Hilton Scottsdale ResortJuly 25, 2014 – 7:30am-2:30pm

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Sheila ShapiroChief Operating OfficerUnitedHealthcare Community Plan

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In Honor of ADA Week

Navajo Nation President, Ben Shelly Advancing Rights of Disabled Citizens of the Navajo Nation

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In Honor of ADA Week

Virginia G. Piper Sports & Fitness Center (SpoFit)• Located at the Disability Empowerment Center• Operated by Arizona Bridge to Independent Living (ABIL)

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In Honor of ADA Week

IronKids Fun Run, November 15, 2014• 1st in Nation to include a special needs fun run

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Goals of Today’s Conference

• Hear Arizona Public Policy, Behavioral Health and Medicaid integration landscape

• Hear colleagues’ best practices when working with individuals with special needs

• Understand the United special needs provider designation

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Introduction: Setting the Stage

Arizona Landscape

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Will HumbleDirectorArizona Department of Health Services (ADHS)

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Building A Healthcare System: The AHCCCS Perspective

Beth LazareDeputy Director, AHCCCS

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Step 1: Medicaid Restoration12/1/2013 6/1/2014 Change

Prop 204 Restoration 67,770 235,478 167,708

Adult Expansion 0 24,560 24,560

KidsCare 46,761 2,012 ‐44,749

Family Planning 5,105 0 ‐5,105

AHCCCS for Families & Children (1931) 672,135 723,369 51,234

All Other 505,379 566,767 61,388

Total Enrollment 1,297,150 1,552,186 255,036

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KidsCare UpdateKidsCare I (covers 133% - 200% FPL)• 7,000 Kids• 2,300 stay in KidsCare – today 2,012• About 4,500 transitioned into Medicaid KidsCare II (expired 2-1-14)• 37,000 Kids• 23,000 Medicaid• 14,000 to FFM - Marketplace

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Transition to Streamlined Eligibility

Health    ‐e‐

Arizona

AHCCCS’ACE

DES’AZTECS

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Transforming Arizona’s Healthcare System

• Reduce fragmentation• Integrate delivery system• Align Incentives• Improve Quality• Lower Costs

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Facilitating System Integration

• Why does this matter?• System fragmentation means providers do not talk

to each other and patients slip through the cracks• Integration at the health plan level – one entity

accountable with utilization data to manage whole health of the member

• Integration at provider level – no longer working in a silo but thinking about serving patients as part of a care team

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Facilitating Integration: Behavioral Health

• Acute care plans for physical health• Regional Behavioral Health Authorities (RBHAs) for

behavioral health• April 1, 2014 – New RBHA for Maricopa County brings

PH and BH together under the same plan for individuals with SMI

• Greater AZ RBHA released to achieve similar alignment• One entity responsible for whole health • Data Sharing requirements between acute plans and

RBHAs for other populations

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Facilitating Integration: CRS

• Children with Special Health Needs navigating 3 to 4 plans – CRS, acute plan, RBHA and Medicare

• Families overwhelmed with responsibility for coordinating between multiple systems

• October 1, 2013 – launched one plan for all services, UnitedHealthcare Community Plan

• Enhanced case management and care coordination

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Facilitating Integration: Dual Eligibles

• Dual eligibles enrolled in Medicare and Medicaid• Many duals have special health care needs yet they must

navigate two enormous systems that do not speak to each other• AHCCCS requires plans to be Medicare D-SNPs• 53,000 out of 130,000 duals aligned, better outcomes • Avalere study: 43% fewer days in hospital; 19% lower average

LOS; 21% lower readmission; 9% fewer ED visits and higher preventive services accessed

• As part of Greater AZ RBHA RFP, integrating BH into acute care plans for duals

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Improving Care Coordination

• Team based approach to care• Access to data at both the administrative/health plan

level as well as the provider level• Understanding what to do with data• Holding all of the players in the system – e.g., State,

health plan, providers – accountable for quality and efficiency

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Care Coordination: The Super Utilizer

Who is the Super Utilizer?• In the top cohort for ED utilization, IP days and risk

score• Many have behavioral health needsDo you have Super Utilizers in your practice?• Many primary care providers don’t even know

patients empaneled to them have been to the ED multiple times while hospitals know them by name

