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LEARNMORE ibhpartners.org
MakingtheCaseandMakingIt
Work:IntegratingBehavioral
HealthintoPrimaryCare
KarenW.Linkins,PhD
May18,2016
Whatwe’llcovertoday
• WhyIntegratedBehavioralHealth
• Changingpolicyenvironment
• Whereweareheaded:Collectiveimpactand
AccountableCommunitiesofHealth
TheProblem:Fragmentation
Clinicaldelivery
Payment/financing
Community
expectation
Training/education
Fragmentation
QuickReview:CaseforIntegration
• 5%ofthepopulationuse50%ofthehealthcareresources(the5/50population)
• 1%use20%ofthehealthcareresources• Halfofbothgroupshaveabehavioralhealthdisorder• PrimarycareisthesolesourceofMHtreatmentfor
1/3ofpatientsreceivingcareforaMHcondition
• Depressedpatientsare3timesmorelikelythannon-
depressedpatienttobenon-compliantwith
treatmentrecommendations
5
BehavioralHealthisaKeyConcernfor
HealthCare• Disparities:Affectslow-incomepopulations
o Nearlyhalf(49%)ofallMedicaidbeneficiarieswith
disabilitieshaveapsychiatricdiagnosis
o AmongDualeligibles (Medicare/Medicaid),44percent
haveatleastonementalhealthdiagnosis
• Costdrivero Behavioralhealthdisordersareamongthefivemostcostly
conditionsintheU.S.withexpendituresof$57billion
oMooddisorderssuchasdepressionarethirdmost
commoncauseofhospitalizationintheU.Sforbothyouth
andadults
Weonlyspend5%ofourhealthdollarstoaddresswhatcauses60%ofouravoidabledeaths
1 McGinnis et al., The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93.2 Centers for Medicare & Medicaid Services, Office of the Actuary. National health expenditures, by source of funds and type of expenditure. 2013.
10%
30%
5%
40%
15%
EnvironmentBehavior
Social factors Health care
Genetics
Causes of avoidable death in the United States1
95%
5%
Health care
Population-wide approaches to health improvement
United States health expenditures in 20132
Behavioral health preventionChemical dependency preventionMaternal and child health programsPublic health activitiesResearchSchool health programs
EconomicImpactofIntegratedBehavioralHealth• CMSP:reimbursingprimarycareclinicsforupto10mentalhealthvisitsand20substanceabusevisits
peryear resulted inadramatic57%dropinpsychiatricdaysbythetreatedgroup (vs.a71%increaseinthebusiness-as-usualcontrols). However,thiscost-savingswasneutralizedbyanincreaseinoutpatientexpenses.Nonetheless,CMSPhaselectedtocontinuetheprogramwiththeexpectationthattherewillbesavingsoncetheprogramisfurtherunderway.EvaluationoftheCMSPBehavioralHealthPilotProject,Draft FinalReport, preparedforCMSPbytheLewinGroup,February,2011
• Depressionmanagementfordepressedprimarycare clientsresultedina$980costdecreaseforthosewhocomplainedofpsychologicalsymptoms,buttherewasa$1,378costincreaseforthosewhocomplainedofphysicalsymptomsonly.MiriamDickinsonetal.,“RCTofaCareManagerInterventionforMajorDepressioninPrimaryCare:2-YearCostsforPatientsWithPhysicalvsPsychologicalComplaints” AnnalsofFamilyMedicine,2005,3:15-22.
• “Theimpactofpsychologicalinterventionsontheuseofmedicalserviceswasevaluatedbyexaminingtheoutcomeof91studiespublishedbetween1967and1997usingmeta-analytictechniquesandpercentage estimates.Resultsprovidedevidenceforamedicalcost-offseteffect,specificallyinthedomainofbehavioralmedicine.Averagesavingsresultingfromimplementingpsychologicalinterventionswasestimatedtobeabout20%.Aboutonethirdofthearticlesdemonstratedthatdollarsavingscontinuedtobesubstantialevenwhenthecostofprovidingthepsychologicalinterventionwassubtractedfromthesavings.”JeremyA.Chilesetal.TheImpactofPsychologicalInterventionsonMedicalCostOffset:AMeta-analyticReviewClinicalPsychology: ScienceandPractice,June1999,Vol.6.
