News & Notes

SAMHSA report shows the importance of public funding during the recession: A new report from the Substance Abuse and Mental Health Services Administration (SAMHSA) highlights the importance of public funding for mental health and substance abuse services during difficult economic times. Analyses of 1986–2009 data showed that from 2004 to 2007, before the recent recession, spending on behavioral health services by all payers (public and private) was growing at a rate of 6.1% per year. From 2007 to 2009, during the recession, that rate fell to 4.3%, reflecting the record-setting 4.5% slowdown in health care spending. A slowdown in private spending on behavioral health services accounted for the weak growth. From 2007 to 2009, private spending on these services grew at an average annual rate of only 2.7%. In contrast, public spending for these services remained strong during the recession, increasing at an average annual rate of 7.4%. Specifically, accelerated growth in federal spending sustained behavioral health spending during the recession, while state and local funding languished. Federal spending on these services grew at an average annual rate of 7.2% from 2004 to 2007 and 11.1% from 2007 to 2009. In contrast, state and local spending on these services declined at an annual rate of 1.2% from 2007 to 2009. Spending by all payers on behavioral health services was $172 billion in 2009 (estimates include only direct treatment of behavioral disorders and exclude treatment of comorbid conditions such as liver cirrhosis). In 2009, mental health spending ($147 billion) accounted for 6.3% of all health spending, and spending on substance abuse treatment ($24 billion) accounted for 1.0%. The 93-page report, National Expenditures for Mental Health Services and Substance Abuse Treatment, 1986–2009, is available on the SAMHSA Web site at store.samhsa.gov/product/SMA13-4740.

IOM report focuses on key role of shared decision making in health care reform: Evidence strongly indicates that when patients are fully informed and engaged in making decisions, patient satisfaction goes up, results improve, and health care costs go down. The importance of shared decision making is emphasized in a new publication from the Institute of Medicine (IOM), which details discussions during a February 2013 IOM workshop that gathered together more than 120 patients and experts. The 240-page workshop summary, Partnering With Patients to Drive Shared Decisions, Better Value, and Care Improvement, is available at www.iom.edu/Reports/2013/Partnering-with-Patients-to-Drive-Shared-Decisions-Better-Value-and-Care-Improvement.aspx. In addition, a four-page meeting summary document presents overarching themes and messages from the workshop (www.iom.edu/Reports/2013/∼/media/Files/Report%20Files/2013/Partnering-with-Patients/PwP_meetingsummary.pdf). One clear message: “Patient engagement is a skill, not a trait.” The skills that patients need to become more engaged and the skills that clinicians need to engage them are not intuitive. Patients and clinicians learn these skills over time and with support.

New AHRQ resources on shared decision making: A recent issue of Health Care Innovations Exchange, an e-newsletter of the Agency for Healthcare Research and Quality (AHRQ), focuses on use of decision aids in shared decision making (www.innovations.ahrq.gov/issue.aspx). Decision aids, including video-based, electronic, and paper-based tools, can support this process and help patients understand available treatment options. The e-newsletter features two programs that use such decision aids. One program, at Group Health in Seattle, uses video-based aids to support shared decision making about joint replacement by patients and their surgeons. The second, CommonGround, uses paper-based and computerized decision support tools to help mental health clients identify treatment preferences and effectively communicate them to their clinicians (see description of the 2013 APA Gold Achievement Award winner on page 1064). The e-newsletter also highlights legislation in Washington State, including a legislatively mandated demonstration project and learning collaborative and a certification process for shared decision-making tools, that promotes shared decision making. Related AHRQ resources include a section of its Web site called “Questions Are the Answer,” which offers tools to promote patient involvement (www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/index.html). The tools include a seven-minute video of patients and clinicians discussing the importance of sharing information, which is ideal for a lobby or waiting room area; and a brochure, “Be More Involved in Your Health Care: Tips for Patients,” that offers helpful suggestions to follow before, during, and after a medical visit.

Kaiser Foundation’s early look at health insurance marketplaces: Under the Affordable Care Act, individuals and families may purchase private insurance coverage through new state-based health insurance exchanges. Open enrollment began on October 1 for coverage beginning January 1, 2014. In states that decide against operating their own exchanges, the federal government will either run the exchange or work with the state to create and operate an exchange. Regardless of who runs the exchange, enrollees with family incomes from one to four times the federal poverty level (about $24,000 to $94,000 for a family of four) may qualify for tax credits to lower the cost of coverage and, in some cases, will also receive subsidies to reduce out-of-pocket costs. A 29-page issue brief from the Kaiser Family Foundation presents an early look at marketplaces in the 17 states plus the District of Columbia (D.C.) that have publicly released comprehensive data about their rates or the rate filings submitted by insurers. These include 11 states operating their own exchanges and seven defaulting to a federally facilitated exchange. The analysis compared premiums in the largest cities in each of the 17 states plus d.C. Premiums were compared for individuals (25, 40, and 60 years old) and families (a family of four and an older couple) in different circumstances to illustrate the insurance rates they might pay with and without tax credits. The analysis found that premiums vary widely across the 18 cities, although they are generally lower than expected, with tax credits varying based on enrollees’ income levels and the second-lowest-cost “silver” plan available in each market. The report is available on the Kaiser Web site at http://kff.org/health-reform/issue-brief/an-early-look-at-premiums-and-insurer-participation-in-health-insur%20.

