A National View: Healthcare 2008 CBHC Annual Training Conference October 5, 2008 Charles Ingoglia, MSW Vice President, National Council for Community Behavioral Healthcare
Today…talk about n Opportunities and Challenges n 2008 National Healthcare Debate n National Council Public Policy and The State of Medicaid n Taking Charge – relationships, quality and communications www. nccbh. org
The National Council n Not for profit association of 1500 + mental health/addiction treatment and rehabilitation organizations n Member organizations employ 250, 000 staff and provide services to 6 million adults and children in communities across the country www. nccbh. org
Membership www. nccbh. org
Our Vision – the big picture A nation where there is prevention and early detection of mental illnesses and addictions; and everyone has access to the effective treatments and supports essential to live, work, learn and participate fully in their communities. www. nccbh. org
Our Job The National Council is the interface between practice and policy. We are the national voice for legislation, regulations and policies that protect, strengthen and expand access to mental health and addictions services. Your job is to support others, our job is to support you. www. nccbh. org
Members – Top Issues n Funding, Medicaid, Medicare n Reform – privatization, competition, managed care n Workforce n Health Integration n Technology www. nccbh. org
Time of opportunity Surgeon General Satcher, President Bush’s New Freedom Commission, and The Institute of Medicine all agree that: n mental health and freedom from addictions are vital to overall health n effective treatments exist and recovery is possible www. nccbh. org
Opportunity Up to 90% of people with a mental illness that are treated with a combination of medication and therapy experience substantially reduced symptoms, enhanced quality of life & increased productivity n Science has revolutionized our understanding of addictions – treatment has been shown to cut drug use in half, reduce crime by 80% & reduce arrests up to 64%. n www. nccbh. org
Challenges Each year 100, 000 + Americans die from alcohol and drug abuse. n 50% jail/prison inmates have mental health problem, 75% substance abuse. n 2/3 homeless - chronic alcoholism, drug addiction, mental illness or combination. n 25% of all hospital admissions have mental illness or addictions disorder. n 25% social security payments are for mental illnesses. n www. nccbh. org
Challenges Staffing crisis - low prestige and salaries/ high turnover n Limited use of outcome data to refine treatment/research based practices n Limited use of knowledge based technology/neuroscience and biological advances n Low rates of access, retention & adherence n www. nccbh. org
Challenges Ambivalence about healthcare: chronic illnesses v. recovery; integration? n Complexity of serious mental illnesses – early mortality – poverty n Protecting individuals with mental illness from harm v. protecting society n Late detection – complex U. S. system n www. nccbh. org
Challenges n No uniform standards of care and layers of regulation and oversight n Multiple hospital and community providers with fierce competition for Medicaid n Dependence on Medicaid and limited to no access for non – Medicaid www. nccbh. org
The Healthcare Debate www. nccbh. org
www. nccbh. org
U. S. Healthcare System The financing system is n Inefficient n Inequitable, and n Fiscally unsustainable. n The delivery system is n Fragmented n Not designed to care for chronic diseases n Haphazard and poor quality n High use of unproven, marginal therapies. n www. nccbh. org
Costs n In 2006, the U. S. spent $2, 100, 000, 000 --$2. 1 trillion –on health care. n $1 out of every $6 spent in the U. S. www. nccbh. org
Costs How Big is a Trillion? n 1 million seconds Last week n 1 billion seconds Richard Nixon’s resignation n 1 trillion seconds 30, 000 BCE www. nccbh. org
Costs 47 million without health insurance n 16% of GDP – no other country above 10% n Fragmented array of insurers and providers drive high administrative costs: 25 -35% compared to 15% n $5, 711 person, Switzerland $3, 847; 31 st in life expectancy n Insurance premiums doubled since 2000 n www. nccbh. org
Costs n n We pay hospitals and doctors more Rely on specialists, using high cost diagnostics & interventions offering possibility of improvement Little to no use of comparative effectiveness/No budget 75% of costs by 4 -5% with chronic illnesses and at end of life. www. nccbh. org
Costs Extremely wealthy country; most like their providers – change for everyone else, but n By 2028, health care will consume 28% of GDP. This is as much as all federal, state and local governments currently spend. n By 2050, Medicare and Medicaid will consume all federal taxes. “Even in fantasy, no one has yet come up with a way to pay for Medicare. ” www. nccbh. org
Solutions? n n Managed care: largely unable to reform care delivery/hated by all Control drug costs, allow Medicare to negotiate: small piece of the pie Pay for Performance: more to providers already doing the right thing, others won’t change for additional 2% or 5% IT: long term can reduce paperwork burden, errors and repeated tests www. nccbh. org
Solutions? Prevention/Disease management/Medical homes: not clear if or when get savings: n Skin in the game: 1974 to 1982 Rand study 30% saving when people paid with same outcomes, exception low income people in poor health n Close hospital beds: match lower spending regions save 20% to 30% n www. nccbh. org
Healthcare Reform n True health care reform must fix both the financial and delivery systems. n Unfortunately, most public discussions focus exclusively on the financing system and getting to (or close to) universal coverage. They ignore delivery system reform. www. nccbh. org
