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NIHB National Tribal Health Reform Implementation Summit April 20, 2011 Dr. Linda Bane Frizzell, Ph.D.

Behavioral Health and the Affordable Care Act. NIHB National Tribal Health Reform Implementation Summit April 20, 2011 Dr. Linda Bane Frizzell, Ph.D. Patient Protection and Affordable Care Act.

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NIHB National Tribal Health Reform Implementation Summit April 20, 2011 Dr. Linda Bane Frizzell, Ph.D.

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  1. Behavioral Health and the Affordable Care Act NIHB National Tribal Health Reform Implementation Summit April 20, 2011 Dr. Linda Bane Frizzell, Ph.D.

  2. Patient Protection and Affordable Care Act • Offers significant opportunities to begin to ameliorate the impact of behavioral health issues upon the lives of American Indians and Alaska Natives (AI/ANs). • Has limited, but new language for “parity”. • Has language specific for: • Tribes • Tribal Organizations • Urban Indian Programs • Indian Health Service • Substance Abuse Mental Health Service Administration

  3. Behavioral Health Issues/Barriers • Access to and the availability of behavioral health professionals, such as psychiatrists, psychologists, drug counselors, and social workers are seriously lacking. • Poverty, geographic location, and cultural differences further limit the amount and quality of services available. • Limited insurance coverage, scarce availability of services, excessive travel distances, weather hazards, increased personal monetary costs, and stigma • Care provided is not intensive enough, not long enough, and/or lacking in important follow-up health and social services

  4. “Behavioral” Health • The Act uses various terms within the context of Behavioral health including: • mental illness • substance related disorders • substance abuse • substance abuse prevention • substance abuse treatment • behavioral therapies • behavioral risk

  5. Behavioral Health Sections • Sec. 1302.ESSENTIAL HEALTH BENEFITS REQUIREMENTS • With respect to any health plan, coverage that provides for the essential health benefits • limits cost-sharing for such coverage • mental health and substance use disorder services, including behavioral health treatment • Sec. 2703.STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES WITH CHRONIC CONDITIONS • …(e) COORDINATION.—A State shall consult and coordinate, as appropriate, with the SAMHSA in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions…

  6. SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION PROJECT • shall establish a demonstration project under which an eligible State shall provide payment under the State Medicaid plan under title XIX of the Social Security Act to an institution for mental diseases • SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR POSTPARTUM DEPRESSION • It is the sense of Congress that the Director of the National Institute of Mental Health may conduct a nationally representative longitudinal study (during the period of fiscal years 2010 through 2019)

  7. SEC. 3012. INTERAGENCY WORKING GROUP ON HEALTH CARE QUALITY • The President shall convene a working group to be known as the Interagency Working Group on Health Care Quality • Sec. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH ADD-ON. • Section 138(a)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110–275) is amended by striking ‘‘December 31, 2009’’ and inserting ‘‘December 31, 2010’’.

  8. SEC. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS. • …the Secretary shall evaluate and revise the risk adjustment system to account for higher medical and care coordination costs associated with frailty, with multiple, co-morbid chronic conditions, a diagnosis of mental illness, and costs associated with higher concentrations of beneficiaries with those conditions… • SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO SUPPORT THE PATIENT-CENTERED MEDICAL HOME. • …Secretary shall establish grants and contracts with eligible entities to establish community-based interdisciplinary, interprofessional teams to support primary care practices, including obstetrics and gynecology practices, within the hospital service areas served by the eligible entities. • …(b) ELIGIBLE ENTITIES • (B) be an Indian tribe or tribal organization, as defined in section 4 of the Indian Health Care Improvement Act;

  9. SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC HEALTH COUNCIL. • The President shall establish, within the Department of Health and Human Services, a council to be known as the ‘‘National Prevention, Health Promotion and Public Health Council’’ • …(11) the Assistant Secretary for Indian Affairs; • …(13) the head of any other Federal agency that the chairperson determines is appropriate. • …(5) establish processes for continual public input, including input from State, regional, and local leadership communities and other relevant stakeholders, including Indian tribes and tribal organizations; • … (3) contains a list of national priorities on health promotion and disease prevention to address lifestyle behavior modification (smoking cessation, proper nutrition, appropriate exercise, mental health, behavioral health, substance use disorder, and domestic violence screenings) and the prevention measures for the 5 leading disease killers in the United States

  10. SEC. 4004. EDUCATION AND OUTREACH CAMPAIGN REGARDING PREVENTIVE BENEFITS. • The Secretary shall provide for the planning and implementation of a national public–private partnership for a prevention and health promotion outreach and education campaign… • … (5) preventive care supported by the CDCP, HRSA, SAMHSA… • …(e) DISSEMINATION OF INFORMATION THROUGH PROVIDERS.— • Secretary, acting through the CDCP, shall develop and implement a plan… health care providers who participate in Federal programs, including programs administered by the IHS, VA, DOD, HRSA, and CMS.

