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.
- No discrimination against children with pre-existing conditions.
- No rescissions based on developing an illness.
- No lifetime limits on coverage.
- Tightly regulated annual limits on coverage.
In addition, for those who are currently uninsured, the law mandates:
- Immediate help for those with pre-existing conditions (an interim high-risk pool).
- 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:
- 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.
- 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.
- 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.
Chris White says:
It will be interesting to see if the efforts of integrating Primary care with Behavioral health from an infrastructure and software standpoint (NHIN connect, HIE’s, RHIOs, etc..) will encourage specialty providers to remain independent. In most of your examples, the path to remaining competitive relies on BH providers to merge with large hospital systems, BUT integrating technologies “should” allow for care coordination and data sharing across specialties. It will be a shame if all CBHOs are driven out of business by large hospitals. Thanks for a very thought-provoking article.
Kathy says:
Thanks for your comment, Chris. I attended a webinar on Integrated Care hosted by CIMH yesterday. One of the speakers was from the National Council and the other from Kaiser Permanente. Most of what they focused on was the public behavioral health and substance use world rather than the arena of private healthcare. The models they discussed included some referral and consultation back and forth between the physical and BH realm (which would be supported by the NHIN), but seemed to me mostly focused on co-located services. I agree that it will be interesting to see what happens. I think payment models will control it. If the “Medical Home” pilots turn out to demonstrate major cost savings, I think that is the way care will go. If they do not, there will be more room for variety. In the public arena, I think we will have co-located services almost exclusively, and that we will have them within the next ten years. I will be curious to see if they fall mostly on the physical health side or on the CBHO side in terms of initiation of the integration. Time will tell…
Dave Zachau says:
Thanks for the ideas to start considering as Health Care Reform prepares to ramp up. Yes, in Ohio we have community mental health boards,but each county has a “Mental Health Network” of community agencies made up of mental health agencies that are accredited by bodies like CARF. The agencies are business competition for the private practices in the community. Historically, the agencies have treated the indigent and the private practices have focused on insurance carrying clients. The only way for our private practice to work with the local mental board would be to become a community mental health agency. We have considered that, but the burden of obtaining CARF certification struck us as overwhelming. So, it would come down to the old saying, “if you can’t beat ’em join ’em.” Perhaps there is some way to work collaboratively, but the current environment is not set up that way for us. On the other hand, the hospital idea is an interesting one. Thanks again for the ideas.
Dave Zachau says:
As a private practice provider I am interested in being a competitor in the new system. What do you mean by “deep pockets and managing the whole range of health care services” as related to being better positioned to compete? Wanting to position ourselves optimally, what are some ways to better perform in an Integrated Care setting?
Kathy says:
Hi Dave,
First, it is useful to remember that most mental health services are provided in the public/community system rather than in private practices.
Second, as I understand what the National Council is saying, they believe that healthcare organizations with significant financial resources and who already provide general and specialty healthcare services will be in the best position to compete within the new system. Since Medicaid will ultimately be significantly expanded because of the changed thresholds for coverage, and since parity will make more insurance dollars available for mental health and addictions care, there will be more organizations/systems who will want to go after those dollars by providing behavioral health services along with the general health services they already provide.
An organization like Kaiser-Permanente is already perfectly positioned. Imagine more such systems springing up. A large hospital system buys the private practices of some of the docs on staff and starts to utilize only the family practitioners and specialists (including behavioral health) within their system, but in a much more integrated, coordinated care sort of way. Perhaps they would even use the same EMR and have access to the patient’s record for all providers who care for them.
In the public setting, they see public health organizations adding behavioral health and addiction treatment, at the same time that community behavioral health organizations are forming connections with public health organizations/clinics so they can provide integrated care.
I think those in private practice who want to participate need to start paying close attention to what is happening locally and become involved. What that means will vary from community to community. Ohio, for example, has county community mental health boards. That is where I would start to look for activity and changes. If Ohio law allows non-physician staff privileges at your local hospital, you might look into that. You might also consider attending some of the National Council webinars on healthcare reform to get an ongoing look at the bigger picture.
Hope this makes some sense. I would love to hear what others think might be useful moves.