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 Behavioral Healthcare for VBP Readiness
Joshua Rubin, Principal
Integrating Primary and Joshua Rubin, Principal Behavioral - - PowerPoint PPT Presentation
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
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 Behavioral Healthcare for VBP Readiness
Joshua Rubin, Principal
OUR OFFICES
ALBANY, NEW YORK ATLANTA, GEORGIA AUSTIN, TEXAS BOSTON, MASSACHUSETTS CHICAGO, ILLINOIS COLUMBUS, OHIO DENVER, COLORADO HARRISBURG, PENNSYLVANIA INDIANAPOLIS, INDIANA LANSING, MICHIGAN NEW YORK, NEW YORK PHILADELPHIA, PENNSYLVANIA PHOENIX, ARIZONA PORTLAND, OREGON RALEIGH, NORTH CAROLINA SACRAMENTO, CALIFORNIA SAN ANTONIO, TEXAS SAN FRANCISCO, CALIFORNIA SEATTLE, WASHINGTON SOUTHERN CALIFORNIA TALLAHASSEE, FLORIDA WASHINGTON, DC
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HMA OFFICES ACROSS THE COUNTRY
Some of the brightest minds in publicly funded healthcare. Working for you.
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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
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WHAT’S AT STAKE
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.
BEHAVIORAL HEALTH DISORDERS WERE THE LARGEST CAUSE OF DISEASE BURDEN IN THE UNITED STATES IN 2015
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Disability Adjusted Life Years (DALYs) Lost per 100,000 population
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.
Behavioral Health Conditions Cancers & Tumors Cardiovascular Disease Injuries Musculoskeletal Disorders Endocrine Disorders Nervous System
Chronic Respiratory
Skin Diseases Sense Organ
3,355 3,131 3,065 2,419 2,357 1,827 1,463 1,050 642 624
MENTAL DISORDERS ARE THE MOST COSTLY CONDITIONS IN THE UNITED STATES
7 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.
$- $50 $100 $150 $200 $250 Mental illnesses Heart conditions Trauma Cancer Pulmonary conditions Annual Cost (Billions)
MENTAL HEALTH CONDITIONS INCREASE MEDICAL COSTS
8 *Note: Does not include any BH spend
0% 20% 40% 60% 80% 100% 120% 140% 160% 180% Arthtitis Hypertension Chronic Pain Diabetes Mellitus Asthma IHD COPD Cancer CHF Stroke
Percentage Increase in PMPM Medical* Spend when there is a Comorbid MH Condition
Anxiety Depression
Source: Melek S, Norris D. Chronic conditions and comorbid psychological disorders. Milliman Research Report. July, 2008.
DRUG OVERDOSE DEATHS IN THE UNITED STATES
9 Source: NCHS: National Vital Statistics System, Mortality.
10000 20000 30000 40000 50000 60000 70000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
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FOLLOW THE MONEY
Source: Medicaid’s Role in Behavioral Health, Henry J. Kaiser Family Foundation, May, 2017.
Medicaid Spending on people with mental health conditions is nearly Four Times as much as for other enrollees
$13,303 $3,564 With BH conditions Without BH conditions
Nearly half of Medicaid spending is for enrollees with BH conditions… …but only 20% of Medicaid enrollees have BH conditions
PUZZLE GRAPHIC
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Risk and reward go hand in hand Whoever pays the piper calls the tune People will do what they are incented to do Money is an effective incentive
SOME OF THE BASIC RULES OF CAPITALISM
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ACCOUNTABILITY, INTEGRATION, AND RISK GO TOGETHER
>80% by end of DSRIP Year 5 >25% by end of DSRIP Year 5
Provider Financial Risk Provider Integration and Accountability
Fee For Service Incentive Payments Pay for Performance (P4P) Bundled/ Episodic Payments Upside Shared Savings Two Way Shared Savings Partial Capitation Full Capitation
Level 0 Level 1 Level 2 Level 3
Cost-based Contract
Retrospective Payments Provider Risk Prospective Payments
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How can you integrate with an
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?
BIG QUESTION FOR BH PROVIDERS
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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?