  11. SEC. 4101. SCHOOL-BASED HEALTH CENTERS. • (a) GRANTS FOR THE ESTABLISHMENT OF SCHOOL-BASED HEALTH CENTERS • …‘‘(B) MENTAL HEALTH.—Mental health and substance use disorder assessments, crisis intervention, counseling, treatment, and referral to a continuum of services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs… • SEC. 4103. MEDICARE COVERAGE OF ANNUAL WELLNESS VISIT PROVIDING A PERSONALIZED PREVENTION PLAN. • (a) COVERAGE OF PERSONALIZED PREVENTION PLAN SERVICES • … ‘‘(ii) A list of risk factors and conditions for which primary, secondary, or tertiary prevention interventions are recommended or are underway, including any mental health conditions or any such risk factors or conditions…

  12. SEC. 4106. IMPROVING ACCESS TO PREVENTIVE SERVICES FOR ELIGIBLE ADULTS IN MEDICAID. • “(C) any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level;’’…. • SEC. 4201. COMMUNITY TRANSFORMATION GRANTS. • The Secretary acting through the CDCP, shall award competitive grants to State and local governmental agencies… • ..(b) ELIGIBILITY… • …(E) an Indian tribe… • …(v) changes in emotional well-being and overall mental health

  13. SEC. 4202. HEALTHY AGING, LIVING WELL; EVALUATION OF COMMUNITY- BASED PREVENTION AND WELLNESS PROGRAMS FOR MEDICARE BENEFICIARIES. • The Secretary, acting through the CDCP, shall award grants to State or local health departments and Indian tribes to carry out 5-year pilot programs to provide public health community interventions, screenings, and where necessary, clinical referrals for individuals who are between 55 and 64 years of age. • …(ii) TYPES OF INTERVENTION ACTIVITIES.—Intervention activities conducted under this subparagraph may include efforts to improve nutrition, increase physical activity, reduce tobacco use and substance abuse, improve mental health, and promote healthy lifestyles among the target population. • … (C) COMMUNITY PREVENTIVE SCREENINGS • (I) mental health/behavioral health and substance use disorders… • (i) EVIDENCE REVIEW • (IV) mental health.

  14. SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION. • It is the purpose of this section to establish a National Health Care Workforce Commission • … (III) Mental and behavioral health care workforce capacity at all levels. • The Commission shall consult with Federal agencies, Congress, the Medicare Payment Advisory Commission, the Medicaid and CHIP Payment and Access Commission, and, to the extent practicable, with State and local agencies, Indian tribes… • SEC. 5203. HEALTH CARE WORKFORCE LOAN REPAYMENT PROGRAMS. • The Secretary shall establish and carry out a pediatric specialty loan repayment …in providing pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care, including substance abuse prevention and treatment services.

  15. SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL MEDICINE, GENERAL PEDIATRICS, AND PHYSICIAN • ASSISTANTSHIP. • … ‘‘(B) proposes innovative approaches to clinical teaching using models of primary care, such as the patient centered medical home, team management of chronic disease, and interprofessional integrated models of health care that incorporate transitions in health care settings and integration physical and mental health provision;… • SEC. 5306. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND TRAINING GRANTS. • The Secretary may award grants to eligible institutions of higher education to support the recruitment of students for, and education and clinical experience of the students… • … ‘‘(c) INSTITUTIONAL REQUIREMENT.—For grants authorized under subsection (a)(1), at least 4 of the grant recipients shall be historically black colleges or universities or other minority serving institutions.

  16. SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES TRACK. • … established a United States Public Health Sciences Track, sites to be selected by the Secretary, with authority to grant appropriate advanced degrees…uniquely emphasizes team-based service, public health, epidemiology, and emergency preparedness and response. • It shall be so organized as to graduate not less than— • ‘‘(E) 100 behavioral and mental health professional students annually • SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES. • (a) AREA HEALTH EDUCATION CENTERS (grants) • ‘‘(A) Develop and implement innovative curricula in collaboration with community-based accredited primary care residency training programs, FQHCs, RHCs, behavioral and mental health facilities, …goal of increasing the number of primary care physicians and other primary care providers prepared to serve in underserved areas and health disparity populations.

