Navigating the ACA: Got Data? Peter J. Delany, Ph.D., LCSW-C RADM, U.S. Public Health Service...
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Transcript of Navigating the ACA: Got Data? Peter J. Delany, Ph.D., LCSW-C RADM, U.S. Public Health Service...
Navigating the ACA: Got Data?
Peter J. Delany, Ph.D., LCSW-CRADM, U.S. Public Health ServiceDirector, Center for Behavioral Health Statistics and QualitySubstance Abuse and Mental Health Services AdministrationRockville, Maryland
Innovations in RecoveryCoronado, CaliforniaMarch 31, 2015
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About SAMHSA
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services (HHS) that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.
One morning, a villager decided to walk along the river on her way to work. As she was enjoying the view, she noticed a crying infant in the river. Horrified by the sight of a helpless child in such a dangerous predicament, the villager dove into the water, grabbed the baby, and brought him ashore. The baby, although afraid and soaking wet, was fine.With a sigh of relief, the villager wiped the water from her own eyes and looked out on the river.
As she tried to warm the baby with her jacket, she heard more crying. She looked out over the river only to see another baby in the water. Once again, she dove into the water and rescued this baby as well. Not a minute had passed before she heard more crying, and looking out over the river, she spotted dozens more babies.
Calling out for help she was soon joined by the entire community, and together they rescued as many babies as they could. But the babies kept on coming ....
After half an hour or so, a group of villagers decided to go upstream to find out why the babies were in the river in the first place. Upstream, they found an ogre, tossing babies into the water!
When the villager called her neighbors to the river, she mobilized community. Going upstream and confronting the ogre is creating a lasting change in the condition that causes the problem. Creating lasting change is what we endeavor to do. We need to focus on "keeping the babies out of the river" in the first place. If we don't, we will be pulling babies out of the river forever.
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About CBHSQ
The Center for Behavioral Health and Statistics and Quality (CBHSQ) is the government’s lead agency for behavioral health statistics. CBHSQ:• Provides national leadership in behavioral health statistics and
epidemiology• Promotes basic and applied research in behavioral health data systems
and statistical methodology• Designs and carries out special data collection and analytic projects to
examine issues for SAMHSA and other federal agencies• Participates with other federal agencies in developing national health
statistics policy• Consults and advises SAMHSA’s Administrator and the HHS Secretary on
statistical matters
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National Survey on Drug Use and Health (NSDUH)
• NSDUH is an annual data collection that is the primary source of information on the prevalence, patterns, and consequences of alcohol, tobacco, and illegal drug use and abuse, as well as mental disorders, in the U.S. civilian, noninstitutionalized population, aged 12 or older.
• Used to generate national, state, and substate estimates• Selected data collected include:
• Lifetime, past year, and past month prevalence of alcohol, illicit drugs, and tobacco
• Past year substance use disorders• History of substance use treatment• Age at first use of substances• Risk and protective factors for
youth substance use
• Past year any mental illness, serious mental illness, and suicidal thoughts/plans for adults aged 18 or older
• Past year mental health treatment for adults aged 18 or older
• Past year Major Depressive Episode (MDE) for adults and for youth aged 12 to 17
SAMHSA Data Collections
National Survey of Substance Abuse Treatment Services (N-SSATS)• N-SSATS is an annual, survey of all known substance abuse
treatment facilities, both public and private.• Selected data collected include :
• Facility operation• Types of services offered (e.g.,
assessment and testing services) • Opioid treatment programs • Medications dispensed or
prescribed• Counseling and therapeutic
approaches• Special programs or groups
• Type of treatment provided• Number of clients• Types of payment accepted• Availability of sliding fee scale• Facility accreditation and licensure• Managed care agreements• Facility focus (e.g., substance
abuse, mental health)• Facility ownership
SAMHSA Data Collections
National Mental Health Services Survey (N-MHSS)• N-MHSS is an annual survey of all known mental health
treatment facilities in the United States, both public and private. N-MHSS began in 2010.
