News and Notes

SAMHSA report summarizes 2013 NSDUH findings: The National Survey on Drug Use and Health (NSDUH) is an in-person interview survey of a random sample of the civilian, noninstitutionalized U.S. population age 12 and older that provides information on substance use disorders and their treatment and mental health service use. Findings from the 2013 survey are summarized in a new report from the Substance Abuse and Mental Health Services Administration (SAMHSA), which funds the annual survey. The 2013 survey found that nearly one in five adults (18.5%) had a mental illness in the past year, 4.2% had a serious mental illness, and 3.9% had serious thoughts of suicide. An estimated 34.6 million adults (14.6% of the population aged 18 or older) received mental health care (inpatient or outpatient treatment or counseling or medications) in the past year. In 2013, an estimated 24.6 million individuals were current illicit drug users (about 9.4% of the population), including 2.2 million adolescents (8.8% of the population age 12 to 17). Marijuana was the most commonly used illicit drug, with 19.8 million current users (7.5% of the population). Slightly more than half (52.2%) of Americans were current alcohol users—or about 136.9 million individuals. Nearly one-quarter (22.9% or about 60.1 million people) reported binge drinking (five or more drinks on the same occasion). In 2013, 11.6% of adolescents, or about 2.9 million individuals, were current alcohol users, including 1.6 million who reported binge drinking. The eight-page NSDUH summary is available on the SAMHSA Web site at www.samhsa.gov/data/2k14/NSDUH200/sr200-findings-overview-2014.pdf.

Commonwealth Fund report assesses state strategies for integrating care: The Affordable Care Act (ACA) provides states with incentives and mechanisms to integrate care delivery to Medicaid beneficiaries with comorbid general medical and behavioral health conditions, with the aim of improving care for this high-cost population. However, states’ efforts are hindered by fragmented behavioral health systems, multiple levels of administration and regulation, and purchasing models that segregate behavioral health services from other Medicaid-covered services. A recent report from the Commonwealth Fund describes administrative, purchasing, and regulatory strategies that states are using to address or eliminate such system-level barriers to integrated care. Authors of the 20-page report, which draws on a literature review and interviews with stakeholders, found that most states are choosing not to tackle long-standing political and structural barriers to consolidating agencies. Instead many have been consolidating behavioral health purchasing, contracting, and rate setting in their Medicaid agency while retaining licensing and clinical policy in the behavioral health agencies. When that is not feasible, states have had to rely on informal collaborations across agencies. In the area of purchasing strategies, Medicaid managed care is the preferred delivery model in most states, and instead of integrating benefits, most states carve out separate reimbursement streams for some behavioral health services. Carve-out arrangements, which are the result of past political, financial, and policy pressures, continue to exist despite mounting evidence that they create barriers to care coordination and information sharing. However, a growing number of states are implementing fully integrated managed care approaches, in some cases targeted to individuals with serious mental illness. The authors conclude that there is no single pathway through which all states will be able to achieve integrated care for this population. The best strategy or combination of strategies will depend on a state’s political and health care environment. State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid Environment is available on the Commonwealth Fund’s Web site (www.commonwealthfund.org).

National Council report explores future payment models in behavioral health care: As health care reform evolves, what service delivery and payment models will emerge for behavioral health care providers? A report from the National Council for Community Behavioral Health attempts to answer that question by examining proposed models. It asks behavioral health care providers to consider several questions: Who might be your payers in two and five years, and what are they currently thinking about payment reform? What direction is the integration of health care taking in your state and community? Will you be able to succeed in partnering with primary care to provide behavioral health services in that setting? The report describes two main roles for behavioral health providers in the new health delivery “ecosystem”: providers inside medical homes, who become deeply embedded as part of primary care teams, and providers in behavioral health specialty “centers of excellence” that partner with medical homes to provide specialty care to individuals with complex conditions. The 14-page report also outlines three predominant payment models that move provider reimbursement away from fee-for-service arrangements: global payments for those working in medical homes, bundled payments through prospective payment systems for those that achieve the recently created designation of “Certified Community Behavioral Health Clinic,” and case rates for providers working in specialty behavioral health clinics. Payments will be based on value not volume, and the report describes how value is measured in each of the proposed models. The 14-page report, Creeping and Leaping From Payment for Volume to Payment for Value, which also offers recommendations to help providers get ready for change, is available on the National Council’s Web site (www.thenationalcouncil.org).

