Navigating the ACA: Got Data? Peter J. Delany, Ph.D., LCSW-C RADM, U.S. Public Health Service Director, Center for Behavioral Health Statistics and Quality.

Navigating the ACA: Got Data?

Peter J. Delany, Ph.D., LCSW-CRADM, U.S. Public Health ServiceDirector, Center for Behavioral Health Statistics and QualitySubstance Abuse and Mental Health Services AdministrationRockville, Maryland

Innovations in RecoveryCoronado, CaliforniaMarch 31, 2015

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About SAMHSA

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services (HHS) that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

One morning, a villager decided to walk along the river on her way to work. As she was enjoying the view, she noticed a crying infant in the river. Horrified by the sight of a helpless child in such a dangerous predicament, the villager dove into the water, grabbed the baby, and brought him ashore. The baby, although afraid and soaking wet, was fine.With a sigh of relief, the villager wiped the water from her own eyes and looked out on the river.

As she tried to warm the baby with her jacket, she heard more crying. She looked out over the river only to see another baby in the water. Once again, she dove into the water and rescued this baby as well. Not a minute had passed before she heard more crying, and looking out over the river, she spotted dozens more babies.

Calling out for help she was soon joined by the entire community, and together they rescued as many babies as they could. But the babies kept on coming ....

After half an hour or so, a group of villagers decided to go upstream to find out why the babies were in the river in the first place. Upstream, they found an ogre, tossing babies into the water!

When the villager called her neighbors to the river, she mobilized community. Going upstream and confronting the ogre is creating a lasting change in the condition that causes the problem. Creating lasting change is what we endeavor to do. We need to focus on "keeping the babies out of the river" in the first place. If we don't, we will be pulling babies out of the river forever.

Only by dealing with the ogre will the villagers be able to keep the babies safe.

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About CBHSQ

The Center for Behavioral Health and Statistics and Quality (CBHSQ) is the government’s lead agency for behavioral health statistics. CBHSQ:• Provides national leadership in behavioral health statistics and

epidemiology• Promotes basic and applied research in behavioral health data systems

and statistical methodology• Designs and carries out special data collection and analytic projects to

examine issues for SAMHSA and other federal agencies• Participates with other federal agencies in developing national health

statistics policy• Consults and advises SAMHSA’s Administrator and the HHS Secretary on

statistical matters

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National Survey on Drug Use and Health (NSDUH)

• NSDUH is an annual data collection that is the primary source of information on the prevalence, patterns, and consequences of alcohol, tobacco, and illegal drug use and abuse, as well as mental disorders, in the U.S. civilian, noninstitutionalized population, aged 12 or older.

• Used to generate national, state, and substate estimates• Selected data collected include:

• Lifetime, past year, and past month prevalence of alcohol, illicit drugs, and tobacco

• Past year substance use disorders• History of substance use treatment• Age at first use of substances• Risk and protective factors for

youth substance use

• Past year any mental illness, serious mental illness, and suicidal thoughts/plans for adults aged 18 or older

• Past year mental health treatment for adults aged 18 or older

• Past year Major Depressive Episode (MDE) for adults and for youth aged 12 to 17

SAMHSA Data Collections

National Survey of Substance Abuse Treatment Services (N-SSATS)• N-SSATS is an annual, survey of all known substance abuse

treatment facilities, both public and private.• Selected data collected include :

• Facility operation• Types of services offered (e.g.,

assessment and testing services) • Opioid treatment programs • Medications dispensed or

prescribed• Counseling and therapeutic

approaches• Special programs or groups

• Type of treatment provided• Number of clients• Types of payment accepted• Availability of sliding fee scale• Facility accreditation and licensure• Managed care agreements• Facility focus (e.g., substance

abuse, mental health)• Facility ownership

SAMHSA Data Collections

National Mental Health Services Survey (N-MHSS)• N-MHSS is an annual survey of all known mental health

treatment facilities in the United States, both public and private. N-MHSS began in 2010.

