insurance offered by employers is the primary source of coverage.
So we wanted -- Congress obviously, then wanted to build on that
foundation of private insurance coverage yet there was broad
recognition that the insurance system might not be as a reliable
partner as it needed to be in order to make this work.
So then there are quite a few changes to the insurance system
contained in healthcare reform to make private health insurance a more stable,
reliable partner and resource for people who need healthcare.
So there are a number of changes to the healthcare system
contained in the law.
I'll just mention a few that I think are particularly important to people
with substance use and mental illness -- substance use disorders
and mental illness.
The first is that insurance companies can no longer deny
coverage based on pre-existing conditions.
That all insurance policies have to be offered and renewed regardless of
the health conditions experienced by people who have that coverage.
There will also be prohibitions on all annual and lifetime limits so
your insurance company can't pay to a maximum in a year or in your
lifetime, that the amount of healthcare that you need is the
healthcare that you need.
Another interesting one is the notion that young adults will have the option
of re-staying on their parents' insurance until the age of twenty-six.
Now this will be particularly interesting as this is a prime time
for people to develop substance use disorders and/or mental illnesses
and -- then it really begs the question of how adequate are the
services that people can access through their private health
insurance and -- so I think that is going to be something we'll need to watch
going into the future.
Another component of healthcare reform is this notion of coverage expansion.
So we currently have fifty million people it's estimated in this
country who don't have health insurance.
What do we do to -- what do we do to cover those people,
to give them some source of health insurance coverage?
And again, the approach that Congress took was to build on what
was already there and it does that in two ways.
The first is to build on the foundation of Medicaid.
That Medicaid is an entitlement program for people -- for poor people
and people with disabilities and it's historically been categorical.
That you qualify for Medicaid through a combination of your income
as well as you meeting certain eligibility characteristics.
So the Federal government has said we're going to expand Medicaid but
we're -- but where it's only going to be based on -- this new expansion
of Medicaid will only be based on your income level.
So that for individuals and families who make a hundred and thirty-three
percent of poverty or less, that they will be eligible to enroll in
their state's Medicaid program.
Unfortunately, that Medicaid expansion will allow states to offer
a reduced benefit from traditional Medicaid but it's also something
I think we need to think about but nevertheless, six million people
are expected to enroll in Medicaid as result of this expansion.
Going back to my previous thought or comment about the role of private
health insurance then what we're -- the Healthcare Reform Law also then
creates a new marketplace for individuals and small employers to
purchase insurance through these things that are called health exchanges.
So states -- individual states or groups of states will have the ability
to create these health exchanges and think about them in two ways.
One is creating a kind of large purchasing pool for insurance.
So it's all these people who either individuals or families or small
employers pooling together to purchase insurance and if you think
about the way this works for employers,
typically the more employees you have the better rates you can get on
your insurance coverage.
So that's -- it's creating this pooling mechanism and in effect,
the exchange will be a state sponsored website that allows you to
know which plans are available in your state and to choose among them.
So I've heard people refer to it as Expedia for health insurance.
And in order to make that work -- so this is for people between one
hundred and thirty-three percent of poverty -- individuals and families
between a hundred and thirty-three percent of poverty and four hundred
percent of poverty that the Federal government will provide subsidies to
help people purchase insurance.
What's important about both the Medicaid expansions and the
insurance that is going to be available through these health
exchanges is that in both cases, mental health and substance use
benefits are required and the federal parity law cross-references
-- I'm sorry.
The Healthcare Reform Law cross-references the Pete Domenici,
Paul Wellstone Mental Health Parity and Addiction Equity Act.
And that bill basically says that you can't -- that everything has to
be even, financial requirements, limitations have to be even between
medical surgical benefits and mental health and substance use.
So we have a situation here that all plans offered through the exchange
have to offer mental health and substance use as part of their
essential health benefits, parity applies and then,
this is also the case then in the Medicaid expansion that mental health
and substance use are mandatory and parity applies there as well.
So obviously, many think tanks, others have been kind of writing
and producing models around, kind of changing
the American healthcare system.
I think one of the most influential groups has been the Commonwealth Fund
and the Commonwealth Fund, really right as healthcare reform
was taking off, issued a paper that said that if there were ten things
-- if these ten things were accomplished in healthcare reform,
it would result in savings of about three trillion dollars over ten years.
And those ten things fall into three buckets.
One of them is near universal coverage so the coverage expansion
(inaudible) is very important then towards achieving this goal
of saving money.
The others then, fall into these categories of payment reforms
and improving quality and outcomes, which are also part
of delivery system redesign.
