Impact of the Affordable Care
Act on Behavioral Health
March, 2014
My Background
•
•
Medicaid Director
Previously DMH Medical Director – 20 years
Practicing Psychiatrist
CMHCs – 10 years
FQHC – 18 years
•
Distinguished Professor, Missouri Institute of
Mental Health, University of Missouri St. Louis
Endorsements
• "He is not only dull himself, he is the cause of
dullness in others.“-Samuel Johnson
• "He uses statistics as a drunken man uses
lamp-posts... for support rather than
illumination." -- Andrew Lang
• "He can compress the most words into the
smallest idea of any man I know." -- Abraham
Lincoln
Today…
It’s not just
Arkansas
•Status of our world
•Healthcare
delivery and
payment “change”
strategies
•Future of specialty
behavioral health
Our niche: caring for complex, costly patients
Socially
vulnerable
patients
Clinically
vulnerable
patients
(income, language,
race/ethnicity,
health disparities)
(complex,
difficult healthcare
needs)
You Are Here
Source: Health Affairs: VA Lewis, et al. “The Promise and Peril of Accountable Care for
Vulnerable Populations: A Framework for Overcoming Obstacles.” 2012.
Co-morbidities in the
Adult Population
Source: Druss & Walker. “Mental disorders and medical comorbidity.” The Robert Wood
Johnson Foundation Synthesis Project, February 2011.
Opportunities…
Defined by
Tragedies
Sandy
Hook
Tucson
Aurora
Virgini
a Tech
2020, behavioral health disorders
surpass all physical diseases as major
cause of disability
MI most common reason for SSD/SSI
More deaths due to suicide than to
accidents, homicides, and war combined
Most mental health treatment is in
primary care - medication, poorly
managed
7
Effective Treatments
www.TheNationalCouncil.org
9
million people
will gain access to
coverage that
includes MH/SUD
at parity
Parity
Robust final rule
11
Role of Parity
– Essential Health Benefit (EHB) for private insurance must be
at parity. What does parity mean?
– Medicaid Benchmark Benefit must be at parity.
– Parity does extend to all new individual and small group plans
beginning in 2014.
– What about parity for current Medicaid beneficiaries?
State Estimates of the Uninsured
• You can access state estimates for the Medicaid
Expansion and for the State Health Insurance
Marketplace at
http://www.samhsa.gov/healthReform/enrollment.aspx
• Three estimates are provided:
– Adults with Serious Mental Illness
– Adults with Serious Psychological Distress
– Adults with a Substance Use Disorder
Essential Benefit Plans (EBP) on the Insurance
Exchanges
• The plan selected by a state to be its EBP benchmark for ACA may not
comply with parity.
• States had until exchanges went live to make it comply with parity - then it
became an EHB benchmark plan
• But so far its unclear if CMS will enforce this – especially since the final
ACA rule stated that “We do not intend to require or request states to
include specific services within EHB categories offered by their ABP.”
• States resisting ACA implementation will not enforce it either
• High deductibles and co-pays will be an obstacle
Alternative Medicaid Benefit (AMB) for
Medicaid Expansion Groups
• Wellstone – Domenici Parity does not apply
• If the individual meets that states definition for
“medically frail” they reverts to the standard
Medicaid benefit
• Serious Mental Illness and Substance Use Disorders
constitute Medically Frail
• But - states get to define which diagnosis is “SMI”
• Many states are not expanding Medicaid
Parity and Case Law
Monitoring and reporting…
•Anthem Health Plans’ Connecticut rate
schedule changes violate the Mental
Health Parity and Addiction Equity Act
•New York against UnitedHealth Group
•California class-action lawsuit against
United Behavioral Healthcare for reviews
of outpatient treatments
•Vermont held Cigna has burden of proving
that disparate treatment of mental health
and medical surgical justified by clinical
standards
Four key elements of the Affordable Care Act
2010
• Prohibits lifetime benefit limits
• Dependent coverage up to age 26 is mandated
• Cost-sharing obligations for preventive services
are prohibited
• Recissions are prohibited
• Pre-existing condition exclusions for dependent
children (under 19 years of age) are prohibited
• Coverage for emergency services at in-network
cost-sharing level with no prior-authorization is
mandated
More 2010
• Require coverage of tobacco cessation programs for pregnant
women under Medicaid free of cost-sharing
• Begin Community Health Centers and National Health Service
Corps Fund expanded funding to total $11 billion over five
years
• Begin Medicaid global payments demonstrations to fund large,
safety-net hospitals in five states to alter payment from feefor-service to a capitated, global payment structure.
