8 behavioral health policy issues in 2015

Although the last Congress was criticized for lack of action, it got quite a bit done on behavioral health, including passage of the Excellence in Mental Health Act and funding for mental health first-aid training. But those are just first steps, and they require lots of follow-up work. Likewise, as the Affordable Care Act (ACA) implementation continues to roll out, behavioral health executives will monitor how it impacts their practices. Behavioral Healthcare asked policy thought leaders to talk about which issues they believe will be top priorities in 2015.

1 Parity Regulation and Enforcement

The top policy issue that will unfold in 2015, observers say, involves parity enforcement now that the rules are on the books. Final regulations of the Federal Mental Health Parity and Addictions Equity Act went into effect in January, but all eyes will be on state insurance commissioners as they monitor compliance among health plans. In 2015, the Centers for Medicare and Medicaid Services (CMS) also is expected to release new guidelines regarding parity in the Medicaid managed care market. Providers should watch for the proposed rules to be published by CMS early in 2015, with a comment period before the final rule is published later in the year.

“With final rules just going into effect, it is going to take several years for the full effects of parity to play out,” says Charles Ingoglia, senior vice president of public policy and practice improvement for the National Council for Behavioral Health.

Federal officials with SAMHSA and CMS have spent time with state insurance commissioners trying to answer their questions and provide technical assistance. The Parity Implementation Coalition and the Coalition for Whole Health also have parity on the radar, he says, adding that there will likely be more class-action lawsuits against insurers that fail to meet requirements.

“Parity is our single largest issue now,” agrees Scott Munson, executive director of Sundown M Ranch, an alcohol and drug treatment facility in Selah, Wash., and a board member of the National Association of Addiction Treatment Professionals (NAATP). “It is going to play out in a state-by-state process.”

He says his organization is watching how proactively federal regulators are overseeing state-level enforcement.

The CMS guidance as to how the federal parity law applies to Medicaid managed care will be crucial for treatment centers that serve the population, especially in states with Medicaid expansion, Ingoglia says.

“We expect for most public-sector providers, that is a much more pertinent issue than the implementation of parity in the commercial space,” he says.

Mary Fleming, director of the Office of Policy, Planning, and Innovation at the Substance Abuse and Mental Health Services Administration (SAMHSA), says that it will take several years to work through the practical implementation of parity regulations from the federal level all the way down to local communities.

“We use our network of regional administrators to provide information on what is happening in various states,” she says, “but enforcement will require action on the part of several federal partners and at the state level.”

2 Excellence in Mental Health Act

One key policy move this year was set up by the April 2014 passage of the Excellence in Mental Health Act. It creates criteria for “certified community behavioral health clinics” as entities designed to serve individuals with serious mental illnesses and substance use disorders to ensure a range of services is available. The act permits pilots to begin this year in eight states that could be replicated nationwide after the two-year pilot phase.

“Historically community mental health centers have been funded at a lower rate than other providers,” SAMHSA’s Fleming says. “The act will provide a way to more equitably fund community mental health centers while still focusing on treatment outcomes.”

Ingoglia says the act is important for several reasons, including the fact that it promises to create standards at federal and state levels about what type of care should be available to people with serious mental illnesses.

“I can’t remember the last time Congress made a $1.1 billion investment in behavioral health. It just doesn’t happen very often,” he says. “This is one of the most significant things that has been lacking in our country: There has been no sense of what the standard of care is. That has led to incredible variation around the country, and there is no excuse for that.”

 SAMHSA, NIH and others have invested millions of dollars determining effective practices for particular populations, and yet the availability of those services is highly variable by state and county.

“So this would create some infrastructure,” he says. “But more importantly it also brings with it federally defined reimbursement to make those standards a reality.”

Later this year states will begin applying for the $25 million in planning grants for the two-year demonstration program. Fleming says providers who are interested in participating should get engaged now at the state level.

“It will require the state Medicaid director to agree to be the grantee,” she says. “Local treatment facilities should be working through their associations or other groups to influence the states.”

3 Mental Health First Aid

There is increasing interest in mental health first-aid training designed to teach first responders and communities about mental disorders and addictions, including the risk factors and warning signs. The federal government and a number of states have passed legislation to make mental health first-aid training available. Congress appropriated $15 million to SAMHSA to work on the cause.

“It has been integrated in the White House’s Now is the Time initiative through Project Aware and through grants to 100 local education agencies, with the hope of reaching 750,000 people,” Fleming says. “In Fiscal Year 2015, we are looking to expand eligibility to other community-based organizations with an emphasis on veterans’ organizations.”

