Professional Advocacy: Looking Ahead at the Impact of Healthcare Reform on Your Profession
By James K. Finley Associate Executive Director and
Director Public Policy
Clinical mental health counselor (CMHC) practice is changing soon, in ways that will alter the business approach of many professionals now in private practice. Driving the changes are healthcare reform, unsustainable growth in national health spending, and a fragmented and inefficient care system that has relatively poor outcomes by international standards. Public and private payers, but particularly Medicare, are restructuring provider payment arrangements, compelling most health professionals and providers to make major changes over the next several years.
The practice environment of many clinical mental health counselors remains largely beyond direct federal regulation; nevertheless, a financial driver of CMHC practice is the Medicare coverage exclusion and the impact it will have under the Affordable Care Act (ACA). Under the ACA, Medicare will be refocused toward new delivery and financial arrangements designed to reshape the healthcare environment.
CMHCs will need to adapt quickly to the changing environment or confront the future at a considerable structural disadvantage relative to other behavioral health professionals. The changing environment is a lot about money, but it’s also about improving the quality of healthcare and demonstrating the value of CMHC services to a broader group of payers and potential business partners.
Accountable Care Organizations (ACO)
ACOs are the critical new service-delivery model piloted under the Affordable Care Act through Medicare and Medicaid demonstration grants. These largely untested delivery systems are intended to improve health-care quality, while achieving better outcomes for consumers, thereby increasing the value of health spending. ACOs are composed of providers from across the continuum of care (including acute and long-term care, home care, and behavioral health).
ACOs take on responsibility for managing the health of a group of beneficiaries with the goal of reducing service fragmentation and costs by employing new payment methodologies designed to improve health outcomes. ACOs will receive primarily fee-for-service payments, but they will also receive bonus payments for improving the health of their consumer group or penalties for exceptionally high rates of hospital readmission.
The success of ACOs will depend on improved care coordination and delivery of the right service at the right time. ACO demonstrations are beginning under various payers such as Medicare, Medicaid, and private insurance plans.
The ACO model is currently flexible, with many key, unanswered questions about their operation and performance. ACOs have options, such as giving participating providers health information technology that includes electronic health records and decision-support tools to help providers and consumers determine care plans. They are also expected to perform key administrative functions, such as negotiating contracts and rates with payers. ACOs are expected to focus particularly on chronic conditions to prevent unnecessary care and expense.
A survey conducted by The Commonwealth Fund in September 2011 found 154 ACOs already serving nearly 2.4 million Medicare beneficiaries, with dozens more in partnerships with private insurers. Furthermore, 13 percent of 1,700 reporting hospitals were either already participating in an ACO, or planning to participate in the next year. Almost three-quarters of all operational ACOs reported sharing clinical information between care settings, such as a hospital and primary-care setting. Nearly 85 percent of ACOs have information systems to track how patients use healthcare services.
Impact on CMHC Practice
Over the next several years, about 32 million more Americans are expected to obtain either Medicaid or private insurance, with greatly improved coverage for behavioral health services. However, CMHCs confront a major obstacle to successful adaptation to the emerging service system—Medicare’s exclusion of CMHCs as independent providers.
Winning Medicare provider status is more important than ever because ACO delivery models advanced primarily under Medicare will require provider participation within integrated care and business/payment models. Yet, integrated networks of providers serving Medicare beneficiaries will confront strong incentives to exclude CMHCs because they cannot be paid for their services.
ACOs are expected to function as integrated provider systems, and the CMHC Medicare exclusion will create a strong bias to hire providers who can serve all of their enrollees. Such a development will have a highly negative impact on practice opportunities for CMHCs as more are unable to participate in the emerging delivery system. These changes are expected to phase in over five to 10 years, but the delivery system is already changing. If CMHCs are not included in Medicare very quickly, CMHCs will face a tremendous disadvantage in the marketplace.
The future of the profession is at stake, and it needs to ramp up Medicare advocacy immediately. Increased congressional advocacy requires a more vigorous and enlarged membership. The profession can shape its future by organizing for full recognition, or get left behind.
Urge colleagues who have not joined with national and chapter advocacy to become a part of the effort, to get involved. AMHCA chapters are essential in this activist effort; work with them to ensure their participation.
Regardless of which political party emerges victorious in the November elections, the
movement toward ACOs and increased provider integration is moving ahead. Both parties support this basic approach; where they differ is over the role played by federal programs or private insurance in driving these changes.
Even repeal of healthcare reform will not greatly delay these changes. The profession and AMHCA must step up to this challenge. Lastly, AMHCA will hold its next national conference in Washington, D.C., on July 18–20, 2013. Plan to attend and “storm the Hill” to push your legislative representatives for action on Medicare recognition.
An expanded version of this article will appear soon in the public policy section of AMHCA’s website.