• Establish Patient-Centered Outcomes Research Institute.
Create a private, nonprofit Patient-Centered Outcomes
Research Institute to set a national research agenda and
conduct comparative clinical effectiveness research.
2011
• 85% MLR for large group (with refund) is mandated
• 80% MLR for individual and small group (with refund) is
mandated
• Primary care physicians and General surgeons in shortage
areas begin 10 percent Medicare payment bonus for next
5 years
• Medicare adds annual wellness visit with no copayment
or deductible and eliminates cost-sharing for evidencebased preventive services
2012
• Medicaid starts option funding Health homes
for persons with chronic conditions
• Prohibit federal payments for Medicaid
services related to hospital-acquired
conditions.
• Begin Medicaid Emergency Psychiatric Care
Demonstration Project. to expand the number
of emergency inpatient psychiatric care beds
available.
2013
• Medicaid payment rates to primary care
physicians for furnishing primary care services
raised no less than 100 percent of Medicare
payment rates in 2013 and 2014.
• Medicaid coverage of preventive services
approved by the U.S. Preventive Services Task
Force with no cost-sharing will receive an
increased federal funds
2014
• Health insurance exchanges established
• Guarantee issue is required
• Community rating required limits use of age and
illness as a rating factor
• All annual and lifetime limits prohibited
• Essential Benefit established and required to
cover MH and SA at Parity
• Individual Mandate Starts
Insurance Exchanges
• To Date:
– 16 states have selected a state-based model,
– 7 are partnering with the federal government and
– 26 states have chosen federally-run exchanges.
• Current enrollment deadline is March 31, 2014
• In non- expansion states low-income individuals
may experience more difficulty finding affordable
coverage because they are not Medicaid-eligible
and do not qualify for federal subsidies in the
exchange.
ACA Affordable Health Insurance
Marketplace
• Fact: Enrollment system went live in ALL STATES on October 1,
2013. Insurance will became effective on January 1, 2014. Scope is
all uninsured adults above 133 percent of poverty (plus discounted
5 percent of income).
• Overall 25% will have a Behavioral Health Condition. (About 6%
will have a Serious Mental Illness and 14% will have a Substance
Use Disorder).
• KEY ISSUES TO CONSIDER:
– Are eligible uninsured persons aware of the opportunity?
– Will persons with mental health and substance use conditions
actually enroll?
– Will the insurance benefits be adequate?
2014 Medicaid Expansion
• To date, 26 states are planning to expand
coverage in 2014
• Some include non-traditional models such as
Medicaid premium support.
• Decisions to expand Medicaid or discontinue
Medicaid expansion in 2015 will impact bids
that insurers submit in the spring of 2014 for
the 2015 enrollment period.
ACA Medicaid Expansion
• Fact: For states that choose this option (now 26 + DC), enrollment
system went live on October 1, 2013 and coverage began on
January 1, 2014. Designed for all uninsured adults up to 133
percent of poverty (plus discounted 5 percent of income).
• Overall 40% with Behavioral Health Conditions. (About 7% will
have a Serious Mental Illness and about 14% will have a Substance
Use Disorder).
• KEY ISSUES TO CONSIDER:
– What is the effect of a State opting out?
– Are eligible uninsured persons aware of the opportunity?
– Will persons with mental health and substance use conditions
actually enroll?
Increased competition in MH/SUD
• Managed care
• Accountable Care
Organizations
• New MH/SUD
coverage under
essential benefits
• New parity
requirements
EHR Meaningful Use Behavioral
Health Quality Measures (Phase 2)
• Quality metrics for chronically ill:
–
–
–
–
•
•
•
•
•
•
Tobacco screening and cessation
Weight screening and counseling
Depression screening and intervention
Hypertension screening
Depression remission rates using PHQ9!
