1 BEHAVIORAL HEALTH 2010 CHALLENGES AND OPPORTUNITIES ACMHA: The College for Behavioral Health Leadership March 24, 2010 Pamela S. Hyde, J.D., Administrator, Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services

2 Today It’s About….   PEOPLE ● ● Making a real & measurable difference   OPPORTUNITIES ● ● Focusing on what can be done ● ● Working with available partners

3   People ● ● Stay focused on the goal   Partnership ● ● Cannot do it alone   Performance ● ● Make a measurable difference   Parity ● ● Mental and substance use disorders are not unlike any other health care condition – acute, chronic or disablingPRINCIPLES

4  Behavioral health is an essential part of health ● Improves health status ● Lowers costs for families, businesses and governments  Prevention works  Treatment is effective  People recover KEY MESSAGES

55 Key Message: Behavioral Health is Part of Health   People with serious mental illness (SMI) are disproportionately overweight or obese & have shortened life-spans   Disproportionate cigarette use by individuals with mental illness (MI) or substance use disorder (SUD)   ¼ of adult stays in community hospitals involve MI or SUDs; persons with SUDs have disproportionately high ER use   High proportion of antidepressants prescribed in health care settings   Mood disorders rank 1st in work loss costs, 2nd in total costs & 3rd in health care costs of five highest conditions

6 KEY MESSAGE: Prevention Works  Cost-benefit ratios for early treatment & prevention for addictions and mental illness programs range from 1:2 to 1:10  Substance abuse prevention programs show: ● Decrease in alcohol, tobacco and other drug use (ATOD) ● Significant percentage of students using ATOD stopped using  School prevention programs show reductions in bullying, fighting, verbal abuse, alcohol and cigarette use, and feeling unsafe at school  Preventive intervention for adolescents can reduce the incidence of depressive disorders

7 Institute of Medicine Report: Preventing Mental, Emotional and Behavioral Disorders Among Young People – Progress and Possibilities (2009)  Positive emotional development, earlier identification & intervention, multiple interventions sustained over time can prevent disorders such as substance abuse, conduct disorders, and depression, and reduce symptoms of mental illnesses  Addressing families, individuals & specific disorders through schools, health care and community programs can develop emotionally healthy adults  Prevention requires attention to multiple risk factors ● Biological (family history) ● Psychosocial (family disruptions) ● Social (poverty, violence, safety in schools, access to health care)

88 KEY MESSAGE: Treatment is Effective   $1 invested in substance abuse treatment has a return of $7 in cost savings from social benefits   Treating late-life depression in primary care settings – reduced prevalence and severity of symptoms or complete remission   Long-term treatment of adolescents with major depression is associated with continuous and persistent improvement of symptoms   Federally funded substance abuse treatment programs improved physical and mental health and reduced: ● ● Illicit drug use ● ● Alcohol/drug related medical visits ● ● Inpatient mental health visits ● ● Reduced criminal activity   SBIRT – 50% increase in abstinence at 6-month post intake   RAISE research on-going now to address symptom severity and episode recurrence after first psychotic break in adolescents

99 Key Message: People Recover   Early treatment reduces disability/recurrences   Recovering people work, pay taxes, have homes and relationships, volunteer, contribute, vote   Recovery rates w/ treatment and/or medication: ● ● Bipolar disorder 80% ● ● Major depression 65-80% ● ● Schizophrenia 60% ● ● Addiction 70%   Pathways are highly personal Focus on lives restored rather than lives managed or services provided   Self-help and peer supports help the recovery process

10   MISSION: To reduce the impact of substance abuse and mental illness on America’s communities   ROLES: ● ● Voice & Leadership ● ● Funding ● ● Information ● ● Standard Setting/Guidance ● ● Practice Improvement   10 STRATEGIC INITIATIVES SAMHSA’S DIRECTION

11 10 Strategic Initiatives 1.Prevention of Substance Abuse and Mental Illness 2.Violence and Trauma 3.Military Families – Active, Guard, Reserve, and Veteran 4.Health Insurance Reform Implementation 5.Housing and Homelessness 6.Jobs and Economy 7. Health Information Technology for Behavioral Health Providers 8.Behavioral Health Workforce – In Primary and Specialty Care Settings 9.Data and Outcomes – Demonstrating Results 10. Public Awareness and Support

12 Impact of Strategic Initiatives 1.Requests for Applications (RFAs) beginning in FY2010 – block grants and grant programs 2.Public messages; communications; materials 3.Budget requests – FY2012 forward 4.Current fiscal resources – FY2010 and FY Human resources – staff time 6.Contracts & technical assistance centers 7.Public forums; meeting time

13 Strategic Initiatives Next Steps 1.Draft narrative sometime in April or early May for public review/input (including posting on website) 2.Public meeting in DC to discuss with key stakeholders 3.SAMHSA’s National Advisory Council (NAC) meeting in May 4.FY2012 budget planning continues in summer Revise and finalize strategic initiatives document/strategic plan – summer or fall Incorporation of initiatives into SAMHSA’s work – now and on- going NOTE: Dates are tentative.