And that's what brings us then to these notions of healthcare homes and
accountable care organizations.
And kind of everyone is talking about healthcare homes and kind of,
"Why is that?"
"Where do they come from?"
"Why do they get that name?" and "Why are they important?"
Those are some of the topics we'll try to navigate.
So the notion of healthcare homes really was born -- kind of came out of
work done by the American Academy of Pediatrics in the seventies.
Trying to think about how to redesign pediatric care to be more
effective to produce better outcomes for kids.
Eventually, that notion was then adopted by all of the large primary
care specialty associations and kind of this notion grew out of this idea
that -- and many of us have experienced this right?
That trying to navigate the healthcare system is like trying to
find your way through a tangled maze.
Those of us who have chronic health conditions or if we have family
members who have chronic health conditions, understand that
individuals could be forced to -- they might have a primary care
physician as well as two or three specialists that they are seeing.
None of these doctors talk to each other.
They don't necessarily share information.
So the idea here is how do we improve that?
How do we take the responsibility off of the consumer to make that
connection to manage their care, that consumer or their family and
how do we make it really part of the healthcare system.
So what healthcare homes are also part of is a larger notion about how
do we redesign care?
And I think if you -- to think about this is really can we picture a
world in which all of us has a long term,
ongoing relationship with a primary care provider.
That the primary care provider stays with us over multiple years.
That that primary care provider has the support in their office,
a care team who collectively takes responsibility for ongoing care.
That there is a team in that healthcare practice that is making
referrals, that is following up with other -- those providers that they
made referrals to, that they're sharing information,
that they are able then, to fit all the pieces together and it's not the
individual or the family's responsibility to do that.
We envision that each of these care teams would have behavioral health
capacity, a behavioral health specialist on it.
So the idea here then, is you would have this practice that's doing this
and the -- really the goals are that as a result of having this
relationship, this care coordination,
the quality and safety are the hallmarks of what is happening,
that medical homes are expected to have enhanced access to care
meaning that you have access to that practice on evenings and weekends
and that payment shifts from being about how many people that I see
that day to added value.
If you think about right now, most primary care -- if you've seen your
primary care doctor recently, right, your appointment is probably about
seven minutes and the reason it's about seven minutes is your primary
care doctor has to get in a certain number of -- amount of volume in a
day in order to make his or her practice profitable.
And the notion here with healthcare homes is to say,
that's not what this is about.
It's not about seven minute appointments in order to generate
enough fee for service billing.
It's really about how do we improve care for the individuals that we're
seeing in our practice.
And we'll hear about ways then, that this has driven the redesign
of care in certain places.
So lots of -- there are -- the last slide referenced these joint
principles that were developed by the (inaudible) medical specialty to
kind of layout the groundwork for kind of what are our expectations
around medical homes and then, individual states,
of course, have to take their own crack at it.
What's the other interesting -- is that Oregon,
I think, what they tried to do is they thought about how are they
going to implement on the concept of medical homes and their Medicaid
program, they took these notions and put them into people first language.
So the idea here then, is that healthcare homes are there when --
that they will be there when I need you,
that they're going to take responsibility for making sure I
receive the best possible healthcare,
the provider helped me get the healthcare and services I need,
they'll be my partner over time in caring for my health,
that they'll help me navigate the healthcare system to get the care I
need in a safe and timely way and recognize that I am the most
important member of my care team and not that I am ultimately responsible
for my overall health and wellness.
So I think that the notion here that's being driven at is improved
quality, patient centered, kind of person-centered care.
What's a little confusing, as I mentioned is that there are many
different names right now for healthcare homes.
As we mentioned, these medical specialties came together and then
they developed standards for patient centered medical homes.
The National Council contributed to this (confusion) in a paper that we
developed and released in 2007 called Person Centered Healthcare
Homes that we wanted the focus to be broader than just the medical system
to explicitly include the specialty behavioral healthcare systems.
Oregon has dubbed theirs patient-centered primary care home.
Sometimes there are abbreviations of medical homes.
In the Affordable Care Act actually uses the term health homes.
All of these terms however, refer to the same goal of trying to convey
the message that the primary care clinic of the future isn't going to
look like the primary care clinic of today.
And Dale, I think I'm going to turn it over to you now.
Dale: Very good. Thank you, Chuck. Can you hear me?
Chuck: Yes, we can.
Dale: Great. Thank you.
I'm going to pick up with the three questions that Chuck was talking
about related to healthcare homes, what are they,
why did they get that name and why are they important by talking about
why they're important.
