Features

Bridging the separation between behavioral and general health care

Interview by Frank Burtnett June 1, 2012

Kathleen Sebelius was sworn in as the 21st secretary of the Department of Health and Human Services (HHS) on April 28, 2009. Since joining the Obama administration, she has been a key strategist in the federal effort to improve the health of Americans and enhance the delivery of human services to some of the nation’s most vulnerable populations, including young children, those with disabilities and older Americans.

Before becoming HHS secretary, Sebelius served as governor of Kansas from 2003–2009 and was recognized as one of America’s top five governors by Time magazine. Born in Ohio and educated in Michigan and Washington, D.C., Sebelius moved to Kansas in 1974. She served as executive director and chief lobbyist for the Kansas Trial Lawyers Association (now the Kansas Association for Justice) from 1977–1986. Her public service includes eight years as a representative in the Kansas Legislature and eight years as the state’s insurance commissioner.

Sebelius is the daughter of former Ohio Gov. John J. Gilligan. Upon her election as governor of Kansas, they became the first father/daughter governor pair in the United States.

Congress and President Obama are finalizing legislation to postpone changes in Medicare’s sustainable growth rate payment formula for physicians to help ensure that Medicare beneficiaries have adequate access to providers. Given the need for better access to outpatient mental health service providers and the wide recognition of licensed professional counselors as mental health professionals in both private and public sector health plans, will HHS consider endorsing Medicare coverage of state-licensed professional counselors?

Mental illness and substance abuse can be significant issues for Medicare beneficiaries. Growing life expectancy, coupled with the aging of the baby boom generation, makes these issues more critical than ever. Preventing these problems from occurring in the first place and addressing signs and symptoms promptly when they do arise can enhance the lives and health of millions. Changes in Medicare payments go through a long process that involves public comment and sometimes changing the law itself. Behavioral health services and who provides the services are certainly areas ripe for assessment as part of the health care reforms taking place under the Affordable Care Act.

Studies suggest that health care costs can be reduced by providing effective mental health treatment for patients with comorbid general medical conditions such as diabetes or congestive heart failure. What is HHS doing to explore — and realize — the potential health care cost savings from providing timely, appropriate mental health services?

According to a study of health care expenditures by the Agency for Healthcare Research and Quality (AHRQ), 5 percent of the population accounted for almost 50 percent of total costs. Chronic conditions, multiple comorbidities and severe mental illness, as well as services that are fragmented among multiple providers, are key drivers of this high utilization.

To address health care quality, care coordination and access for people with comorbidities, HHS has implemented a number of new initiatives, including health homes. Specifically addressing behavioral health, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration are working with community-based health agencies to initiate or expand the integration of primary care services for people in treatment for serious mental illnesses and co-occurring substance use disorders. These efforts, along with implementation of the Affordable Care Act, will vastly improve the quality of and access to care for people with multiple chronic conditions, including behavioral health conditions.

The portion of overall health care spending devoted to mental health treatment has dropped significantly over the past decades, and reimbursement rates to mental health professionals in both public and private sector health plans continue to fall. How can HHS help reverse this trend as it works to implement the Patient Protection and Affordable Care Act?

 

 

 

People with mental illnesses and substance use disorders often lack health insurance coverage. Even if they have access to health insurance and can navigate the enrollment process, the cost can be high, and there is no requirement that the insurance even provide coverage for behavioral health.

There are a number of steps being taken to eliminate the barriers to care for people with behavioral health needs. First, the Centers for Medicare & Medicaid Services and SAMHSA are working to support implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) through stakeholder and employer engagement and ongoing educational efforts. Additionally, in many cases, MHPAEA requirements apply to Medicaid and CHIP (Children’s Health Insurance Program) beneficiaries.
The Affordable Care Act will improve access to behavioral health services by including those services as part of the essential health benefits that must be provided by health plans offered in the Affordable Health Exchanges beginning in 2014.
The expansion of benefits will be substantial for people with behavioral health concerns. Of the currently uninsured population eligible for premium subsidies through the exchanges in 2014 — 19.9 million individuals — an estimated 6 percent have a serious mental illness and 14.6 percent have a substance use disorder. To raise awareness about new eligibility for insurance coverage and care, HHS will be reaching out to people with mental health and substance use disorders and providers of behavioral health services.

What challenges and opportunities lie ahead for implementation and enforcement of the MHPAEA, and how can the American Counseling Association and its 50,000-plus counselor members help make sure the legislation achieves its goals?

The Affordable Care Act is already changing the American health care landscape. People who currently have health coverage for behavioral health services are seeing improvements in their coverage as a result of the implementation of [MHPAEA]. For people who have no health coverage at all, exchanges created under the Affordable Care Act will provide new access to coverage, and that coverage will have to include essential health benefits, one of which is behavioral health services.
In addition, the Affordable Care Act will help bring together behavioral health services and the general health care system, which historically have been separated. Integrating services is increasingly recognized as important to achieving both the quality and cost-savings goals of health reform. For example, according to the World Health Organization, mental health and substance use disorders will surpass all physical diseases as a major cause of disability worldwide by 2020, and according to AHRQ, almost one-fourth of all adult stays in U.S. community hospitals involve mental health or substance use disorders. Additionally, the rapid adoption of health information technology, including electronic health records, opens new vistas for coordinating and improving the quality of patient care.
These system changes are occurring in parallel with scientific advances in prevention and treatment services for mental health and substance use disorders and a growing understanding of the importance of consumer self-direction in the prevention and treatment of behavioral health conditions.
Clearly, prevention, treatment and recovery support services for behavioral health are important parts of health service delivery and communitywide strategies that work to improve health and lower costs for individuals, families, businesses and governments. In order to reach the optimal potential of the [MHPAEA], ACA must remain engaged in the dialogue about implementation of the Affordable Care Act and take proactive steps to educate state governments, employers, insurers and insurance consumers of the importance of coverage for behavioral health disorders and the appropriate role for the association’s members in the delivery of high-quality, life-improving services

Editor’s note: Frank Burtnett originally conducted this interview for publication in the Spring 2012 issue of ACAeNews for Mental Health, Private Practice and Community Agency Counselors.

Frank Burtnett is the editor of ACAeNews and ACA’s four special focus electronic newsletters for school counselors; counselor educators; counseling students and new professionals; and mental health, private practice and community agency counselors. Contact him at fburtnett@counseling.org.

To opt in to any of the free ACA electronic newsletters, contact ACA Member Services at 800.347.6647 ext. 222 or email acamemberservices@counseling.org.

Letters to the editor: ct@counseling.org

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