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Implementing Healthcare Reform: First Steps to Transforming Your Organization A Practical Guide for Leaders Recommendations from the Moving Forward Alliance. A collaborative effort coordinated by: Contents The Moving Forward Alliance .................................................................................................. 2 Introduction ............................................................................................................................ 3 Purpose of this guide .................................................................................................................. 3 Failure to Act ............................................................................................................................... 5 A Note for Prevention ................................................................................................................. 5 Resources for Getting Started ..................................................................................................... 6 Reform: Transformed Healthcare ............................................................................................. 8 Healthcare 2010 .......................................................................................................................... 8 Key Provisions ............................................................................................................................. 9 Transformation ...................................................................................................................... 11 Transformation in a new world ................................................................................................. 11 Opportunities ............................................................................................................................ 13 Threats ...................................................................................................................................... 14 Agency Transformation .......................................................................................................... 15 Creating change ........................................................................................................................ 15 Steps to transforming your agency ........................................................................................... 16 Planning................................................................................................................................. 16 Resourcing the plan .............................................................................................................. 20 Hiring a consultant ................................................................................................................ 20 Hot Topics .................................................................................................................................. 21 First Steps .................................................................................................................................. 24 Next Steps ................................................................................................................................. 24 Future Steps .............................................................................................................................. 24 Conclusion ............................................................................................................................. 25 In Closing ................................................................................................................................... 25 Advocacy ................................................................................................................................... 26 Frequently Asked Questions .................................................................................................. 27 1 The Moving Forward Alliance Recognizing the tremendous challenges and opportunities facing the addiction services field as a result of the passage of parity and healthcare reform legislation, a group of field leaders and national organizations began to meet informally. The purpose of their meeting was two-fold:  To share the latest information on implementation activities related to this ground-breaking legislation;  To explore opportunities for cooperation and collaboration to ensure that effective policies are in place and that addiction services providers are prepared for healthcare reform and parity implementation. This guide is a product of those discussions. The authors of this document wish to thank the Alliance members for their commitment and dedication, to this effort and to the field of addiction healthcare and the millions of Americans in need of substance use disorder (SUD) services: Victor Capoccia John Coppola Mady Chalk David Faulkner Kim Johnson Carol McDaid Mike Reagan Art Schut Julie Shepard Neal Shifman Paul Samuels Gabrielle de la Gueronniere Dan Belnap John Daigle Becky Vaughn Angela Halvorson Open Society Institute/NIATx NY Association of Alcoholism and Substance Abuse Providers Treatment Research Institute Day One, Maine NIATx Capitol Decisions ProAction Alliance, Michigan Arapahoe House, Colorado Iowa Behavioral Health Association Advocates for Human Potential (AHP) Legal Action Center Legal Action Center Legal Action Center Legal Action Center/NIATx/SAAS SAAS SAAS/TopLine Professional Strategies, LLC Special thanks to Victor Capoccia, the Legal Action Center, the Florida Alcohol and Drug Abuse Association (FADAA), the Illinois Alcoholism and Drug Dependence Association (IADDA), and Advocates for Human Potential for their significant contributions to this document. The primary author of this document is Angela Halvorson, TopLine Professional Strategies, with consultation from John Daigle, Becky Vaughn, Kim Johnson, and Patrick Gauthier, (AHP). 