Transcript Universal Coverage/Parity: Will Likely Improve MH/SU

Overview from the Field: Key
Conceptual Models, Definition of
Integrated Behavioral Health, CA IPI
and CALMEND Projects
Department of Health Care Services
Behavioral Health Technical Workgroup
2-24-2010
Barbara Mauer, MSW, CMC
MCPP Healthcare Consulting Inc.
Seattle, Washington
Overview from the Field
Part One (Meeting 2/24)
1.
Universal Coverage/Parity
Service Delivery Redesign
• Importance of MH/SU
conditions
• Patient-centered medical
homes
• Care management
• The Care Model
Integrated Primary Care/MH/SU
–
–
–
–
Person-centered healthcare homes
Definition of integrated healthcare
Models for clinical care
Four Quadrant model
California
–
–
Healthcare Environment
–
–
2.
3.
4.
Integrated Policy Initiative (IPI) report
CalMEND Learning Collaborative
Financing
–
–
Paradigms
SPD Plans
Part Two
1.
Financing and the Waiver
–
–
2.
3.
Alignment with the Waiver
Management Models
–
–
4.
SPD Plans
Paradigms and Cost Offsets
Assumptions
Examples
Integration Pilots
Part One
Universal Coverage/Parity: Will Likely Improve MH/SU
Access and Available Services
• Mental Health and Substance Use Services must be provided at parity
with general healthcare services (no discrimination)
– Large Employers (Parity Act)
– Medicaid (Parity Act & Reform Legislation)
– Health Insurance Exchanges for Individual and Small
Group Policies (Health Reform Legislation)
– Medicare: on the way (Medicare Modernization Act of 2003)
• But... the parity regulations may not be the most important component if
health reform passes; keep your eye on the Benchmark
Benefit Package that ‘s currently in the Senate bill
– In Medicaid most/all enrollees may be guaranteed a
benchmark benefit package that at least provides “essential
health benefits”
– Mental Health and Substance Use are included in the
definition of “essential health benefits”
4
Service Delivery Redesign: MH/SU Conditions are Now
on the Health Policy Community’s “Radar Screen”
•
•
49% of Medicaid beneficiaries with disabilities have a psychiatric illness (this is new
information; previous studies that excluded pharmacy claims calculated the rate at 29%)
Substance use conditions do not show up in this study at the expected levels because it’s
based on an analysis of claims and pharmacy scripts
The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions
Center for Health Care Strategies, Inc., October 2009
5
Service Delivery Redesign: MH/SU Conditions are Now
on the Health Policy Community’s “Radar Screen”
Morbidity and Mortality in People with Serious Mental Illness
• Persons with serious mental illness (SMI) are dying earlier than the
general population (average age of death is 53)
• While suicide and injury account for about 30-40% of excess mortality,
60% of premature deaths in persons with schizophrenia are due to
medical conditions such as cardiovascular, pulmonary and infectious
diseases (NASMHPD, 2006)
• OR state study found that
those with co-occurring
MH/SU disorders were at
greatest risk (45.1 years)
6
Service Delivery Redesign: Patient-Centered Medical
Homes (PCMH)
• 45 percent of Americans
have one or more chronic
conditions.
• Over half of these people
receive their care from 3 or
more physicians.
• Treating these conditions
account for 75% of direct
medical care in the U.S.
• PCMH, with care
management, is a key
strategy
7
Service Delivery Redesign: PCMH Principles
• Ongoing Relationship with a PCP
• Care Team who collectively take
responsibility for ongoing care
• Provides all healthcare or
makes Appropriate Referrals
• Care is Coordinated and/or
Integrated
• Quality and Safety are hallmarks
• Enhanced Access to care is available
• Payment appropriately recognizes the Added Value
See the www.pcpcc.net site for more information
8
Service Delivery Redesign: Care Management
• Care management is a multidimensional activity with models ranging in
level of intensity and breadth of scope (key components of care
management include: patient identification; individual assessment of
risks/needs; care planning with patient/family; teaching patient/family about
management of disease(s); coaching patient/family; tracking over time; and
revising care plan as needed).
• Studies of care management in primary care show convincing evidence of
improving quality; however it takes time to realize these quality outcomes
(e.g., 12 months is probably not enough time).
