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2 CHALLENGES & OPPORTUNITIES IN A CHANGING HEALTH CARE ENVIRONMENT Pamela S. Hyde, J.D. SAMHSA Administrator NASMHPD Washington, DC July 16, 2012

3 TODAY’S DISCUSSION SAMHSA’S BUDGET HEALTH REFORM DISASTER/EMERGENCY RESPONSE

4 SAMHSA’S OVERALL BUDGET – TRENDS AND POSSIBILITIES Total Program Level Includes: Budget Authority, PHS Evaluation Funds, and ACA Prevention Funds. FY2012 Enacted amount incorporates the 0.189% recession. *FY2013 also includes $1.5 M estimated for user fees for Extraordinary Data and Publication Requests.  ACA  PHS  BA

5 FY 2013 LIKELY SCENARIOS  President’s Budget, Senate Committee Mark, and House Mark (7/18/12) All signal positions, not decisions  CR(s) Likely How long and how much depends... Likely equal to or less than FY 2012  Sequester Jan 2013 = ~ 7.8 percent ↓ from FY12 Applied to FY 2013 (enacted or CR) Executive’s/OMB’s role

6 FY 2013 BUDGET ISSUES  Prevention  Block Grants  Disaster Distress Hotline  Grants for Adult Trauma Screening and Brief Intervention (GATSBI)  PHS Evaluation/HHS Taps  SAMHSA’s 4 Appropriations & Central Cost Budget (CCB)

7 FY 2014 CHALLENGES  Flat From or 5 Percent ↓ From President’s FY 2013  Enacted FY 2013 or FY 2013 CR(s) = Different Base  Impact of Health Reform on Individual Line Items

8 SAMHSA’S FY 2014 PRINCIPLES (IF POSSIBLE...)  Continue holistic approach through joint funding  Build off innovations from previous funding cycles  Maintain support for Strategic Initiatives; target available funding for top priorities  Avoid terminations and reducing continuation awards  Maintain ratio of SA and MH funding (~ 70/30)  Maintain approximate ratio of block grant to discretionary funding (~ 65/35)

9 HEALTH REFORM

10 SAMHSA’S HEALTH REFORM PRIORITIES – FY 2012 AND FY 2013  Uniform Block Grant Application FYs In Fed Reg for 60-day public comment as of  Enrollment – Preparation  Essential Benefits and Qualified Health Plans  Provider Capacity Development  Workforce  Continuing Work with Medicaid Health homes, rules/regs, service definitions and evidence, screening, prevention, duals, PBHCI Parity – MHPAEA/ACA Implementation & Communication  Quality and Data (including HIT)

– 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** M (29%) – Have BH condition(s) * Source: 2010 NSDUH ** Eligible for premium tax credits and not eligible for Medicaid

12 PREVALENCE OF BH CONDITIONS AMONG MEDICAID EXPANSION POP CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

13 PREVALENCE OF BH CONDITIONS AMONG EXCHANGE POPULATION CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

14 FOCUS: ENROLLMENT  Consumer Enrollment Assistance (in 8 states) Outreach/public education Enrollment/re-determination assistance Plan comparison and selection Grievance procedures Eligibility/enrollment communication materials  Enrollment Assistance Best Practices TA and Toolkits  Communication Strategy – Message Testing, Outreach to Stakeholder Groups, Webinars/Training Opportunities  SOAR Changes to Address New Environment  Data Work with ASPE and CMS

15 ESSENTIAL HEALTH BENEFITS (EHB) 10 BENEFIT CATEGORIES 1.Ambulatory patient services 2.Emergency services 3.Hospitalization 4.Maternity and newborn care 5.Mental health and substance use disorder services, including behavioral health treatment 6.Prescription drugs 7.Rehabilitative and habilitative services and devices 8.Laboratory services 9.Preventive and wellness services and chronic disease management 10.Pediatric services, including oral and vision care

16 EHB BENCHMARK APPROACH  Serves as Reference Plan Reflecting scope of services and limits offered by a “typical employer plan” in that state  States Allowed to Select a Single Benchmark Plan: 1 of 3 largest small group market plans (default), or 1 of 3 largest state employee plans, or 1 of 3 largest federal employee plans, or Largest HMO plan in a state  EHB Mini Rule – Thru 9/30/12 Critical

17 FOCUS: BENCHMARK PLANS  If State Does Not Select, Default To Largest Plan By Enrollment In Largest Product in Small Group Market  Must Include All 10 Benefit Categories Regardless What Selected Benchmark Plan Covers or Excludes Supplement from other plans if category not sufficiently covered Substitution within categories  Parity Applies in Individual, Small & Large Group Markets Both MHPAEA and ACA parity requirements Parity work within HHS and with DOL and Treasury