I happen to live in Seattle and (Group Health) story to tell about
what they've done with medical homes.
Group Health was started after World War II by a group of Quakers and
they've always seen themselves as being prevention and early
intervention oriented, patient oriented.
They used to actually have -- make major decisions for the cooperative
by having members and advisory council literally sit around in a
circle and decide whether to build a new hospital or a new clinic or how
to change the practices.
In 2002, they realized that they weren't really doing enough in the
primary care area so they made some changes and they said we're going to
do three things different with our primary care clinics.
Everybody can email their doc.
You can have online access to your medical records and you can have --
get into care to see a doc or nurse practitioner same day, next day.
And as you can imagine, this increased patient satisfaction but
we also saw provider burnout and we saw decline in quality scores,
which makes perfect sense because if you look at those three bullets,
everybody was being asked to do more in the provider,
but they weren't adding any more services.
So they got really nervous about the provider burnout and the quality
score decreases and so they tried an experiment on the East Side in Seattle
in one of the clinics where there were ninety-two hundred adult patients.
They decided not to experiment on the kids and what they did was they
said we're going to implement some medical home idea closer to fidelity
so if you think about what Chuck was talking about with those principles,
there were two key interventions that they made.
They added substantially more staff.
If you look at the numbers on the screen,
you can see lots more docs, lots more nurse practitioners, etc.
And they shifted -- they've (inaudible) their appointment
schedules for all the docs and nurse practitioners.
They basically said everybody has a default of thirty minutes.
And Chuck's seven-minute example is what I experienced in healthcare and
so this is a radical departure from what Group Health is trying.
What they did was they -- by adding more staff and increasing the time
the doc had with those patients, they lowered what's called the panel size
so given doc or nurse practitioner had fewer patients that
they needed to manage.
And their hypothesis was maybe in a few years they could break even
because think about how much more money they're spending by making
these 2007 changes.
Group Health has a very good research arm.
At the end of the year, they realized -- they were measuring this
as they went along.
The quality scores went back up.
They indeed reduced burnout but what sort of blew everybody away around
the country is that they broke even in the first year.
For every extra dollar that they spent on primary care,
they saved a dollar on inpatient.
This was really beyond their dreams.
And in 2008, they continued the pilot at this clinic and what they
found in 2008 was that for every extra dollar they spent in primary care,
they saved four dollars on inpatient.
And this was for an organization that prides itself on good primary care,
good prevention and early intervention.
It just showed how much further they had to go to helping do what Chuck
had described earlier as moving further upstream with prevention,
early intervention and helping folks better manage the
chronic health conditions.
I was talking to a colleague who didn't know about this research.
In 2009, Group Health said we're going to this system-wide.
All of our clinics are going to move their and the colleague of mine had
just been to the doctor the week before and he had had a forty-five
minute visit with his doc and the doc just kept asking him questions
and he was like -- felt a little bit nervous like maybe he should be
leaving the room.
And they went through five different programs -- I'm sorry.
Five different conditions and came up with treatment plans for how to
deal with all five conditions.
It was a totally life changing experience for him in terms of his
interactions with the healthcare system.
So what we know is that if you do healthcare homes right,
there is -- the data is starting to come out of the woodwork that you
can actually improve quality and save a ton of money.
Why don't we go to the next slide?
The patient centered primary care collaborative which Chuck was
talking about that put together those principles that we saw on a
few slides ago has been a leader in this work.
And Paul Grundy who is one of the board members is a doc who works for IBM
and he's been talking about health care homes and why they're important
and there's a couple of factoids that I want to plant in your brains.
Denmark has been working on this for much longer than we have and
as you see from the slide, there's been a radical change in how healthcare
is delivered and what happens when you do good primary care.
You can see that the number of hospitals have dropped from a hundred
and fifty-five to twenty-one in the country over the last couple of decades
because of the work that they've been doing with healthcare homes.
I look at this number and I almost fall over and faint but I --
it really supports the idea that if you actually help people manage --
keep their -- manage the care so that their health conditions don't become
chronic health conditions.
And for those of us do get chronic health conditions,
if you become a hospital prevention organization really helping people
manage those chronic health conditions,
you can make a major difference in the number of surgeries,
the number of specialty procedures that need to be performed,
the number of emergency room visits.
It really has the potential of being a radical change in
the healthcare system.
Chuck, if you push the next button, we'll see the other part of this.
The Geisinger System in Pennsylvania has also been working on healthcare homes.
They're one of the leaders like Group Health,
around the country and what they've found is that -- as you can see,
they've been able to achieve reductions in emergency room
utilization, reductions in hospitalizations and a rather
dramatic reduction in re-hospitalizations.
