Author: SOS Blog

Health Care Reform and Behavioral Health

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On March 21, 2010, the U.S. House of Representatives passed the Patient Protection and Affordable Care Act. Subsequently, they passed the Reconciliation Act  (H.R. 4872) making changes in the original bill. After some maneuvering, all the necessary legislation was passed by both houses of congress and on Tuesday, March 30, 2010, President Obama signed the Healthcare and Education Affordability Reconciliation Act of 2010 into law.

In the past week or two I have seen many questions about what the effects of this legislation will be. Behavioral health provider organizations are especially concerned about what the effects will be on mental health and addiction service funding.

One of the most useful resources I have come across was forwarded to the Florida Psychological Association member listserv by Dr. Bob Porter. The Bazelon Center for Mental Health Law has done an excellent job of summarizing the law and its impact on coverage for mental health services. While it will take years for all of the provisions of the new law to be implemented, a Congressional document summarizes some of the immediate effects.

In the private insurance sector, generic requirements of the law have particular impact for those with mental illnesses. In the past, such diagnoses have routinely triggered pre-existing condition clauses in policies. Within the first 6 months, the new law prohibits this discrimination.

  1. No discrimination against children with pre-existing conditions.
  2. No rescissions based on developing an illness.
  3. No lifetime limits on coverage.
  4. Tightly regulated annual limits on coverage.

In addition, for those who are currently uninsured, the law mandates:

  1. Immediate help for those with pre-existing conditions (an interim high-risk pool).
  2. Extending coverage for young people up to their 26th birthday through parents’ insurance.

Since so many who have been diagnosed with mental illnesses or with substance abuse issues have been denied coverage or have had coverage revoked or have reached the limits of their benefits, we should see immediate increased access to behavioral health and addiction services. The ability for parents to keep young adults on their insurance plans until they are 26 years old will assist some of the young people who experience late adolescent onset of serious mental illness or substance abuse conditions. This will allow a period during which their parents will be more able to facilitate transition to some other form of insurance coverage.

The National Council for Community Behavioral Healthcare, the trade association of behavioral health community service providers, hosted a webinar on healthcare reform and its impacts, Healthcare Reform: What Happens Next? Additionally, their Public Policy Update for April 1 gives links to resources as well as information about moving forward from here.

I attended the Council’s webinar this week and was struck by a couple of things. Because the Council primarily represents organizations that provide services in the public sector, their information is generally focused in this direction. For me, there were three take-aways from this session, and they were not all for public sector providers:

  1. The Council believes Fee for Service will probably go away in the long run, to be replaced by Case Rates with a Bonus for improvement of the consumer.
  2. Behavioral health providers need to position themselves for the long term. Integrated care is likely to be the way of the future and it is best to start to get positioned for that now.
  3. Private practices can be competitors in the new system; however, those with deep pockets who can manage the whole range of healthcare services will be better positioned to compete.

Community Behavioral Health Organizations (CHBOs) have been working on these steps for the past couple of years and there will be pilot programs using CBHOs together with Federally Qualified Health Programs to start to provide integrated care. Unless private behavioral health practitioners also start to position themselves to play in the Integrated Care setting, they are likely to get left behind.

Even the American Psychological Association’s advocacy efforts focus on the assurance that mental health services will be part of integrated care. This sounds very much like an integration of mental health services into such settings to me.

What do you think about how the new health care reform law will affect behavioral health services? Do you foresee changes in how care is provided? What changes are you willing to make in your organization in order to assure participation in a reformed health care system? Please enter your comment below. If you don’t see the comment box, just click on the title of the article and then enter you comment at the bottom.

The Day the Earth Stood Still: Humans & our planet

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Note: This article is my once-in-a-while exploration of human behavior and climate change. While it is in no way related to health care, it may be directly related to health.

Last weekend, we watched the critically unacclaimed remake of The Day the Earth Stood Still starring Keanu Reeves. While the movie left a great deal to be desired, it reminded me of the ongoing issue of human behavior and how we affect our world. This particular movie ends on a hopeful yet doubtful note that we will be able to change our behavior in time to keep climate change from destroying our species.

The American Psychological Association’s Climate Change Task Force Report has now been published in a nice booklet format. I am hopeful that the shorter, more attractive read will make the report accessible to more readers.

Section 2 of the report discusses the human behavioral contributions to climate change along with psychological and contextual components of the contributions. As is frequent in reports and studies by psychologists, ethical concerns are high on the list of issues to be considered. Since population growth and consumption of raw materials to manufacture those things which increase our perception of quality of life are two factors documented to contribute to the manner by which humans impact climate change, how we address population growth and consumption is crucial. Expecting developing nations to forego growth and consumption while the developed countries (like us) continue to consume is blatantly unjust. Many argue that expecting the developing world to forego growth is unjust even if we were to completely alter our own patterns of consumption.

