David A. Casey, M.D. University of Louisville

David A. Casey, M.D. University of Louisville

The Affordable Care Act is one of the most controversial and far-reaching reforms in US medical history Psychiatry and mental health are not the major focus of the legislation, yet the ACA may have dramatic effects on psychiatric practice ACA best seen in context of various public and private reforms which are ongoing and likely to continue Very high level of change (and stress) in psychiatric practice in past few years

Psychiatric practice has been deeply affected by many previous reform movements 1950s: Deinstitutionalization and civil commitment reform 1960s: Community Mental Health Act Medicare originally with psychiatric limits Medicaid mental health initially excluded Private insurance coverage for mental health

Heyday of private insurance based practice Fee for service indemnity payment Late 1970s to early 1980s: advent of managed care and psychiatric carve-outs 1980s: beginning of prospective payment: Medicare cost savings programs (RBRVS; RVUs; DRGs)

DSM III (published by the APA) New approach to criterion based diagnosis Attempt to bring validity and reliability to psychiatric diagnosis APA under pressure internally and from federal government and insurance industry to bring science to psychiatry Also a prelude to establishing best practices and instituting cost controls in face of rapidly escalating mental healthcare costs

Managed care programs set aggressive limits on mental health outlays of about 5-6% of total insurance outlays a form of rationing Precerts, recerts, post-discharge reviews The Mental Health Parity Act of 1996 (MHPA) Primarily focused on equalizing limits on annual and lifetime dollar limits of care Did not have desired effect in promoting overall parity

Called for much more thorough mental health parity reform Final rules never published, so had little practical impact Tenets of this act were subsumed under the ACA

Very little direct mention of psychiatry or mental health However, the points that are mentioned are vital Expansion of parity definition to mean equality with general medical care in process and financial outlay Mental health defined as an essential benefit Required to be included in ACA compliant plans

Substance abuse coverage No preexisting condition exclusion Coverage on parental policy for dependent children until age 26 Reduced donut hole costs for Medicare Expansion of Medicaid; Decoupling Medicaid eligibility from requirement to have SSI Expansion of Medicaid has disproportionate effect on psychiatrically ill population

Controversy over individual mandate Resistance to expanded Medicaid and state exchanges Possible repeal of parts of the act under a Republican Congress (politically difficult to repeal entire act) Although the act as a whole is unpopular in many circles, may aspects are very popular

Widespread misunderstanding and mischaracterization Unclear whether cost savings will be realized Unclear whether enrollment goals will continue to be realized Second enrollment period approaching

Possibility of substantial rollback or repeal Insurance programs can still require intrusive treatment certification Many states did not expand Medicaid States may define certain aspects of essential benefits End of the Disproportionate Share (DISH) program and other safety net programs which are to be replaced by ACA; especially damaging in non-participating states

Very large and growing number of inmates have serious psychiatric disabilities Many receive poor care and are victimized by others in the correctional system Incarceration is far more expensive than any other form of management for psychiatrically ill inmates ACA fails to deal with this problem and many other structural issues in mental health care

An ACO is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to defined quality metrics and reductions in total cost of care for an assigned population of patients. A group of coordinated healthcare providers forms an ACO, which is accountable to its patients and third party payers such as Medicare.

Primary care providers may participate in only one ACO at a time Specialists may work with multiple ACOs ACOs instituted by Medicare in 2011 Incorporated into the ACA New payment models Possible prelude to a move away from fee-forservice

A new form of group practice Somewhat like an HMO Effects on mental healthcare not yet clear but could be far-reaching Not envisioned to be run by insurance companies, but may lead to merging of insurance and clinical care functions into single entities (e.g., Kaiser, Group Health)

Also recognized and promoted in the ACA Concept overlaps with ACO, but not identical Medical Home involves base of care in a physician driven practice which is medically and financially accountable Many medical homes may be included in an ACO ACO: medical neighborhood

They envision close relationship with a network of primary care and specialist practitioners New payment models driven partly by network participation and quality metrics Psychiatry currently lacks convincing quality metrics These movements mirror the integrated care model being put forward in psychiatry

Lacks a strict definition Coordinated network of psychiatrists, psychologists, social workers, nurses, social service agencies and others Close affiliation (possibly embedded) with primary care providers Current face-to-face payment models would hinder development of integrated care networks