What we know is that if you have Medicare in this country and you go
into the hospital and you get discharged,
eighteen percent of you are going to be readmitted within thirty days
because the handoffs aren't working because of the fragmentation and
lack of coordination, which takes us to our next slide.
Now all this stuff is not going to magically happen and
I'm a CPA by training.
It's very clear to me that the payment reform if you think about
the four boxes that Chuck was talking about is very critical to
helping change the incentives in the system so that we fund healthcare
homes and we change the incentives so that we actually -- what we're
trying to do here is move from having what I would describe as a
sick care system in this country where you basically don't -- once
you get sick, there's lots of care available if you have insurance to a
healthcare system where we are incentivizing the provision of
prevention, early intervention and the management of chronic health
conditions and behavioral health disorders.
There's payment reform going on all around the country in medical homes.
And I believe that fee for service is headed towards extinction.
That removing what's called from paying for volume to a
healthcare system where we're paying for value.
There's the three layer funding design that's unfolding that you
should plant away if you're a behavioral health provider because
I'm expecting that these kinds of models are going to come to a
community behavioral health center near you relatively soon as this
gets further tested in the medical homes.
And what we're seeing is that there is a case rate that's being paid for
nurse care managers or behavioral health specialists or nutritionists
to do prevention, early intervention, care management for chronic
health conditions and behavioral health disorders in primary care.
We're seeing that some of these early models like in Maine are
continuing to use fee for service for the doc and nurse practitioner
services but they're paying a higher rate and the most what I call
radical payment reform is a bonus layer that's being added.
So that's -- what we're talking about in healthcare is twenty to
thirty percent of practice incomes come in from bonuses in medical
homes if the medical homes do a good job getting their quality scores and
managing the total health expenditures of their patients.
Basically, the idea is to do sharing the savings.
It costs so little really to provide good primary care compared to what
it costs for the kind of hospitalizations and all the other
complications related to chronic health conditions that don't get
managed and folks end up in the hospital.
Let's move on to the next slide.
Many of you have probably heard this term accountable care organization.
They're a critical piece of the puzzle.
The reasons why Group Health was able to --
Bob: Dale, could you -- would mind -- this is Bob (Inaudible).
Would you speak directly into the phone?
We've got a few people who say the sound is wavering a little bit.
Dale: Yes, thank you.
Bob: Okay. Thank you, Dale.
Dale: Please holler if there are any problems.
Accountable care organizations are the other part of integrated health systems.
Integrated health systems like Group Health and Kaiser and Intermountain
Healthcare and Geisinger basically are both an insurance company and a
delivery system so the payer pays a pot of money,
a capitated payment to the health plan and then that integrated health
system provides and organizes all the care.
Well, that's only ten percent of the population in this country so the
question that folks have been asking for several years is what do we do
about the other ninety percent of folks that aren't in these
integrated health systems where the incentives are lined up.
And this idea of accountable care organization which I would call an
integrated health system (light) is a model that is unfolding as an
organizational structure to support the coordination of care that Chuck
was talking about and the payments among healthcare homes,
specialists and hospitals so that we're moving towards achieving
better coordination of care, better incentives,
prevention, early intervention, a lot more money spent on primary care
and I predict then, behavioral health.
And it's also a way for the small to mid-size primary care practices to
obtain the infrastructure that's going to be necessary to work inside
this healthcare home world.
So it's really interesting as we see by the next slide that's coming up,
I'm seeing that in predicting that medical homes are going to become,
if you will, the center of the healthcare universe.
This model shows that a health plan will make a payment to this thing
called the accountable care organization,
that the provider owned entity -- it's owned by the docs and the
specialists and the hospitals and when I say specialists,
I'm thinking about cardiologists and I'm thinking about behavioral health
clinicians and behavioral provider organizations and being part of the
accountable care organization where they are working together to
coordinate care for the patients, to reduce duplication,
to reduce medical errors.
For these organizations, working together to become hospital
prevention organizations and if we think about what happened in Denmark
where there was a fairly major drop in the number of hospitals in the
country, it's really about if you have a healthcare system rather than
a sick care system.
You have to have an organizational structure that's the framework
for getting all of these provider organizations and individual
providers working together within a common IT system,
a common set of performance measures, etc.
Let's go on to the next slide.
So these are some of the ideas that are being kicked around around
service delivery, design and payment reform.
People say that there is about seven hundred billion dollars a year that
is spent that is waste, that's duplication,
that's treating people after they fall off the cliff as opposed to
putting fences up at the top.