• Selected data collected include in 2010:• Facility information• Facility ownership• Single-day count of clients /
patients by type of service• Supportive services offered• Mental health treatment
approaches• Special programs or groups• Age categories served
• Languages in which treatment is provided
• Type of treatment provided• Types of payment/funding
accepted• Sliding-fee scale or other types of
payment assistance
SAMHSA Data Collections
Treatment Episode Data Set (TEDS)• TEDS is an annual data collection that tracks the national flow of
admissions and discharges to specialty providers of substance abuse treatment. The collection has been ongoing since 1992.
• Selected data collected include: • Client demographic characteristics• Health insurance status• Expected source of payment• Employment status • Type of service at
admission/discharge • Number of prior treatment episodes• Number of arrests in past 30 days
• Injection drug use for up to three substances of abuse
• Age of initiation for up to three substances of abuse
• Past 30 day use for up to three substances of abuse
• Principal source of referral• Presence of co-occurring mental
health disorders
SAMHSA Data Collections
SAMHSA’s Emergency Department Surveillance System (SEDSS)• As part of the new National Hospital Care Survey conducted
by the National Center for Health Statistics, SAMHSA will publish data on drug- and mental health- related visits to emergency departments as SAMHSA’s Emergency Department Surveillance System (SEDSS).
• Published data are expected in 2016.
Substance Abuse and Mental Health Data Archive
A resource that our lead statistician for data policy calls a “health data-palooza”
CBHSQ contracts with University of Michigan to host the SAMHDA website
Access at: http://www.datafiles.samhsa.gov
More than 400 behavioral health data sets
Public-use data files, file documentation, online analysis tools, plus restricted-use and confidential data file
Substance Abuse and Mental Health Data Archive
Drug Abuse Warning Network (DAWN)
National Survey on Drug Use and Health (NSDUH)
National Survey of Substance Abuse Treatment Services (N-SSATS)
Treatment Episode Data Set—Admissions and Discharges (TEDS-A & TEDS-D)
National Mental Health Services Survey (NMHSS)
Other archived studies available (e.g. NYS)
Substance Abuse and Mental Health Data Archive
Three No-Cost Avenues of Access Public-use files
No log-in required
R-DAS (Restricted-use Data Analysis System) Log-in account required
Data Portal (this is changing) Log-in account required Verification of approved IP address Unique username and password MToken
Substance Abuse and Mental Health Data Archive
For assistance with this archive, contact our “data-palooza” statistician—she has all the information.
Brooklyn [email protected]
(240) 276-0532
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Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2013
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
Illicit Drugs
Marijuana
CocaineHallucinogens
Psycho-therapeutics
Percent Using in Past Month
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Past Month and Past Year Heroin Use among Persons Aged 12 or Older: 2002-2013
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
Past Year
Past Month
Numbers in Thousands
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Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing
but Not Receiving Treatment for Illicit Drug or Alcohol Use: 2013
20.2 Million Needing but Not Receiving Treatment for Illicit Drug or Alcohol Use
Felt They Needed Treatment and Did
Make an Effort
Did Not Feel They Needed Treatment Felt They Needed
Treatment and Did Not Make an Effort
1.6%2.9%
95.5%
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Reasons for Not Receiving Substance Use Treatment among Persons Aged 12 or Older Who Needed and Made an Effort to Get Treatment
but Did Not Receive Treatment and Felt They Needed Treatment: 2010-2013 Combined
Percent Reporting Reason
No Health Coverage and Could Not Afford Cost
Not Ready to Stop Using
Had Health Coverage but Did Not Cover Treatment or Did Not Cover Cost
Did Not Know Where to Go for Treatment
No Transportation/Inconvenient
Might Have Negative Effect on Job
Could Handle the Problem without Treatment
Did Not Feel Need for Treatment at the Time
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Past Year Substance Use Disorders and Serious Mental Illness among Adults Aged 18 or Older: 2013
SMI = serious mental illness; SUD = substance use disorder.
SUD,No SMI
17.9 Million
SUD and SMI
7.7 Million
20.3 Million Adults Had SUD
10.0 Million Adults Had SMI
2.3 Million
SMI,No SUD
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NSDUH Short Reports
• This short report summarized key state-level mental illness findings from the 2011 and 2012 NSDUHs.