Depression followup using PHQ9
Substance Abuse assessment in Bipolar patients
Alcohol Treatment initiation and Engagement
Maternal depression screening at < 6 month child visit
Suicide assessment for depressed patients
30
Delayed Changes
• Employer mandate delayed from 2014 to 2015
• First reduction of Disproportionate Share Hospital
(DSH) funds delayed from 2104 to 2015
• Compliance of small business Existing Plans with
new Rules
–
–
–
–
CMS has delayed until September 2015
15 States will permit renewal of non-compliant plans
18 States will not
17 States are undecided
2015 - 2017
• Innovation Waivers
– Beginning 2015, states may consider developing
proposals to waive portions of the ACA beginning in
2017.
– “Innovation Waivers” must cover at least as many
people as under the ACA and provide coverage that is
at least as comprehensive and affordable, at no extra
cost to the federal government.
– States that receive waivers may finance their reforms
with federal funding that otherwise would have been
provided for premium tax credits, cost-sharing
reduction and small business tax credits
Estimated changes in payer mix
Source: The Commonwealth Fund: “Including Safety Net Providers in Integrated Delivery
Systems: Issues and Options for Policymakers”
50 Years of Federal Spending
Chart depicting 50 years of federal spending; image taken from NPR.org
The future…
www.thenationalcouncil.org
The greatest danger in
times of turbulence is not
the turbulence. It is to act
with yesterday’s logic.
Peter Drucker
Contact: communications@thenationalcouncil.org
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Population based - Health homes…
37
Health Home Functions:
CMHCs are well positioned
• CMHC teams already fulfill many Healthcare Home
functions:
– Providing individualized services and supports
– Linking consumers to community and social supports
– Hospital admission and discharge follow-up
– Communicating with collaterals
• CMHCs already serve people with high rates of chronic
medical conditions
• Many CMHCs have been trained by PBHCI Grant
Project
Defining Health Homes
• Enumerated in Sec. 1945 of the Social Security Act
• Provides states the option to cover care coordination
for individuals with chronic conditions through health
homes
• Intended to improve access and quality of care
• Eligible Medicaid beneficiaries have:
– Two or more chronic conditions,
– One condition and the risk of developing another, or
– At least one serious and persistent mental health condition
Defining Health Homes
• Provides 90% FMAP for eight quarters for:
–
–
–
–
–
–
Comprehensive care management
Care coordination
Health promotion
Comprehensive transitional care
Individual and family support
Referral to community and support services
• Services by designated providers, a team of health care
professionals or a health team
What is a Health Home?
• Not just a Medicaid Benefit
• Not just a Program or a Team
• A System and Organizational
Transformation
What is Different about Health Homes?
Treatment as Usual
Health Homes
• Individual Practitioner
• Integrated Primary/Behavioral
Health Care Team
• Episodic Care
• Continuous Care
• Focus on Presenting
Problem
• Comprehensive Care
Management
• Referral to meet other
Needs
• Managed Care
– Manages access to
care
– Does not change
clinical practice
– Coordinates care across the
healthcare system
– Data driven population
management
– Transforms clinical practice
– Emphasizes healthy lifestyles
and self-management of
chronic health problems
Apples and Oranges
Managed-Care Care Management
Health Home Care Management
Population = most are well most of the time
Population = all have multiple chronic conditions
Most have a few health care providers
Most have many Healthcare providers
Primary focus = avoidable over utilization
Primary focus= inappropriate underutilization
Mostly communicates with providers
Mostly communicates with patients directly
Administrative relationship
Face-to-face personal relationship
Mostly e-mail, fax or telephone
Mostly in person communication
Intermittent contact by different care managers
Ongoing contact with stable team
Strangers working together
You know them and they know you
Do not have to provide service to be paid
Have to provide service to receive payment
Health Care Home Strategy
•
Case management coordination and facilitation of healthcare
•
Primary Care Nurse Care Managers
•
Disease management for persons with complex chronic medical conditions,
SMI, or both
•
Behavioral Health management and behavior modification as related to
chronic disease management for persons with Medical Illness
•
Preventive healthcare screening and monitoring by MH providers
•
Integrated Primary Care and Behavioral Healthcare
Health Home Strategy
•
Health technology is utilized to support the service system.
•
“Care Coordination” is best provided by a local community-based provider.
•
MH Community Support Workers who are most familiar with the consumer
provide care coordination at the local level.
