Improving Public Health, Transforming Communities. Jose Belardo Regional Health Administrator, Region 7 U.S. Department of Health and Human Services

Transcription

1 Improving Public Health, Transforming Communities Jose Belardo Regional Health Administrator, Region 7 U.S. Department of Health and Human Services

2 Office of the Assistant Secretary of Health (OASH) The Office of the Assistant Secretary for Health oversees 14 core public health offices including the Office of the Surgeon General and the US Public Health Service Corps as well as 10 regional health offices across the nation and 10 Presidential and Secretarial advisory committees.

3 Assistant Secretary for Health Howard K. Koh, MD, MPH Larger Portrait (940 KB)

4 18 th Surgeon General of the United States Regina M. Benjamin, MD, MBA

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6 The National Quality Strategy Ø HHS adopted the strategy in March 2011with three broad goals: Ø Better Care: Ø Improve the quality of care by making health care more outcome-based, reliable, accessible and safe Ø Healthy People/Healthy Communities: Ø Improve the health of the U.S. population by addressing behavioral, social and environmental determinants of health Ø Affordable Care: Ø Reduce the cost of quality health care for individuals, families, employers and government

7 Affordable Care Act Overview n Creates Consumer Protections n Prevents denials of coverage for pre-existing conditions n Make health insurance affordable for middle class families and small businesses with tax credits n Expands access to care through Exchanges and Medicaid expansion

8 Enrollment in the Insurance Marketplace Enrollment in Context Enrollment : October 2013 to March 2014 Outreach and Marketing: Building On Past Efforts Key outreach and Education

9 Enrollment in the Insurance Marketplace Consumer Assistance

10 Top Priorities Ø HHS adopted 6 priorities: Ø Make care safer by reducing harm caused in the delivery of care Ø Engage each person and family as partners in their own care Ø Promote effective communication and coordination of care Ø Promote the most effective prevention and treatment practices, starting with cardiovascular disease Ø Promote wide use of best practices to enable healthy living Ø Develop new delivery models to make quality care more affordable for individuals, families, employers and government

11 Emphasizing Prevention Ø The Problem: Ø Americans receive only about half the clinical preventive services that are recommended Ø In Region 7, the percentages are even lower: Ø Iowa: 43 percent Missouri: 42 percent Ø Kansas: 41 percent Ø The Solution: Nebraska: 39.5 percent Ø Most private health insurance plans are now required to cover a wide range of preventive services with no co-pay, no deductible and no out-of-pocket cost Ø 2,601,000 residents in Region 7 s four states became eligible in 2011 Ø Beginning Jan. 1, 2011, Medicare covers preventive care with no co-payments or deductibles

12 Improving Public Health for Individuals No-cost preventive services include: Ø Mammograms Ø Colonoscopies Ø Pap smears Ø vaccinations for flu, tetanus, HPV, pertussis polio, measles, hepatitis A&B Ø help quitting tobacco Ø No-cost screenings for: Ø osteoporosis high blood pressure depression Ø diabetes substance abuse anemia Ø obesity high cholesterol HIV In 2011: Ø Ø 729,809 seniors in Missouri received at least one free preventive service through Medicare 1,102,000 Missourians received access to free preventive care through private insurance

13 Prevention & Public Health Fund Ø Provides $15 billion over 10 years as an ongoing investment in prevention and public health Ø Funding supports: Ø illness-prevention research Ø health screenings Ø public health initiatives Ø immunization programs Ø Funding levels: Ø FY 2010 $500 million; Ø FY $750 million; Ø Rises each year to $2 billion a year from 2015 through 2019

14 Public Health Workforce Grants $48 million in grants to improve public health Ø $23 million awarded by HRSA to 37 Public Health Training Centers Ø Goals: Ø provide training to current and future public health workers Ø expand competency in nutrition and epidemiology Ø enhance the workforce s basic public health skills with emphasis on prevention, health promotion and improving access and quality in underserved areas Ø Grants in Region 7: Ø $650,000 to University of Iowa for the Upper Midwest Public Health Training Center Ø $650,000 to University of Nebraska Medical Center for the Great Plains Public Health Training Center Ø $25 million awarded by the Centers for Disease Control and Prevention to place fellows in state and local public health departments nationwide Ø 227 new fellows placed in contract and field positions to provide screening services and community education

15 Community Transformation Grants Ø Grants are open to state and local governments and to community groups to: Ø develop preventive activities to reduce chronic disease Ø address health disparities Ø develop stronger evidence of programs that really work Ø Ø Ø $510,199 for the Douglas County Health Department in Nebraska Ø Funding will be used to encourage tobacco-free living and healthy eating and to improve chronic disease management in the Omaha area $705,708 for Mid-America Regional Council in Kansas City Ø Funding will promote tobacco-free outdoor venues, encourage health eating and physical activity in schools and improve training in diabetes care $3,007,856 for the Iowa Department of Public Health Ø Funding used to encourage smoke-free public housing projects, improve school meals nutrition content and improve treatment of high blood pressure and high cholesterol

