W W W . H E A L T H M A N A G E M E N T . C O M Integrating Primary and Joshua Rubin, Principal Behavioral Healthcare for VBP Readiness
A LBANY , N EW Y ORK OUR OFFICES A TLANTA , G EORGIA A USTIN , T EXAS B OSTON , M ASSACHUSETTS C HICAGO , I LLINOIS C OLUMBUS , O HIO D ENVER , C OLORADO H ARRISBURG , P ENNSYLVANIA I NDIANAPOLIS , I NDIANA L ANSING , M ICHIGAN N EW Y ORK , N EW Y ORK P HILADELPHIA , P ENNSYLVANIA P HOENIX , A RIZONA Some of the P ORTLAND , O REGON brightest minds in R ALEIGH , N ORTH C AROLINA publicly funded S ACRAMENTO , C ALIFORNIA healthcare. S AN A NTONIO , T EXAS Working for you. S AN F RANCISCO , C ALIFORNIA S EATTLE , W ASHINGTON S OUTHERN C ALIFORNIA HMA OFFICES ACROSS THE COUNTRY T ALLAHASSEE , F LORIDA 2 W ASHINGTON , DC
AGENDA ❑ What’s at Stake ❑ A Word of Preface ❑ A Quick Reminder re VBP ❑ Integrating Primary and Behavioral Healthcare ❑ Problems we need to address ❑ Models 3
WHAT’S AT STAKE
WHAT’S AT STAKE People with Serious Mental Illness die 25 years younger than the general population. Source: National Association of State Mental Health Program Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: Parks, J., et al. 5
BEHAVIORAL HEALTH DISORDERS WERE THE LARGEST CAUSE OF DISEASE BURDEN IN THE UNITED STATES IN 2015 Disability Adjusted Life Years (DALYs) Lost per 100,000 population 3,355 3,131 3,065 2,419 2,357 1,827 1,463 1,050 642 624 Diseases Nervous System Endocrine Disorders Respiratory Sense Musculoskeletal Disorders Organ Skin Chronic Behavioral Health Conditions Cardiovascular Disease Cancers & Tumors Injuries Source: Kamal R, Cox C, Rousseau D, et al. Costs and Outcomes of Mental Health and Substance Use Disorders in the US. JAMA 2017;318(5): 415. 6
MENTAL DISORDERS ARE THE MOST COSTLY CONDITIONS IN THE UNITED STATES Pulmonary conditions Cancer Trauma Heart conditions Mental illnesses $- $50 $100 $150 $200 $250 Annual Cost (Billions) Source: Roehrig C, Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion. Health Affairs 35, no. 6 (2016) 1130 – 1135. 7
MENTAL HEALTH CONDITIONS INCREASE MEDICAL COSTS Percentage Increase in PMPM Medical* Spend when there is a Comorbid MH Condition Stroke CHF Cancer COPD IHD Asthma Diabetes Mellitus Chronic Pain Hypertension Arthtitis 0% 20% 40% 60% 80% 100% 120% 140% 160% 180% Anxiety Depression *Note: Does not include any BH spend Source: Melek S, Norris D. Chronic conditions and comorbid psychological disorders. Milliman Research Report. July, 2008. 8
DRUG OVERDOSE DEATHS IN THE UNITED STATES 70000 60000 50000 40000 30000 20000 10000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Source: NCHS: National Vital Statistics System, Mortality. 9
FOLLOW THE MONEY Medicaid Spending on people with Nearly half of Medicaid spending is mental health conditions is nearly for enrollees with BH conditions… Four Times as much as for other …but only 20% of Medicaid enrollees enrollees have BH conditions $13,303 $3,564 $ With BH Without BH conditions conditions Source: Medicaid’s Role in Behavioral Health, Henry J. Kaiser Family Foundation, May, 2017. 10
A W A WORD ORD OF PREF OF PREFACE CE
PUZZLE GRAPHIC
SOME OF THE BASIC RULES OF CAPITALISM Risk and Whoever pays reward go the piper calls hand in hand the tune People will do Money is an what they are effective incented to do incentive 13
A QUICK REMINDER A QUICK REMINDER RE RE VBP VBP
ACCOUNTABILITY, INTEGRATION, AND RISK GO TOGETHER >80% by end of DSRIP Year 5 >25% by end of DSRIP Year 5 Level 0 Level 1 Level 2 Level 3 Full Capitation Partial Capitation Provider Financial Risk Two Way Shared Savings Bundled/ Episodic Payments Upside Shared Savings Pay for Performance (P4P) Incentive Payments Fee For Service Provider Integration and Accountability Cost-based Retrospective Payments Prospective Payments Contract Provider Risk 15
BIG QUESTION FOR BH PROVIDERS How can you integrate with an organization that has attribution, infrastructure, and scale in a way that enables you to access medical care for your clients, and provide BH care to theirs, while maintaining your focus on the population about which you are most concerned? 16
BIG QUESTION FOR PC PROVIDERS How can you access – in a coordinated, integrated, coherent way – the comprehensive suite of BH services that will enable you to meet your VBP targets and maximize your revenue? 17
INTEGRATING PRIMARY INTEGRATING PRIMARY AND AND BEHAVIORAL BEHAVIORAL HEALT HEALTHCARE HCARE