• Selected data collected include in 2010:• Facility information• Facility ownership• Single-day count of clients /

patients by type of service• Supportive services offered• Mental health treatment

approaches• Special programs or groups• Age categories served

• Languages in which treatment is provided

• Type of treatment provided• Types of payment/funding

accepted• Sliding-fee scale or other types of

payment assistance

SAMHSA Data Collections

Treatment Episode Data Set (TEDS)• TEDS is an annual data collection that tracks the national flow of

admissions and discharges to specialty providers of substance abuse treatment. The collection has been ongoing since 1992.

• Selected data collected include: • Client demographic characteristics• Health insurance status• Expected source of payment• Employment status • Type of service at

admission/discharge • Number of prior treatment episodes• Number of arrests in past 30 days

• Injection drug use for up to three substances of abuse

• Age of initiation for up to three substances of abuse

• Past 30 day use for up to three substances of abuse

• Principal source of referral• Presence of co-occurring mental

health disorders

SAMHSA Data Collections

SAMHSA’s Emergency Department Surveillance System (SEDSS)• As part of the new National Hospital Care Survey conducted

by the National Center for Health Statistics, SAMHSA will publish data on drug- and mental health- related visits to emergency departments as SAMHSA’s Emergency Department Surveillance System (SEDSS).

• Published data are expected in 2016.

Yes, We Even Threw In…

Substance Abuse and Mental Health Data Archive

A resource that our lead statistician for data policy calls a “health data-palooza”

CBHSQ contracts with University of Michigan to host the SAMHDA website

Access at: http://www.datafiles.samhsa.gov

More than 400 behavioral health data sets

Public-use data files, file documentation, online analysis tools, plus restricted-use and confidential data file

Substance Abuse and Mental Health Data Archive

Drug Abuse Warning Network (DAWN)

National Survey on Drug Use and Health (NSDUH)

National Survey of Substance Abuse Treatment Services (N-SSATS)

Treatment Episode Data Set—Admissions and Discharges (TEDS-A & TEDS-D)

National Mental Health Services Survey (NMHSS)

Other archived studies available (e.g. NYS)

Substance Abuse and Mental Health Data Archive

Three No-Cost Avenues of Access Public-use files

No log-in required

R-DAS (Restricted-use Data Analysis System) Log-in account required

Data Portal (this is changing) Log-in account required Verification of approved IP address Unique username and password MToken

Substance Abuse and Mental Health Data Archive

For assistance with this archive, contact our “data-palooza” statistician—she has all the information.

Brooklyn [email protected]

(240) 276-0532

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And Now…

What you’ve all been waiting for:Numbers! Graphs! Charts!

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Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2013

+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.

Illicit Drugs

Marijuana

CocaineHallucinogens

Psycho-therapeutics

Percent Using in Past Month

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Past Month and Past Year Heroin Use among Persons Aged 12 or Older: 2002-2013

+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.

Past Year

Past Month

Numbers in Thousands

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Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing

but Not Receiving Treatment for Illicit Drug or Alcohol Use: 2013

20.2 Million Needing but Not Receiving Treatment for Illicit Drug or Alcohol Use

Felt They Needed Treatment and Did

Make an Effort

Did Not Feel They Needed Treatment Felt They Needed

Treatment and Did Not Make an Effort

1.6%2.9%

95.5%

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Reasons for Not Receiving Substance Use Treatment among Persons Aged 12 or Older Who Needed and Made an Effort to Get Treatment

but Did Not Receive Treatment and Felt They Needed Treatment: 2010-2013 Combined

Percent Reporting Reason

No Health Coverage and Could Not Afford Cost

Not Ready to Stop Using

Had Health Coverage but Did Not Cover Treatment or Did Not Cover Cost

Did Not Know Where to Go for Treatment

No Transportation/Inconvenient

Might Have Negative Effect on Job

Could Handle the Problem without Treatment

Did Not Feel Need for Treatment at the Time

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Past Year Substance Use Disorders and Serious Mental Illness among Adults Aged 18 or Older: 2013

SMI = serious mental illness; SUD = substance use disorder.