16 Small Community Transformation Grants Ø $70 million awarded to 40 communities in September 2012 Ø These are designed to prevent chronic disease and promote health in neighborhoods, school districts, villages, towns, cities, and counties with fewer than 500,000 residents Ø 2 grants were awarded in Region 7: Ø Ozarks Regional YMCA in Springfield, Mo. Ø $1,319,403 to serve 159,000 residents, focusing on low-income residents Ø promote healthy eating and active living Ø encourage tobacco-free living Ø expand access to and use of clinical and preventive services Ø creating a safer built environment Ø YMCA of Wichita, Kan., and the Wichita Health & Wellness Coalition Ø $2,461,198 to serve 382,000 residents with focus on low-income communities Ø promote a healthy environment Ø encourage healthy eating Ø promote tobacco-free living

17 Maternal, Infant and Childhood Home Visiting Ø Grants to Missouri state government: $3.7 million Ø Voluntary program for pregnant women or those with children birth to age 5 Ø Nurses, social workers or other professionals assess the need for improved health care, developmental services, early education, parenting skills, child abuse prevention and nutrition education or assistance Ø The program attempts to: Ø improve maternal and child health Ø prevent of child injuries, child abuse, or maltreatment Ø reduce emergency department visits Ø improve school readiness and achievement Ø reduce crime or domestic violence Ø A new round of grants for nonprofit agencies is now open Ø Applications will be accepted until Jan. 22, 2013

18 RICH HISTORY & MANY ACHIEVEMENTS CHALLENGES & OPPORTUNITIES REMAIN è BH affects most Americans; o1en co- exists with other health condi8ons yet s8ll o1en seen as social/moral issue è Increases risks for other diseases (e.g., HIV/AIDS) è High propor8on of pediatric visits and community hospital stays, as well as readmissions è High impact of dispari8es (race, gender, ethnicity, LGBT, poverty) & social issues (homelessness, jails, child welfare) è High # of BH related deaths; premature death and preventable illnesses 18

19 PREVALENCE OF BH CO- MORBIDITIES (MEDICAID- ONLY BENEFICIARIES W/DISABILITIES) Asthma and/or COPD CongesIve Heart Failure Coronary Heart Disease 23.8% 30.1% 26.3% 76.2% 69.9% 73.7% Diabetes 32.1% 67.9% Hypertension 31.4% 68.6% No Behavioral Health Problem With 1 or More Behavioral Health Problem Boyd, C., Clark, R., Leff, B., Richards, T., Weiss, C., Wolff, J. (2011, August). Clarifying Mul8morbidity for Medicaid Programs to Improve Targe8ng and Delivering Clinical Services. Presented to SAMHSA, Rockville, MD.

20 SURGEON GENERAL S NATIONAL STRATEGY FOR SUICIDE PREVENTION è Every year, over 11 million Americans seriously consider taking their own lives; over 38,000 died from suicide in 2010 è Almost 2.5 million Americans > 14 yrs are distressed enough to actually a`empt it è America loses ~100 people every 24 hours not to ba`les of war or acts of terrorism, not to natural disasters, but to incredibly sha`ering act of suicide è NSSP developed with input from survivors of suicide a`empt and suicide loss; released 9/10/12 on World Suicide Preven8on Day

21 THE PATH FORWARD: MHPAEA/PARITY AND AFFORDABLE CARE ACT (ACA) 21

22 UNDERSTANDING MHPAEA & PARITY 22 è October 3, 2008: Paul Wellstone and Pete Domenici Mental Health Parity and Addic8on Equity Act of 2008 (MHPAEA) è HHS, DOL and Treasury Federal regula8ons issued to implement are now effec8ve (as of 2010) for all plans covered by MHPAEA è MHPAEA does not require group health plans to cover M/SUDs è Requires group health insurance plans that do offer coverage for M/SUDs to provide those benefits in a way that is no more restric8ve than all other medical and surgical (Med/Surg) procedures covered by the plan Covered at levels no lower than the levels of other Med/Surg benefits offered by the plan Treatment limita8ons no more restric8ve than other offered benefits

23 WHO IS COVERED BY MHPAEA? è Insurance plans sponsored by private and public sector employers with more than 50 employees (large groups) 23 è Plans that choose to offer a mental health and/or substance use benefit Employers/plans can choose to not cover specified diagnoses è Medicaid managed care programs è Children's Health Insurance Reauthoriza8on Act (CHIPRA) è In total, approximately 150 million Americans