The question is will the current Healthcare Reform Law and the
accompanying payment reform and delivery system tools really be
enough to make a difference before we go bankrupt.
Our prediction which is not in the last -- here is where I sort of go
out on a limb saying it's not going to work unless the healthcare system
addresses the needs of individuals with mental health and co-occurring
disorders which takes us on to chapter two in the next slide.
If you remember -- the question is how will the answer to this first question
-- let's pretend that these healthcare homes and accountable
care organizations and new service delivery designs really work
generally in healthcare, will they work for folks with behavioral
health disorders and will organizations that serve folks with
behavioral health disorders fit into this new healthcare eco-system.
Next side, please.
Remember the slide about the alignment of the stars?
I think that there is a lot happening and let's go on to the next slide.
I've been following the Accountable Care Act and one of the questions
that I've been contemplating is did the authors of the Act understand
these issues, the needs of folks with behavioral health.
And I would say that the short answer is yes and I'd also say that
I think that President Obama basically pulled together a dream team
around healthcare reform.
If you think about Don (Berwick) as the head of CMS,
if you think about Richard (Crank) (inaudible) in an important position
and (Aspey) the planning and evaluation arm of HHS and he being a
medical economist from Harvard who specializes in mental health medical
economics and Pam Hyatt is the head of SAMHSA.
I mean truly this is what I consider the dream team.
Also, what we see is there are over a hundred funding opportunities,
pilot projects and demonstration projects that are in the
Accountable Care Act.
I've got a few on the screen.
Parity is embedded, is required in healthcare reform.
There is (inaudible) national prevention,
on the next slide, the National Prevention Council that's appointed
to really think about moving further upstream,
workforce expansion, names, behavioral healthcare workers as
high priority in the bills, workforce strategy and addiction and
mental health providers are eligible for community health team grants.
These are just a few.
I've counted no less than two dozen items in the Healthcare Reform bill
that allows behavioral health -- the behavioral health system to be
included in healthcare reform not excluded.
Moving onto the next slide, I want to think about what are the
implications of these changes for mental health and substance use and
co-occurring disorder provider organizations.
And I think that there are two critical ones that behavioral health
providers -- I'll use that term so that I -- as a shortcut -- need to
get involved in healthcare homes and we're going to talk about
what that looks like.
And secondly, they need to be close -- much more closely linked to the
rest of the healthcare system and seen as high performing specialists
that can support the management of total healthcare expenditures and as
it says on the side, minimize the defect rate.
What we're talking about is if we have a very large number of folks in
this country with behavioral health disorders and those folks as we saw
from the California slides cross so much not because their behavioral
health conditions but their healthcare conditions.
I think it's absolutely essential that behavioral health clinicians be
deeply embedded in the DNA of the healthcare delivery system to help
folks with behavioral health disorders,
be able to help better manage their health conditions,
have access to early intervention and prevention services so that we
can bring down the cost because of their unmanaged health conditions.
So let's go on and talk a little bit about the healthcare home.
There's a couple of slides here I want to cover and explain.
A number of you may have seen or heard about the four quadrant
clinical model of integration that talks about folks with low to
moderate physical health risks and complexity and low to moderate
mental health and substance use disorder risk and complexity.
And what this model postulates is that folks with low to moderate
behavioral health disorders ought to get their care and primary --
their behavioral health services in primary care and folks with serious and
severe behavioral health disorders generally ought to get their primary
care services in behavioral health or at least that's an option.
But as I'm looking at this slide, I'm going oh, my gosh.
The print is too small so let's look at the next couple of slides.
So quadrant one are folks with low behavioral health and low
physical health disorders.
Those folks generally -- what we're seeing in the models around the
country -- John was talking about the number of integration projects
that was mentioned that are going on as everybody should have a primary
care provider in a medical home.
There should be a behavioral health clinician working in that primary
care clinic and there should be a psychiatric -- psychiatrist or a
psychiatric nurse practitioner supporting the team of the primary
care provider and the behavioral clinician in the mental health
center helping folks who have mild to moderate behavioral health
disorders, wellness programming and other interventions.
For folks that have low to moderate behavioral health disorders but
chronic health conditions like diabetes or hypertension,
you add more medical specialists so that you support their health conditions
in the primary care clinic.
Moving on to the next slide.
For the folks that have more serious and severe behavioral health
disorders, what's being tested now in the SAMHSA grants are a very
critical piece of this is embedding medical clinics in behavioral health center.
My neighborhood mental health center,
(Navos), here in Seattle has a medical clinic embedded as do a
number of other behavioral health centers around the Northwest.