SUD,No SMI

17.9 Million

SUD and SMI

7.7 Million

20.3 Million Adults Had SUD

10.0 Million Adults Had SMI

2.3 Million

SMI,No SUD

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NSDUH Short Reports

• This short report summarized key state-level mental illness findings from the 2011 and 2012 NSDUHs.

• Among the key findings:– The percentage of adults aged

18 or older with serious mental illness in the past year ranged from 3.1 percent in New Jersey to 5.5 percent in West Virginia.

– Nationally, 42.5 million adults experienced any mental illness in the past year; the rates ranged from 14.7 percent in New Jersey to 22.3 percent in Utah.

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NSDUH Data Spotlights

• Using combined 2011 to 2012 NSDUH data, this Data Spotlight indicated that 8.5 percent of pregnant women aged 15 to 44 drank alcohol in the past month; 2.7 percent binge drank.

• Alcohol use was lower during the second and third trimesters than during the first (4.2 and 3.7 percent vs. 17.9 percent).

• These findings suggest that many pregnant women are getting the message and not drinking alcohol.

Health Services Research

• Examines how people get access to health care providers and health care services

• How much care costs• What happens to patients as a result of this care• How social factors, financing systems, organizational

structures and processes, technology, and personal behaviors affect access to treatment, quality and cost of care, and quantity and quality of life

Health Services Research

How SAMHSA does behavioral health services research:• The aim is to perform health services research that

can be applied by providers, policy makers, and programs to make decisions about behavioral health prevention and treatment

• The principles of health services research to behavioral health prevention and treatment

Evaluation

The Quality, Evaluation, and Performance (QEP) Branch in CBHSQ, composed of 6 evaluation desk officers, has worked closely with 26 program evaluations with the potential for providing support to a number of other evaluations that are being considered or planned. In addition to program-specific work, Branch staff coordinate some SAMHSA-wide activities, such as the evaluation of the diverse portfolio of SAMHSA behavioral health mobile applications.

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PREVALENCE OF BH CONDITIONS AMONG UNINSURED ADULTS AGES 18-34 WITH INCOMES <400% FPL

44.0% SMI/ SPD/ SUD

56.0%

“Behavioral Health Conditions” includes serious mental illness (SMI), serious psychological distress (SPD) and

substance abuse disorders (SUD)

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PREVALENCE OF BH CONDITIONS AMONG UNINSURED ADULTS AGES 35 AND OVER WITH INCOMES <400% FPL

23.8%SMI/ SPD/ SUD

76.2%

“Behavioral Health Conditions” includes serious mental illness (SMI), serious psychological distress (SPD) and substance abuse

disorders (SUD)

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More are Insured than Ever

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Saving Tax Dollars Every Day

The Impact of Policy on Health Care Delivery Today

Many health and health-related policies affect health care delivery. Some examples: Reportable events/conditions, such as animal bites,

interpersonal violence, anthrax exposure, death, etc. HIPAA

Some policies are specifically related to or have important linkages to behavioral health: Parity legislation (MHPAEA) Patient Protection and Affordable Care Act (ACA)

Parity Before ACA: The Mental Health Parity and Addiction Equity Act of 2008

MHPAEA requires that financial requirements and treatment limitations for mental health/substance use disorder benefits be no more restrictive than for essentially all other benefits

Applies to plans sponsored by private and public sector employers with more than 50 employees

Supplements Mental Health Parity Act of 1996 (MHPA), which required parity on annual and lifetime coverage costs

MHPAEA Limitations

Act provides significant new protections to participants in group plans…but MHPAEA does not mandate that a plan provide MH/SUD benefits

Also…does not apply to policies for employers with 50 or fewer employees, or to individual policies

Patient Protection and Affordable Care Act

December 24, 2009

Promotes improved access to health care coverage and health services

Many items specific to Medicare and Medicaid

ACA expected to: Improve quality in health care Lower costs over time, or at least stabilize costs

Patient Protection and Affordable Care Act

Key Issues Addressed

Preventive health care

Integrated health care

Quality care

Dependent coverage

Minimum standards

Parity

Patient Protection and Affordable Care Act

Mental Health Parity ACA builds on MHPAEA to extend federal parity

protections to 62 million Americans

Requires MH/SUD benefits for millions of Americans in individual and small-group markets

Expands parity to apply to millions whose coverage did not previously comply with those requirements.