Psychiatrists needs were generally low priority in development of EHR products Psychiatrists have been slow to accept EHR Current EHR systems are deeply unpopular with physicians, especially rank and file Doctor-patient relationship issues Confidentiality questions for psychiatry in shared medical records systems

Meaningful use requirements are confusing for psychiatric practice EHR constructed to meet requirements of CMS Medicare and Medicaid, who have been the de facto customers of EHR vendors Desire for big data rather than usability largely driving EHR development EHR mandate by CMS preceded ACA, but has been incorporated into it

Despite concerns over new handbook, few issues have emerged in adult practice Changes in autism diagnosis remain most controversial Many psychiatrists have yet to adopt DSM 5 DSM 5 designed to crosswalk with ICD-10

ICD-10 implementation in the US has been repeatedly delayed Was scheduled for October 2014, but delayed until October 2015 Rest of world has used ICD-10 for many years, and are preparing for ICD-11 Unlikely to be delayed again

Higher requirement for documentation against diagnostic criteria New alpha-numeric coding system High stakes for hospitals as they must assure MD documentation is adequate to justify hospital billings

The psychiatric CPT code revisions of January 1, 2013 have been controversial Designed to facilitate psychotherapy by psychiatrists and ensure fair pay for this component Also to make basic psychiatry coding more similar to rest of medicine by move to e/m Insurance companies have been slow to respond Hampered by confusion over time requirements for psychotherapy and Chinese menu system for e/m coding

Disadvantageous for CMHC Allows non-mds to bill Question of substance abuse coverage policies Drastic payment delays

Despite these challenges the demand for psychiatric care continues to rise The changes in the ACA and other reforms continue to favor expansion of outpatient rather than hospital based care Psychiatrists will be encouraged to join various integrated care groups, possibly as a requirement to participate in insurance plans New payment systems are likely to develop (moving away from traditional fee-for-service)

Despite the unpopularity of the ACA legislation, many individual aspects of the program are extremely popular and will be difficult to repeal Medicare went through a similar stage in the 1960s Assuming that Medicaid expansion and reform survives, many of the formerly indigent will become paying patients However, the rate of reimbursement may continue to be a problem for practitioners Current programs for the indigent will adapt or be eliminated (such as DISH)

States may see the ACA as an opportunity to further downsize and/or outsource state hospital services The constantly evolving game of cat and mouse between psychiatrists and insurance companies over parity is likely to continue despite parity legislation and the ACA Nothing in healthcare reform precludes psychiatrists from continuing cash-based practices

Difficult changes will not be going away EHR is here to stay, including meaningful use requirements. Future iterations of EHRs will need to be more efficient and physician friendly The number of EHR vendors will dwindle and the products will become more compatible ACOs will grow and become more important

ICD will be here next year CPT coding will not change before the next 5 year review in 2018, if then DSM 5 will gradually become the standard Medicaid managed care is also here to stay

New approaches may be required under various levels of healthcare reform Psychiatrists may be more widely embedded in primary care practices May be reimbursed for case management and consulting with primary care without a face to face or fee for service requirement Telepsychiatry is likely to continue its expansion

Psychiatrists have fared poorly under previous HMO type systems New payment models (such as global payments) may lead to internal competition for dollars within ACOs; psychiatrists may have difficulty in such a model Governmental skepticism may erode our position Lack of metrics

In the wake of shootings by psychiatric patients (Aurora, Newtown, others) many have called for further reform and increased availability of mental health treatment. If history is an indicator, this is unlikely to happen Legislators (especially in conservative states) still see mental health as a lower priority than roads, schools, etc; and are often skeptical of the effectiveness of psychiatric treatment

Despite predictions of psychiatry s demise at the beginning of the managed care revolution of the mid 1980s, demand for psychiatric services continues to grow This is likely to continue Healthcare reform in psychiatry has occurred in numerous steps since at least the 1950s, and the ACA is simply one step in this ongoing and continuing process

Comprehensive services for the persistent, severely mentally ill remain a problem in need of reform The presence of huge numbers of mentally ill in jails and prisons has not been dealt with The issue of how society should respond to the violent mentally ill is unresolved; including the adequacy of commitment laws, access to firearms, and access to treatment The growing number of demented elders with severe psychiatric symptoms will require new and different approaches