2013 survey finds modest rise in premiums for private health insurance: Annual premiums for employer-sponsored family health coverage reached $16,351 this year, up 4% from in 2012, with workers on average paying $4,565 out of pocket toward the cost of their coverage, according to the 2013 Employer Health Benefits Survey released by the Kaiser Family Foundation and the Health Research & Educational Trust. During the same period, workers’ wages and general inflation were up 1.8% and 1.1%, respectively. This year’s rise in premiums is moderate by historical standards. Since 2003, premiums have increased 80%, nearly three times as fast as wages (31%) and inflation (27%). Survey data show that firms with many lower-wage workers (at least 35% earning ≤$23,000 annually) require workers to pay $1,363 more on average toward family premiums than workers at firms with fewer lower-wage workers ($5,818 compared with $4,455 annually). The lower-wage firms also offer less costly coverage, creating a disparity in the share of the premium that their workers must pay (39% compared with 29% at firms with fewer lower-wage workers). This year, 78% of all workers with employee-sponsored coverage had an annual deductible, up from 72% in 2012. Workers must pay this deductible before most services are covered. The average 2013 deductible for worker-only coverage is $1,135, similar to that in 2012 ($1,097). The survey found that large deductibles (≥$1,000) are common, especially for workers at smaller firms: 38% of all covered workers had such a deductible, compared with 58% at small firms. Nearly a third of workers at small firms (31%) had deductibles of at least $2,000, up from 12% in 2008. Employee wellness programs are a popular strategy to control costs. Nearly all large employers (at least 200 workers) surveyed offer at least one such program. These and other findings from the 15th annual survey are summarized in an eight-page report available on the Kaiser Web site at kff.org/private-insurance/report/2013-employer-health-benefits.

Financing options for Medicaid health homes for people with serious mental illness: A provision of the Affordable Care Act permits Medicaid coverage of health homes, a service delivery model that promotes care coordination and related supports for individuals with chronic conditions, including people with serious mental illness, who are at dramatically higher risk of premature death. A report from the Center for Integrated Health Solutions (CIHS) reviews options for states and providers to establish reimbursement methods and payment rates for these health homes. As of July 2013, the Centers for Medicare and Medicaid Services (CMS) had approved Medicaid health homes in 12 states, six of which include mental and substance use disorders as eligible chronic conditions. The 43-page report describes how the these states have structured their health homes, with a particular focus on Missouri and Rhode Island, which were the first states to receive federal approval for health home services coverage. The report is designed for use by community-based primary care and behavioral health providers. It includes a general overview of most aspects of health home service design and a detailed description of specific policy areas, such as use of CMS core quality measures and available reimbursement options. The 43-page report, Financing and Policy Considerations for Medicaid Health Homes for Individuals With Behavioral Health Conditions: A Discussion of Selected States’ Approaches, is available on the CIHS Web site at www.integration.samhsa.gov/integrated-care-models/Health_Homes_Financing_and_Policy_Considerations.pdf. CIHS is funded jointly by SAMHSA and the Health Resources and Services Administration (HRSA) and run by the National Council for Behavioral Health.

SAMHSA releases latest NSDUH results: Findings from the 2012 National Survey on Drug Use and Health (NSDUH) indicate that use of illicit drugs among Americans age 12 and older remained stable since the last survey in 2011. Data show that 23.9 million Americans were current (past month) illicit drug users (9.2% of the population age 12 and older). Marijuana was the most commonly used illicit drug: 7.3% of Americans were past-month users of marijuana, up from 5.8% in 2007. Although use of marijuana rose in nearly every age group from 2007 and 2012, it dropped among those aged 12 to 17—from 7.9% in 2011 to 7.2% in 2012. The report also showed a drop in the rate of past-month use of tobacco products among 12- to 17-year-olds—from 15.2% in 2002 to 8.6% in 2012. Many Americans who need treatment for a substance use disorder are still not receiving specialty treatment: 23.1 million Americans aged 12 or older needed treatment for a substance use problem in 2012, and only 2.5 million (or 10.8% of those in need) received it in a specialized treatment setting. The complete survey findings are available on the SAMHSA Web site at www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/Index.aspx.