Outcomes in Behavioral Health

Thomas Smith, MD

Associate Medical Director, NYS Office of Mental Health

Special Lecturer, Columbia University Medical Center

2

OverviewWith the increasing emphasis on value based payment (VBP) strategies,

behavioral health providers need to consider measuring their care and

outcomes. This session will:

• Review process and outcome measures commonly used in oversight,

quality improvement, and accountability (e.g., VBP) programs involving

behavioral health.

• Identify key decisions and activities that behavioral health providers must

pursue in adopting a measurement approach.

• Provide an overview of a tracking system that ACL members are currently

using in the Central region to look at how housing programs impact

hospital usage for people in the behavioral health system.

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Key Recommendations

• Understand where your agency fits in the larger system of care.

• Know the oversight and payment authorities’ priorities for the system

of care.

• Align some (not all!) of your agency’s priorities and strengths with the

system priorities

• Implement tracking and reporting of key agency practices that align

with the system priorities.

• Have summary reports ready for external audiences—brag about

what you do well.

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Why do we measure quality and performance?

1. Monitor and understand systems, providers, and populations

2. Internal Quality Improvementa. To support point-of-care decision making

b. For provider continuous quality improvement projects

c. Managed care organization performance improvement

3. Accountabilitya. Public reporting

b. Value-based payment

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What do we measure?

1. System of Care priorities (understanding)

2. Payers’ priorities (accountability)

3. Provider priorities (quality improvement)

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System Priorities: Transforming the NYS Medicaid Program

• 2012: Health HomesGoal: Comprehensive care management services for high-need populations

• 2014: Delivery System Reform Incentive Payment (DSRIP) ProgramGoal: Shift locus of care from acute to community; reduce unnecessary readmissions

• 2015: Medicaid Managed Care: Capitated Behavioral HealthGoal: Fully capitated system with managed care plans overseeing integrated behavioral and general medical care.Up to 150,000 members enrolling in fully integrated special needs plans for individuals with serious BH conditions(HARPs)

• 2015: Advanced Primary Care (APC)Goal: 80% of population receives care in APC setting with focus on prevention and coordinated care as well asthrough an alternative payment model

• 2017: Value-Based Payment ModelsGoal: Shift reimbursement model from volume to value: by 2020, 80% of Medicaid Managed Care providerpayments will be in shared savings arrangements, with 35% of those including downside risk to providers

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BH Statewide Overview A disproportionate amount of total cost of care and hospital visits in NYS can

be attributed to the BH population

Overview:

• Medicaid members

diagnosed with BH

account for 20.9% of the

overall Medicaid

population in NYS

• The average length of stay

(LOS) per admission for

BH Medicaid users is 30%

longer than the overall

Medicaid population's

LOS

• Per member per month

(PMPM) costs for

Medicaid Members with

BH diagnosis is 2.6 times

higher than the overall

Medicaid population

* This data includes Medicaid Members with 1+ Claims with primary or secondary diagnosis of behavioral health issues

$28,824,105,821

$ 19,224,273,571

Medicaid members diagnosed with BH account for 60% of the total cost of care in NYS

1,415,454

1,724,531

Medicaid members diagnosed with BH account for 45.1% of all ED Visits

584,503

508,538

Medicaid members diagnosed with BH account for 53.5% of admissions

5,509,029

11,729,701

Medicaid members diagnosed with BH account for 32% of Medicaid Primary Care

Physicians (PCP) visits

Total PCP Visits from Medicaid Members: 17,238,730 Total ED visits from Medicaid Members: 3,139,985

Total Medicaid Cost of Care in NYS: $48,048,379,392 Total Medicaid Admissions: 1,093,041

Source: SIM Database. 2014 Claims Data – analysis based on data from January – December 2014. New York State.*

Total Medicaid Pop. Excluding

Medicaid BH Pop.

Medicaid members diagnosed w/ BH

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Much higher Prevention Quality Indicator (PQI) rates in adult non-dual Medicaid

members with mental health condition (MH) or Serious Mental Illness (SMI)

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50

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Prevention Quality Indicators (PQIs)

Non MH

Medicaid MH

SMI

*PQI01: Diabetes Short-Term Complication Admission Rate (Inpatient hospital admissions per 100,000 enrollee months)*PQI05: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults Asmission Rate (Inpatient hospital admissions per 100,000 enrollee months)*PQI08: Heart Failure Admission Rate (Inpatient hospital admissions per 100,000 enrollee months)*PQI15: Asthma in Younger Adults Admission Rate (Inpatient hospital admissions per 100,000 enrollee months)

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Much higher Potentially Preventable Readmissions (PPR) rates in adult non-dual

Medicaid members with MH/SMI

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2000

3000

4000

5000

6000

Non MH Medicaid MH SMI

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*PPR: Potentially Preventable Readmissions (Readmission chains per 100,000 enrollees)

Potentially Preventable Readmissions (PPR)

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BHO Phase I post-discharge outcomes for Adult Mental Health discharges, CY 2012

Medicaid claims data

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

30-day readmission rate Outpatient MH or SUDtreatment within 7 days of

discharge

Two or more MH outpatientvisits within 30 days of discharge

NYC Rest of state

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• A Five-Year Roadmap outlining NYS’ plan for Medicaid Payment

Reform was required by the MRT Waiver.