24 WHO IS NOT COVERED BY MHPAEA? è Employer groups 50 and under in size (small groups) 24 è Individual insurance plans (individual market) è Medicaid plans not covered by managed care è Medicare è State and local government plans reques8ng exemp8on è Covered employer group plans that can prove a1er implemen8ng their costs have increased by >2% for 1 yr

25 PARITY IN AFFORDABLE CARE ACT 25 è Affordable Care Act (ACA) embraces and goes beyond MHPAEA to create broader parity è Iden8fied services that must be included In non- grandfathered plans; In individual and small group markets; Inside and outside of insurance exchanges (qualified health plans or QHPs); and In benchmark and benchmark- equivalent plans in Medicaid expansion Beginning in 2014

26 ESSENTIAL HEALTH BENEFITS (EHBs) Ambulatory pa8ent services 2. Emergency services 3. Hospitaliza8on 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescrip8on drugs 7. Rehabilita8ve and habilita8ve services and devices 8. Laboratory services 9. Preven8ve and wellness services and chronic disease management 10. Pediatric services, including oral and vision care

27 IN 2014: MILLIONS MORE AMERICANS WILL HAVE HEALTH COVERAGE OPPORTUNITIES è Currently, 37.9 million are uninsured < 400% FPL* 18.0 M Medicaid expansion eligible 19.9 M ACA exchange eligible** M (29%) Have BH condi8on(s) 27 * Source: 2010 NSDUH **Eligible for premium tax credits and not eligible for Medicaid

28 PREVALENCE OF BH CONDITIONS AMONG MEDICAID EXPANSION POP Uninsured Adults Ages with Incomes < 138% FPL (18 Million) 18.0% 28 Percent with Condition 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 7.0% 14.9% 14.2% 4.0% Percent with a Serious Mental Illness (1,283,000) CI: 6.3%-7.7% Percent with Serious Psychological Distress (2,731,742) CI: 14.0%-15.9% Percent with a Substance Use Disorder (2,603,405) CI: 13.2%-15.2% CI = Confidence Interval Sources: Na8onal Survey of Drug Use and Health 2010 American Community Survey

29 PREVALENCE OF BH CONDITIONS AMONG EXCHANGE POPULATION Uninsured Adults Age with Incomes between % FPL (19.9 Million) % Percent with Condition 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 6.0% 13.3% 14.6% 4.0% Percent with a Serious Mental Illness (1,195,600) CI: 5.5%-6.6% CI = Confidence Interval Sources: Na8onal Survey of Drug Use and Health 2010 American Community Survey Percent with Serious Psychological Distress (2,650,247) CI: 12.4%-14.2% Percent with a Substance Use Disorder (2,909,294) CI: 13.7%-15.6%

30 SIMPLE STREAMLINED APPLICATION PROCESS Now è Different applications for different programs è Denied? Back to the drawing board è Applications often only available on paper or as PDFs if online è In-person interview requirements 2014 è A single application as gateway to all coverage programs è Must be available online, by telephone through a call center, by mail, and in person è Interview requirements prohibited 30

31 IN 2014: MILLIONS MORE AMERICANS WILL HAVE HEALTH COVERAGE OPPORTUNITIES è Currently, 37.9 Million Are Uninsured <400% FPL* 18.0 M Medicaid expansion eligible 19.9 M ACA exchange eligible** M (29%) Have BH conditon(s) h`p:// Source: 2010 NSDUH **Eligible for premium tax credits and not eligible for Medicaid

32 PARITY/ACA: PROJECTED REACH Individuals who will gain MH, SUD, or both benefits under the ACA including federal parity protecions Individuals with exising MH and SUD benefits who will benefit from federal parity protecions Total individuals who will benefit from federal parity protecions as a result of the ACA Individuals currently in individual plans Individuals currently in small group plans Individuals currently uninsured 3.9 million 7.1 million 11 million 1.2 million 23.3 million 24.5 million 27 million n/a 27 million Total 32.1 million 30.4 million 62.5 million NOTE: These esimates include individuals and families who are currently enrolled in grandfathered coverage Source: ASPE Research Brief, February 2013

33 WHY BEHAVIORAL HEALTH MATTERS TO PUBLIC HEALTH - 2 High Impact on Health Systems Prac8ce and Costs ~ ¼ of pediatric visits and community hospital stays ~ 1/5 of ER visits involve illicit drugs (21 percent) or alcohol (19 percent) 2010: Medicare spent 5 x more on beneficiaries age 65+ w/smi & SUDs than similar beneficiaries w/out these diagnoses 2010: Of Medicare beneficiaries w/out SMI, 17 percent were hospitalized; 46 percent of those w/smi diagnosis; 88 percent of those with SMI/SUDs