• Care management studies in primary care are mixed regarding reductions
in hospital use and healthcare costs (two promising studies included
emphasis on training of care manager team, care management panel sizes
at reasonable levels, close relationships between care managers and
PCPs, and interactions with patients in-clinic, at home and by telephone).
Service Delivery Redesign: Care Management
• Selecting the right patients for care management is associated with
reducing costs and improving quality (e.g., individuals who need end-oflife care need different services).
• Training of care managers is an important factor in the success or failure
to reduce costs and improve quality.
• Successful programs have care managers as part of multidisciplinary
teams that involve physicians.
• Presence of family caregivers improves success of care management,
and use of coaching techniques is a viable approach.
• The intensity of the care management needed for success in improving
quality and reducing costs is unclear.
Bodenheimer T, Berry-Millett R. Care management of patients with complex health care needs Robert Wood
Johnson Foundation Research Synthesis Report No. 19. December 2009. www.policysynthesis.org
Service Delivery Redesign: Overall Model for
Improving Primary Care (CALMEND version)
Integrated Care: Patient-Centered Medical Homes
become Person-Centered Healthcare Homes
PCMH Principles
•
•
•
•
•
•
•
Ongoing Relationship with a PCP
Care Team who collectively take
responsibility for ongoing care
Provides all healthcare or
makes Appropriate Referrals
Care is Coordinated and/or
Integrated
Quality and Safety are hallmarks
Enhanced Access to care is
available
Payment appropriately recognizes
the added value
Person-Centered Healthcare Home
• Not a clear articulation in the PCMH model of the
role of MH/SU
• Change to Person Centered Healthcare Home
signals that MH/SU is a central part of healthcare
and that healthcare includes a focus on supporting
goals for improved self management
• Use a bi-directional approach to address the
integration of primary care services in MH/SU
settings as well as the need for MH/SU services in
primary care settings
• Build in the care manager/ behavioral health
consultant and consulting prescriber functions that
have proven effective in the IMPACT model and
mirror this model to bring planned primary care
into MH/SU settings
Integrated Care: Recent Reports
• World Health Organization
– Integrating Mental Health Into Primary Care: A Global Perspective
(Fall 2008)
– http://www.who.int/mental_health/resources/mentalhealth_PHC_200
8.pdf
• Agency for Healthcare Research and Quality
– Integration of Mental Health/Substance Abuse and Primary Care
(Fall 2008)
– http://www.ahrq.gov/clinic/tp/mhsapctp.htm
• Hogg Foundation for Mental Health
– Connecting Body and Mind: A Resource Guide to Integrated Health
Care in Texas and the United States (Fall 2008)
– http://www.hogg.utexas.edu/programs_RLS15.html
Integrated Care: A Definition
• “It has been defined in many ways, but in
essence integrated healthcare is the systematic
coordination of physical and behavioral health
care. The idea is that physical and behavioral
health problems often occur at the same time.
Integrating services to treat both will yield the
best results and be the most acceptable and
effective approach for those being served… The
question is not whether to integrate, but how.
Neither primary care nor behavioral health
providers are trained to address both issues.”