• By DSRIP Year 5 (2020), all Managed Care Organizations (MCOs)

must employ non fee-for-service payment systems that reward value

over volume for at least 80-90% of their provider payments (outlined

in the Special Terms and Conditions of the waiver).

• If Roadmap goals are not met, overall DSRIP dollars from CMS to

NYS will be significantly reduced.

Recap: Moving Towards VBP

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In addition to choosing which integrated services to focus on, Managed Care Organizations and

contractors can choose different levels of VBP:

Level 0 VBP Level 1 VBP* Level 2 VBP Level 3 VBP

(feasible after experience with

Level 2; requires mature

contractors)

FFS with bonus

and/or withhold

based on quality

scores

FFS with upside-only shared

savings available when

outcome scores are sufficient

(For PCMH/IPC, FFS may be

complemented with PMPM

subsidy)

FFS with risk sharing (upside

available when outcome

scores are sufficient)

Prospective capitation PMPM

or Bundle (with outcome-

based component)

FFS Payments FFS Payments FFS Payments Prospective total budget

payments

No Risk Sharing Upside Risk Only Upside & Downside Risk Upside & Downside Risk

Acronyms: FFS = Fee-for-Service PCMH = Patient Centered Medical Home VBP = Value Based PaymentsPMPM = Per Member Per Month IPC = Integrated Primary Care

Recap: VBP Contracting

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NYS OMH Mental Health System Transformation Goals

1. Shift locus of care from acute to community-based (outpatient) services

2. Improve early identification and intervention for at-risk populations and for active MH conditions

3. Improve individuals’ experience of health care

4. Improve both general medical health and functional outcomes for individuals with SMI

5. Increase % of individuals identified as in recovery

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NYS DOH

Clinical Advisory Groups (CAGs)

15 1515

Measure Measure StewardMeasure Identifier Classification

1Diabetes Screening for People with Schizophrenia or Bipolar Disorder using

Antipsychotic Medications

National Committee for

Quality Assurance (NCQA)NQF 1932 P4P

2 Adherence to Mood Stabilizers for Individuals with Bipolar I DisorderCenters for Medicare &

Medicaid Services (CMS)NQF 1880 P4P

3 Follow-up after Hospitalization for Mental Illness (within 7 and 30 days) NCQA NQF 0576 P4P

4 Initiation of Medication-Assisted Treatment (MAT) for Opioid Dependence NYS OASAS P4P

5 Follow-up after Emergency Department Visit for Alcohol and Other Drug Dependence NCQA P4P

6 Rate of Readmission to Inpatient Mental Health Treatment within 30 Days NYS OMH P4P

7 Continuity of Care within 14 Days of Discharge from Any Level of SUD Inpatient Care NYS OASAS P4P

8 Percentage of Members Enrolled in a Health Home NYS OMH P4R

9 Initiation of Medication-Assisted Treatment (MAT) for Alcohol Dependence NYS OASAS P4R

10Percentage of Members who Receive PROS or HCBS for At Least 3 Months in

Reporting YearNYS OMH P4R

11Percentage of Members who Maintained/Obtained Employment or

Maintained/Improved Higher Education StatusNYS OMH P4R

12 Percentage of Members with Maintenance of Stable or Improved Housing Status NYS OMH P4R

13 Percentage of Members with Reduced Criminal Justice Involvement NYS OMH P4R

HARP VBP Category 1 Required Measures: Behavioral Health

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Measure Measure StewardMeasure Identifier Classification

1 Adherence to Statins for Individuals with Diabetes Mellitus CMS NQF 0545 P4P

2 Breast Cancer Screening NCQA NQF 2372 P4P

3 Cervical Cancer Screening NCQA NQF 0032 P4P

4 Colorectal Cancer Screening NCQA NQF 0034 P4P

5 Chlamydia Screening NCQA NQF 0033 P4P

6Comprehensive Diabetes Care: All Three Tests (HbA1c, dilated eye exam, and medical

attention for nephropathy)NCQA

NQF #s 0055, 0062, 0057

P4P

7 Comprehensive Diabetes Care: Eye Exam (retinal) performed NCQA NQF 0055 P4P

8 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testing [performed] NCQA NQF 0057 P4P