Incremental Reform n Incremental reform is business as usual. n If you like the current system, you like incremental reform. n Builds on a broken system. n Fails to achieve universal coverage, no cost control, no improved delivery system. www. nccbh. org
Political Feasibility Many barriers to change: 1) Rule of Satisfaction— 85% of Americans have health insurance and many are satisfied. 2) James Madison Rule of Government— American government was designed with many places for special interests to kill legislation. With 16% of the GDP, health care has many special interests. www. nccbh. org
Political Feasibility A majority of Americans are for health care reform. But they are divided among many different plans. After their preferred reform, their second choice is the status quo. www. nccbh. org
2007 Lobbying Leaders n n n n US Chamber of Commerce $52, 750, 000 General Electric $23, 660, 000 Pharmaceutical Rsrch & Mfrs of America $22, 733, 400 American Medical Assn $22, 132, 000 American Hospital Assn $19, 734, 545 AARP $19, 540, 000 Exxon Mobil $16, 940, 000 www. nccbh. org
Healthcare Lobbying in 2007 n n n Pharmaceuticals/Health Products $226, 757, 501 Hospitals/Nursing Homes $91, 208, 297 Health Professionals $70, 378, 540 Health Services/HMOs $52, 990, 044 Misc Health $4, 985, 719 Total spending: $446, 320, 101 www. nccbh. org
What we must do… Broad, strong, engaged membership. n Assertive/focused policy agenda. n Strategic alliances - industry leadership. n Reputation for quality - expert education & practice improvement initiatives. n Effective communications with members, media, advocates, policymakers & public. n www. nccbh. org
The National Council An assertive, focused policy agend www. nccbh. org
Assertive, focused policy agenda Understanding and Defending Medicaid n Parity/ Medicare n Veterans n Criminal Justice: Mentally Ill Offender Treatment and Crime Reduction Act/Second Chance Act n Community Mental Health Services Improvement Act - Primary care in behavioral sites n www. nccbh. org
Assertive, focused policy agenda The State of Medicaid www. nccbh. org
In 2007, Over 2/3 of States Offered New Proposals n Governors in 34 states offered plans to reduce uninsured children, parents, adults, aged and disabled in their state through n Medicaid expansions n SCHIP expansions n DRA waivers n Comprehensive Section 1115 waivers n Prevention and better management of chronic conditions www. nccbh. org
2008 Response: n Expansion plans in jeopardy or delayed n States once again freezing or cutting rates www. nccbh. org
Illustrative Medicaid Dynamics; Ohio Department of Mental Health State General Fund and Medicaid FY 1990 – FY 2007 millions $200 $150 millions $200 Medicaid FFP Medicaid Match Remaining GRF $150 $100 $50 $0 $0 -$50 -$100 -$150 The Squeeze 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 -$150 www. nccbh. org
Federal Regulations Reflect Federal Goals n Make Medicaid look like commercial health insurance. ” n “Medicaid should not be a financing option for other public systems for non. Medicaid purposes. ” n “Rein in federal health spending. ” www. nccbh. org
It’s Raining Regulations! n 10 new regs in first six months of federal fiscal year (15+ in last 2 years) n Most issued as either “interim final” regulations or with shortened public comment periods n Fighting new regs – Congressional moratoriums www. nccbh. org
Council Leadership - Rehab Option/Case Management In DRA, Congress rejected Bush efforts to legislate changes - President uses administrative measures for $6. 1 billion savings over next 10 years n Council – member political heat, member testimony, rallying partners n Achieved moratorium n Working with Congress on legislation to address rehab and case management regs n www. nccbh. org
Assertive, focused policy agenda Parity www. nccbh. org
Commercial Parity Senator Paul Wellstone Mental Health Parity Act of 2007 – parity for both mental health and addictions treatment services n Senate - introduced by Senators Edward Kennedy (D-MA), Michael Enzi (D-WY), and Pete Domenici (R-NM)/House - introduced by Representatives Patrick Kennedy (D-RI) and Jim Ramstad (R-MN) n Rally on 9/17; ad campaign Agreement on content, added to rescue/tax bill (AMT) n www. nccbh. org
Parity Use The Toll-Free Parity Hotline: 1 -866 -parity 4 (1 -866 -727 -4894, the Parity Hotline reaches the U. S. Capitol switchboard, which connects you to your Senators' offices. ) "I'm calling to ask that the Senator vote YES on the energy and tax package that includes parity for mental health and addiction services. This legislation must pass this month before Congress adjourns. " www. nccbh. org
Medicare n n n Historic milestone – Congress ( HR 6331) ending discrimination of outpt. mental health benefits between 2010 and 2014 Re-authorization of SCHIP - 2 provisions related to Medicare: 1. marriage&family therapists and licensed professional counselors as providers 2. additional covered services including case management, ACT, rehab Vetoed by President but passage by Congress is important legislative record moving forward www. nccbh. org
Assertive, focused policy agenda Veterans www. nccbh. org
Veterans authorization S. 38 calls for the VA to contract with community providers to meet needs of reserves and National Guard n Recent VA directive to all VISN'S that describes expectations for access and services and calls for individual medical centers to contract with community providers n www. nccbh. org