Demographers have developed formulae to demonstrate the effect humans have on the environment. The basic

and widely known formula from the 1970s is I = PxAxT where I = Impact, P = Population, A = Affluence per capita and T = Technology. (APA Climate Change booklet, p 30, from Ehrlich & Holdren, 1971; Commoner, 1972; Holdren & Ehrlich, 1974)

Newer models take into account that countries with the highest per capita Gross Domestic Product plus intense consumption of goods and services requiring greenhouse gas production (environmental consumption) produce the most emissions and therefore the greatest environmental impact. These models are lovely ways to show in graphical form the impact of our reproductive and consumption choices. They do not, however, in any way address the variety of factors that contribute to growth in population (for example , individual and cultural religious beliefs; gender role beliefs; beliefs about individual vs. government control of reproduction; norms about when to start having children and how many to have; infant mortality; availability of food resources; and longevity. Population growth is a very complex phenomenon).

Consumption is an even more complex set of events and requires equally complex analysis. Each consumption behavior is multifactorially determined and requires analysis at different levels including institutional, sociocultural and physical environment context, individual factors such as demographics and psychological drivers, consumption of economic resources, consumption of environmental resources, greenhouse gases produced and emitted, and specific climate change.

The APA report discusses the need to separate consumption behaviors so we can determine which have the greatest impact on climate change. To spend significant resources researching behaviors with minimal impact will not be cost effective. To spend our time and energy learning about and affecting behaviors which have the most direct and largest impact on climate will be the best expenditure of psychological expertise.

While this report assesses what psychologists and the behavioral science community can do to impact climate change, the booklet is an articulate and readable explication of human behavior and climate change.

The question I have asked you before and will ask you again is the following: should we just sit helplessly by while the world (and our climate) changes around us, or should we learn what each of us can do in our individual and organizational lives to affect that change? What do you think?

How to Choose an EMR…and other pressing questions

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For those of you who attend to news about Health Information Technology (HIT) last week was a busy one.

  • The 10th annual meeting of the Health Information Management Systems Society (HIMSS) in Atlanta took top billing. One of my favorite bloggers [EMR (EHR) and HIPAA] attended and posted frequently during the conference. John has been writing about EMRs since December 2005 and his knowledge is considerable. In fact, he just published his own e-book on how to choose an EMR. He is sincerely interested in the best ways for a facility or practice to choose the best EMR for their organization. John’s Sunday post referenced an article by Didier Thizy from macadamian titled “Electronic Medical Records – 3 Key Differentiators“.The three most interesting and possibly most important differentiators Mr. Thizy heard being promoted by EMR vendors at HIMSS about their systems were:

The EMR has excellent UI (user interface) and usability.
The EMR is designed for a specific speciality.
The EMR’s technology makes the user’s life easier.

Obviously, when it comes to electronic medical records, one size does not fit all. Making sure that you take usability, specialty specificity, and life simplification into consideration is likely to make your selection a better fit for your organization.

  1. The Veterans Administration and the Department of Defense have been working diligently through a contractor to connect their respective EMRs so they can communicate with one another. After incorrect communication of patient information (providing information about the wrong patient in response to a user query), the VA decided to shut down access to the DoD system. Hopefully, this is a very temporary glitch and does not mean a complete return to the drawing board.
  2. The Medical Group Management Association (MGMA) expressed concern about results of a survey they completed recently. They found that practice executives are not as optimistic about productivity gains as software and information management executives. Over two-thirds of those surveyed believe that physician productivity will decrease because of the proposed meaningful use criteria. The other third of practice executives felt productivity would increase. This split resulted in MGMA’s chief Dr. William F. Jessee’s statement: “For the incentive program to succeed, the meaningful use criteria must be practical and achievable. If the final rule mirrors those outlined in the current proposal, there is significant risk that the program will fail to meet the intent of the legislation, and that a historic opportunity to transform the nation’s health care system will be missed.”The survey results indicated which criteria will be most difficult to meet:
  • The proposed requirement that 80 percent of all patient requests for an electronic copy of their health information be fulfilled within 48 hours (45.9 percent) and
  • The proposed requirement that 10 percent of all patients be given electronic access to their health information within 96 hours of the information being available (53.5 percent).