• Collaborativecare,implementedthroughbriefcognitive-behavioraltherapyandenhancedpatienteducationinprimarycare,increaseddepressiontreatmentcosts,butimprovedthecost-effectivenessoftreatment forpatientswithmajordepression.Acostoffsetinspecialtymentalhealthcosts,butnotmedicalcarecosts,wasobserved.VonKorff,“Treatmentcostoffsetsandcost-effectivenessofcollaborativemanagementofdepression”,PsychosomaticMedicine,1998,60.
• Whenclientswithdiabetesanddepressionreceiveddepressioncollaborativecare(adepressioncaremanager offered education,behavioralactivation,andachoiceofproblem-solvingtreatmentorsupportofantidepressantmanagementbytheprimarycarephysician),anincrementalnetbenefitof$1,129wasfoundovertwoyears.Thestudyconcludedthatthisinterventionis“ahigh-valueinvestmentforolderadultswithdiabetes;itisassociatedwithhighclinicalbenefitsatnogreatercostthanusualcare.”WayneKaton etal.“Cost-EffectivenessandNetBenefitofEnhancedTreatmentofDepressionforOlderAdultswithDiabetesandDepression.”DiabetesCare29:265-270,2006.
• Whenfamilyphysiciansworkedcollaborativelywithmentalhealthprofessionalstotreatpersonsonshort-term mentalhealthdisabilityleave,theirpatientsreturnedtoworkathigherrates thanthosetreated byphysiciansalone.Theaveragecostsavingstoemployerswas$503perpatient.CarolynDewaet al.“Cost,EffectivenessandCost-Effectivenessof a CollaborativeMentalHealth CareProgram forPeopleReceivingShort-Term Disability BenefitsforPsychiatricDisorders”, CanadianJournalofPsychiatry, 54(6),2009.
• Over24months,clientshavingbothdiabetesanddepressionwhowereassignedtoastepped-caredepressiontreatment programhadoutpatienthealthservicescoststhataveraged $314lesscomparedtothosewhoreceivedcareasusual.Theauthorsconcludethat“foradultswithdiabetes,systematicdepressiontreatment appearstohavesignificanteconomicbenefitsfromthehealthplanperspective.”Gregory Simonetal.,“Cost-effectivenessofSystematicDepressionTreatmentAmongPeopleWithDiabetes Mellitus”,ArchivesofGeneralPsychiatry,January,2007,Vol.64,No.1.
• AstudyofMedicaidrecipientsdiagnosedaschemicallydependentfoundthatthosenotusingmentalhealthservicesincreasedtheir medicalcostsby91%duringthestudyperiod,comparedtodecreasedcostsforrecipientsofmentalhealthtreatment.Inthefirsttwelvemonthsaftertreatment, someinterventionsproducednetdecreasesofapproximately$514perperson.N.,Cummings,etal.“Theimpactofpsychologicalinterventiononhealthcareutilizationandcosts”.Biodyne Institute,1990.
• Acollaborativecare interventionforprimarycareclientswithpanicdisorder,includingsystematicpatienteducationandapproximatelytwovisitswithanon-siteconsultingpsychiatrist,resultedinnosignificantdifferencesintotaloutpatientcosts,andananalysissuggestsa70%probabilitythattheinterventionledtolowercostsandgreatereffectiveness comparedwithusualcare.WayneJ.Katon,“Cost-effectiveness andCostOffsetofaCollaborativeCareInterventionforPrimaryCarePatientswithPanicDisorder”, ArchGenPsychiatry. 2002;59.