14 No. 1 Prevention of Substance Abuse and Mental Illness   Reduce/prevent substance abuse & mental illness through prevention prepared communities President Obama’s National Drug Control Strategy, with ONDCP Prescription drug abuse Emotional health per IOM report   Suicides – especially youth, military, tribes   Underage drinking   Tobacco use among persons with serious mental illness and substance use disorders

15 Prevention Highlights in FY 2011 Budget   Project LAUNCH (Kids 0-8) ↑ $12 million to $37 million   Prevention Prepared Communities (Young people 9-25) $23 million for this new initiative   Strategic Prevention Framework/Partners for Success ↓ $7 million to $103.5 million   Preventing Suicide ↑ $6 million to $54 million   SBIRT ↑ $8 million to $37 million   Prescription Drug Monitoring $2 million   Stop Act (Sober Truth on Preventing Underage Drinking) $8 million

16 No. 2 Trauma & Justice   Trauma-informed screening and care in behavioral health, health and justice settings   Youth & adults with behavioral health needs in juvenile and criminal justice systems – diversion and prevention   Impacts of violence and trauma on youth   Incidence of community violence   Prevalence data   Helping communities reduce violence

17 Trauma & Justice FY 2011 Budget Highlights   Children’s Mental Health Initiative (CMHI) ↑ $5 million to $126 million   Transformation grants   Safe Schools/Healthy Students $95 million   Drug Courts ↑ $13 million to $56 million

18 No. 3 Military Families - Active, Guard, Reserve, & Veteran   Suicide   Homelessness   Prevention for families   Access to treatment in civilian service settings in partnership with states and VA, DOD, Guard   FY 2011 Budget highlights which could focus on military families: ● ● Prevention, Housing, Children’s MH, Suicide Prevention, Block Grant Increases ATR ↑ $10 million to $109 million

19 No. 4 Health Insurance Reform   Health Insurance Reform implementation   Medicaid & Medicare policies and opportunities   Parity regulation – implementation of interim final rule Effective April 4 th ; comments through May 4 th Comments & research on scope of services, non-quantitative treatment limitations, common deductibles, etc. Medicaid parity regulation still to come   Block grants – consideration of future use and implications

20 WHY CARE ABOUT HEALTH INSURANCE REFORM?   Rising cost for families, businesses and government   Health care quality   Disproportionate impact on persons with mental illness and substance use disorders

21 WHAT REFORM GETS US:   32 million Americans covered (95%)   $2,000 projected reduction in premiums for American families   4,000,000 jobs created as health costs decline   $1 trillion+ reduction in federal deficit in next decade   $36 billion reduced spending on uninsured over next decade

22 WHAT’S IN REFORM FOR BEHAVIORAL HEALTH – 1  COVERAGE ● Expands Medicaid to 133% FPL – an estimated 16 million new enrollees of which 1/3 are likely to have MI/SUD service needs ● Focus grant dollars for recovery support services not paid for through insurance benefit plans ● Changes in Medicaid to assist youth to maintain coverage in times of transition ● Allows dependent coverage to age 26 ● Elimination of pre-existing condition exclusions & policy terminations; guaranteed renewability ● Expands possibility of home and community-based services for individuals with mental health and substance use disorders

23 WHAT’S IN REFORM FOR BEHAVIORAL HEALTH – 2  SERVICES ● New home visiting programs for young children—with a focus on families with substance use disorders ● Programs to expand “medical homes” to include behavioral health ● School-based health clinics to provide mental health and substance use disorder assessments, crisis intervention, counseling, treatment ● Begin closing Medicare “doughnut hole” for prescription drugs for seniors and disabled individuals ● Establishes a “Medicaid Emergency Psychiatric Demonstration”  PARITY ● Parity required in essential benefits plans offered through exchanges ● Employer mandate requires parity in private health plans

24 WHAT’S IN REFORM FOR BEHAVIORAL HEALTH – 3  PREVENTION ● Prevention research programs and national prevention plans ● Coverage of preventive services in benefits packages, including SBIRT, without cost-sharing ● Allowing states to cover prevention services under Medicaid ● Prevention Trust Fund  TRAINING & RESEARCH ● Increased patient-centered health research ● Training grants for behavioral health workforce ● Training on MH/SUD for Primary Care Extender