Veterans appropriations $100 million to be allocated to community mental health organizations in the Veterans Administration’s health care budget lineitem to increase mental health care for National Guard members, reservists, and family members of veterans with service connected mental disorders www. nccbh. org
Assertive, focused policy agenda Community Mental Health Services Improvement Act www. nccbh. org
Community Mental Health Services Improvement Act Primary care in behavioral sites *** n Co-occurring disorders funding demo n Workforce improvements, salary study n Paperwork reduction - elimination of regulatory redundancy n Advancing tech. & electronic health record n Rural behavioral health treatment incentives n www. nccbh. org
Assertive, focused policy agenda n Coming soon www. nccbh. org
Coming Soon Federal funding stream to cover the mental health treatment costs of the uninsured n Restore eligibility for social security disability for people with addictive disorders n Cost based re-imbursement that supports salaries that can attract and retain skilled staff n Chronic disease management project – medical home n www. nccbh. org
Strategic relationships Chronic Disease, Healthcare, Medicaid Coalitions, Medicaid Directors n Addiction Treatment Advocacy and Criminal Justice Leadership n Mental Health Groups – Campaign, NAMI, MHA, Consumers, NASMHPD, Guilds n Feds – SAMHSA, HRSA, CMS n Presidential Election – Whole Health n www. nccbh. org
Reputation for quality – Member Benefits n Promoting Wellness - Saving Lives n Survey on medical services n Health & Wellness Roundtables n Primary Care and Behavioral Health Learning Community - 23 organizations *** n Primary Care/Behavioral Health Collaborative Project *** n Medical/healthcare homes *** www. nccbh. org
Primary Care/Behavioral Health Collaborative Project Objectives: n n Safety net population in every community has seamless access to both mental health/addiction and physical healthcare services. Strong working partnership among mental health/addiction and physical healthcare providers, with roles defined, referral protocols in place, and cross-placement of clinical staff. n Phases I and II : 12 sites in 10 states n Phase III – 4 additional sites www. nccbh. org
www. nccbh. org
Reputation for quality – Member Benefits Continuity of Care -Access, Engagement and Adherence Project n Six Sigma Initiative *** n Recruitment and Retention n Psychiatric Leadership Project *** n Middle Management and Leadership Development – Culture diversity n National Benchmarking Project *** n www. nccbh. org
Access and Engagement Executive Staff Walkthrough n n Objectives: Experience Intake, Assessment, and First Appointment Process from Client’s Perspective; Identify Barriers; and Identify Strategies for Improvement Requirements: Site Teams Work in Pairs (One Client, One Observer/Recorder); and Mock Clients Complete All Paperwork/ Processes Client Completes www. nccbh. org
Access and Engagement n n n Number of data elements collected in the process = 1, 854 Number of redundant elements = 564 Number required = 957 Staff time required to administer original flow process = Four hours ten minutes Staff time required to administer revised flow process = One hours twenty minutes www. nccbh. org
Quality – Member Benefits n Criminal Justice Leadership Forum n Project Helping Hands*** n Awards of Excellence*** n Jo. Bank n International Community and “Passport” program *** n Mental Health First Aid *** www. nccbh. org
Few are bigger, none are better National Council Conference The Hyatt River. Walk San Antonio, Texas April 5 - 8, 2009 www. nccbh. org
Conference Attendance www. nccbh. org
Effective Communications Electronic and Print n Public Policy Update n Technical Assistance Newsletter n State Policy Focus n National Council Magazine n Letter from Linda n n Journal of Behavioral Health Services & Research Addictions/Co-occurring Disorders Newsletter www. nccbh. org
Communications – messaging and marketing National Council Live n Marketing - Message piece/ Policy Guide/Annual Report n Print Media – member stories and voices: news, letters, op-eds and magazine articles in trade and mainstream press Redesigned website, www. nationalcouncil. org q Offering stories of recovery q Sharing member writings q National Council resources q Special interactive sections n www. nccbh. org
How do we move our agenda… Change requires 4 things to coalesce: 1) A problem attracts widespread public and political attention. 2) A proposal to solve the problem is agreed on by the major actors. 3) There is a major actor or set of actors who vigorously champion the policy proposal. 4) A transforming political event creates an open policy window to enact the agreed upon proposal. Political opportunity is unpredictable. We must be ready when the policy window opens. www. nccbh. org
What do we need to succeed? n An organized and effective grassroots n Congressional champions www. nccbh. org
What we must do politically… Be informed, www. thenationalcouncil. org understand influence the national dialogue: mental health and freedom from addictions are vital to overall health and effective treatments exist n Tell our story commit to using our influence: Congress doesn’t know us very well and CMS doesn’t always like us n www. nccbh. org
Build relationships with policymakers • • Meet them in Washington or the District Get to know their staff Help them — contribute to their campaign, attend a fundraiser, put up yard signs, serve as a content expert etc. Maintain contact www. nccbh. org
n Political action is the highest responsibility of a citizen. ” “Political action “ is the highest responsibility of a citizen. ” John F. Kennedy Hill Day: June 9 and 10 www. nccbh. org
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