And there's -- they're working on developing a clinical model based in
this case, on the impact model which uses a particular design working with
tracking health conditions in the behavioral health clinic, providing
residential treatment if necessary, really trying to help folks
manage both their health and behavioral health conditions
in a setting that's comfortable and preferred by consumers who choose
to get their medical care in their mental health center.
And folks that have both behavioral health conditions and serious
physical health conditions, they also need to ramp up the medical
care so that folks have a really robust set of behavioral health and
medical care for quadrant four folks.
Moving on to the next slide.
What we're talking about -- what I'm really describing
is illustrated by this picture here.
It's called bi-directional care.
The left hand box basically says generally speaking we need to have
folks with low to moderate behavioral health disorders getting
their primary care -- their behavioral health and the primary
care in their primary care clinic or medical home.
And adults with moderate to high behavioral health risk and
complexity having the choice of going to an embedded primary care clinic
inside their mental health center or their substance use provider organization.
On to the next slide, thank you.
Folks in California have spent a great deal of time figuring out the
who, how many, what and where and -- so they've been thinking about how
many people that live in California that are members of the safety net
population fit in to the mild, moderate, serious and severe
categories in term of the risk and complexity and need.
And they've also been saying well, okay.
Let's think about mental health and primary care,
substance use and primary care, behavioral health services having
medical clinics embedded.
And what' they've concluded is that folks with mild behavioral disorders
generally ought to get their behavioral health care in primary care.
Folks with serious disorders often have their medical care in
behavioral health and folks who are in between,
if you will, in terms of the risk and complexity that they have at a
given point in time, is a local decision.
The community mental health center, the community substance use provider
needs to be working with the local primary care practice whether it's
an FQHC or a private practice to work together to say what's the best
way to do bi-directional care based on the skills and abilities of the
folks in our respective clinic.
So this stuff is being worked out.
All healthcare is local.
This stuff is being worked out state by state,
community by community.
Next slide, please.
And I've been thinking a lot about accountable care organizations for
persons with co-occurring disorders is a sort of quicker way to
(inaudible) folks with mental health substance use (blowing) it but if
you think about folks with co-occurring disorders,
it helps me wrap my brain around this easier.
Good medical care alone isn't the answer.
We need to expand the available services in medical homes so that we
have a focus on not just behavioral health but housing,
social and personal supports needed to achieve and maintain health.
So this picture envisions an accountable care organization with
specialty clinics including behavioral health clinics as members
of the accountable care organizations,
are working very closely with the person centered healthcare homes and
connected, in many ways, with social service agencies,
schools, childcare and a whole host of other systems that I would
describe as the safety net system.
That it's not just about medical care and what we're really pushing
is a safety net healthcare system that takes into account all of these
pieces of the puzzle that are needed to support folks with
behavioral health disorders.
Next slide, please.
I'd like to leave you with the question so -- we've --
our time has been short.
We've raced through a number of the concepts but the question I'm
continuing to ruminate on will all these great ideas really work?
And I guess I have to say the short answer is we don't know but the
longer answer is we have a once in a generation opportunity to reform the
healthcare system and to make sure that folks with mental health
and substance use disorders aren't left out.
We have the knowledge, the technology to move from what I, again,
call a secure system to a healthcare system and include persons
with mental health and substance use and co-occurring disorders.
But I believe that the general healthcare system,
the folks that work there generally don't understand the complexities or
the population that we're talking about today.
It's going to take strong advocacy, a lot of education on the part of consumers
and advocates to make sure that we're included in healthcare reform.
And it's also going to take a lot of hard work by provider organizations
to prepare for what I think is the brave new world.
I think the Pandora's box is opened.
Healthcare reform is happening.
The Accountable Care Act is an accelerant.
It's not mission -- healthcare reform will -- would have occurred
without the Accountable Care Act but the Accountable Care Act makes
a huge difference in terms of helping move this forward.
So with those comments, I'd like to turn it back to the organizers
for questions and answers.
Rebecca: At this time, we'll take questions from the audience.
You can recall that you can submit a question using the questions pane on
the control panel of your screen.
Just type your question in the box and send it to the organizer.
Our first question is about the mental health and substance use
coverage changes under healthcare reform.
Chuck: So the -- as both I and Dale mentioned that in both the expansion
of Medicaid as well as in the private health insurance that will
be offered through the exchanges, the legislation is very clear that
in both instances, both services for mental health conditions as well as
substance use disorders must be offered and that the Mental Health
Parity and Addiction Equity Act standards need to be applied.
