Healthcare Reform – Where Are We?  What’s Ahead?

An update…
All signs point to the passage of healthcare reform legislation. The President will keep the “blue dogs” in line as the only thing worse for the Democratic Party than passing healthcare reform along party lines is failing to pass healthcare reform at all. The surprise might be some Republican votes.

The first phase of reform, wooing stakeholders—including hospitals, physician groups, pharmaceutical companies, and the insurance industry—is long over. The town halls have been held and the Congressional committees have had their say and produced their bills. Now, with the Senate Finance Committee bill as the framework, the horse trading is underway to work out differences among the five pieces of legislation —3 in the House and 2 in the Senate—that are on the table.

The National Council’s job—led by the grassroots efforts of our members and working with sister advocacy groups—has been and continues to be, promoting the interests of individuals with mental illnesses and substance use disorders. Our job has been to fight for robust behavioral health benefits in a newly created commercial insurance Exchange and in the expansion of Medicaid, and to be sure that our communities can effectively serve those that have been marginalized by long neglected mental and substance use disorders. And we’ve had success.

Almost all of the proposals related to behavioral healthcare in the House and Senate bills can be directly connected to the National Council’s advocacy. Congressional champions have offered specific proposals in pending legislation—to apply behavioral health parity to all plans offered in healthcare reform; establish Federally Qualified Behavioral Health Centers nationwide to provide coordinated and affordable care; fund demonstration grants to assess the effectiveness of co-locating primary and specialty mental healthcare in community-based centers; and modify a Medicaid Medical Home State Plan Option to give individuals with serious mental illnesses and behavioral health organizations the opportunity to participate.

Our work is far from done, now we need to carry these proposals through the process, ensuring they are in the final legislation. We can do no less. A decade after the Surgeon General’s Report on mental health, which revealed that mental illnesses are as treatable as physical illnesses, a majority of those with mental illnesses still receive no services. As a consequence, untreated mental illnesses and addictions remain the major cause of disability worldwide and a significant public health problem in medical practices, hospitals, schools, prisons, shelters, and on the streets.

Healthcare reform won’t be perfect and it certainly won’t solve all of our problems, but millions of Americans that were uninsured will be insured; and payment reform and improvements in quality are real possibilities. Reform is a step in the right direction particularly for vulnerable individuals with mental illnesses and addictions.

Looking ahead…
Even as we remain vigilant about the details of pending legislation, we must plan for the future. Will the world be different—for consumers, their families, practitioners, and organizations that provide behavioral health services?  

We expect Medicaid will be expanded to 133% of the Federal Poverty Level, single adults will be covered and behavioral health benefits will be mandatory not optional. The National Council estimates that fully 2.8 million uninsured Americans have conditions severe enough that they require the intensive services provided by specialty mental health organizations. This could potentially increase the number of individuals expecting services from America’s public mental health system by an astounding 50 percent. We think significant changes lie ahead.

In the short term, for some it might be business as usual—just more of it. As the numbers of people with insurance increases, they will use their new coverage to access emergency and primary care. The short term result could be more psychiatric treatment in primary care—usually a prescription with no adjunct therapies and no objective measurement of response; prescriptions that will be unused or just not renewed with little to no follow-up. Physical medicine enjoys the same continuity problems as specialty behavioral healthcare without the commitment to care coordination or experience with outreach and engagement strategies.

In the longer term the Administration and Congress will be seeking opportunities to introduce greater accountability into the healthcare system, while promoting initiatives that increase efficiency and reduce variations in care. Recurrent themes in the current healthcare debate include: provider accountability for clinical outcomes; systemic application of evidenced-based interventions; reduced reimbursement for sub-optimal outcomes; and specific reporting of detailed encounter data. The National Council’s response is a federal healthcare reform agenda—Person-centered Healthcare Homes and Federally Qualified Behavioral Health Centers—which take into consideration the overarching principles of the reform debate, and offers delivery and payment reform to better equip our communities to address the whole health concerns of individuals with mental illnesses and substance use disorders.