9 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA NQF 0059 P4P

10 Comprehensive Diabetes Care: Medical Attention for Nephropathy NCQA NQF 0062 P4P

11 Controlling High Blood Pressure NCQA NQF 0018 P4P

12Medication Management for People With Asthma (ages 5 - 64) – 50 % and 75% of Treatment Days Covered (Calculation to be constrained to the appropriate age range)

NCQA NQF 1799 P4P

HARP VBP Category 1 Required Measures: Integrated Primary Care Bundle

Continued on next slide

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Measure Measure StewardMeasure Identifier Classification

13 Comprehensive Diabetes Care: Foot Exam NCQA NQF 0056 P4R

14 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%) NCQA NQF 0575 P4R

15Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

CMS NQF 0421 P4R

16 Preventive Care and Screening: Influenza Immunization

American Medical Association Physician Consortium for

Performance Improvement (AMA PCPI)

NQF 0041 P4R

17Preventive Care and Screening: Tobacco Use: Screening and Cessation

InterventionAMA PCPI NQF 0028 P4R

18 Statin Therapy for Patients with Cardiovascular Disease NCQA P4R

19 Use of spirometry testing in the assessment and diagnosis of COPD NCQA NQF 0577 P4R

HARP VBP Category 1 Required Measures: Integrated Primary Care Bundle (cont.)

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What do we measure?

1. System of Care priorities (understanding)

2. Payers’ priorities (accountability)

3. Provider priorities (quality improvement)

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NYS Mental Health Performance Measurement Priority Focus Areas

1. Shift the locus of care: Improve care transitions; offer prevention, early intervention, and crisis services; decrease inpatient admission and ED visit rates.

2. Promote Integrated Care: strategies to incentivize integrated (medical - behavioral health) care.

3. Improve functioning and recovery: Increase the numbers of individuals returning to work or school; decrease criminal justice contacts; promote individuals’ pathways to recovery.

2020

What should a community-based organization measure?

1. Shift the locus of care: Don’t need to measure readmission rates, but consider tracking adherence to your agencies relevant P&P, e.g.: – Check-ins with all clients within 7 days of discharge from hospital or emergency

department to check symptoms, reconcile medications, and review aftercare appointments;

– Accompany clients to aftercare appointments in first 30 days following discharge from hospital;

– Enrollment in a Health Home, and regular communications with HH Care Manager

2. Promote Integrated Care: What measurement strategies will best incentivize integrated (medical - behavioral health) care?

3. Improve functioning and recovery: How do we measure functional and recovery outcomes?

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What should a community-based organization measure?

1. Shift the locus of care

2. Promote Integrated Care: Don’t need to measure blood sugar and cholesterol, but consider tracking:1. Attendance at annual primary care appointments/wellness appointments

2. Monthly medication reconciliation for both psychotropic and general medical medications

3. Regular reviews (e.g., monthly or more when in crisis) of safety plans for individuals with depression or history of suicidal thinking/behavior

3. Improve functioning and recovery: How do we measure functional and recovery outcomes?

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What should a community-based organization measure?

1. Shift the locus of care

2. Promote Integrated Care

3. Improve functioning and recovery: How do we measure functional and recovery outcomes?

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Measuring functioning and recovery

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Functional OutcomesHARP members have low rates of participation in work/education activities

Education status for 5,189 HARP members in NYS

Employment status for 5,187 HARP members in NYS

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% Employed % Unemployed,seeking employment

% Unemployed, notseeking employment

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% In full- or part-timeeducation program

% Not in education program

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Functional OutcomesHARP members state preferences for receiving services and supports for functioning

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% prefers change in peersupports (N= 5,193)

% prefers change ineducation supports

(N=5,189)

% prefers change inemployment supports

(N= 5,191)

Among the 76% who were unemployed and not seeking employment, only 16% preferred changes in employment reports. Are those reports reliable?

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Perception of CareMost HARP members feel involved in their treatment

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Perception of CareBut many feel unable to set priorities and pursue interests

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Measuring Functioning and Recovery• Much work to do to outline domains for measurement and data collection

strategies

• NYS will use a participatory process to engage individuals and providers in planning efforts

• Providers can adopt the same strategy described previously to identify key elements of your vision and measure adherence to related P&P

• Examples include rates of clients with: – Complete, comprehensive Plans of Care;

– Personalized recovery goals;

– Housing stability;

– Involvement with justice system

– Etc.

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ConclusionsEfforts to identify value and efficiency in health care are here to stay. What you can do:

• Understand where your agency fits in the larger system of care.

• Know the oversight and payment authorities’ priorities for the system of care.

• Align some (not all!) of your agency’s priorities and strengths with the system priorities

• Implement tracking and reporting of key agency practices that align with the system priorities.

• Have summary reports ready for external audiences—brag about what you do well.

• Retain your unique identity, and brag about that too!

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Thank you