Healthcare reform: Implications for organizational systems

By Todd Molfenter, NIATx Deputy Director

One of the goals of the Patient Protection and Affordable Care Act (ACA) is to lower the cost and improve the quality of care for everyone. Behavioral healthcare providers may be uncertain about the future of the legislation and what impact it will have. But the national trend toward fee-for-service and managed care—which also aims to lower the costs and improve quality of care—is requiring behavioral healthcare leaders to develop the same competencies they’ll need to be fully prepared for the changes anticipated with healthcare reform. 

These competencies include understanding and implementing health information technology (HIT), especially electronic health records (EHR) to improve quality, contain costs, and give patients greater control of their personal health.

Integration with primary care, another component of the ACA, is already happening, as behavioral health works to operate in conjunction with the broader health system.  In the HealthReform Readiness Index survey administered by NIATx, the percentage of behavioral health organizations that offer primary care increased from 6% to 15% from 2010 to 2012.

The movement toward managed care and fee-for-service reimbursement has been accompanied by changes in state funding. Behavioral healthcare providers are learning to expand their payer mix and their business skills, developing new systems for billing, managing accounts receivables, and reducing claim denials. Providers will need to have these systems firmly in place to accommodate both the Medicaid expansion anticipated with ACA and the Health Insurance Exchanges that will emerge—the new competitive markets that will allow consumers to purchase affordable private insurance plans.

·      Enrollment: Changes in state funding are requiring providers to help their patients determine their eligibility for public or private insurance coverage.  Efficient enrollment systems will also be essential with Medicaid expansion and HIEs.   

·      Workforce development: Today’s changes in funding and reimbursement are also driving the need for a workforce with the credentials and clinical competence that payers require.

·      Using outcomes to influence clinical decision-making: State governments and managed care increasingly require documentation that demonstrates quality indicators are being tracked and  a plan to continuously improve performance.

Whether or not the ACA is fully implemented as designed, behavioral health care providers who are working on these areas are setting themselves up for success in a funding environment that’s changing rapidly.

If you haven’t yet embarked on making the transition to this new environment, or if you’re not sure where to begin, take a look the HealthReform Readiness Index (HRRI) that NIATx developed. It’s a quick (under 15 minutes) survey that will let you know immediately where you are on the readiness spectrum. You might find that you’re in the early stages in one area, but well on your way in another. The HRRI is just one of many tools that you can use to help plan how to adapt your organization’s systems to the transformation of the behavioral healthcare field.

Ready or Not, Here it Comes: Health Reform

Kim Johnson, Deputy Director, NIATx

With Election Day fast approaching, healthcare reform is a hot topic. Many believe the election results will determine the future of the Affordable Care Act, which is designed to extend health insurance coverage to more than 30 million Americans.  Yet regardless of who wins in November, behavioral healthcare providers need to adapt to changes that are already taking place and are not likely to be reversed.

The Mental Health Parity and Addiction Equity Act, passed in 2008, requires insurance plans that offer coverage for mental illness and substance use disorders provide those benefits at the same level as medical and surgical procedures. The Affordable Care Act will require all insurance plans to provide coverage for mental illness and substance abuse disorders. Both pieces of legislation present behavioral health providers with the option of billing third-party payers for the services they provide—for some new sources of revenue to replace rapidly shrinking state and federal grant funds. 

While some states oppose making changes required to prepare for the ACA, others are moving forward with Accountable Care Organizations and Health Insurance Exchanges. Treatment organizations need to stay on top of what’s happening in their states. Rather than “wait and see,” the best approach may be build capacity to bill for services, because no matter who gets elected, grant funds are not likely to increase.

States across the country have slashed funding, and we can’t assume that the federal block grants for mental health and substance abuse treatment are going to continue at their current level, especially with the “fiscal cliff” of tax increases and spending cuts looming ahead of us at the end of 2012 if Congress doesn’t act. It’s likely that we’ll see more cuts. Finding other sources of revenue will be even more crucial.  

Aside from healthcare reform, other forces are driving change in the addiction treatment field. The Partnership at Drugfree.org recently reported that visits to physicians for substance use disorders, primarily opioid abuse, increased by 70% between 2003 and 2009. With an increase in the awareness of addiction as a treatable disease, more people will seek treatment from their primary care providers. Specialty treatment programs need to consider partnering with these providers, or addiction treatment may go the way of depression treatment–with most people seeking medication, and counseling becoming an ancillary service.

The health reform ball has been rolling for some time now for behavioral health providers. What happens in November may slow it down or adjust its course, but not stop it.  Now’s the time to prepare.

Where are we with parity?