• Comprehensivecollaborativeandstructuredmentalhealthservicesprovidedtohighutilizersofmentalhealthservicesresultedina65%reductionincommunityhospitaldays.NancyAnderson,“MedicalCostOffsetsAssociatedwithMentalHealthCare”ABriefReview,WashingtonStateDept.ofSocialandHealthServices, December, 2002.
• Useofmanagedmentalhealthcare(structured, targeted, focusedandbrieftreatment)forMedicaidenrolleesreducedmedicalservicescostsandutilizationby23to40percentrelativetocontrolgroups.Forenrolleeswithchronicmedicaldiagnoses,managedtreatmentreducedmedicalcostsby28to47percent.Forenrolleeswithoutchronicmedicaldiagnoses,traditionalfee-for-servicealsoreducedmedicalcostsbyabout20%butusedthreetimesasmanyoutpatientvisits.Costsofmanagedtreatmentwere recovered in6to24months.Themanagedmentalhealthgroupspentfewerdaysinthehospitalandusedtheemergencyroomless.MSPallak etal.,“Medicalcosts,Medicaid,andmanagedmentalhealthtreatment:theHawaiistudy”, ManagedCareQ, 1994Spring;2(2).
• Aneight-sessionmind/bodyeducationprogramforpeoplepronetosomatizationandaneightsessionchronicpainmanagementprogram“decreasedmedicalofficevisitsbyabout35%”.DanielBruns etal.,“TheImplementationofIntegratedPrimaryCareatKaiserPermanente”:An InterviewwithRogerJohnson,Dec.,1998.
• Primarycare clientsassignedtoenhancedcarefordepressionnotonlyexperiencedsignificantlymoredepression-free dayscomparedwithusualcareclients,butcostthehealthplansignificantlyless($568vs-$12inincrementalcosts;P<.001).KatherineRost,“Cost-EffectivenessofEnhancingPrimaryCareDepressionManagementonanOngoingBasis”,2005,AnnalsofFamilyMedicine3:2005.
• “JohnsHopkinsHealthCareexaminedthefirst12monthsofclaimshistoriesof603adultMedicaidenrolleeswhofrequentlyusedmedicalservicesandhadarecenthistoryofsubstanceabuse.Aninterventiongroupof400wastargetedformanagement bysubstanceabusecoordinatorsandnursecaremanagerswhoreceivedtrainingintheintegrationofmedicalcasemanagementandsubstanceabuseservices.Thetrainingincludedmockinterviews,lectures,andcaseconferencesonsubstanceabusetopics.Acomparisongroupof203membersreceived routinecareintheformofseparateoutreach fromsubstanceabusecoordinatorsandcaremanagers. Early resultsindicatethattheinterventiongroupreducedmedicalcostsby$122permemberpermonthascomparedtoanincreaseinthecomparisongroup.Theinterventiongroup’scostreductionswererealizedthroughadecrease of288admissionsper1,000membersaswellasadecreasein92daysadmittedper1,000members.Moreover,theinterventiongroupexperiencedincreasedenrollmentinsubstanceabusetreatment andcasemanagement,whichappropriatelyoffsetsomeofthesavingsfromhospitalutilization.Inall,thePMPMcostreductionsamonginterventiongroupmemberstotaled$503,616throughthefirstyearoftheprogram,relative tobaseline.”see JohnsHopkinsHealthcare:DemonstratingaReturnonInvestmentforIntegrated Substance AbuseandTreatment
• Thoughtheaprimarycaredepressionmanagementinterventionaddedtothetotalcarecoststhefirstyearofoperation,thesecostswerelargely off-setbygeneral healthcaresavingsduringthesecondyear.Theinterventionproducedhealthandmentalhealthimprovementswithoutasignificantincreaseincosts.WayneKaton etal.,“Cost-effectivenessofImprovingPrimaryCareTreatment of Late-LifeDepression”,ArchivesofGeneral Psychiatry,2005,62.