•
Primary Care Nurse Care Managers working within each Health Home provide
system support.
•
Behavioral Health Consultants in each Primary Care Health Home
•
Statewide coordination and training support the network of Health Homes.
Principles
• One Team
– CMHC’s composed of pre-2012 CPRC staff plus NCM and
PC Consultant
– PCHH’s composed of new infrastructure and team
members
• One Treatment Plan for the Whole Person
– Rehab Goals
– Medical Goals
– Healthy Lifestyle Goals
• Some Goals and Outcomes reference Health Home
Performance Measures
• Wrap –Around approach to outside treating PCP,
mental health providers, community supports, etc
What is a Health Home?
• Not just a Medicaid Benefit
• Not just a Program or a Team
• A System and Organizational
Transformation
What is Different about Health Homes?
•
Individual Practitioner
•
Episodic Care
•
Focus on Presenting Problem
•
Referral to meet other Needs
•
Managed Care
– Manages access to care
– Does not change clinical
practice
Treatment as Usual
•
Integrated Primary/Behavioral Health
Care Team
•
Continuous Care
•
Comprehensive Care Management
– Coordinates care across the
healthcare system
– Data driven population management
– Transforms clinical practice
– Emphasizes healthy lifestyles and
self-management of chronic health
problems
Health Homes
Disease Management
Diabetes
( 2434 Continuously Enrolled Adults)*
January, 2014
80%
70%
67%
65%
60%
59%
60%
50%
47%
57%
53%
50%
46%
Feb'13
42%
38%
40%
36%
30%
June'13
27%
Jan'14
22%
18%
20%
GoaL
10%
0%
LDL
Feb'12
BP
A1c
*29% of continuously enrolled adults
Hypertension and
Cardiovascular Disease
80%
70%
70%
62%
60%
55%
55%
Feb'12
49%
50%
41%
40%
60%
37%
Feb'13
June'13
30%
Jan'14
24%
21%
Goal2
20%
10%
0%
LDL Cardio
302
BP HTN
3176
Improving Diabetes (HbA1c)
• 7.2% Uncontrolled (too high)
• For 51% there are 2 results so we can find the trend
• The uncontrolled group average HbA1c decreased from
9.50% to 8.95% (-0.55%)
– 1% point decrease in HbA1c yields:
• 21% decrease in Diabetes related deaths
• 14% decrease in Heart Attacks
• 37% decrease in micro-vascular complications
Improving Cholesterol (LDL)
• 46.3% Uncontrolled (too high, greater than 100)
• For 58% there are 2 results so we can find the trend
• The uncontrolled group average LDL decreased from 122 to
115 (-7)
• A 10% Cholesterol Reduction yields a 30% reduction in
Coronary Heart Disease
Improving Hypertension (BP)
• 23% Uncontrolled (too high, greater than 140/90)
• For 61% there are 2 results so we can find the trend
• The uncontrolled group average BP decreased from 142/90 to
137/86 (-5/4)
• A 6 point reduction yields:
– 16% reduction in Coronary Heart Disease
– 42% reduction in Stroke
Hospital Follow Up
Jan. 2012 through May, 2013
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6 7 8 9 10 11 12 13 14 15 16 17
% Followed-up
% Med Rec.
Outcomes
Reducing Hospitalization
Primary Care Health Homes
CMHC Healthcare Homes
Intial Estimated Cost Savings after 18
Months
• Health Homes
– 43,385 persons total served (includes Dual Eligibles)
– Cost Decreased by $51.75 PMPM
– Total Cost Reduction $23.1M
• DM3700
– 3560 persons total served (includes Dual Eligibles)
– Cost Decreased by $614.80 PMPM
– Total Cost Reduction $22.3M
Intial Estimated Cost Savings after 18
Months
• CMHC Health Homes
– 20,031 persons total served (includes Dual Eligibles)
– Cost Decreased by $76.33 PMPM
– Total Cost Reduction $15.7 M
• PC Health Homes
– 23,354 persons total served (includes Dual Eligibles)
– Cost Decreased by $30.79 PMPM
– Total Cost Reduction $7.4 M
State Health Home Activity-March 2014
2
3
2
2
3
#
*Some states may be in the planning phase.