Ingoglia says that although the National Council is excited about what will happen with mental health first aid in fiscal year 2015, his concern is the vulnerability of federal discretionary spending.

“The size of cuts to discretionary spending could be pretty severe,” he says. “So that is the big unknown as we move forward next year, around mental health first aid, but also around funding for all kinds of things.”

4 Overdose Rescue Medication

Seventeen states and Washington, D.C., now have laws in place to expand access to, and use of naloxone by laypeople. Ingoglia says there has been federal legislation introduced to offer safe harbor protection for first responders using naloxone, and he anticipates similar attention at the state level.

Fleming says SAMHSA allows use of substance abuse block-grant funds to purchase naloxone, so that could be an avenue for providers to pursue in 2015.

“The national dialog around opioid overdose, deaths and prevention is at a place it has not been for several years,” she says. “Whether that provides a forum for Congress to take some action or not, I don’t know, but states certainly can move in that direction.

5 Behavioral Health and the Affordable Care Act

Fleming expects 2015 to see a few innovations at the intersection of behavioral health and health reform coming from the federal Center for Medicare and Medicaid Innovation  (CMMI), which was created under ACA. “The challenge for the field is how to sustain those innovations for the long term and deciding which ones we want to sustain and how,” she says.

Another issue is defining what integration of services actually looks like in practice. Discussions frequently examine primary care and behavioral health services, but Fleming says SAMHSA is focused on a public health perspective for prevention, treatment and recovery support along a whole continuum of healthcare.

 “We are trying to think a little bit more broadly than primary care and behavioral health integration,” she says. “The ACA provides us some opportunity to do that. It certainly focused the dialog around the need for behavioral health services.”

Additionally, as states move forward with ACA-designed Medicaid expansion, Munson says a segment of NAATP’s membership will continue to seek relief from the IMD exclusion (a rule that doesn’t allow Medicaid to pay for residential mental health services in facilities greater than 16 beds). Along with other providers, they are seeking a revision to the federal rule to exempt stays of 30 days or less. Advocates say this would allow Medicaid to be the payer source for mental health evaluation and treatment facilities as well as substance abuse detoxification facilities that are larger than 16 beds.

6 Health Information Technology

The National Council has worked for several years to get Congress to amend the federal incentives for implementing electronic health records to allow behavioral providers to qualify, and it will continue that effort in 2015.

“We have commitments for re-introduction in the 114th Congress,” Ingoglia says.

However, many of the programs originally authorized by the HITECH Act, such as regional extension centers, are winding down, making new initiatives more challenging. Some states are taking advantage of grants from CMMI to work on health IT capability.

“We would encourage behavioral health providers and advocates to have conversations with state Medicaid offices,” he says because there are ways that funding could be used to help support electronic sharing of information.

One complicating factor in such data exchange in the behavioral specialty has been the historical challenges related to 42 CFR Part 2 regulation protections of patient privacy.

“Health IT is one of SAMHSA’s strategic initiatives for the next three years,” Fleming says, “and one of the paths we are undertaking is reviewing the 42 CFR Part 2 regulation, with a goal of seeing if there is a way of promoting exchange and use of information for treatment data while still preserving privacy and confidentiality.”

7 Marijuana Legalization

For providers such as Munson, whose facility is located in the state of Washington, the impact of marijuana legalization also will be closely watched. It’s likely too soon to tell how the policy impacts public health, the corrections system or other community indicators.

“It is an issue that is going to come to every state,” Munson says. “The role of treatment providers is to provide education as to some of the realities of chronic marijuana use. As a treatment provider in a state that already went through it, I think we made some mistakes in not being more engaged.”

8 Provider Shortages

 Ongoing provider shortages, especially in rural areas, will be another focus as more individuals gain access to health coverage. Having benefits doesn’t guarantee that an insured person can receive treatment.

“In 2015, you will see people explore a lot of different opportunities to expand ways to provide access, including telemedicine,” NAATP’s Munson says.

Even with the progress of digital patient interaction, providers are still short on qualified clinicians in many markets nationwide, some even nixing plans to open facilities because of the lack of staff available. As part of the Now is the Time initiative, SAMHSA has two new grant programs that focus on increasing the behavioral health work force.

“We want to go further upstream, early on in a person’s career path and encourage them to choose behavioral health as a career for themselves,” Fleming says. “We want to get them interested in the field to begin with.”