• Partner with your health plan, BH, hospital

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• Data exchange between Acute Plans and RBHAs to reduce ED visits by 10% and develop better care management protocols

• Improve provider and member engagement • Develop prevention model• Best practices: coordination at administrative level,

regular team meetings of clinicians, sharing real-time date, mutual care plan, ensuring availability of support services, pediatric check-up protocol

Care Coordination: The Super Utilizer

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Payment Reform: More Than A Buzz Word

• Must shift away from Fee-for-Service Model that pays for quantity

• Value Based Purchasing – rewarding providers for quality outcomes

• AHCCCS has not dictated a model• Health plans and providers should arrive at a

payment model that makes the most sense for that practice

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AHCCCS Requirements• 5% of acute plan payments in shared savings• Increasing to 10% for 2013• 1% capitation withhold returned if quality metrics metChallenges/Opportunities• Provider capacity to enter modernized payment

structures, including data exchange with plans• SIM Grant opportunity to assist plans and providers

to partner on value-based contracting tied to care coordination, reduced ED utilization and increased use of PCPs

Payment Reform: More Than A Buzz Word

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Preparing for This New World

• Open your practice to people with special health care needs

• Embrace electronic records and get help if you need it (AzHEC; incentive payments)

• Think broadly about your practice as a critical part of your patient’s care team

• Get to know your care team partners – hospitals, behavioral health providers, health plans/RBHAs

• Look to your associations for technical support in transforming your business models and practice flows

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Cory Nelson, MPADeputy Director

Arizona Department of Health Services

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Why Integration Matters

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Its just the right thing to do

• Arizonans with a Severe Mental Illness die nearly 25 years earlier than other Arizonans

• Many times this is due to preventable medical conditions that, if treated, would improve quality of life

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How should I treat a person with a Severe Mental Illness?

The answer is simple – Just like you would anyone else• Nearly 1 in 4 Americans has a diagnosable

mental illness 2

• These individuals are mothers, fathers, grandparents and children-Just like the rest of us “normal” people

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Its about the whole person

“Mental illnesses and chronic diseases are closely related. Chronic diseases can exacerbate symptoms of depression, and depressive disorders can themselves lead to chronic diseases.” 5

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Is it really that big of a deal?

• Between 4%-6% of Americans has a Severe Mental Illness 1

• Mental disorders are the leading cause of disability in the U.S. and Canada.3

• Many people suffer from more than one mental disorder at a given time. Nearly half (45 percent) of those with any mental disorder meet criteria for 2 or more disorders, with severity strongly related to comorbidity.1

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They are related

– 68% of adults with mental disorders have medical conditions6

– 29% of adults with medical conditions have mental disorders6

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Chronic Diseases

• Key Chronic Diseases Identified by CDC –Heart disease, Cancer, Stroke, Diabetes, Arthritis, Obesity

• Chronic diseases are the No. 1 cause of death and disability in the U.S.7

• In 2009, 145 million Americans – almost half of all Americans – lived with a chronic condition.8

• Treating patients with chronic diseases accounts for 75 percent of the nation's health care spending.9

• Presenteeism is responsible for the largest share of lost economic output associated with chronic health problems.10

• The most expensive conditions in terms of presenteeism are arthritis, hypertension and depression.11

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Prevalence of Treatment for Chronic Conditions12

• Mental Illness– 45.1M impacted; 37.9% receiving treatment

• Substance Use Disorder– 22.4M impacted; 18.3% receiving treatment

• Diabetes– 25.8M impacted; 84% receiving treatment

• Heart Disease– 81.1M impacted; 74.6% receiving screening

• Hypertension– 74.5M impacted; 70.4% receiving treatment

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Leading causes of death for selected age groups – United States, 2005