This month marks the anniversary of the Wellstone and Domenici Mental Health Parity and Addiction Equity Act (MHPAEA), signed into law on October 3, 2008. Behavioral health care providers welcomed this legislation. It requires group health plans that cover mental illness and substance use disorders to provide those benefits at the same level as medical and surgical benefits.

While MHPAEA was intended to eliminate unequal coverage and inequities in access to behavioral health treatment, providers and their patients continue to face challenges in making sure the law is fully understood and implemented.

Patrick Gauthier, Director of AHP Healthcare Solutions, addressed these issues in a recent presentation for NIATx, “Parity & Equity Compliance Checker: Disputing the Decisions that Affect Your Bottom Line.”  

 “MHPAEA was and continues to be an important victory for all Americans,” said Gauthier. “It’s as much a civil rights success story as it is an insurance reform. Viewed in relation to the Affordable Care Act…MHPAEA is our gold standard for behavioral health benefits. We should all be actively involved in its implementation and enforcement. That work must happen at the state and community levels.”

The October 15 issue of Alcoholism and Drug Abuse Weekly discusses problems with parity implementation in the article “Some payers still defy parity law with ‘fail-first’ and reviews.”   Do you work with any health plans that fail to adhere to the federal parity law?  If so, what action have you taken in response?  

What makes a great conference?

The 2012 SAAS National Conference and NIATx Summit in New Orleans reminded me once again what makes a great conference: people, of course.

As always, the attendees at our conference helped make it great. Your dedication to the field and the clients you serve really energized the event. I’d like to thank you for attending and helping make this conference a success.

Other people helped make this a great conference, too. That includes the conference advisory committee, co-chairs, and members of the NIATx, SAAS, and Site Solutions Worldwide teams involved in the planning and execution of the conference: from choosing a location, to selecting and scheduling presenters and workshops, to producing the conference program, and just in general, taking care of the hundreds of details involved in hosting a national event.

In New Orleans, these teams and the Blue Crew once again came through with their characteristic flexibility, making quick adjustments behind the scenes when necessary-so if there was a glitch anywhere, you never knew it. This year's exhibitors presented another great array of products and services, and the staff at the New Orleans Marriott showed us the hospitality the city is famous for. And some pretty good food, too!

You can find the conference workshop and Deep Dive materials on the conference web page, along with details of next year’s event in San Diego, July 14-17. I hope to see you there!

Of course we want next year to be even better. So post a comment and let us know your thoughts. And again, thank you for attending.

Using a smartphone app to intervene before relapse into alcohol abuse: preliminary results

ACHESS is a mobile phone-based relapse-prevention system that offers support to alcohol dependent people when and wherever it is needed. Developed at the Center for Health Enhancement Systems Studies (CHESS), of which NIATx is a part, the ACHESS smart phone app is now being studied in a randomized clinical trial.

CHESS Researcher Andrew Isham presented some initial findings on the study at the 2011 Medicine 2.0 Congress last September. Click here to read a summary of his presentation.

Interested in using ACHESS? Click here for more information on using ACHESS through the CHESS Health Education Consortium.

Process Improvement and Technology

Process improvement increases efficiency, and so does technology. As NIATx Director Dave Gustafson pointed out in his January 23 blog post, communications technology is playing a bigger role in efforts to increase efficiency and serve customers better. Technology can help close the gap between the 20 million people in the United States who need treatment for a substance use disorder and the three to four million who actually receive it.

Kentucky River Community Care is one organization that is using both process improvement and technology to meet customer needs. This organization serves eight counties in eastern Kentucky, and was a grantee in the first NIATx initiative, Paths to Recovery. “Technology and process improvement go hand in hand in helping us adapt to the rapidly changing behavioral healthcare environment,” says KRCC Director Mike Kadish, who credits NIATx with helping his organization create a culture of change. Read more about KRCC’s innovations in the February 6, 2012, issue of Mental Health Weekly.

Building a Culture of Quality Improvement

A few weeks ago we highlighted the great work being done at St Christopher’s Inn, a substance abuse treatment facility that has been working with NIATx from the very beginning. Through the years they have built a culture of quality improvement at their agency. David Gerber, Director of Counseling and Shelter Services, says, “…it becomes a part of you. I can be having a casual conversation with an employee who will come up with an idea and I will say "Hey that sounds like a NIATx process improvement", and we will get to work on something.“

Another long time NIATx member, Denver Health, was featured in the January 23, 2012 edition of Alcoholism and Drug Abuse Weekly. Denver Health has used NIATx along with the Toyota LEAN philosophy to improve services throughout the organization. NIATx improvement projects have increased the 90-day retention rate in Denver Health’s methadone clinic; increased admissions of HIV clients to substance abuse treatment, and helped women in the detox unit get access to prenatal care.

