Transcript Depression in Primary Care: Quality Improvement and Economics

Integration in Behavioral
Health: New Opportunities
and Challenges
Richard G. Frank
Harvard University
Overview of Presentation

What is integration and why do we like the
idea?

What is the basis for believing more
integration will improve behavioral health
care?

What stands in the way of adoption of
evidence based approaches to integration?

What are the opportunities offered by the
ACA?
Aspirations for Integration

“…evidence of a link between mental and
substance use illnesses and general health is
very strong …improving the nation’s general
health and resolving quality problems…will
require attending to the quality problems in
mental and substance use care”---IOM
Committee on Crossing the Quality Chasm:
Adaptation to Mental Health and Addictive
Disorders (2006)

Surgeon General Satcher referred to
mending the destructive split between
physical and mental health (1999)
Integration: Meaning

A brief search in “google scholar” leads one
to understand behavioral health integration
as involving the incorporation of evidence
based mental health care into primary care
practice

If meeting the health needs of individuals
and families, as stated in our National
Quality Strategy (2011), is to be a central
goal of U.S. health care then a broader
view of integration is called for
A Refined View Integration

A commitment to patient centered care
calls for “meeting people where they are”

Heightened importance for populations that
have heterogeneous needs and face
impediments to negotiation of a complex
health system

Implication: bringing general medical care
to specialty behavioral health settings is
central as incorporating behavioral health in
primary care practices
Importance Of Increased Integration
Of Behavioral Health Into Primary
Care

Growth in treated prevalence has come from
primary care

Share of primary care in mental health care has
grown to 53% of cases

Advances in pharmaco-therapies and
manualized psychotherapies especially
significant for PCPs

PCP historically weak in recognizing and treating
behavioral health disorders
Need to Integrating Medical
Care into Behavioral Health

People with SPMI frequently suffer from poor
general health

Relative risk of premature mortality for people with
SPMI is roughly 4x that of otherwise similar
people (Druss 2011)


Poverty, behavioral health treatment and illness
features are sources of elevated risk
Average Medicaid spending on behavioral health
for people with schizophrenia = $11,900 plus
$5700 in other medical care compared to $4000
for average adult beneficiary
What Do We Know About
Making Integration Work?

Primary Care Settings


Extensive research focused on depression and
anxiety disorders
Specialty Behavioral Health Settings
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Limited evidence
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Promising Models
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Major investments in demonstrations (ACA)
Elements of Evidence Based
Treatment in PCP: Depression
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Physician time
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Care manager services
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Specialty consultation
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Registry-decision support
Learning About Impacts of
Evidence Based Care

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Effectiveness: Meta Analysis (Gilbody et al
Arch Int Med 2006)
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Six month gains ~ 0.25
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Five year gains ~ 0.15
Key elements of treatment
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Medication adherence

Credentials and supervision of care managers
Cost Effectiveness of Evidence Based
Care for Depression in Primary Care
Primary Care Depression
$3,500.00
QALY = $100,000
$3,000.00
AJ
QALY = $50,000
QALY = $25,000
$2,500.00
Incremental Cost
$2,000.00
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$1,500.00
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$500.00
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($500.00)
($1,000.00)
QALY
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0.08
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Cost-Effectiveness
Evidence based treatment increases treatment
costs and improves outcomes

Estimates of incremental costs per QALY $11,270
to $19,510 when Canadian cut offs were $20,000
to $30,000 (Lave et al 1998)

Little evidence of general medical offsets
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Results in improved work outcomes; probability of
working; hours of work (Timbie et al, 2006)

Finding replicated in several different settings
Usual Care for Depression Differs
from EBT

PCPs still frequently fail to recognize depression

PCPs visit duration increases by 1.8 minutes with
cases of depression/anxiety (Frank and
Zeckhauser, 2007)
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High percentages of usual care patients do not
have follow-up contact

Typical PCP treating depression adjusts treatment
according to level of symptoms not change in
symptoms (Henke et al, 2007)
What Stands In The Way Of Adoption
Of Evidence Based Treatment?