25 WHAT’S IN REFORM FOR BEHAVIORAL HEALTH – 4  COSTS & FUNDING ● Tax credits for businesses offering coverage ● Tax credits for individuals purchasing insurance ● Vouchers for low-income individuals not eligible for Medicaid to purchase insurance through exchanges ● Increased Medicaid and commercial insurance funding of mental health and substance abuse services ● Allows SAMHSA block grant and grant dollars to be focused on recovery support services not paid for through insurance benefit plans

26 WHAT’S IN REFORM FOR BEHAVIORAL HEALTH – 4  INVOLVEMENT ● SAMHSA consultation on regulations, demonstrations, implementation ● States that develop health homes must “consult and coordinate” with SAMHSA regarding the prevention and treatment of MH/SUD ● Demonstration initiatives within HHS at discretion of HHS Secretary allow for MH/SA inclusion

27 Behavioral Health must be at the table to participate in, inform and influence the future of the Nation’s health care system

28 No. 5 Jobs and Economy   Place-based approach to impacting increasing behavioral health needs of communities with significant effects from the current economic conditions   Employers – role in supporting employees behavioral health while positively impacting their costs   Employment – for persons with histories of mental illness or substance abuse diagnoses or treatment   Policy, legal, capacity, and knowledge barriers   FY 2011 Budget: ● ● Community Mental Health Block Grant at $421 million ● ● Substance Abuse Prevention & Treatment Block Grant at $1.8 billion ● ● Community Resilience & Recovery Initiative (CRRI) $5 million

29 No. 6 Housing & Homelessness   Moving from services for homeless persons to permanent supportive housing for persons who experience chronic homelessness due to substance abuse and/or mental illness Policy barriers Financing barriers Capacity and knowledge barriers   Interagency Council to End Homelessness – Report to Congress, Spring 2010 Families Youth Veterans Adults experiencing chronic homelessness   FY 2011 Budget: ● ● PATH ↑ $5 million to $70 million ● ● HUD/HHS demo – ↑ $16 million provision of 10,000 new homeless and special needs vouchers, 4,000 of which are targeted for persons with mental illness/substance abuse disorders eligible for Medicaid through creative state waivers or other programs

30 No. 7 Health Information Technology (HIT) & Electronic Health Records (EHR)   SA/MH provider capacity to utilize electronic health records, including access to federal assistance (meaningful use; ARRA)   Behavioral health outcomes and data using health information technology – standards   Privacy/confidentiality of mental health and substance abuse treatment information while supporting integration of health and behavioral health care   April 15, 2010 public meeting with ONC and ASPE, in DC   FY 2011 Budget: ● ● $4 million new in the Office of the National Coordinator (ONC) for Behavioral Health HIT

31 No. 8 Workforce No. 8 Workforce   Numbers and distribution of practitioners with aging workforce   Behavioral health/primary care integration   Support for recovery coaches peer and paraprofessional or non- traditional workers   Evidence-based thinking; evidence-based practices adoption   Recovery in core competencies and curriculum for education of all practitioners and workers   FY2011 Budget: $25 million to HRSA for BH in FQHCs

32 No. 9 Data and Outcomes – Demonstrating Results   Consolidation of fragmented and multiple SAMHSA data systems   Consistent data requirements for states and grantees – block grants and grant programs   Common National Outcome Measures (NOMS) across funding streams for state mental health, substance abuse, and Medicaid agencies   Common approach to evaluation and services research   FY 2011 Budget: ● ● National data collection ↑ $33 million to $136 million – DAWN & New C- EMS ● ● Internal work regarding common data elements and approaches

33 No. 10 Public Awareness and Support   Consistent messages, focusing on key messages, principles and 10 strategic initiatives   Redesign and consolidation of websites   Utilization of social marketing mechanisms   Increase understanding of where and how to seek help

34  Behavioral health is an essential part of health ● Improves health status ● Lowers costs for families, businesses and governments  Prevention works  Treatment is effective  People recover KEY MESSAGES

35   People ● ● Stay focused on the goal   Partnership ● ● Cannot do it alone   Performance ● ● Make a measurable difference   Parity ● ● Mental and substance use disorders are not unlike any other health care condition – acute, chronic or disabling PRINCIPLES

36 Partnership: Cannot do it alone Faith & Community- based Providers States, Territories & Tribes Consumers & Recovery Community Substance Use Treatment Providers Mental Health Treatment Providers Individuals, Families & Communities Medical Community Criminal Justice Community Practitioners Researchers Advocates EducatorsService Agency Administrators Policy Makers Media Military

37 THE ONLY FAILURE IS FAILURE TO AIM HIGH “Not failure, but low aim is sin.” – Benjamin E. Mays – Benjamin E. Mays “Not failure, but low aim, is crime.” – James Russell Lowell – James Russell Lowell