Kaiser Foundation brief describes ACA’s benefits for justice-involved populations: Coverage expansions in the ACA, particularly the Medicaid expansion, provide new opportunities to increase health coverage for individuals transitioning out of the criminal justice system, especially adults with low incomes who have significant general medical and mental health needs. A new issue brief from the Kaiser Family Foundation provides an overview of the U.S. adult population involved in the criminal justice system, most of whom are uninsured, and the potential impacts of the ACA on their health coverage. As described in the report, the justice-involved population includes many more people than the approximately 2.3 million who are incarcerated in prisons and jails at any given time. Millions more interact with the system annually. For example, between July 2012 and June 2013, an estimated 11.7 million people were admitted to local jails, and about 4.1 million adults entered and exited community supervision over the course of 2012. In the 28 states that have implemented Medicaid expansion as of August 2014, many of these individuals are eligible for coverage via Medicaid or marketplace insurance plans. Many states have introduced programs to connect inmates with coverage upon release, usually in prisons only. However, the Cook County Jail in Chicago screens detainees on entry for eligibility in the county’s expanded Medicaid program, as described in the issue brief. The ten-page brief, Health Coverage and Care for the Adult Criminal Justice-Involved Population, is available on the Kaiser Foundation site, along with a May 2014 brief that examines the same issues for adolescents involved in the juvenile justice system (www.kff.org/uninsured).

SAMHSA reports examine substance use disorders in the workplace: Two new reports from SAMHSA highlight the importance of addressing the needs of people in the workplace who have substance use disorders. Both reports used combined NSDUH data from 2008–2012. Data analyzed in the first report indicate that about three-fifths of the U.S. population age 18 to 64 (113.1 million persons) are full-time workers. As a result, the report notes, most adults with substance use disorders are employed full-time (55%). This finding highlights the importance of addressing substance use in the workplace. Data in the second report, Workplace Policies and Programs Concerning Alcohol and Drug Use, indicate that about 81% of adult full-time workers work for employers that have a written policy about employee use of alcohol and drugs. Those who used illicit drugs or who drank heavily in the past month were generally less likely than those who did not do so to work for an employer with a written policy. In addition, 60% of adult full-time workers reported having access to an employee assistance program (EAP) or other type of counseling program available through the workplace, and 45% had received educational materials about substance use from their employer. Small but statistically significant increases in the percentage of workers reporting written workplace policies and EAP access were noted over the past decade. Both reports are available on the SAMHSA Web site (www.samhsa.gov).

CHCS brief presents care framework for dual-eligibles: Over 10 million people in the United States are dually eligible for Medicare and Medicaid. These individuals are more likely than those covered by Medicare alone to have multiple chronic conditions and disabilities requiring complex care. Frailty, mental illness, and homelessness may compound their health challenges. Because they are served by two separate programs covering different benefits and services, “dual eligibles” are more likely to experience fragmented, inefficient care. Policy makers have noted that high-performing health plans are critical to the success of efforts to align Medicare and Medicaid services. To increase the number of high-performing plans, the Commonwealth Fund supported the creation of PRIDE (PRomoting Integrated Care for Dual Eligibles), a consortium of seven integrated health care organizations brought together to advance strategies for providing care for dual eligibles. An issue brief from the Center for Health Care Strategies (CHCS) introduces a framework of key attributes necessary for high-performing health plans to support integrated care developed through the PRIDE project. The framework is structured around five domains: leadership and organizational culture; infrastructure to “scale up” and “stretch out” while maintaining quality and value; financial and nonfinancial incentives that align plan, provider, and member interests; coordinated care provided through comprehensive, accessible networks and person- and family-centered care planning; and the capacity to attract and retain members, expand enrollment, and increase retention. The framework describes critical attributes within each domain. The framework is intended as a guide rather than a set of formal criteria. It can help states and health plans establish the elements essential to successfully providing coordinated, person-centered, integrated care for individuals with complex needs. The 11-page brief, Key Attributes of High-Performing Integrated Health Plans for Medicare-Medicaid Enrollees, is available on the CHCS site (www.chcs.org).

Kaiser Foundation analysis of 2015 premium changes in ACA marketplaces: The second open enrollment period for health insurance marketplaces begins on November 15, 2014. An analysis by the Kaiser Family Foundation of available 2015 data from 15 states and the District of Columbia indicates that in general, individuals will pay slightly less to enroll in the second-lowest-cost plan than they did in 2014. Although premium changes vary substantially across and within states, 2015 changes are modest in regard to low-cost insurers in the marketplaces, where enrollment is concentrated. As data for all 50 states become available, the overall picture may change, the report notes. The report is available on the Kaiser Web site (www.kff.org).