• PatientsparticipatingintheIMPACTprogramfortreatingdepressioninprimarycarehadlowermeantotalhealthcare coststhanusualcarepatientsduringafouryearperiod.JurgenUnutzeretal.,“Long-termCostEffects ofCollaborativeCareforLate-life Depression”,AmericanJournalofManagedCare,Vol.14,No.2,2008
• “Patientswhoreceivecare fordepressioninprimarycareclinicswithroutinementalhealthintegrationteamsandcareprocesseswere 54%lesslikelytousehigher-orderemergencydepartmentservices.”BrendaReiss-Brennanetal.,“CostandQualityImpactofIntermountain’sMental HealthIntegrationProgram”,JournalofHealthcareManagement,55:2,2010.
• Primarycare patientswithdiabetesandmajordepressionassignedtoaninterventionprogramincludingeducationaboutdepression,behavioralactivationandand achoicebetweenanti-depressantmedicationorproblem-solvingtherapyhad improveddepressionoutcomescomparedtotheusualcaregroupwithnoevidenceofgreater long-termcosts.Wayne Katon etal.,“Long-TermEffectsonMedicalCostsofImprovingDepressionOutcomesin PatientswithDepressionandDiabetes:, DiabetesCare,Vol.31,2008
• Whencomparingclientswiththehighestriskscoresenrolledinpatient-centered healthhomes(PCHM)vs.thosenotenrolled,thePCMHmodelwasshowtohaveasignificantreductionintotalcostsinthefirsttwoyears andsignificantlylowerclientadmissionsinthethreeyearsstudied.SusannahHigginsetal.,March,2014. Publishedon-line
TheSolution
9
Primary Care
IntegratedCareDefinition
• Integrationofbehavioralhealthandphysicalhealthcarereferstotheintentional,ongoing,and
committedcoordinationandcollaborationamong
allprovidersandtheindividualintreatment.
Providersrecognizeandappreciatethe
interdependencetheyhavewitheachotherand
thepatient/clienttopositivelyimpacthealthcare
outcomes.(AgencyforHealthCareResearchandQuality(AHRQ))
Differenttypesofmodelsforintegrated
behavioralhealthhavechallenges
BH Med
BH Medical
BH
Medical
Referral
Coordination/partnership
Colocation
KeyFeaturesofSuccessfulModels
• Communication:Warmhandoffsvs.referrals
• Shiftinscopeandapproachtopractice: e.g.,Consultingpsychiatristvs.extendedevaluationwith
caseload
• Coordination: e.g.,PCPprescribingvs.twoprescribers
• EngagementandActivation: Recoveryorientationandpatientselfmanagementskills
• Datadrivencare: e.g.,Dataanddocumentation
sharing;outcometracking
TwoRolesofBHProviders
13
Food MartMH/SU
BehavioralHealthinPrimaryCare
Embeddedmentalhealthandsubstanceuseservicesinaprimarycareclinicwiththeabilitytoaddressneedsofpersonswithmildto
moderatebehavioralhealthdisorders
PC
Food Mart
MH/SU
BehavioralHealthSpecialtyCentersofExcellence
Apartnerwithmedicalhomes,providinghighvalue,wholehealth-
oriented,specialtycaretoindividualswithcomplex
behavioralhealthconditions
PC
IntegratedCareisMovingintheRightDirection,but
hasChallenges
• Lackofknowledgeandexperiencewithvaluebasedpurchasing(ratherthanvolume)andconnectionto
outcomes
• Disconnectbetweenbeliefinrecoveryphilosophyandexpectationsforpatientoutcomes
• Perceivedandrealbarrierstodatasharing• Stigmatowardspatientswithmentalillnessand
addictionpersistsamongmedicalproviders– creating
barrierstoaccessandtreatmentfollowthrough
14
NewModelsofCareareChangingFasterthan
WorkForceSupply&Preparedness
• Mostprovidersreceivelimitedtrainingonworkinginteams;
happens“onthejob”
• MHprovidershortages– CAruralcounties(OSHPD,2011)
• DemandforMH/SUsocialworkersisprojectedtoincrease
by22.8percentand35.4percent,respectively,from2006to
2016(CaliforniaEmploymentDevelopmentDepartment)
• MedicalandBHfieldshavedistinctlydifferenttraining
programs,professionalcultures,andtreatmentapproaches.