Lisa Gawenus, Associate Director of Signal Behavioral Health, the managed services organization that distributes public addiction funding dollars in Colorado, said in the article, “A lot of times performance improvement can lead you into a quagmire of work, but [NIATx] is a data-driven method that's manageable. Denver Health has done really well in instituting a process improvement culture.”

Read more about Denver Health and their change projects to increase admissions of HIV positive patients and to help women in detox gain access to prenatal care.

How have you used the NIATx model to improve systems across your organization, beyond access to and retention in treatment?

Interactive Health Communications (their present and future)

It wasn't long ago that cell phones were considered innovative and that personal computers were the center of an individual's access to information and communication technologies. More recently, the field has grown so much that that it has become a major focus of research and development. As a result one of the most respected journals in the health systems research field is the Journal of Medical Internet Research. We now can be confident that computers can improve quality of life and some data suggests it can reduce the costs of care and improve clinical outcomes.

The capability of smart phones continues to increase. Features such as GPS, accelerometers, two way cameras, light sensors, fuzzy matching, optical object recognition and sound are continuously improving. Further more, add-ons make it possible for a smart phone to be able to read bar codes and RFID chips. And the increasing brute strength of smart phones, tablets, and data services will reach the point that they function as fast as one's home computer.

Recently health and healthcare have become a prominent focus for developers of apps for smart phones. Specifically, more and more apps are being produced to help people deal with their health needs. By November 2011 nearly 13,000 health apps were available for smart phones, many related to substance abuse and behavioral health more generally.

Of course, quantity rarely equals quality. And because of the wide variation in quality, it has become hard to differentiate good from bad, useful from harmful. The old Latin expression caveat emptor is very important in this context where they may be a lot of good stuff out there but it is very hard to find. In fact we completed a randomized clinical trial a few years ago where we compared breast cancer patients with access to the Internet to patients without it. We found that if anything, Internet users did more poorly than those who had no such access.¹

In a sense, it makes sense. When you go to the Internet, you're faced with myriads of websites that offer conflicting information and operate in very different ways. Feelings of frustration, fear, anger and uncertainty are close to the surface. Smartphone and tablet apps can bring on the same feelings.

Computers (including tablets and smartphones) can be frustrating in and of themselves. But here, unlike the Internet, there is hope for the future. As those of you who know me already realize, I am older than dirt. Three years ago I had a heart transplant. The anti-rejection drugs that I take have had two side effects. First I am getting cataracts from the Prednisone. Second, my hands tremble from the Prograf. Believe me I am very happy to have these minor inconveniences rather than the alternative. But they do have implications for smart phone use. First, it is hard to see the small screen and second, it is hard to type in messages. Of course if you are young, you probably don’t have these problems, but many of us do.

The exciting thing is that the world is changing. Smartphones are very close to being completely navigable by voice. Apple's Siri is a recent example of how close we are. And text-to-voice lets users listen to content rather than just ready it. And sensors (many already built into the smart phone – like GPS, accelerometers, cameras, etc.) now allow us to measure the quality of sleep by putting the phone under the mattress, identify if you are approaching a favorite bar with GPS, measure your heart rate with the camera, etc. Right now they are pretty accurate but in the near future they will be very good and just the beginning for what is to come.

Moreover, research is already demonstrating the power of computer apps. It is pretty clear that computer programs (including some apps) can improve quality of life, change behavior, improve coping, act as motivators and can provide emotional and instrumental support². What is less clear is how to distinguish the great programs from others, because no matter what problem you have, there really is an app for that.

So what can I tell you? Well, start out by being skeptical. Assume that most of the stuff you find is a gimmick, and commit yourself to being very careful before you buy. I just purchased an app to take my heart rate and blood pressure. I was excited because I had heard that such devices do exist. The description sounded good and it had a four-star rating out of five. So I downloaded it for just 99¢. It seemed like my only way to try it out. What the description did not say was that you used your standard way to collect the data (your home blood pressure monitor or by counting). So all it really does is store and display information that I put into the phone. What it does, it does well. But it was not what I had expected. I should have been skeptical when only 20 people had reviewed it. I should have read the description more carefully. I should have tried to find out whether the system had been tested. I should have read the reviews instead of just looking at the average rating score. Caveat emptor, after all.