  17. SEC. 5405. PRIMARY CARE EXTENSION PROGRAM. • The Secretary, acting through the AHRQ, shall establish a Primary Care Extension Program. • ‘‘(2) PURPOSE - provide support and assistance to primary care providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health services (including substance abuse prevention and treatment services), …working with community-based health connectors (referred to in this section as ‘Health Extension Agents’). • ‘‘(ii) collect data and provision of primary care provider feedback from standardized measurements of processes and outcomes to aid in continuous performance improvement; • ‘‘(iii) collaborate with local health departments, community health centers, tribes and tribal entities, and other community agencies to identify community health priorities and local health workforce needs, and participate in community-based efforts to address the social and primary determinants of health, strengthen the local primary care workforce, and eliminate health disparities;…

  18. SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH PROFESSIONS WORKFORCE NEEDS; EXTENSION OF FAMILY-TOFAMILY HEALTH INFORMATION CENTERS. • … ‘‘(C) ASSURANCE OF OPPORTUNITIES FOR INDIAN POPULATIONS.— • The Secretary shall award at least 3 grants to an eligible entity that is an Indian tribe, tribal organization, or Tribal College or University. • ‘‘(3) REPORTS AND EVALUATION.— • … ‘‘(A) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a State, an Indian tribe or tribal organization, an institution of higher education, a local workforce investment board established under section 117 of the Workforce Investment Act of 1998, a sponsor of an apprenticeship program registered under the National Apprenticeship Act or a community- based organization. • …‘(G) TRIBAL COLLEGE OR UNIVERSITY.—The term ‘Tribal College or University’ has the meaning given that term in section 316(b) of the Higher Education Act of 1965 (20 U.S.C. 1059c(b)).

  19. (Continued) • SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH PROFESSIONS WORKFORCE NEEDS; EXTENSION OF FAMILY-TOFAMILY HEALTH INFORMATION CENTERS • …‘‘(3) TEACHING HEALTH CENTER.— • ‘‘(B) INCLUSION OF CERTAIN ENTITIES.—Such term includes the following: • ‘‘(i) A FQHC • ‘‘(ii) A community mental health center (as defined in section 1861(ff)(3)(B) of the Social Security Act). • ‘‘(iii) RHC • ‘‘(iv) A health center operated by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act).

  20. SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE IN COMMUNITY-BASED MENTAL HEALTH SETTINGS. • ‘‘(1) ELIGIBLE ENTITY. - qualified community mental health program defined under section 1913(b)(1). • ‘‘(2) SPECIAL POPULATIONS. - adults with mental illnesses who have co-occurring primary care conditions and chronic diseases. • ‘‘(b) PROGRAM AUTHORIZED. - demonstration projects for coordinated and integrated services to special populations through community co-location of primary and specialty care services

  21. SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR MEDICARE AND MEDICAID INNOVATION. • For purposes of testing payment and service delivery models • ‘‘(xix) Utilizing entities located in medically underserved areas and facilities of the Indian Health Service (whether operated by such Service or by an Indian tribe or tribal organization, telehealth services— • ‘‘(I) in treating behavioral health issues (such as post-traumatic stress disorder) and stroke; and • ‘‘(II) to improve the capacity of non-medical providers and non-specialized medical providers to provide health services for patients with chronic complex conditions…

  22. SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE COMPREHENSIVE WORKPLACE WELLNESS PROGRAMS. • The Secretary shall award grants to eligible employers to provide their employees with access to comprehensive workplace wellness programs • … (D) Supportive environment efforts (including workplace policies to encourage healthy lifestyles, healthy eating, increased physical activity, and improved mental health). • SEC. 10410. CENTERS OF EXCELLENCE FOR DEPRESSION. • (a) SHORT TITLE.—‘‘Establishing a Network of Health-Advancing National Centers of Excellence for Depression Act of 2009’’ or the ‘‘ENHANCED Act of 2009’’. • … ‘‘(5) ELIGIBLE ENTITIES.— • ‘‘(A) REQUIREMENTS.—To be eligible to receive a grant under this section, an entity shall— • ‘‘(i) be an institution of higher education or a public or private nonprofit research institution

  23. Summary American Indian/Alaska Native aspects. There are specific provisions that specifically name tribes: Sections 3502, 4001, 4201, 4202, 5101, 5405, 5507, and 10306; and one (1) Section 5507 that names urban Indian programs. American Indian/Alaska Native impact. At this time the impact is unclear, but there is potential for innovative, far reaching treatment and prevention programs, an emergency demonstration project, education and trainings, school based centers, leadership development, work force development, research, data base development, loan repayment, and reimbursement improvement for behavioral health services.

  24. Thoughts? • The behavioral health features of the PPACA are numerous and complex. There are a variety of different opportunities that can impact or begin to impact the tremendous needs of Indian Country. • Contact Information: • Dr. Linda Bane Frizzell, Ph.D. • Northwest Portland Area Indian Health Board • 2121 SW Broadway, Suite 300 • Portland, OR 97201 • Lfrizzell@npaihb.org • www.npaihb.org

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