2 I ntroduction The goal of a “good” and “modern” system of care is to provide a full range of highquality services to meet the range of age, gender, cultural and other circumstances. —John O’Brien, SAMHSA Senior Adviser for Health Finance Purpose of this guide I wish I had an instruction manual that would tell me, step-by-step, how I am supposed to make my agency ready for healthcare reform. I don’t even know where to start. ‒CEO of an addiction treatment agency upon hearing that healthcare reform had passed and business practices would have to change as a result. Even before the passage of healthcare reform legislation in early 2010, experts were predicting that specialty addiction services providers would need to assess and adjust their business philosophies and practices to take advantage of the many opportunities that would follow reform. Reform is now a reality. It is time for organizations to determine how they are going to 3 transform in order to reach the more than 20 million people who need treatment and are not getting it. Reform also means an expansion in available funding for prevention, treatment, and recovery support services as Medicaid reimbursement expands and the door opens to third-party payer reimbursements. However, to capitalize on the opportunities created by parity and healthcare reform, organizations will have to: Recognize the need to transform; Help their boards of directors, managers, and staff to understand not only the elements of transformation but why change is crucial to the survival of the organization; Honestly assess the strengths and weaknesses of the organization at every level; With conscious thought and purpose, develop a workable strategic plan and/or business plan that comprehensively addresses all aspects of the organization’s culture, practices, and processes; Agencies that can accomplish the following will be positioned to succeed in the era of healthcare reform:  Recognize the need to transform  Educate boards, managers, and staff  Assess the strength and weaknesses of the organization  Strategically plan and implement transformation  Create partnerships with primary health entities  Assess changes and adjust as needed Develop or enhance partnerships with primary health clinics, physician group practices, and hospitals; Implement the plan, immediately assess its effectiveness, and identify areas for sustainment and improvement. This guide is not intended to be all-inclusive but rather to serve only as a starting point for the transformation process. The information contained in this document is an initial set of recommendations and resources to aid in preliminary planning efforts. Its purpose is to serve as a resource to help leaders change their organization’s business practices to meet requirements under healthcare reform. 4 Failure to Act In most significant transformation efforts, some individuals and groups hold out. They choose to do nothing in the hope that the experts are wrong in their assessments. However, in the case of healthcare reform, alternate ways of doing business are already occurring. While no one can predict what will happen to an organization that does not undertake the type of transformative processes discussed here, the expert consensus is that organizations that fail to adjust will struggle to survive:  Inadequate or poor billing practices will result in rejected claims and lost revenue.  Lack of partnerships with primary health providers will reduce referral opportunities, leaving many people without access to critical addiction services. This will result in a loss of potential revenue for specialty addiction services agencies. Individuals in specialty treatment with other health-related illnesses may also fail to gain access to needed primary care services.  Other enterprises will step in to fill the void left by specialty treatment agencies unwilling to adjust to the changing environment, threatening the existence of the specialty treatment system. This contradicts the belief held by addiction healthcare agencies that specialty treatment services should be provided by those most knowledgeable and with the most experience in addiction sciences. The bottom line: millions of people will continue to go untreated; millions of dollars will be lost to organizations in desperate need of revenue sources beyond the cash-strapped, publicly funded system; specialty treatment services will become obsolete as primary healthcare enterprises fill the void to meet the demand. A Note for Prevention Prevention will be a key component of healthcare as reform evolves. Language in the Patient Protection and Affordable Care Act refers to wellness, health promotion, and prevention. This underscores what SUD prevention advocates have known for decades—prevention saves lives and saves money. As a result, prevention will also need to undergo significant transformation in the new environment—perhaps even more so than treatment agencies. Prevention programs are not structured to bill on a fee-for-service basis, a billing method required by insurance and other third-party payers. 