Now the question is going to be how does that actually translate that into
-- through the regulatory and/or guidance process that will unfold?
So the first thing that is going to have to happen is the Department of
Health and Human Services will be creating regulations related to then
what's (going to) be essential health benefits.
So what we'll be monitoring then is any opportunity to provide comment
about the scope of those benefits offered by health plans
participating in the exchange.
And secondarily, also looking for regulatory or guidance --
regulations or guidance coming from the centers for Medicare and
Medicaid services regarding the Medicaid expansion and the benefit
that has to be offered there.
I would note, however, I think that work in this area has already begun by SAMHSA.
SAMHSA recently released a paper in which they expound on what is a good
and modern mental health and addiction system.
And then, it contains within it a chart of the kinds of services from
prevention -- starting off at prevention and going all the way to
inpatient of the kinds of services that a good system would have to
adequately treat substance use conditions as well as mental illnesses.
So then I think that SAMHSA has put us in a good position then with
other federal agencies as we go down this road.
So the short answer is we're not sure exactly what it will look like.
We know that it is mandated and we'll have opportunities to provide
comment to shape that into the future.
Rebecca: Our next question is for Dale.
Dale, could you please provide a little bit of clarification on how
the pay for performance or bonus payment system will work for
individuals with co-occurring, chronic disorders like serious and
persistent mental illness or substance use disorders?
Dale: Yes. I think that what's going to happen is we're going to see some
of these pay for performance models roll out first in general healthcare
especially in medical homes and hospitals that are already under way.
And for me, the key question is how do we in the behavioral health
community use that same model so we're not creating a completely
different model to support the needs of folks with behavioral health
disorders especially folks that have serious disorders and I think that
there is two things that are going to happen.
One is because there is such a high -- there are so many folks with
serious mental illness and substance use disorders that have chronic
health conditions, the performance measures and bonuses related to
helping folks manage their chronic health conditions will apply to
those folks as well.
And what's really clear to me is that if somebody has let's just say
major depression and diabetes, there's no way that a healthcare
provider who is at risk -- their bonus is at risk,
is going to be able to ignore a person's major depression as they
try and earn the bonus off their diabetes treatment.
So it's really kind of cool because primary care providers are basically
going to have to do a much better job helping folks manage their major
depression because there is no way they are going to be able to manage
the diabetes -- help them manage their diabetes otherwise.
So we're going to see a sort of a naturalistic unfolding of folks
getting a lot better coordinated care,
a lot better attention to their behavioral health disorders in order
for primary care docs, if you will, earn their bonuses.
The second thing we need to do is start designing the performance
measures and the pay for performance models in behavioral health so that
we basically mirror that.
I think it's very important to think about what it means for folks to be
able to get their lives back who have serious mental illness and
serious substance use disorders.
How we measure that, how we put in place systems to track -- for me,
it's all about if we can help people get their lives back,
that's where the bonuses come in and we can help people manage who have
serious conditions.
We have (inaudible) conditions managed their health disorders
without helping them move towards recovery and wellness.
So we have to do both pieces, figuring out the measures on the
behavioral health side get embedded in the healthcare piece.
Rebecca: Thank you, Dale. Our next question is for Chuck and Dale.
We have a few folks on the line who are asking about collaborations
between behavioral health centers and primary care providers.
Do we have any good resources on how these collaborations can best be
structured and what would your advice be to organizations seeking to have
a more collaborative relationship with their primary care provider?
Chuck: Dale, do you want to take a crack at it first?
Dale: Sure.
What's really fascinating to me is my partner,
Barbara (Mauer) started working on thinking about primary care
behavioral health integration eight years and at that time,
there were just a few places around the country that we could look to:
Cherokee in Tennessee and the Washtenaw County Health System in
Ann Arbor, Michigan to sort of figure out what's going on and how
folks are working together.
Today, if you go to Colorado, they actually have a website that has a
Google map of the state and there's over a hundred collaboration
projects between the behavioral health providers and folks in the
healthcare system.
The thing that we need to do is to -- I think do a better job getting
information out into the field about who to actually talk to to have
person to person conversations about how you're doing it.
There's also a number of things on the Web,
the Council's website that talks about the different collaboration pilots
that they have been running and information that's written on that.
I think it's both about reading about how this is being done and
talking to folks that are actually doing it.
John: And this is John. I don't want to interrupt you.
I think that's a really important point and I want to say that
SAMHSA through the National Technical Assistance Center on
primary care behavioral health integration will (offer) those once
we get that off the ground.
Dale: Thanks, John.