PCP attitudes and habits

Organization of PCP practices
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Implementation of quality improvement
efforts
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Payment policies
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Use of decision supports
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Note integration has succeeded in resource
lean settings
Attitudes and Habits

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Physicians do not devote extra time
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Average visit 17 minutes; depression cases get
less than 19 minutes on average

When mental health problems are raised with
PCP; video tape evidence suggests subject is
changed in about 1 minute (Tai-Seale et al,
2007)
Cases of depression less likely to have
return visits than other chronic conditions
Organization of Physician Practice

Approximately 30% of PCPs are in solo
practice and 20% to 30% more are in small
groups (<5)
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The costs of a care manager are typically
higher in small groups and solo practices


Difficult to spread quasi fixed cost of care
manager
Small groups less likely to use electronic
records
Payment Policies


Carve-outs can be an impediment to evidence
based treatment in primary care

Some plans that carve-out behavioral health do not pay
PCPs for treatment of mental disorders

Referral networks between PCP and carve-out may not
overlap (although this is a declining problem)
Medicare and other payers do not pay for care
management or some types of consults

Payment system are frequently inflexible
Integration in Specialty Setting

Main point of contact with health care
delivery system for people with severe
behavioral health disorders
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Established relationships

Simple referral methods do not work; care
is easily disrupted (New Freedom
Commission)

Primary care settings often a poor fit for
people with SPMI
Models of Integration in
Specialty Settings
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Fully Integrated
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VA
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FQHCs
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Cherokee and Crider (Missouri)
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Economic viability
Partnership with FQHCs
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Nurse placement in CBHC
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Nurse case manager in CBHC
Evidence to Date
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The organizational approach less important
to outcomes than the quality of clinical
services and training of the key personnel

Small randomized trial in VA showed
promising outcomes wrt quality of medical
care and health outcomes

Early Partnership Evaluations (PCARE)
show positive results

Improved receipt of evidence based preventative
care and improved care for cardiometabolic dx
Towards Renewed Improvement:
Care Management
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Spreading costs/ training are key

Generic chronic disease care managers
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Experiences in 6 major demonstrations suggest
case loads of 40-80 patients per care manager
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Use of carve-outs for virtual/telephonic care
management

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UCSF-UBH-BCBS Model
Only virtual model compatible with solo/small
group practices
Physician Time

Altering scheduling is very difficult
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UCSF experimented with adjustment to
productivity formula to give PCP more time for
depression care

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Adjustment allowed 30 minute depression visit to count as
two visits
Few PCPs availed themselves of extra time

Suspect that since only a share of patients were eligible
for adjustment habits did not change (Feldman et al 2006)
Behavioral Health in the ACA
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Guiding Principles
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Improved insurance through parity/coverage
expansion (mostly Medicaid)

Integration

Prevention
Opportunities for Expanded
Efforts in the ACA
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Primary Care Integration Demonstration
(SAMHSA)

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FQHC Integration M/SUD


SAMHSA Technical Assistance investment
Medicaid Health Home option

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Initial investment $50 million > expanding
Recognizes CBHC as health homes; prioritizes
SPMI; sees SUD as chronic condition
ACOs
Meaning of Opportunities
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Integration Demos
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Rigorous test of models of integration into
specialty settings
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ACOs flexible funding (gain sharing) and
integrated delivery system

Health Homes
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Offers flexible payment systems and generous
matching for coordination such as care
management for chronic conditions
Decision Support
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Behavioral health lags in adoption of HIT

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Partly a policy problem; partly a management
issue; benefits to expanded HIT potentially big
PCPs do not typically measure
symptoms/progress longitudinally

Convenient tools exist
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Tracking symptoms appears to alter treatment
adjustment behavior
Bottom Line

We have learned a great deal about how to bring
behavioral health to primary care settings in a
cost-effective manner

Important progress has been made in learning
how to incorporate medical care into specialty
behavioral health settings

More understanding is imminent

The ACA offers organization and financing
arrangements that can overcome some significant
impediments to integration

The opportunity should not be wasted