18 BENCHMARK AND EHB REVIEW  HHS Will Assess Benchmark Process for 2016 State choices in 2012 will remain for two years (2014 & 2015)  Periodically Review and Update EHBs Difficulties with access due to coverage or cost Changes in medical evidence or scientific advancement Market changes Coverage affordability  SAMHA’s Good and Modern Service Definitions & Assessing the Evidence Process Will Inform

19 QUALIFIED HEALTH PLANS – NETWORK ADEQUACY  Qualified Health Plans (QHPs) Offered through affordable health exchanges (marketplaces) State choice to set up exchange or use federally facilitated exchange (FFE)  QHPs’ Networks – Providers Sufficient In Number/Types To Assure Services Accessible w/o Unreasonable Delay Encourages QHPs to provide sufficient access to broad range of MH/SUD services, particularly in low-income & underserved communities Highlights MH/SUD providers – must be sufficient providers available to deliver!

20 PROVIDERS ACCEPTING HEALTH INSURANCE PAYMENTS *  Inpatient – 95 percent  Outpatient – 68 percent Primary MH plus some SA – 85 percent Primary SA (w/ none or some MH) – 56 percent Residential SA – 54 percent Other (e.g., Homeless Shelters, Social Services Agencies) – 37 percent *Source: NSATSS

21 SOURCE OF FUNDS FOR CMHCS *  State/County Indigent Funds – 43 percent  Medicaid – 37 percent  Private health insurance – 6 percent  Self-pay – 6 percent *Source: 2011 National Council Survey

22 FOCUS: PROVIDER READINESS  SAMHSA Provider Training/TA Topics for FY 2013 Business strategy under health reform Third-party contract negotiation – provider network skills Third-party billing and compliance Eligibility determinations and enrollment assistance HIT adoption to meaningful use standards Targeting high-risk providers  Provider Infrastructure (“Biz Ops”) Contract Proposals in review; selected before end of FY 2012 Training and technical assistance Learning collaboratives

23 WORKFORCE CHALLENGES  Worker shortages and distribution  More than one-half of BH workforce is over age 50  Between 70 to 90 percent of BH workforce is white  Inadequately and inconsistently trained workers  Education/training programs not reflecting current research base  Billing involves increasing licensing & credentialing requirements  High levels of turnover  Difficulties recruiting people to field – esp., from minority communities  Inadequate compensation  Poorly defined career pathways

24 SAMHSA WORKFORCE ACTIVITIES  Plans and Reports To Congress – in Process  Training/TA – Technology Transfer & Evidence-Based Practices ATTCs, SBIRT Medical Residency Training, TA Centers, Webinars, Mtgs  Resources – Written and Electronic Publications, TIPS, TAPS, Websites, Facebook, Texting, Archived Webinars  Learning Collaboratives National Network to Eliminate Disparities in BH (NNED)  Minority Fellowship Program

25 HRSA BH WORKFORCE ACTIVITIES  Community Health Centers (CHCs) 2/3 Provide MH and 1/3 Provide SA Services (SBIRT encouraged through training and data reporting)  National Health Service Corps 2,426 BH Providers (May 2012) Up from 5 in 1995  Graduate Psychology Educ Prog 710 trainees in ; ½ in underserved areas  Mental and BH Education and Training Grants – FOA 280 Psychologists and Social Workers

26 HRSA/SAMHSA EFFORTS  June 5 Listening Session re BH Workforce Data – National Database thru HRSA National Center for Workforce Analysis Capacity – National Health Service Corps; minority internships; same day billing analysis w/ Medicare; credentialing issues; DOL SBIRT training Training – e.g., military culture for health/BH providers w/ AHECs; integrated care thru joint TA Center (CIHS) Non-Traditional Workforce – e.g., peers, recovery coaches Partnerships – e.g., professional orgs, peer/recovery/family orgs, community colleges

27 DISASTER/EMERGENCY PREPAREDNESS AND RESPONSE

28 FEMA ISSUES IN PROCESS  ISP Grant Period Extension Historical analysis of past ISP extensions in progress Possible regulatory change needed  Use of Existing BH Professionals – Pay SAMHSA & FEMA working together to determine feasibility  Streamlined and/or Preapproved Applications SAMHSA & FEMA working together to determine what can be pre-populated FEMA will continue to offer training for states at EMI  Indirect Costs for CCP Regulation change needed – in process

29 FEMA TRAINING  July 16 – 19, 2012  Emmitsburg, MD  22 State Representatives  FEMA Offer to Meet with NASMHPD Reps