5 So what will prevention look like in the new environment? That answer is unknown. However, prevention agencies should be prepared to undergo the same level of transformation as their treatment counterparts. Preventionists should read this guide, keeping in mind that while the future is unclear, transformation is likely in their future as well. Use this guide as a resource and a starting point for organization transformation efforts. The time to act is now! Resources for Getting Started There are many resources available to organizations on the topics discussed in this guide. Before an organization begins this process, the Moving Forward Alliance recommends the following reading:  A Path Forward to Measuring Continuing Care Management for Substance Use Illness: Patient-Focused Episodes of Care, developed by the National Quality Forum, November 4, 2009 http://www.niatx.net/PDF/AcceleratingReform/Nation alQualityForum.pdf  National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices, developed by the National Quality Forum http://www.rwjf.org/files/research/nqrconsensusreport2007.pdf  Effects of State Health Care Reform on Substance Abuse Services in Maine, Massachusetts, and Vermont: Considerations for Implementation of the Patient Protection and Affordable Care Act (PPACA), developed by National Association of State Alcohol and Drug Abuse Directors (NASADAD), June 2010 http://www.nasadad.org/resource.php?base_id=2104  Accountable Care Organizations, Health Cost Containment and Efficiencies: A brief to state legislators from the National Council of State Legislators (NCSL) http://www.ncsl.org/default.aspx?tabid=19927 6  Transforming Your Organization: Global Organizational Development White Paper Series, by John B. McGuire, Charles J. Palus, William Pasmore & Gary B. Rhodes, from the Center for Creative Leadership http://www.ccl.org/leadership/pdf/solutions/TYO.pdf  Strategies for Strengthening Substance Use Prevention, Treatment and Recovery Systems: Provider Networks and Impact on the Workforce, prepared by State Associations of Addiction Services, January 2009 http://saasnet.org/PDF/SAAS_Provider_Networks_Report1-9-08.pdf  California Primary Care, Mental Health, and Substance Use Services; Integration Policy Initiative, September 14, 2009  Preparing for Parity: Investing in Mental Health, A Milliman White Paper http://publications.milliman.com/research/health-rr/pdfs/preparing-parity-investingmental-WP05-01-09.pdf  Additional resources are also available at: o The SAMHSA Financing Center of Excellence at http://www.samhsa.gov/Financing o http://www.managementhelp.org, a free, online library for not-for-profit and forprofit managers  Also check out http://www.niatx.org for information on the ACTION Campaign, the Accelerating Reform Initiative (ARI), and the Provider ToolKit. NIATx resources are free to providers. 7 R eform: Transformed Healthcare This legislation will not fix everything that ails our health care system, but it moves us decisively in the right direction. ‒ President Barack Obama following the passage of historic health care reform legislation, March 21, 2010 Healthcare 2010 On April 5, 2010, the final rule governing implementation of the Wellstone/Domenici Mental Health Parity and Addiction Equity Act went into effect. These regulations include several provisions that improve access to critically important addiction and mental health treatment for millions of Americans, primarily requiring many health plans to cover addiction and mental health services on par with other health conditions. Passage and implementation of parity marked a milestone for addiction and mental healthcare advocates who had for decades fought for its passage. On March 23, building on the success of parity, advocates watched as President Obama signed into law H.R. 3590, the “Patient Protection and Affordable Care Act.” The new law, approved by the U.S. Senate on December 24, 2009, and the U.S. House of Representatives on March 21, 2010, includes a number of provisions aimed at improving coverage for and access to substance use disorder and mental illness prevention, treatment, and recovery services. The unified and coordinated effort by advocates for people in need of substance 8 use disorder and mental illness prevention, treatment and recovery support services contributed greatly to the passage of this federal statute. The new federal healthcare law will expand coverage to tens of millions of uninsured Americans, resulting in coverage for approximately 95 percent of the legal population. Key Provisions The following is an overview of key components of the final legislation: Substance use disorder and mental health (SUD/MH) services will be included in basic benefit packages. All plans in the health insurance exchange will be required adhere to the provisions of the Wellstone/Domenici Parity Act. Medicaid enrollees, including newly eligible childless adults, will receive adequate health coverage, including SUD/MH coverage. SUD/MH will be included in chronic disease prevention initiatives. SUD/MH workforce in health workforce development initiatives. SUD prevention, treatment, and MH service providers to be eligible for community health team grants aimed at supporting medical homes. Expanded Medicaid coverage for all Americans below 133 percent of the federal poverty level. Health insurance exchanges created for individuals and small employers to pool risk and purchase insurance. Who is affected? By various estimates, at least 111 million people 82 million are in self-insured plans Self-insured state and local government plans may opt out. 460 health insurers and 120 Managed Behavioral Healthcare Organizations (MBHOs) 9