• Among the key findings:– The percentage of adults aged
18 or older with serious mental illness in the past year ranged from 3.1 percent in New Jersey to 5.5 percent in West Virginia.
– Nationally, 42.5 million adults experienced any mental illness in the past year; the rates ranged from 14.7 percent in New Jersey to 22.3 percent in Utah.
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NSDUH Data Spotlights
• Using combined 2011 to 2012 NSDUH data, this Data Spotlight indicated that 8.5 percent of pregnant women aged 15 to 44 drank alcohol in the past month; 2.7 percent binge drank.
• Alcohol use was lower during the second and third trimesters than during the first (4.2 and 3.7 percent vs. 17.9 percent).
• These findings suggest that many pregnant women are getting the message and not drinking alcohol.
Health Services Research
• Examines how people get access to health care providers and health care services
• How much care costs• What happens to patients as a result of this care• How social factors, financing systems, organizational
structures and processes, technology, and personal behaviors affect access to treatment, quality and cost of care, and quantity and quality of life
Health Services Research
How SAMHSA does behavioral health services research:• The aim is to perform health services research that
can be applied by providers, policy makers, and programs to make decisions about behavioral health prevention and treatment
• The principles of health services research to behavioral health prevention and treatment
Evaluation
The Quality, Evaluation, and Performance (QEP) Branch in CBHSQ, composed of 6 evaluation desk officers, has worked closely with 26 program evaluations with the potential for providing support to a number of other evaluations that are being considered or planned. In addition to program-specific work, Branch staff coordinate some SAMHSA-wide activities, such as the evaluation of the diverse portfolio of SAMHSA behavioral health mobile applications.
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PREVALENCE OF BH CONDITIONS AMONG UNINSURED ADULTS AGES 18-34 WITH INCOMES <400% FPL
44.0% SMI/ SPD/ SUD
56.0%
“Behavioral Health Conditions” includes serious mental illness (SMI), serious psychological distress (SPD) and
substance abuse disorders (SUD)
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PREVALENCE OF BH CONDITIONS AMONG UNINSURED ADULTS AGES 35 AND OVER WITH INCOMES <400% FPL
23.8%SMI/ SPD/ SUD
76.2%
“Behavioral Health Conditions” includes serious mental illness (SMI), serious psychological distress (SPD) and substance abuse
disorders (SUD)
The Impact of Policy on Health Care Delivery Today
Many health and health-related policies affect health care delivery. Some examples: Reportable events/conditions, such as animal bites,
interpersonal violence, anthrax exposure, death, etc. HIPAA
Some policies are specifically related to or have important linkages to behavioral health: Parity legislation (MHPAEA) Patient Protection and Affordable Care Act (ACA)
Parity Before ACA: The Mental Health Parity and Addiction Equity Act of 2008
MHPAEA requires that financial requirements and treatment limitations for mental health/substance use disorder benefits be no more restrictive than for essentially all other benefits
Applies to plans sponsored by private and public sector employers with more than 50 employees
Supplements Mental Health Parity Act of 1996 (MHPA), which required parity on annual and lifetime coverage costs
MHPAEA Limitations
Act provides significant new protections to participants in group plans…but MHPAEA does not mandate that a plan provide MH/SUD benefits
Also…does not apply to policies for employers with 50 or fewer employees, or to individual policies
Patient Protection and Affordable Care Act
December 24, 2009
Promotes improved access to health care coverage and health services
Many items specific to Medicare and Medicaid
ACA expected to: Improve quality in health care Lower costs over time, or at least stabilize costs
Patient Protection and Affordable Care Act
Key Issues Addressed
Preventive health care
Integrated health care
Quality care
Dependent coverage
Minimum standards
Parity
Patient Protection and Affordable Care Act
Mental Health Parity ACA builds on MHPAEA to extend federal parity
protections to 62 million Americans
Requires MH/SUD benefits for millions of Americans in individual and small-group markets
Expands parity to apply to millions whose coverage did not previously comply with those requirements.
