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CHALLENGES & OPPORTUNITIES IN A CHANGING HEALTH CARE

ENVIRONMENT

Pamela S. Hyde, J.D.SAMHSA Administrator

NASMHPDWashington, DC • July 16, 2012

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TODAY’S DISCUSSION

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SAMHSA’S OVERALL BUDGET – TRENDS AND POSSIBILITIES

$3,234

$3,335

$3,431$3,379

$3,348

$3,152

$3,343

$122

$132

$132

$132

$129

$165

$129

$20$88

$88

$105

$88

$2,900

$3,000

$3,100

$3,200

$3,300

$3,400

$3,500

$3,600

$3,700

FY 2008 Actual

FY 2009 Actual

FY 2010 Actual

FY 2011 Actual

FY 2012 Enacted

FY 2013 President's

Budget

FY 2013 Senate

Committee Mark

FY 2013 House

Committee Mark?

Do

lla

rs i

n M

illi

on

s

SAMHSA FY 2008 - FY 2013 Total Program Level$3,32

$3,356

$3,466 M

$3,583 M

$3, 565 M

$3,599 M

$3, 423 M*

#$3,560 M*

?

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

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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

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FY 2013 BUDGET ISSUES

PreventionBlock GrantsDisaster Distress HotlineGrants for Adult Trauma Screening and Brief

Intervention (GATSBI)PHS Evaluation/HHS TapsSAMHSA’s 4 Appropriations & Central Cost

Budget (CCB)

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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

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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)

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HEALTH REFORMhttp://www.samhsa.gov/HealthReform/

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SAMHSA’S HEALTH REFORM PRIORITIES – FY 2012 AND FY 2013Uniform Block Grant Application FYs 2014-2015

• In Fed Reg for 60-day public comment as of 7-13-12Enrollment – PreparationEssential Benefits and Qualified Health PlansProvider Capacity DevelopmentWorkforceContinuing Work with Medicaid

• Health homes, rules/regs, service definitions and evidence, screening, prevention, duals, PBHCI

• Parity – MHPAEA/ACA Implementation & CommunicationQuality and Data (including HIT)

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2014 – MORE AMERICANS WILL HAVE HEALTH COVERAGE OPPORTUNITIES

Currently, 37.9 million are uninsured <400% FPL*

• 18.0 M – Medicaid expansion eligible • 19.9 M – ACA exchange eligible**• 11.019 M (29%) – Have BH condition(s)

* Source: 2010 NSDUH**Eligible for premium tax credits and not eligible for Medicaid

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PREVALENCE OF BH CONDITIONS AMONG MEDICAID EXPANSION POP

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

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PREVALENCE OF BH CONDITIONS AMONG EXCHANGE POPULATION

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

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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

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ESSENTIAL HEALTH BENEFITS (EHB) 10 BENEFIT CATEGORIES

1. Ambulatory patient services

2. Emergency services3. Hospitalization4. Maternity and newborn

care5.5. Mental health and Mental health and

substance use disorder substance use disorder services, including services, including behavioral health behavioral health treatmenttreatment

6. Prescription drugs7. Rehabilitative and

habilitative services and devices

8. Laboratory services9. Preventive and wellness

services and chronic disease management

10.Pediatric services, including oral and vision care

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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

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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

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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

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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!

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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

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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

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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

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WORKFORCE CHALLENGES

Worker shortages and distributionMore than one-half of BH workforce is over age 50Between 70 to 90 percent of BH workforce is white Inadequately and inconsistently trained workersEducation/training programs not reflecting current research baseBilling involves increasing licensing & credentialing requirementsHigh levels of turnoverDifficulties recruiting people to field – esp., from minority

communities Inadequate compensationPoorly defined career pathways

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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

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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 2010-2011; ½ in

underserved areas

Mental and BH Education and Training Grants – FOA• 280 Psychologists and Social Workers

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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

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DISASTER/EMERGENCY PREPAREDNESS AND

RESPONSE

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FEMA ISSUES IN PROCESSISP 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

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FEMA TRAINING

July 16 – 19, 2012Emmitsburg, MD22 State Representatives

FEMA Offer to Meet with NASMHPD Reps