Chuck: The -- I think -- Dale, I think your answer is right on.
And I know that for many organizations it's daunting to try
to make those connections.
I think it's really valuable to focus on what are our areas of common interest.
You're -- typically, community health centers are safety net providers.
Behavioral health organizations are safety net providers in their own right.
Can you identify common patients and work on protocols about
where people will be served?
In one of our collaboration projects,
a community mental health center had an obscene waiting list for
individuals to see their psychiatrist and in collaboration
with their health (inaudible) identified that a large majority of
those people were already being seen at the health center and they were
able to -- by providing psychiatric consultation to the primary care
docs, get people into access much more quickly.
So I think, try to think about it in very practical terms.
What are things that you can bring to the table that would be of help
to your primary care -- local primary care organization and
vice versa what are some of the practical things that you need
that they might be able to provide.
I think it's always helpful to have something concrete as you look
to have those conversations.
Rebecca: Our next question is for Chuck.
We know that having access to health information technology and
electronic health records is an important part of integration.
In the Economic Stimulus Act, there were incentive payments enacted for
the adoption of electronic health records.
Our question is how is this going to be applied to behavioral health centers?
Chuck: So the High Tech Act basically creates Medicare and
Medicaid incentive payments to particular -- in two ways to
particular types of facilities, at this point limited to certain types
of hospitals and then to certain types of eligible professionals.
And the eligible professional payment is agnostic about the place
of employment of that eligible professional.
So that right now, if you were a physician or a nurse practitioner
and you meet the meaningful use criteria, you are eligible
for the Medicaid incentive -- Medicaid or Medicare incentive payment
and then you can turn that payment over to your employer.
So behavioral healthcare organizations that have doctors or
nurses on staff will still be eligible to get the payment that way.
And for the Medicaid incentive payment over a course of four years
per eligible professional, it's $63,750.
There are efforts under way in Congress to expand that.
I'll just mention that there are two bills.
HR5040 in the House of Representatives introduced
cooperatively by Patrick Kennedy and Tim Murphy now has seventy-eight
co-sponsors in the House of Representatives.
And then there is the Senate Companion bill,
Senate 3709 that was introduced by Senator Sheldon Whitehouse of Rhode
Island and it currently has seven co-sponsors.
That legislation would expand the types of organizations that are eligible
for facility payments to better reflect mental health and
substance use treatment organizations as well increase the types of eligible
professionals that would be available to receive incentive payments.
Rebecca: Our next question is for Chuck and Dale.
As healthcare reform rolls out over the coming years, what are the next
developments and the next steps that we need to be aware of?
Chuck: Well, I think already this year,
we've see HHS release a number of regulations.
There are a bunch of provisions of the affordable care act that actually go
into effect this week related to the oversight private health insurance.
The next wave then, there are a number of provisions that come
online over the next few years and into next year.
The National Council on our website, on our blog...
Rebecca: On our blog, we're keeping track of all the federal regulations
that are being issued in regards to healthcare reform.
So if you visit our blog,
and search for federal regulations, you'll be able to find a
comprehensive list not only of the regulations and what they mean for
behavioral healthcare providers but also of the National Council's comments.
Chuck: And what we'll try to do is keep people apprised as regulations come out
and then, if time allows, we'll also share draft comments for your feedback.
So I think John, at the beginning at the top of the Webinar mentioned a
particular section 2703, which creates a new health home state plan option.
That goes live January 1 so we would expect guidance from CMS
sometime before then.
Obviously, then, we'll be looking for regulations that come out
related to the essential health benefits, the Medicaid expansion.
There are a number of areas where there will be guidance forthcoming
as well as additional grant opportunities,
which will be coming online.
So check out our -- the blog and the White House also has a really good
health reform website where all of this is posted.
Rebecca: Unfortunately, I think we're out of time for more questions
at this point.
We want to thank everyone in our audience again for your time and interest
in healthcare reform and its implications for behavioral health providers.
We'd like to thank Charlene (LaFove),
(Najay Saleem), Deborah (Stone) and John O'Brien from SAMHSA once again
for sponsoring this Webinar.
And of course, to our presenters, Chuck Ingoglia and Dale Jarvis for
their valuable contributions today.
As we mentioned earlier, the Webinar will be archived on the
National Council website.
You can see the link there on your screen:
And it will also be archived on the CODI website which is currently
under development at
All participants on the Webinar today are going to receive a
follow-up email with a link to an evaluation form.
We very much appreciate everyone's feedback and will be using it in our
development of future Webinars.
Thank you again and this concludes our call for today.