Patient Protection and Affordable Care Act

Payers and Quality Providers must be accredited on local performance

Judged on clinical quality measures such as: Healthcare Effectiveness Data and Information Set Patient experience ratings Consumer access Credentialing Network adequacy Handling of complaints, etc.

Patient Protection and Affordable Care Act

Prevention Services and Efforts

PreSmoking cessation

Weight management

Stress management

Physical fitness

Nutrition

Heart disease prevention

Healthy lifestyle support

Diabetes prevention

Patient Protection and Affordable Care Act

Chronic Conditions

Mental health

Substance use disorder

Asthma

Diabetes

Heart disease

Overweight (BMI>25)

Patient Protection and Affordable Care Act

Important Points

Does not remove obligation to provide emergency services

Still different tiers (Bronze, Silver, Gold) in levels of insurance—important to remember in considering access issues

Patient Protection and Affordable Care Act

What Does This Mean for Clinical Practices? Often a clinical context

Data usually associated with the event, condition, or activity

Provides an opportunity to understand Events leading up to a health situation Time-related context of the health situation Prevalence and incidence Outcomes Intervention potential

Patient Protection and Affordable Care Act

How does health policy—in particular ACA—affect clinical care and care transformation?

How can research and evaluation improve and inform the field?

Our Path is Clear

Behavioral Health Care

Those of us in behavioral health services must seize all opportunities

for translating policy into practice and research

Behavioral Health Care Treatment and Cost

How many uninsured (pre-ACA) American adults received treatment? According to the National Survey of Drug Use and

Health (2009-2011), there were 37 million uninsured Americans between the ages of 18 and 64

Of that group, it is estimated that 3.9 million received any behavioral health treatment

Behavioral Health Care Treatment and Cost

How many of the previously uninsured are likely to seek behavioral health treatment within Medicaid or health insurance exchanges (ACA)?

Prior to ACA, estimated that 1.5 million uninsured with incomes at or below 138% of the federal poverty level had behavioral health treatment Estimated that an additional 1.2 million will have behavioral health treatment under

Medicaid/ACA

Prior to ACA, estimated 2.2 million with incomes above 138% of the poverty level had behavioral treatment Estimated that an additional 1 million will have behavioral health treatment under

Medicaid/ACA

Source: National Survey of Drug Use and Health (2009-2011)

Behavioral Health Care Treatment and Cost

Income at or below 138% FPL: Behavioral health: $2,100 All health: $9,400

Income 138-400% FPL: Behavioral health: $1,600 All health: $8,500

Among those who do not use behavioral health treatment services, regardless of income, the annual health care cost is approximately $3,000.

Source: Medical Expenditure Panel Survey (2009-2010)

The Challenges

Can health systems help to improve what we know about the cost of care delivery for patients with psychiatric and other behavioral health conditions?

Is there a capacity—given the availability of billing, claims, EMR, and other data—to more completely examine cost and expenditure?

National Behavioral Health Quality Framework

http://www.samhsa.gov/data/NBHQF/index.html#exhibit1

Payer/System/Plan

(e.g., SAMHSA, HRSA, Medicaid/Medicare, State Govt)

Provider/Practitioner Patient/Population

NBHQF Goal 1: Promote the most effective prevention, treatment, and recovery practices for behavioral health disorders (Recommended Measures) LINKED TO AND REFLECTIVE OF MEASURECONCEPTS

Relevant EBPs in

preventive, clinical, and recovery support settings tracked, summarized, and publicly available

Outcomes reflecting

recovery Social connectedness

of persons with behavioral health issues

NQF #0004: Initiation and

Engagement of Alcohol and other Drug Dependence Treatment

In NQF review: Screening, brief

intervention, and referral for treatment for alcohol misuse

NQF #0576: Follow-up After

Hospitalization for Mental Illness

Consumer Evaluation of Care:

Reporting Positively About Outcomes (adult and child)

