November 1st, 2011

Health care reform offers options

The federal Patient Protection and Affordable Care Act remains under legal attack even while its provisions begin to take effect. While there’s plenty of information about the PPACA and behavioral health at the American Psychological Association Web site, among others, two health policy analysts with New England connections noticed that not much had been written in the popular press. So they compiled a three-page précis in The New England Journal of Medicine, published online Aug. 17, that lays out how health care reform will improve access to care and address system fragmentation – and describes the challenges that remain.

“We thought there was a gap to fill in informing the public about provisions of the law that specifically related to behavioral health,” says Colleen Barry, Ph.D., formerly of Yale and now at Johns Hopkins Bloomberg School of Public Health.

Haiden Huskamp, Ph.D., at the Harvard Medical School Department of Health Care Policy, says the federal Mental Health Parity Equity Act of 2008 got so much press in winning equal coverage for mental health and physical health that people overlook the fact that PPACA actually requires behavioral health services to be part of the essential benefits package offered by state-offered Medicaid-equivalent plans and the PPACA-mandated health insurance exchanges, due to be in place by 2014.

“Both pieces of legislation will bring dramatic changes and we think improvements for those with mental health and addiction disorders,” Huskamp says.

PPACA will extend coverage to 32 million more Americans, among them 5.4 million adults with mental health needs (according to Congressional Budget Office assumptions), via three main mechanisms: expanded insurance options, insurance market reform and redesigned delivery and payment systems.

Increased access will come from softened Medicaid eligibility, more employer-offered plans and the creation of subsidized state-based insurance exchanges to make it easier for individuals to enroll. Allowing dependents to remain on parental coverage until age 26 will also have an effect.

Insurance market reforms include prohibiting private health plans from rescinding coverage, from excluding those with preexisting conditions and from establishing annual and lifetime benefit limits. Plans must have an effective appeals process, establish consumer assistance offices and guarantee renewal.

Perhaps most exciting is that PPACA provides opportunities to better integrate behavioral health care and physical health care via primary care, accountable care organizations (ACOs), patient-centered medical homes and other delivery innovations that will allow psychologists to participate.

For example, the new state-based Medicaid “health home” option is already being rolled out to provide team-based services to people with multiple chronic conditions, including mental illness. Such services as care management, inpatient transitions and IT support, which haven’t traditionally been reimbursable, will be reimbursed by federal matching funds up to 90 percent.

In addition, Medicaid will support states to provide home- and community-based services to those who would be unable to live on their own without them and to support co-location of primary and specialty care in community behavioral health centers.

ACOs remain a concept that is currently being tested on a case-by-case basis for Medicare beneficiaries. The idea is that care follows the patient from setting to setting. Providers in those settings will be paid as a team with incentives for keeping patients healthy while reducing costs. For ACOs to be most effective, behavioral health care must be included.

“It can be as simple as making sure behavioral health has representation on the governing board of an ACO on the consumer or provider side or both, and to make sure performance benchmarks that give bonuses to high performers include measures around mental health and addiction care,” Barry says.

Peter Newbould, APA director of congressional and political affairs, who spent eight years getting the parity law passed, says that while integrated care is designed to get physicians talking to each other, psychology has a huge role to play in ameliorating illnesses that have behavioral components like diabetes and heart disease.

“Psychologists are no longer going to be providing services using codes. It goes beyond the frame of psychotherapy for 50 minutes,” Newbould says. “The paradigm of psychologists working on coordinated interdisciplinary teams will lead to the recognition and value of assisting patients in this way.”

Along with the focus on integrated care may come a new mindset for psychologists to be team players.

“There may be pressure to be less of a stand-alone provider and to build connections with other sectors of the health care delivery system,” Barry says. “It’s happening across all of health care and mental health providers are not exempt.”

Other provisions relevant to psychologists, according to the APA, include $10 million in grants to accredited doctoral, internship and postdoctoral training programs to help expand the psychology work force; elimination of co-pays for eligible preventative health services that address depression, postpartum disorder and elder abuse; and for the Preventive Services Task Force to consider best practices presented by scientific organizations, including the APA, when developing recommendations.

The analysts say health care reform offers opportunities to benefit both behavioral health care providers and consumers.

“Hopefully, we can figure out as a society how to take advantage of the opportunities and further improve care,” Huskamp says.

“Our members are dealing with a marketplace that all too often has undervalued their services,” Newbould says. “We hope that along with the implementation of new methods and programs will be a greater understanding of the value of psychological services.”

By Nan Shnitzler

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