34 WHY BEHAVIORAL HEALTH MATTERS TO PUBLIC HEALTH - 3 High # BH- Related Premature Deaths/Preventable Illnesses Persons w/bh condi8ons die 8+ years younger, mostly from preventable health issues Half of all tobacco deaths occur among those w/bh condi8ons More deaths from suicide than HIV/AIDS and traffic accidents combined; plus breast cancer for all BH- related deaths

35 WHY BEHAVIORAL HEALTH MATTERS TO PUBLIC HEALTH - 4 High Impact of Dispari8es (race, gender, ethnicity, LGBT, poverty) and Social Issues/Costs (homelessness, jails, child welfare) Most homeless and jailed individuals have BH needs; rela8vely few receive treatment; most are in or released to the community LGBT popula8on elevated rates of tobacco use, certain cancers, depression and suicide deaths/a`empts Majority of foster children have drug- involved parents Ethnic minori8es more likely to be uninsured, have rates of certain disorders or incidence (e.g., suicide, drinking) Persons with BH needs more likely to be uninsured and to churn, crea8ng issues within the health delivery system

36 WHY DOES IT MATTER? Public sees social consequences of behavioral health rather than health consequences Homelessness, gangs, jails, tragedies (e.g., mass casualty shoo8ngs), disability, lost produc8vity, high government costs M/SUDs seen as ma`er of will instead of diseases or condi8ons to be prevented, treated and recovered from Compare diabetes not just about ea8ng choices Universal Knowledge of First Aid for Health Condi8ons; Don t Teach or Know Signs, Symptoms, How to Get Help for MH or SA Issues

37 Health Literacy in the U.S. Adult Health Literacy Levels 12% 14% 21% Below Basic Basic Intermediate Proficient 53% Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

38 Defining Health Literacy The degree to which individuals have the capacity to obtain, communicate, process, and understand basic health information and services needed to make appropriate health decisions.

39 CONSUMER ENROLLMENT è Navigator Func8ons ASSISTANCE IN ACA Include at least one consumer- focused non- profit Maintain exper8se in eligibility and enrollment and facilitate enrollment in QHPs Conduct public educa8on ac8vi8es to raise awareness about the state s exchange Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman 39

40 SAMHSA ENROLLMENT ACTIVITIES è Consumer enrollment assistance subcontracts (BRSS TACS) Outreach/public educa8on Enrollment/re- determina8on assistance Plan comparison and selec8on Grievance procedures Eligibility/enrollment communica8on materials è Learning collabora8ves in AZ, CA, ME, MD, MO, NM, NY, VT è Enrollment assistance best prac8ces TA Toolkits è Communica8on strategy message tes8ng, outreach to stakeholder groups, webinars/training opportuni8es 40

41 ENROLLMENT ASSISTANCE OPPORTUNITIES 41

42 BH AND PRIMARY CARE INTEGRATION: SAMHSA, HRSA, AHRQ, CMS/CMMI Joint or Coordinated Products, TA, Grants Models of Integrated Care Primary SBIRT approach; integrated care approach Specialty Before, A1er or AS primary care Clinical Prac8ce Issues Capacity Workforce competencies System issues Office flow issues Payment Financing Cost Issues Metrics re Value (Quality and Cost)

43 SAMHSA/HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS (CIHS) è Goal: Promote planning and development of integrated PC and BH care for those w/smi and/or addic8on disorders, whether seen in specialty or PC sengs (bi- direc8onal) è Purpose: Serve as a na8onal training and technical assistance center on bi- direc8onal integra8on of PC and BH care and related workforce development needs

44 SAMHSA s WORK WITH OTHER FEDERAL PROGRAMS AHRQ Center for IntegraIon Models: Developing models of integrated BH care in primary care sengs CMS/CMMI InnovaIve Financing Models for IntegraIon: Grants to test models è SAMHSA S Primary/BH IntegraIon (PBHCI) Grants: Physical health of adults w/ SMI and TA for bi- direc8onal integra8on è HRSA FQHCs: Integra8ng BH screening, brief interven8on and treatment è Medicare Accountable Care OrganizaIons: Payment for integrated care and outcomes è CMS Health Homes: Whole person care for persons with specific characteris8cs or health condi8ons è CMS Partnership for PaIents: Reducing hospital readmissions; increasing quality

45 HHS/SAMHSA VISION è A Na8on that Acts on the Knowledge that: Behavioral health is essen8al to health Preven8on works Treatment is effec8ve People recover A naton of communites free of substance abuse and mental illness and fully capable of addressing behavioral health issues that arise from events or physical conditons