• BHproviderslagbehindmedicalprovidersintheircapacity
totracktreatmentoutcomesandusedataforclinical
decisionmaking
Consumersfeelstigmatizedbyhealth
providers
• Orientationofprimarycareisreactive– which
detersclientsreluctantorunabletoseekhelp
• Physiciansinexperiencedinwithmentalhealth
workmayresistgettingfurtherinvolvedwitha
clientbynotactivelyaskingaboutsymptoms(M.
Phelan,2001)
• Crampedschedulescanlimit timephysicianshave
todiscussbehavioralhealthissueswithclients
• Subtleornotsosubtlejudgmentsand
communicationaboutpatients’mentalhealthand
substanceuseissues
16
Whystigmashouldmatterto
providers
• Issueswithmedicationadherence
• Drop-outsandnoshows• Access• Poorphysicalhealthoutcomes
• PatientExperience:Keycomponentandmeasurein
theTripleAim
17
IBHaKeyStrategyforImprovingPatientExperience
• Researchevidence:IBHisaneffectivestrategytoreducestigmaandimproveaccesstobehavioral
healthservices,especiallyforvulnerable
populations
• A2005IOMreportconcludedthattheonlywayto
achievetruequalityandequality inthehealthcaresystemistointegratedprimarycarewithmental
healthandsubstanceuseservices
18
*Ivbijaro,G.&Funk,M.(2008.)Nomentalhealthwithoutprimarycare.MentalHealthinFamilyMedicine,5(3),
September,127-128.
*Kautz C,Mauch D,andSmithS.ReimbursementofMentalhealthservicesinprimarycaresettings.Rockville:
CenterforMentalHealthServices,SubstanceAbuseandMentalHealthServicesAdministration,2008.
ChangingPolicyLandscape
HealthReformisPushingforSystemRealignmentto
ReduceCosts
Prevention,EarlyIntervention,
PrimaryCare,andBehavioralHealth
Inpatient&Institutional
NeededResourceAllocation
AllthingsInpatientandInstitutional
Prevention,PrimaryCare,BH
CurrentResourceAllocation
$$
21
ExamplesofChangingIntegratedBehavioralHealth
PolicyLandscape
• Medi-CalExpansion:ExpandedroleofMCOsand
expandedpopulation
• ACASection2703HealthHome– Practice
Transformation
• CAMedi-Cal1115Waiver
• AccountableCommunitiesforHealth
22
Medi-CalExpansionandExpandedBenefit
• Startedin2014,butsystemsarestilladjusting
• Newrelationshipsatthecountylevel– CountyBehavioralHealth,HealthPlans,Managed
BehavioralHealthOrganizations(e.g.,Beacon),
FQHCsandCHCs
• Emphasisplacedoncaretransitionsand
maintainingcontinuityofcare– e.g.,hospitalto
community
• Accelerationofnewintegratedcaredeliverymodels,e.g.team-basedcare
23
ACAà PracticeTransformation
• Integrated,CoordinatedCare,e.g.Patient-CenteredMedicalHome(section2703)
o Growingawarenessoftheconsequencesofuntreatedmental
healthandSUDneeds
o RecognitionofneedforIntegration/Person-Centered/Whole
PersonCaretoachieveTripleAim
o Increasedrecognitionoftheroleofhousing;needtodevelop
newpartnershipswithnon-medicalproviders(HousingFirst)
o Parity
• ImplementationdelayedinCAuntil2018,butit’sstill
importanttoinvestincapacityandinfrastructure
24
Medi-Cal1115WaiverComponents
• Shiftfromfee-for-servicetoGlobalPayment
Programforservicestotheuninsuredindesignated
publichospitalsystems
• Deliverysystemtransformationandalignment
incentiveprogramforpublicandmunicipal
hospitals
• WholePersonCarePilots totargetmoreintegrated
careforhigh-risk,vulnerablepopulations