Rank 10‐14 years 15‐19 years 20‐29 years 30‐39 years 40‐49 years 50‐59 years

1 Unintentional

Injuries

Unintentional

Injuries

Unintentional

Injuries

Unintentional

Injuries

Malignant

Neoplasms

Malignant

Neoplasms

2 Malignant

Neoplasms

Homicide Homicide Malignant

Neoplasms

Heart

Disease

Heart

Disease

3 Suicide Suicide Suicide Heart

Disease

Unintentional

Injuries

Unintentional

Injuries

4 Homicide Malignant

Neoplasms

Malignant

NeoplasmsSuicide Suicide Diabetes

Mellitus

5 Congenital

Malformations

Heart

Disease

Heart

Disease

Homicide Liver

Disease

Cerebro‐vascular

6 Heart

Disease

Congenital

Malformations

HIV

HIV

HIV

Liver

Disease

7 Chronic

LowerRespiratory Ds

Cerebro‐vascular

Congenital

Malformations

Diabetes

Mellitus

Cerebro‐vascular

Chronic

LowerRespiratory Ds

8 Influenza &pneumonia

Influenza and pneumonia

Diabetes mellitus

Cerebro‐vascular

Diabetes

MellitusSuicide

Source: CDC vital statistics

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A Growing Need

• Between 1996 and 2006, the number of individuals with health care expenditures for mental disorders increased 88% (36 million people)

• This is the single largest increase among the top 5 health conditions

• During the same period health care expenditures for mental disorders increased 63% to $57.5 billion14

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Primary and Mental Health Shortages

• 30% of Arizonans live in a primary care Health Professional Shortage Area (HPSA) 13

• 80% of Arizonans live in a mental health HPSA– 2nd highest percentage in the nation13

• It will take everyone working together to better utilize our collective resources

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Integrated Healthcare at the State Level

• Maricopa County– $1B annual contract with Mercy Maricopa

Integrated Care to manage behavioral and physical health for individuals diagnosed with Serious Mental Illness as well as behavioral health for GMH/SA individuals

• Greater AZ– RFP released soon that will incorporate the

Maricopa County integrated care approach. Region divided into North and South geographic service areas.

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Integration at the Provider Level

• Offering integrated services improves the patient experience and can enhance compliance with treatment

• Integrated services can lower costs by reducing administrative overhead, reducing missed appointments and enhancing care coordination through technology

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How Do I Make a Difference?

• Encourage a culture of taking mental health seriously, from the top down.

• Have formal and informal policies about workplace conduct when working with patients experiencing mental health issues.

• Hold a Mental Health Awareness Month or other visible mental health-friendly events/activities and educational/informational materials.

• Understand that it may take a little more time to help a person with mental illness up front but the long term payoff is worth it

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How Do I Make a Difference?

• Collaborate– Be a network provider for a RBHA providing

integrated care– If not…be open to care coordination efforts

• Think about the whole person– Rule other conditions out before ruling MI/SUD in

• We tend to be more dismissive of symptoms for individuals with MI/SUD conditions

• Not treating the whole person costs everyone in the end

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References

1. (Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.)

2. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/

3. The World Health Organization. The global burden of disease: 2004 update, Table A2: Burden of disease in DALYs by cause, sex and income group in WHO regions, estimates for 2004. Geneva, Switzerland: WHO, 2008. http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_AnnexA.pdf.

4. http://www.cdc.gov/nationalhealthyworksite/docs/nhwp_mental_health_and_chronic_disease_combined_3.pdf

5. Chapman DP, Perry GS, Strine TW. The Vital Link Between Chronic Disease and Depressive Disorders.

6. The Synthesis Project, New Insights from Research Results, Policy Brief NO. 21, February 2011

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References

7. Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: final data for 2005. National Vital Statistics Reports 2008;56(10). Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf

8. Anderson G. Chronic Care: Making the Case for Ongoing Care. Princeton, NJ: Robert Wood Johnson Foundation; 2010. http://www.rwjf.org/content/dam/web-assets/2010/01/chronic-care

9. Anderson G. Chronic conditions: making the case for ongoing care. Baltimore, MD: John Hopkins University; 2004.

10. Partnership to Fight Chronic Disease. Almanac of Chronic Disease: 2008 Edition. 2008. 11. American Hospital Association12. http://www.cdc.gov/nationalhealthyworksite/docs/nhwp_mental_health_and_chronic_disease_combine

d_3.pdf13. Arizona Department of Health Services14. http://meps.ahrq.gov/mepsweb/data_files/publications/st248/stat248.pdf

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Thank You

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Thank you speakers – Will Humble, Beth Lazare, Cory Nelson

Break – Salon 19:45am-10:00am

Breakout Sessions – Sonora Ballrooms A, B, C10:00am-12:30pm

Lunch & Keynote SpeakerGrand Ballroom12:30pm

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