Hogg Foundation for Mental Health
Integrated Care: The Models for Clinical Care
• Co-location
– House BH specialists and primary care providers in same facility, supporting “warm
hand-off”
– Does not ensure that providers collaborate in treatment; this may vary greatly across
clinics
– Research is somewhat limited—“simply placing a BH specialist in PC is unlikely to
improve patients’ outcomes unless care is coordinated and based in evidence-based
approaches”
• Primary Care Behavioral Health Model
– BH consultant serves as consultant to PCP, focusing on optimizing the PCP’s quality
of BH care for patients
– Targets behavioral issues related to medical diagnoses instead of traditional BH
problems like depression and anxiety
– Has not yet been systematically evaluated—”although likely beneficial, the
effectiveness of the model is not yet known”
Integrated Care: The Models for Clinical Care
• Collaborative Care
– Adaptation of the chronic care model for psychiatric disorders, used stepped
care to treat depression, anxiety disorders, bipolar disorder
– Integration of BH care manager and consulting psychiatrist into PC setting, with
registry to track and monitor response to treatment
– Numerous studies of clinical and cost effectiveness, with adolescents, adults,
and older adults, with and without co-morbid medical illnesses and from
different ethnic groups—”significant research evidence demonstrates that
collaborative care improves outcomes for a wide range of patients”
– This is the model the Hogg Foundation has been implementing in a number of
Texas PC clinics
Hogg Foundation for Mental Health
The National Council’s Four Quadrant Clinical Integration
Model (MH/SU)
Quadrant II
MH/SU PH 
High


MH/SU Risk/Complexity



















Outstationed medical nurse
practitioner/physician at MH/SU site (with
standard screening tools and guidelines)
or community PCP
Nurse care manager at MH/SU site
MH/SU clinician/case manager
External care manager
Specialty medical/surgical
Specialty outpatient MH/SU treatment
including medication-assisted therapy
Residential MH/SU treatment
Crisis/ED based MH/SU interventions
Detox/sobering
Medical/surgical inpatient
Nursing home/home based care
Wellness programming
Other community supports
Persons with serious MH/SU conditions could be served
 in all settings. Plan for and deliver
services based upon the needs of the individual, personal choice and the specifics of the
community and collaboration.
Quadrant I
MH/SUPH 






Low
Outstationed medical nurse
practitioner/physician at MH/SU site
(with standard screening tools and
guidelines) or community PCP
MH/SU clinician/case manager w/
responsibility for coordination w/ PCP
Specialty outpatient MH/SU treatment
including medication-assisted therapy
Residential MH/SU treatment
Crisis/ED based MH/SU interventions
Detox/sobering
Wellness programming
Other community supports
Quadrant IV
MH/SU PH 
PCP (with standard screening tools
and MH/SU practice guidelines for
psychotropic medications and
medication-assisted therapy)
PCP-based BHC/care manager
(competent in MH/SU)
Specialty prescribing consultation
Wellness programming
Crisis or ED based MH/SU
interventions
Other community supports
Quadrant III
MH/SU PH 









PCP (with standard screening tools and
MH/SU practice guidelines for
psychotropic medications and
medication-assisted therapy)
PCP-based BHC/care manager
(competent in MH/SU)
Specialty medical/surgical-based
BHC/care manager
Specialty prescribing consultation
Crisis or ED based MH/SU interventions
Medical/surgical inpatient
Nursing home/home based care
Wellness programming
Other community supports
Physical Health Risk/Complexity
Low
High
Focus: Quadrants I and III
Primary Care and Depression
• Most PCPs do a good job of diagnosing and beginning treatment for
depression (studied 1,131 patients in 45 primary care practices across 13 states)
• PCPs do less well following up with treatment over time
– Less than half of patients completed a minimal course of medications or psychotherapy
– Few patients who don’t respond to initial treatment get adequate changes in treatment or
referrals to specialists
– Lowest quality of care among those with the most serious symptoms, including those
with evidence of suicide or substance use
• “Our finding of low rates of referral to mental health specialists for complex
patients is typically addressed in collaborative care interventions through
stepped care (e.g. , IMPACT) that prioritizes mental health specialist referrals
on the basis of need.”
Hepner et al, Ann Int Med, 9/07
Bipolar Disorder in Clinical Populations
Patients Treated for Depression in a Family Medicine Clinic
649 outpatients
receiving treatment
for depression
Bipolar prevalence
among 649 depressed
patients = 27.9%
Screened positive*
for bipolar disorder
21%
MDQ sensitivity = 58%,
specificity = 93%;
based on SCID for
DSM-IV
*Using the Mood Disorder Questionnaire (MDQ)
Hirschfeld RM, et al. J Am Board Fam Pract. 2005;18:233-239.