NQF #0418: Screening for Clinical

Depression

NQF #0104: Major Depressive Disorder: Suicide Risk Assessment

NQF#0710-0711-0712: Depression Utilization of PHQ-9 and Remission at 6 and 12 months

NQF #0105: Anti-depressant Medication Management: (a) Effective Acute Phase Treatment and (b) Effective Continuation Phase Treatment

NQF #1364/1365: Child/Adolescent Depressive Disorder: Diagnostic Evaluation

NQF #1401: Maternal Depression Screening

NQF #0028: Preventive Care and Screening Measure Pair: (a) Tobacco Use Assessment and (b) Tobacco Cessation Intervention

NQF #0110: Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use

Emergency Department Alcohol

Use Screening and Follow-up

Employment/Education:

Changes in employment status (increased/no change) or in school status at a date of last service compared to first service

Abstinence: ATOD-related suspensions and expulsions

Housing: Increase in stable housing status from date of first service to date of last service

Abstinence: Family communication around drug use

Percentage of patients with

annual encounter data with a primary care physician OR pediatrician OR obstetrician/gynecologist

MU2 Screening for Intimate

Partner Violence

Translational Research: Questions to Face on Behavioral Health Care Integration

What is the right model? What other health issues should be considered? Outcomes? (BH vs. physical) What are the evidence-based metrics that matter? How do the models translate across systems and settings? Are there cost savings? How are the patterns of utilization affected by these strategies? What are the barriers to implementation? How sustainable?

Some Congressional Issues: “Dual-eligibles” and ACA

Improve quality of care and long term services

Increase patient literacy of and satisfaction with coverage

Eliminate regulatory conflict

Improve continuity of care; safe and effective care transitions

Eliminate cost-shifting

Improve quality of performance

Study provision of drug coverage for new full-benefit, dual-eligible people, monitor total expenditures, health outcomes, and access to benefits

Other Topics that Might Emerge Under ACA

Integrated care delivery Who got covered? Who didn’t? Why? Health literacy—how does it affect behavioral health care delivery

and choice of care settings? Health care costs—what are the right questions in behavioral health? Behavioral health care quality—what matters at the clinical level? Health care workforce—is capacity sufficient? Who is still not covered? What kind of care are people accessing and using? Impacts on chronic disease management and health care costs

Other Topics that Might Emerge Under ACA

How to engage behavioral health population in prevention programming

Religious sects may be exempt Vulnerable populations Re-admissions Development of recommendations for additional task force activities School-based behavioral health services Tobacco cessation, particularly among pregnant women Strengthening public health surveillance Contribution of private health care providers to surveillance of

behavioral health

Data Resources for Translational and Policy-Relevant Research

“Big Data”

Mini-Sentinel…a $116-million government pilot project

Pro-actively seeks adverse events linked to marketed drugs

Mines huge databases of medical records (privacy protected)

A five-year experiment coming to an end

FDA deciding what to do next

General agreement that the ability to sift through huge amounts of patient data is the way of the future—but what’s the best way to do that sifting?

Electronic health records and health information exchanges (EMR, HIE, HIT)

Claims data

Evaluation data

Local and internal surveys

SAMHSA health data information

Data Resources for Translational and Policy-Relevant Research

Conclusion

As our nation continues to move toward the full roll-out of a health policy that is expected to reach most citizens, questions still remain

Organizations delivering health care have opportunities to develop and test new models that can improve care delivery, outcomes, and potentially reduce costs

Use your evidence. We won’t know the impact of policy until we know how to use data to tell our story—data will prove the value of your innovations

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Resources

• For more about NSDUH data, visit: http://www.samhsa.gov/data/population-data-nsduh

• For more about SAMHSA, visit: http://www.samhsa.gov/

• For more about CBHSQ, visit: http://www.samhsa.gov/about-us/who-we-are/offices-centers/cbhsq

Questions?

Navigating the ACA: Got Data?

Peter J. Delany, Ph.D., LCSW-CRADM, U.S. Public Health Service

Director, Center for Behavioral Health Statistics and QualitySubstance Abuse and Mental Health Services Administration

Rockville, [email protected]

Dee S. Owens, Special Assistant to the [email protected]