25
ChallengesintheNewPracticeEnvironment
• SignificantprogressinpracticeandsystemtransformationinCAandnationallythatprovidestrongevidencebase,BUT thereareissueswithsustainabilityandspread• Infrastructureandworkforce(andpracticeculture)challengesinachieving:
² Integrated,teambasedcarewithallmembersworkingtothetopoftheirlicense,delegatingactivitiestodifferentteammembers,asappropriate
² Improvedpopulationmanagement² BetterimplementationanduseofHIT,e.g.,QItrackingof
treatmentoutcomes
² Paymentreform(e.g.,valuebasedpurchasing)
² Shiftingfromdatacollectionforcompliancetousingdataforaccountability
26
KeyReformIngredientà OutcomesMeasurement
• USbehavioralhealthsystemismovingfrom50states
(50setsofrules)toanationalqualityframeworkfor
BH
• BUT– therearecurrentlymanydifferentquality
measuresrelevanttoBH(noclearconsensus):
o116 indraftNBHQFo64inMeaningfulUseset
o44inthePhysicianQualityReportingSystemo37intheSAMHSAStateURSset
o28intheFQHCUDSset
27
ChangingtheFrame:Collective
Impact
TheCollective
ImpactFoundation
• CollectiveImpactisthecommitmentofa
groupofactorsfrom
differentsectorstoa
commonagendafor
solvingaspecificsocial
problem,usinga
structuredformof
collaboration.
Kania &Kramer,CollectiveImpact,
StanfordSocialInnovationReview,2011
29
IsolatedImpact:TheCollectiveImpactFoundation
• Whatweknow…
• IsolatedImpact:
o TheprevailingmodelofhealthandhumanservicesintheUS.
o Historicallypromotedbypayorsandfunders.
o Hasresultedinthedevelopmentofover1millionUSnonprofitorganizationsdevotedtoisolatedimpact.
• IsolatedImpactDefinition:Effortstoeffectivelyaddressahealthorsocialproblembycontractingwithorganizationsthatspecializeinthatparticularproblem.
• Problem:ComplexSystemswithmanyinterconnectedcomponentsdoNOTrespondwelltoisolatedimpact.
• Reality:Thepeople,families,andcommunitiesyouworkwitharetheposterchildofComplexSystems.
30
5CollectiveImpactComponents
31
AccountableCommunitiesforHealth
• Emergingstrategyforimprovingpopulationhealth
• ACHsintegratemedicalcare,behavioralhealthcare,andsocialservicesupportstoimprovethesocialdeterminantsthatshapehealthandwellbeinginageographicalarea
• Collectivelyengagemajorhealthcareprovidersacrossageographicareatooperateaspartnersratherthancompetitors
• Focusesonthehealthofallresidentsinageographicarearatherthanjustapatientpanel
• NewInitiative:TheCaliforniaAccountableCommunitiesforHealthInitiative(CACHI)willassessthefeasibility,effectiveness,andpotentialvalueofamoreexpansive,connectedandprevention-orientedhealthsystem
32
Prevention EarlierIntervention
ModerateConditions
HighNeed/ChronicConditions
Commun
ityClinical Screening
ACES
SBIRT
PHQ-9
Primary,Coordinated
Care
CommunityPrograms(schools,
CBOs)
PrimaryandSecondaryPreventionWellness
Interventions–Smoking,Food
33
ChronicHealth/HighUtilizers
SnapshotofInterventions,EntryPoints,&PopulationHealth
Upstream Downstream
AsthmaandDiabetes
TheWorkYouDoisEssential…
• Allofthisisnewandnobodyhasthealltheanswers!• Theonusisonallofustoadvanceintegratedprimary
care,mentalhealth,substanceuse,andotherperson-
centeredservices(e.g.,dental,socialservices,and
housingsystemofcare).
34