But having said that, apps are not going away, thank heavens. The good apps and the more sophisticated programs like CHESS³ and TES⁴ , have been carefully reviewed and proven to be effective. In fact we currently have a research consortium where agencies are using A-CHESS for different purposes and jointly finding best practices for effectively implementing the technology. And there are many more great programs to come that will revolutionize our fields. We will know so much about a person and we will know it when it happens, not three weeks later. We will be able to intervene just in time. And the technology will be able to deliver care anytime and anywhere, with a consistently high degree of quality.

But one more caveat. We won’t be able to just take these innovations and plop them down in the middle of an existing treatment system. Agencies who have tried distance counseling know that the way you counsel when a person is in the same room with you is very different than if you are doing it by Skype or some other video communication system. Retraining may be needed. Incentives, policies and job descriptions may need to change. The scary part of this is that it may actually be easier to start from scratch than to get organizations to change. And there in lies the challenge. Do we want to be the buggy whip manufacturers of old or do we have the energy to lead the revolution?

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1. Gustafson, D.H., Hawkins, R., McTavish, F., Pingree, S., Chen, W.C., Volrathongchai, K., Stengle, W., Stewart, J.A., & Serlin, R.C., (2008). Internet-based interactive support for cancer patients: Are integrated systems better? Journal of Communication, 58(2), 238-257. PMCID: PMC3144782
2. Gustafson, D.H., Boyle, M.G., Shaw, B.R., Isham, A., McTavish, F., Richards, S., Schubert, C., Levy, M., & Johnson, K. (2011). An e-Health solution for people with alcohol problems. Alcohol Research & Health, 33(4), 327-337. NIHMSID: NIHMS316851
3. Gustafson, D.H., Shaw, B.R., Isham, A., Baker, T., Boyle, M.G., & Levy, M. (2011). Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence. Substance Use and Misuse, 46(1), 96-111. PMCID: PMC3179272
4. Marsch, L. A., Grabinski, M. J., Bickel, W. K., Desrosiers, A., Guarino, H., Muehlbach, B., Solhkhah, R., Talfique, S., & Acosta, M. (2011). Computer-assisted HIV prevention for youth with substance use disorders. In Special Issue on Technology and Substance Use Disorders (Guest Editor: Marsch, L. A.) Substance Use and Misuse, 46, 46-56

NIATx: Quality improvement with staying power

St. Christopher’s Inn in Garrison, New York, was among the first organizations to test whether the NIATx model could improve processes in substance abuse treatment settings. The Inn's Chief Operating Officer, Marianne Taylor Rhoades, got the Inn started by submitting a successful proposal for the first NIATx learning collaborative, the Robert Wood Johnson Foundation-funded Paths to Recovery. St. Christopher's was one of only ten selected out of the more than 300 proposals submitted.

St. Christopher’s first change project aimed to increase admissions by reducing time to return phone calls. A walk-through revealed the Inn's nationally advertised toll-free number went to a voice mailbox–that was never checked. And having all staff take lunch at the same time—leaving the phones uncovered—was contributing to missed calls. Within a month of correcting these issues with simple changes, the Inn saw increases in admissions and revenue.

That was back in 2003. Since then, process improvement has become part of the culture at St. Christopher’s Inn. Taylor Rhoades and David Gerber, Director of Counseling and Shelter Services, credit the NIATx model with contributing to the overall quality of the Inn's treatment services—and its recent recognition by the New York State of Alcoholism and Substance Abuse Services (OASAS).

In December 2011, OASAS for the first time released to the public a scorecard of all licensed chemical dependency treatment programs in New York State. Outpatient chemical dependency programs were ranked in 11 categories to determine program quality. St. Christopher's Inn was the only Day Rehabilitation Program in New York State to receive the highest scores (5 stars) in 9 of the 11 categories, signifying that St. Christopher's Inn is among the highest performing and most successful programs in New York State. In the 2 categories that SCI did not receive 5 stars in, the Inn met state averages. (View scorecard here.)

Congratulations to all the staff at St. Christopher's Inn!

We know that the NIATx model has become part of the way many treatment organizations “do business” – from the veterans of our first demonstration projects to those who learned about NIATx more recently, from a colleague or a visit to our web site. We’d love to hear from you! Send us a blog comment, an e-mail, or post on our Facebook page.

What gives the NIATx model staying power in your organization?

NIATx Year In Review - 2011

The success of the NIATx model in substance abuse and mental health treatment settings sparked an increase in projects in other human services areas in 2011: aging, criminal justice, HIV/AIDS, and programs for pregnant and parenting women. NIATx also introduced process improvement to several state agencies in our home state of Wisconsin.

While we expanded to other areas of behavioral health and social services, in 2011 we continued to offer new programs and tools for our original customer, the substance abuse treatment field.

Read all about it in the NIATx Year In Review - 2011.