58
Psychiatrist Shortage Overview
•
•
•
•
•
Currently Demand for Psychiatrists exceeds the supply
Demand for psychiatric workforce is increasing
Psychiatric workforce is projected to shrink
The current psychiatric care delivery model is not sustainable
So what can be done differently?
Drivers of Increased Demand
• ACA requires newly covered populations meet the parity
requirements of Wellstone Domenici Parity Act
• Multiple parts of ACA require or incentivize integration of
Behavioral Health and general medical care
• Stigma continues to drop releasing pent up demand
• In responding to recent press coverage of mass shootings
increasing mental health services is more popular than gun
control
CURRENT SHORTAGE
• Best data: Study by University of North
Carolina commissioned by Health Resources
and Services Administration (HRSA)
• Demonstrated shortages for all MH
professionals, especially “prescribers”
• 77% of U.S. Counties have “a severe shortage of
prescribers, with over half their need unmet”
• 96% of US counties have “some unmet need”
Konrad et al, Psych Services, 60: 1307-14, 2009
Current Supply and Need for Psychiatrists
• Estimated need of 25.9 psychiatrists/100,000
population
– With current population of 300,000,000, this is
78,000.
• Current supply is ~ 48,000 (~ 16/100,000)
• Current gap = at least 30,000
• Much greater supply vs. need gap for child
and adolescent psychiatry (~ 7,500 total)
Sources: Konrad et al, Psych Services, 60: 1307-14, 2009
Psychiatric Times Series on Psychiatrist Shortage
(Summer 2010)
• “Psychiatry Job Openings Surge into the Future”:
Physician recruitment company, Merritt Hawkins
reported a 121% increase in requests for
psychiatrists between 2007/2007 and 2009/2010
• “45,000 More Psychiatrists, Anyone?”: HRSA
commissioned studies considered “very
conservative” because of exclusion of many
patients with disorders that require some type of
treatment (ADHD, Conduct Disorder, Dysthymia)
Demand for Psychiatrists Continues to Grow
• The Bureau of Health Professions predicts that
demand for General Psychiatry services will increase
nearly 20% between 1995 and 2020
• 100% increase in the need for Child and Adolescent
Psychiatry
Supply of Psychiatrists has been flat for 20+
years
Number of Psychiatry Residents in US 1969 - 2006
7000
6000
5000
4000
3000
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
Note: there has been a linear increase in number of physicians overall during this
time
Current Psychiatrists are Aging Out Fast
Percent of MD’s by Specialty over age 55
% > Age 55
• Off all sub-specialties
(35), Psychiatry is
second oldest (Second
only to Preventive
Medicine)
54.5
32.3
33.6
36.7
38.5
• 55% of current
psychiatrist are > age 55
Internal Pediatrics
Medicine
Family
Practice
Ob/Gyn
Psychiatry
Projected Supply and Demand of All Physicians
2010 - 2025
1,000,000
950,000
900,000
850,000
Physician Supply
800,000
Physician Demand
750,000
700,000
650,000
600,000
2010
2015
2020
2025
Source: AAMC Center for Workforce Studies, June 2010 Analysis
Anticipated Supply and Demand of Psychiatrists?
?
Anticipated Demand
Anticipated Supply
Time
?
So, what to do…
• There is NO one magic bullet
• More and larger “help wanted” signs won’t
work
• Warm bodies with prescription pads won’t
work
• Locums Tenens isn’t “the solution”
• Tele-psychiatry isn’t “the solution”
Collaboration Models
• Clearly must change the way we do business
• Primary Care Physicians with Consulting
Psychiatrist
• Advanced Practice Nurse Practitioners as LIPs
with Collaborating Psychiatrists (practice
agreements or prescriptive agreements)
• Psychologists with Supervising Psychiatrists
• Physician Assistants as psychiatrists’ extenders
Potential Options and Concerns
1. Primary Care Physicians take on more psychiatric
patients – already overloaded and not doing the best
job in treating people with psychiatric problems
2. Train more Psychiatrist – $100,000 per residency slot
(times 45,000 = $4.5B)
3. Train more APRNs and Physician Assistants in
Psychiatry – very little training in psychology or
psychotherapy
4. Psychologists Prescribing Authority – What is
“adequate training” in basic science medicine and
clinical science medicine to prescribe?