THE CASE FOR INTEGRATION ✚ ROI of $6.50 for every $1 spent ✚ 70+ randomized controlled trials demonstrate it is both more effective and more cost-effective ✚ Across practice settings ✚ Across patient populations ✚ For a wide range of the most common BH disorders ✚ Better medical outcomes for common chronic medical diseases ✚ Greater provider satisfaction Source: Unützer J, Harbin H, Schoenbaum M, Druss B. The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes, Health Home Information Resource Center Brief, May 2013. Unützer J, Harbin H, Schoenbaum M, Druss B, (2013). The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes, Health Home Information Resource Center, Brief May 2013. Unützer J, Harbin H, Schoenbaum M, Druss B, (2013). The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes, Health Home Information Resource Center, Brief May 2013. Hwang W, Chang J, LaClair M, Paz H (2013), Effects of Integrated Delivery System on Cost and Quality. Am J Manag Care. 2013;19(5):e175- e184. Katon WJ, Russo JE, Von Korff M, Lin EH, Ludman E, Ciechanowski PS. “Long -term Effects on Medical Costs of Improving Depression Outcomes in Patients with Depression and Diabetes.” Diabetes Care. June 2008;31(6):1155 -1159. Levine S, Unützer J, Yip JY, et al. “Physicians’ Satisfaction with a Collaborative Disease Management Program for Late -life Depression in Primary Care.” General Hospital Psychiatry. November -December 2005;27(6):383-391.
FOUR CORE PRINCIPLES OF INTEGRATED CARE Team-based Evidence- care based care Measurement- Population- based care based care Source: aims.uw.edu 20
STEPPED MODEL OF INTEGRATED BEHAVIORAL HEALTHCARE Referral to BH specialty care 5 PCP supported by collaborative care team 4 with systematic treatment to target PCP is supported by brief intervention 3 from on-site BH consultant PCP receives ad-hoc consultation, usually 2 from off-site specialist PCP Provides first-line treatment 1 Source: aims.uw.edu 21
BH IS NOT YOUR AVERAGE SPECIALTY, BUT NEEDS TO ACT MORE LIKE ONE Source: Raney, Lasky, and Scott (2017). Integrated Care: A guide to effective implementation. 22
PROBLEMS WE NEED PROBLEMS WE NEED TO ADDRESS TO MAKE TO ADDRESS TO MAKE PC PC-BH I BH INTEGRAT NTEGRATION ION WORK WORK
FUNDAMENTAL PROBLEMS ✚ Demand for BH services far exceeds the supply of BH services ✚ Siloed services ✚ BH is both a typical specialty service and a highly atypical specialty service ✚ Differential metrics, roles, histories, languages ✚ BH spending leads to medical savings, not BH savings ✚ Power dynamics
TWO CULTURES: ONE PATIENT/CLIENT/CONSUMER Primary Care Behavioral Health ✚ Continuity is the goal ✚ Termination is the goal – “discharge” ✚ Empathy and compassion ✚ Professional distance ✚ Data are shared ✚ Data are private ✚ Large panels ✚ Small panels ✚ Flexible scheduling ✚ Fixed scheduling ✚ Fast-paced ✚ Slower pace ✚ Time is independent ✚ Time is dependent – “Fifty minute hour” ✚ Flexible boundaries ✚ Firm boundaries ✚ Treatment is external (labs, x-ray, etc.) ✚ Relationship with provider is treatment ✚ Patient not responsible for illness ✚ Patient is responsible for participating ✚ 24-hour communication ✚ Mutual accountability ✚ Saved lives ✚ Meaningful lives ✚ Disease management ✚ Recovery model 25
REALITY CHECK We cannot ignore the historical realities that have shaped the system of today + Stigma of behavioral health disorders + Historical underfunding of behavioral healthcare + Historical underfunding of social services + Silos impeding integration + Power dynamics impacting our conversations + Cultural impediments to health equity 26
MODELS MODELS
A BOLD(ISH) PREDICTION Someday every agency in this room will be a part of an accountable provider-led entity + Therefore, the question is not if, the question is how + These PLEs will need to have a comprehensive package of medical (primary, secondary, tertiary, quaternary), behavioral, LTSS, and social services + How these different services agglomerate will differ from PLE to PLE based on a range of factors 28
AN IMPERFECT ANALOGY 29
PLE STRUCTURES LED BY PC Secondary Secondary Quaternary Medical Medical Medical Social Tertiary Tertiary Services Medical Medical Primary Care Primary Care Quaternary LTSS LTSS Medical Behavioral Behavioral Health Health Social Services 30
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