    • Those of you who like to closely follow news in the health care IT space might consider following these two excellent sources yourselves:

    EMR (EHR) and HIPAA and FierceHealthIT

    EMR Certification Picture Gets Enlarged

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    On March 2, the Office of the National Coordinator for Health Information Technology (ONC) announced a plan to approve organizations to certify electronic health record software programs. ModernHealthcare.com reported the announcement of this new plan by ONC head, Dr. David Blumenthal, at the big meeting of the Health Information Management Systems Society (HIMSS) occurring in Atlanta this week. The rule being developed will create a system for temporary testing and approval of products that meet the ARRA “meaningful use” criteria as well as a permanent structure for such certification. This is a process for certifying the certifiers.

    Since the passage of ARRA last year, there has been rampant speculation about whether the Certification Commission for Health Information Technology (CCHIT) would be the only certifying body approved by HHS. Many who have felt that CCHIT is too closely tied to the large players in the medical EMR community have believed that diversification in the certification community should be a given.

    Currently, CCHIT is the only organization designed to certify EMRs. Prior to ARRA, the certification was to a particular set of standards, features and functionalities decided upon by CCHIT as necessary for any electronic medical record program to call itself a player. In the past few months, CCHIT has added an ARRA certification to meet the requirements of “meaningful use” so that providers could qualify for ARRA funds. Unfortunately, the “meaningful use” definition is not yet finalized…and the cost of the ARRA certification is significant.

    This cost of certification by CCHIT has been the primary concern for small software vendors. Those of us who have limited financial resources and small development staff have been worried that the fees and methodology of CCHIT would prevent us from obtaining certification for our products. Dr. David Kibbe, senior advisor to the American Academy of Family Physicians Center for Health IT is one of the critics. As reported by Neil Versel at FierceEMR, Dr. Kibbe believes that the cost and complicated nature of the CCHIT certification method stifles innovation and the development of new technologies.

    This announcement by ONC may well open the playing field significantly. Whether the stimulus funds are worth the cost to achieve “meaningful use” is a separate issue that eligible providers will need to determine for themselves. Since these incentives are largely aimed at primary care providers, not many behavioral health organizations are likely to be impacted or even eligible for funds. But we must assume that the move toward EMRs in the general medical world will increase the pressure upon behavioral health providers to follow suit.

    Parity Interim Final Rule Guidance Released

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    On January 29, 2010, the federal departments of Health and Human Services, Labor and Treasury released their “guidance” on the Wellstone-Dominici Mental Health Parity Act. The National Council discussed some of the contents of the Interim Final Rule (IFR) in their February 4 Public Policy Update. The IFR goes into effect April 5, 2010 and applies to policies with plan years that start on July 1 or later.

    Since some insurance carriers have already begun changes in their policies and claims filing procedures in an attempt to meet the requirements of law, it is possible that procedures just put in place may be changed. For example, Blue Cross/Blue Shield of Florida, a company that had a limit of 25 sessions per year for psychotherapy with no authorizations required for most plans, in January started to require authorization for all mental health services. According to the information provided by The National Council, this may need to change again.

    Group insurance plans for groups of 50 or more may need to carefully match how they manage medical/surgical and mental health/addictions benefits. It is not just the “quantitative limits” that must be the same; the “non-quantitative limit” also must be the same. The IFR forbids plans from using specific non-quantitative limits unless similar restrictions exist for medical/surgical benefits: medical management, prescription formulary design, “fail-first” or step therapies, and prior authorization.

    The National Council has continued discussion of the IFR in several articles on their web site. Take a look at their press releases, policy issues and resources, and slides and recording from a recent health care reform webinar. The National Council does a wonderful job of staying on top of and advocating for issues of this sort and should be on your radar all the time.

    The American Psychological Association also advocated strongly for this law and information about its implementation can also be found at the APA web site. More detailed and current information about the IFR has been shared with state psychological associations and should be available to APA members who are connected with the practice organization. The email I received through Florida Psychological Association contained a thorough analysis of the IFR along with examples and hypotheticals. A quick read of this article suggests that it will not be a simple matter for a provider or a consumer to determine if their insurance carrier is following the rule. I am hopeful that simpler guidelines will follow.

    Dr. Ronald Manderscheid’s article in Behavioral Healthcare Magazine suggests that this law is just the first step in our move toward parity in payment for mental health and substance abuse services. Four other doors need to be opened more widely to assure true parity: 1. the extension of insurance benefits to more individuals and the extension of the rule to more policies; 2. clear statement of what determines medical necessity for access to care; 3. improving scope and quality of the care accessed; and 4. expecting the outcome of care to be at least as good as in the medical/surgical realm. This law brings us a long way toward the goal of equity, but we as advocates have a long way to go to assure that consumers of mental health care can actually get the care they deserve.

    What effect do you think the parity law will have on your organization? Do you foresee a big impact or a small change? Please share your comments below.