Benefits of Co-Location and Integration
• Patients prefer it
• Percent complying with a referral rises from 15-20% to 40-60%
• Builds personal relationships – the foundation of any enduring
arrangement
• Allows more accurate understanding of each other’s incentives,
methods and constraints
• Opportunities for informal consultation
• Single clinical record reduces errors
• Facilitates converting BH clinicians into consultants to PCPs
University Clinic & CMHC Practice
•
•
•
•
Over 10 years duration
Patient Volume – small and static
Never saw PCP or Patients-in-waiting
Model
– Initial Evaluation all in one visit of 90-120 min
– Med visit w/ a little therapy
• 20-39 minute duration
• Every 1-4 weeks
• Termination criteria - death or disappearance
• 20-39 minute duration
• Every 1-4 weeks
Phase 1 –Co-Location Into the FQHC
• Two years duration
• Model
– Got my office in the corner
– PCP refers them, I evaluate and keep them
– Evaluations 60 min, return visits 20 min
• Outcomes
– Patient volumes a little larger but still static
– Get to regularly come across PCPs and Patients-inWaiting who are unhappy about lack of access
– 3 month wait list and 30 % no-show rate
Talk a different
language with
unfamiliar
colleagues
Phase 2 Desperation
• Duration – 1 year
• Method – Squeeze Down the appt times
– Initial Eval 30 min – Learn and do just enough to
get to a 2nd visit
– Return Visits 15 Mins
• Outcomes
– 33% increase in caseload
– Case load static again 6 months later
– Running really fast but not getting ahead
Phase 3 – Enhancing Access by Consultation
• Duration 3 years
• Two New Consult Access Methods
– Interrupt me if it’s urgent and brief
– Separate Wait Lists
• Rapid access to one time consult visit
• Regular wait list for ongoing care
• Outcomes
– Moderately larger patient volumes
– Consult service turns over constantly
Phase 4 – The PCPs Catch on to Me
• Duration 2 years
• The Power of See One- Do One- Teach One
– PCPs see my usual prescribing pattern by diagnosis in
our common EMR
– PCPs practice implementing my recommendations
– PCPs see me interview during interruptive consults
• Outcomes
– PCPs decide that they will try my 1st 3 moves before
referral
– Referral pressure drops
– I get more phone calls for curbside advice
Phase 5 - We Leave the Nest
• Duration 3 years
• Method
– Add a collaborative Psychiatric APN
– Convert to Open Access Scheduling
– Refer all ongoing patients back to APN or PCPs unless
acutely unstable or scary to APN and PCPs
• Outcome
–
–
–
–
2-3 week wait max
can always fit urgent in next week
Much higher patient volume
No Shows down to 10%
Breath vs. Depth
• Choices
– Give the best to a few
– Give minimally adequate to many
• Which Patients do You have a Duty To?
– The ones on your case load now
– The rest in your community waiting to get in
Psychiatrist View of Working in Primary Care Clinics
• Advantages
–
–
–
–
Can treat many more patients
Working more often at top of their expertise
Immediate access to MD records of prior treatment
Lots more support of practice
• Nurses – verbal orders, refill protocols, do EKGs, 1st on call
• PCP - consults, handles CS refills, reads EKG, 2nd on call
• Labs, pulse-ox, EKGs, scheduling specialty referrals
• Problems
–
–
–
–
Intermittent Consultant, not an ongoing relationship
New Culture – interruptions and variable appt times
Less access to CMHC specialty services and BH colleagues
PCPs start controlled substances then refer to Psychiatrist
Consumer View of Getting BH Services in
Primary Care Clinics
• Advantages
–
–
–
–
Easier Access, more available appts, shorter waits
Attention to the Medical causes of BH symptoms
Getting Medical Care including healthy lifestyle advice
Relation ship less fear based than with psychiatrist
• Problems
– Know less about Dx & Tx of BH illness other than
Depression and Anxiety
– Medical Culture, Not familiar with Recovery concepts
– Less awareness of and access to non-Med interventions
– Don’t use comprehensive Bio-Psycho-Social Assessment
www.thenationalcouncil.org
Status of our world…
When you make a
choice, you change
the future.
D e e p a k
C h o p r a
Contact: communications@thenationalcouncil.org
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