SU Conditions are Relevant for Primary Care
• SU conditions are prevalent
in primary care
– Tens of millions (McClellan)
– 21% + (Willenbring)
• SU conditions add to overall
healthcare costs, especially
for Medicaid
• SU conditions can cause or
exacerbate other chronic
health conditions
• SU interventions can reduce
healthcare utilization and
cost
In Treatment ~2.3 million
“Abuse/Dependence” ~23 million
“Unhealthy Use” ?? million
Little/No Substance Use
Primary Care and SU Services
• Diffusion of screening and brief intervention (SBI) is underway
• Motivational interviewing with fidelity should be a consistent
component of SBI
• Repeated BI in primary care is a promising practice
• Medication-assisted therapies in primary care can be expanded
IMPACT Collaborative Care in Primary Care
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IMPACT: Doubles the Effectiveness of Usual Care for
Depression
50 % or greater improvement in depression at 12 months
Usual Care
70
IMPACT
60
50
40
%
30
20
10
0
1
2
3
4
5
6
7
8
Participating Organizations
Unutzer et al., JAMA 2002; Psychiatr Clin N America 2005
Washington State GA-U Project
(General Assistance Unemployable)
DSHS | GA-U Clients: Challenges and Opportunities August 2006
GAU Goal: Collaborative Care
6 FQHC systems (26 clinic sites), 10 mental health
agencies, the safety net health plan, the RSN and
UW
GA-U
Client
PCP
CMHC
Level II
Care
CSO
(benefits)
Consulting
Psychiatrists
Care
Coordinator
DVR
(employment
)
Other clinicbased mental
health
providers*
Level I Care
* Available in some clinics
Substance
Use
Treatment
Washington State GA-U Project (First Year Findings)
• Clients with follow up within 4 weeks of initial assessment
– Level I: 42% (range across clinics: 32%-64%)
• Clients with Psychiatrist Consultation
– Level I: 31% (range across clinics: 20%-83%)
• Level I outcomes 12 weeks after initial assessment
– Clients with PHQ-9 score improved at least 50% over 12 weeks = 20% (range
across clinics: 12%-28%)
– Clients with GAD-7 score improved at least 50% over 12 weeks = 20% (range
across clinics: 13%-26%)
• Quality Improvement effort, with attention to core components/workflow
–
–
–
–
High rates of engagement (100%) and 4 week follow-up (93%)
Effective use of in-person and telephone contacts
Psychiatric Consultation at 60%
63-72 % with substantial (>50 %) clinical improvement
Unutzer. University of Washington
Washington State GA-U Project
• Removing many of the barriers commonly identified (finance,
regulation, sharing of information) did not remove the cultural differences,
historic lack of trust, or the challenges of implementing evidence-based
practices
• While all of the “usual suspect” barriers must be addressed, the most
formidable is changing practice in the field
– There was significant variation in work processes across PC and MH clinics and in
implementation of the care coordinator role across PC clinics
– This created variation in client follow up and use of psychiatric consultation
– This reduced ability to provide stepped care and lack of fidelity to the stepped care
model, and negatively impacted outcomes
• However, client outcomes were positively impacted by greater fidelity to
the model
The Person-Centered Healthcare Home: Q I and III
• Incorporate the lessons of the IMPACT model, explicitly building into the
medical home the care manager/ behavioral health consultant (MH and
SU competent) and consulting prescriber functions that have proven
effective in the IMPACT model
– DIAMOND project in MN—monthly case rate payments for covering
these components in primary care practices, all major payors
participating
• All healthcare is local—working out the details of who does what, for what
levels of MH/SU services (Intermountain model), has to engage local
partnerships—the California IPI Continuum is a guide for these dialogues
http://www.cimh.org/Services/Special-Projects/Primary-Care/Initiative-Feedback.aspx
29
Focus: Quadrants II and IV
Massachusetts Study: Deaths from Heart Disease by
Age Group/DMH Enrollees with SMI Compared to
Massachusetts 1998-2000
40
Rates per 100,000
35
DMH
MA
30
2.2RR
4.9RR
1.5RR
25
20
15
10 3.5 RR
5
0
25-34
35-44
45-54
55-64
CATIE Study
Comparison of Metabolic Syndrome and Individual
Criterion Prevalence in Fasting SMI Subjects and
Matched General Population Subjects
Males
SMI
Gen.Pop.
N=509
N=509
Metabolic Syndrome
Prevalence
Waist Circumference Criterion
Females
SMI
Gen.Pop.