Primary care doctors treat heart attack patients with depression; National Council members see consumers who have co-morbid chronic physical conditions. At the core of the clinical approach of the Person-centered Healthcare Home is team-based care that provides care management and supports individuals in their self-management and recovery goals, shifting away from a focus on episodic acute care to a focus on managing the health of defined populations, especially those living with chronic health conditions. Another vehicle that supports and protects the needs of individuals with mental illnesses and substance use disorders is federal designation for behavioral health organizations. Federally Qualified Behavioral Healthcare Centers—with accompanying benefits and responsibilities align the behavioral health safety net with the general healthcare safety net of Federally Qualified Health Centers.

Healthcare reform is likely to move financing of currently uninsured populations into public-private partnerships that build on commercial insurance products. Providing services to individuals with third-party payers increases the ability to meet the mental health and substance use treatment needs of all community residents and to offer a diversified treatment mix. The expansion of mental health services is expected and the effect may be even more profound for substance use services. Healthcare reform is signaling that behavioral health has come of age, indeed viewed as fundamental to good general health. We have made great strides since the time that mental illnesses and addictions were seen primarily as moral failings and recovery as unexpected. But insurance expansion will be incremental and not without unintended consequences.

The process for writing the parity regulations—eliciting stakeholder comments—made clear that insurance companies will interpret benefits narrowly. They are doing their job, answering to their owners and stockholders, and we must do ours, answering to individuals and their families that struggle every day to get help for mental illnesses and addictions. Healthcare reform cannot allow insurers to continue to create barriers to behavioral healthcare, limit evidence-based treatments, and pay inadequate rates.

Protecting the safety net…
As increasing numbers of Americans gain insurance coverage—it is estimated that up to 95% of the population will be covered under reform—we expect the shift away from dedicated state and local behavioral health general funds to accelerate. It is possible that states will eliminate their general fund support for outreach, jail diversion and re-entry programs, employment supports, and the much needed but time-consuming cross-agency “collaboration.” Initially the costs for increasing Medicaid to 133% of the FPL will be borne by the federal government but in time states will be asked to assume their portion of the match. It’s too soon to know how states will finance what they will consider an unfunded mandate but it is cause for concern and it’s important to note that mental health is currently an optional state Medicaid service.

The National Council understands that we must protect the safety net particularly as reform unfolds. Our policy agenda goes beyond reform legislation to advocacy for block grant increases —the mental health block grant has not had an increase in ten years and we are determined to rectify that failing. We are also working in Congress to increase funding for the new $7 million SAMHSA program bringing primary care to people with serious mental illnesses that the National Council championed in 2008. And we are determined to obtain health information technology funds—the behavioral health community can’t be left behind as technology increases transparency to the consumer, supports improved clinician practice, reduces errors, and connects all the pieces and parts of the healthcare community.

The opportunities and challenges of reform will move from policy to implementation—affecting purchasers, consumers, peer run programs and behavioral health organizations. The expression “follow the money” may be a truism with a flood of companies moving into states vying to administer, manage, and deliver services. For smaller community organizations that have little to no experience billing insurance, the leap into an insurance-centric world will be a feat. The organizational challenges abound, including: creating additional service capacity to ensure timely access to treatment; using levels of care/benefit package designs in clinical processes; reviewing internal utilization management processes to ensure preauthorization, appropriate referrals, cycle management procedures to enhance timely collections; and responding to the demand for measureable results—by providing high quality specialty behavioral healthcare that manages the total healthcare expenditures of their clients.

What we must do…
With your help, the National Council will continue to fight for the changes we believe are critical to ensure adequate services for mental illnesses and addictions in any healthcare reform legislation and subsequent implementation. We will continue to offer practical solutions to complex problems—bringing to the table real world experiences of our members, consumers, and families.

As we await further deliberations in Congress, you can:

•    Participate in the National Council’s healthcare reform webinars. The next is scheduled for 2 pm eastern on Wednesday, October 21.

•    Continue to lobby and educate your Senators and Representatives and their staff.       
•    Respond to the National Council’s Action Alerts you receive via email.

•    Empower consumers and families to be their own best advocates.

•    Position and prepare for the opportunities ahead—ask questions, get useful information, and join me March 15 when we convene the National Council’s 40th Annual Conference, where you’ll find a strong focus on community implementation of healthcare reform.

Best Regards,
Linda