Patient Protection and Affordable Care Act
Payers and Quality Providers must be accredited on local performance
Judged on clinical quality measures such as: Healthcare Effectiveness Data and Information Set Patient experience ratings Consumer access Credentialing Network adequacy Handling of complaints, etc.
Patient Protection and Affordable Care Act
Prevention Services and Efforts
PreSmoking cessation
Weight management
Stress management
Physical fitness
Nutrition
Heart disease prevention
Healthy lifestyle support
Diabetes prevention
Patient Protection and Affordable Care Act
Chronic Conditions
Mental health
Substance use disorder
Asthma
Diabetes
Heart disease
Overweight (BMI>25)
Patient Protection and Affordable Care Act
Important Points
Does not remove obligation to provide emergency services
Still different tiers (Bronze, Silver, Gold) in levels of insurance—important to remember in considering access issues
Patient Protection and Affordable Care Act
What Does This Mean for Clinical Practices? Often a clinical context
Data usually associated with the event, condition, or activity
Provides an opportunity to understand Events leading up to a health situation Time-related context of the health situation Prevalence and incidence Outcomes Intervention potential
Patient Protection and Affordable Care Act
How does health policy—in particular ACA—affect clinical care and care transformation?
How can research and evaluation improve and inform the field?
Behavioral Health Care
Those of us in behavioral health services must seize all opportunities
for translating policy into practice and research
Behavioral Health Care Treatment and Cost
How many uninsured (pre-ACA) American adults received treatment? According to the National Survey of Drug Use and
Health (2009-2011), there were 37 million uninsured Americans between the ages of 18 and 64
Of that group, it is estimated that 3.9 million received any behavioral health treatment
Behavioral Health Care Treatment and Cost
How many of the previously uninsured are likely to seek behavioral health treatment within Medicaid or health insurance exchanges (ACA)?
Prior to ACA, estimated that 1.5 million uninsured with incomes at or below 138% of the federal poverty level had behavioral health treatment Estimated that an additional 1.2 million will have behavioral health treatment under
Medicaid/ACA
Prior to ACA, estimated 2.2 million with incomes above 138% of the poverty level had behavioral treatment Estimated that an additional 1 million will have behavioral health treatment under
Medicaid/ACA
Source: National Survey of Drug Use and Health (2009-2011)
Behavioral Health Care Treatment and Cost
Income at or below 138% FPL: Behavioral health: $2,100 All health: $9,400
Income 138-400% FPL: Behavioral health: $1,600 All health: $8,500
Among those who do not use behavioral health treatment services, regardless of income, the annual health care cost is approximately $3,000.
Source: Medical Expenditure Panel Survey (2009-2010)
The Challenges
Can health systems help to improve what we know about the cost of care delivery for patients with psychiatric and other behavioral health conditions?
Is there a capacity—given the availability of billing, claims, EMR, and other data—to more completely examine cost and expenditure?