BIG QUESTION FOR PC PROVIDERS
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.
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Team-based care Evidence- based care Measurement- based care Population- based care
FOUR CORE PRINCIPLES OF INTEGRATED CARE
Source: aims.uw.edu
STEPPED MODEL OF INTEGRATED BEHAVIORAL HEALTHCARE
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1 5 4 3 2
PCP Provides first-line treatment PCP receives ad-hoc consultation, usually from off-site specialist PCP is supported by brief intervention from on-site BH consultant PCP supported by collaborative care team with systematic treatment to target Referral to BH specialty care Source: aims.uw.edu
BH IS NOT YOUR AVERAGE SPECIALTY, BUT NEEDS TO ACT MORE LIKE ONE
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Source: Raney, Lasky, and Scott (2017). Integrated Care: A guide to effective implementation.
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
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TWO CULTURES: ONE PATIENT/CLIENT/CONSUMER
Primary Care
✚ Continuity is the goal ✚ Empathy and compassion ✚ Data are shared ✚ Large panels ✚ Flexible scheduling ✚ Fast-paced ✚ Time is independent ✚ Flexible boundaries ✚ Treatment is external (labs, x-ray, etc.) ✚ Patient not responsible for illness ✚ 24-hour communication ✚ Saved lives ✚ Disease management
Behavioral Health
✚ Termination is the goal – “discharge” ✚ Professional distance ✚ Data are private ✚ Small panels ✚ Fixed scheduling ✚ Slower pace ✚ Time is dependent – “Fifty minute hour” ✚ Firm boundaries ✚ Relationship with provider is treatment ✚ Patient is responsible for participating ✚ Mutual accountability ✚ Meaningful lives ✚ Recovery model
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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
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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
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AN IMPERFECT ANALOGY
PLE STRUCTURES LED BY PC
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Primary Care Secondary Medical Tertiary Medical Quaternary Medical Behavioral Health Social Services LTSS Primary Care Secondary Medical Tertiary Medical Quaternary Medical Behavioral Health Social Services LTSS
PLE STRUCTURES LED BY HOSPITALS
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Hospital (Tertiary and Quaternary) Secondary Medical Primary Care Behavioral Health (Clinical) Social Services LTSS Behavioral Health (Rehab) Hospital (Tertiary and Quaternary) Secondary Medical Primary Care Behavioral Health Social Services LTSS
PLE STRUCTURES LED BY BH PROVIDERS
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Behavioral Health Secondary Medical Tertiary Medical Quaternary Medical Primary Care Social Services LTSS
STRATEGIC PARTNERSHIP OPTIONS
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Level of Collaboration Level of Autonomy Level of Disruption to Existing Operations Strategic Partnership Alliance/Affiliation Joint Venture Merger Co-sponsored program(s) Programmatic Administrative d Back office collaboration/ Joint purchase of MSO services Federation/ Consortium/ BHCC Management Services Agreement Independent Practice Association Accountable Care Organization Merger Parent/ Subsidiary Low Low Low High High High Promotes preparedness for VBP Low High
There are a lot of variations on these two main themes
Mergers IPA-driven partnerships
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TWO PRIMARY OPTIONS
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WHILE THERE ARE NO RULES RE MERGERS…
…THERE ARE SOME BASIC GUIDERAILS
+ Attribution matters a lot + FQHCs have some big advantages + PPS + 340b + HRSA grant opportunities + And some disadvantages + Board requirement + NAP requirements + Grant restrictions
WHAT SERVICES NEED TO BE IN THE SPECIALTY BH PORTFOLIO?
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24x7 Crisis Services Screening, Assessment and Diagnosis MH Tx SUD Tx Patient-Centered Planning and CM Psych Rehab: Supported Ed Psych Rehab: Supported Employment Peer and Family Support Medical Screening and Monitoring
Basically, CCBHC plus housing
IPA-DRIVEN COLLABORATION
✚Matryoshka IPA
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Peer-run agencies Behavioral Health Providers Outpatient services Health system
CONTACT ME JOSHUA RUBIN Principal
646.590.0233 jrubin@healthmanagement.com www.healthmanagement.com
@MedicaidGeek