National Behavioral Health Quality Framework
http://www.samhsa.gov/data/NBHQF/index.html#exhibit1
Payer/System/Plan
(e.g., SAMHSA, HRSA, Medicaid/Medicare, State Govt)
Provider/Practitioner Patient/Population
NBHQF Goal 1: Promote the most effective prevention, treatment, and recovery practices for behavioral health disorders (Recommended Measures) LINKED TO AND REFLECTIVE OF MEASURECONCEPTS
Relevant EBPs in
preventive, clinical, and recovery support settings tracked, summarized, and publicly available
Outcomes reflecting
recovery Social connectedness
of persons with behavioral health issues
NQF #0004: Initiation and
Engagement of Alcohol and other Drug Dependence Treatment
In NQF review: Screening, brief
intervention, and referral for treatment for alcohol misuse
NQF #0576: Follow-up After
Hospitalization for Mental Illness
Consumer Evaluation of Care:
Reporting Positively About Outcomes (adult and child)
NQF #0418: Screening for Clinical
Depression
NQF #0104: Major Depressive Disorder: Suicide Risk Assessment
NQF#0710-0711-0712: Depression Utilization of PHQ-9 and Remission at 6 and 12 months
NQF #0105: Anti-depressant Medication Management: (a) Effective Acute Phase Treatment and (b) Effective Continuation Phase Treatment
NQF #1364/1365: Child/Adolescent Depressive Disorder: Diagnostic Evaluation
NQF #1401: Maternal Depression Screening
NQF #0028: Preventive Care and Screening Measure Pair: (a) Tobacco Use Assessment and (b) Tobacco Cessation Intervention
NQF #0110: Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use
Emergency Department Alcohol
Use Screening and Follow-up
Employment/Education:
Changes in employment status (increased/no change) or in school status at a date of last service compared to first service
Abstinence: ATOD-related suspensions and expulsions
Housing: Increase in stable housing status from date of first service to date of last service
Abstinence: Family communication around drug use
Percentage of patients with
annual encounter data with a primary care physician OR pediatrician OR obstetrician/gynecologist
MU2 Screening for Intimate
Partner Violence
Translational Research: Questions to Face on Behavioral Health Care Integration
What is the right model? What other health issues should be considered? Outcomes? (BH vs. physical) What are the evidence-based metrics that matter? How do the models translate across systems and settings? Are there cost savings? How are the patterns of utilization affected by these strategies? What are the barriers to implementation? How sustainable?
Some Congressional Issues: “Dual-eligibles” and ACA
Improve quality of care and long term services
Increase patient literacy of and satisfaction with coverage
Eliminate regulatory conflict
Improve continuity of care; safe and effective care transitions
Eliminate cost-shifting
Improve quality of performance
Study provision of drug coverage for new full-benefit, dual-eligible people, monitor total expenditures, health outcomes, and access to benefits
Other Topics that Might Emerge Under ACA
Integrated care delivery Who got covered? Who didn’t? Why? Health literacy—how does it affect behavioral health care delivery
and choice of care settings? Health care costs—what are the right questions in behavioral health? Behavioral health care quality—what matters at the clinical level? Health care workforce—is capacity sufficient? Who is still not covered? What kind of care are people accessing and using? Impacts on chronic disease management and health care costs
Other Topics that Might Emerge Under ACA
How to engage behavioral health population in prevention programming
Religious sects may be exempt Vulnerable populations Re-admissions Development of recommendations for additional task force activities School-based behavioral health services Tobacco cessation, particularly among pregnant women Strengthening public health surveillance Contribution of private health care providers to surveillance of
behavioral health
Data Resources for Translational and Policy-Relevant Research
“Big Data”
Mini-Sentinel…a $116-million government pilot project
Pro-actively seeks adverse events linked to marketed drugs
Mines huge databases of medical records (privacy protected)
A five-year experiment coming to an end
FDA deciding what to do next
General agreement that the ability to sift through huge amounts of patient data is the way of the future—but what’s the best way to do that sifting?
Electronic health records and health information exchanges (EMR, HIE, HIT)
Claims data
Evaluation data
Local and internal surveys
SAMHSA health data information
Data Resources for Translational and Policy-Relevant Research
Conclusion
As our nation continues to move toward the full roll-out of a health policy that is expected to reach most citizens, questions still remain
Organizations delivering health care have opportunities to develop and test new models that can improve care delivery, outcomes, and potentially reduce costs
Use your evidence. We won’t know the impact of policy until we know how to use data to tell our story—data will prove the value of your innovations
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Resources
• For more about NSDUH data, visit: http://www.samhsa.gov/data/population-data-nsduh
• For more about SAMHSA, visit: http://www.samhsa.gov/
• For more about CBHSQ, visit: http://www.samhsa.gov/about-us/who-we-are/offices-centers/cbhsq
Navigating the ACA: Got Data?
Peter J. Delany, Ph.D., LCSW-CRADM, U.S. Public Health Service
Director, Center for Behavioral Health Statistics and QualitySubstance Abuse and Mental Health Services Administration
Rockville, [email protected]
Dee S. Owens, Special Assistant to the [email protected]