N=180
N=180
36.0%
19.7%
51.6%
25.1%
35.5%
24.8%
76.3%
57.0%
Triglyceride Criterion
50.7%
32.1%
42.3%
19.6%
HDL Criterion
48.9%
31.9%
63.3%
36.3%
BP Criterion
47.2%
31.1%
46.9%
26.8%
Glucose Criterion
14.1%
14.2%
21.7%
11.2%
CATIE source for SMI data
NHANESIII source for general population data
Meyer et al., Presented at APA annual meeting, May 21-26, 2005.
McEvoy JP et al. Schizophr Res. 2005;(August 29).
CATIE Study
• At CATIE baseline:
– 88% of subjects who had dyslipidemia
– 62.4% of subjects who had hypertension
– 30.2% of subjects who had diabetes
WERE NOT RECEIVING TREATMENT FOR THESE CONDITIONS
Bi-directional Primary Care/MH/SU Services
•
•
•
•
Many individuals served in specialty MH/SU have no PCP
Health evaluation and linkage to healthcare can improve MH/SU status
On-site services are stronger than referral to services
Housing First settings can wrap-around MH, SU and primary care by mobile
teams
• Person-centered healthcare homes can be developed through partnerships
between MH/SU providers and primary care providers
• Care management is a part of MH/SU specialty treatment and the
healthcare home
The Person-Centered Healthcare Home : Partnership
• Assure regular screening and registry tracking/outcome measurement for all
MH /SU consumers
• Locate medical NPs/PCPs in MH/SU settings—provide routine primary care
services in the MH/SU setting via staff out-stationed under the auspices of a
full scope person-centered healthcare home MH/SU organization hiring a nurse practitioner
directly, without the backup of a skilled PCP and a full scope healthcare home cannot be described as providing a
healthcare home, and is not a recommended pathway
• Identify a primary care supervising physician within the full scope healthcare
home to provide consultation on complex health issues
• Assign nurse care managers to support individuals with elevated levels of
glucose, lipids, blood pressure, and/or chronic medical conditions
• Use evidence-based preventive care practices, adapting these practices for
use in the MH/SU system (immunizations, cancer screening, etc.)
• Create wellness programs that use peer counselors
California: The Primary Care, Mental Health, and
Substance Use Services Integration Policy Initiative (IPI)
Vision: Overall health and wellness is embraced
as a shared community responsibility
• To achieve individual and population health and wellness (physical,
mental, social/emotional/ developmental and spiritual health),
healthcare services for the whole person (physical, mental and
substance use healthcare) must be:
– seamlessly integrated
– planned for and provided through collaboration at every level of
the healthcare system, as well as coordinated with the supportive
capacities within each community
36
California: IPI Principles (Additional Handout)
•
Ten principles introduce the expectation that planning and implementation ensure that:
– Each individual has a person-centered healthcare home, which provides mental
health (MH) and substance use (SU) services in the primary care setting or primary care
services in the MH/SU setting.
– Each community has established a Collaborative Care Mental Health/Substance
Use Continuum (the IPI Continuum). The IPI Continuum is a framework for service
development that identifies population need across MH/SU levels of
risk/complexity/acuity and assigns provider responsibilities within any given community
for delivering those services. The community dialogue to establish the Continuum should
result in mechanisms for stepped MH/SU healthcare back and forth across the
Continuum, mechanisms to address the range of physical health risk/complexity/acuity
needs of the population, and collaborative links between the integrated healthcare
system and other systems, community services and resources.
– Measurement is aligned to support the IPI Continuum, Quality Improvement and
fidelity implementation of proven models as well as evaluation of emerging models,
with accountability, transparency and measures matched to the levels of the Continuum.
37
California: IPI Continuum
38
California: CalMEND—Joint Project of DHCS and DMH
• State agencies working together to use the Care Model and use the IHI
Breakthrough Series Learning Collaborative model to make major rapid
changes that produce significant breakthrough results and sustained use
of these changes
• Pilot Collaborative will bring together mental health and primary care
practitioners: Orange County, San Diego County, San Mateo County and
Santa Clara County
• CalMEND Primary Care and Mental Health Integration Change Package
developed over the last year includes change concepts that
operationalize the Care Model and integrated care
–
–
–
–
–
Health Care Organization
Delivery System Design
Decision Support
Clinical Information system
Community
California: CalMEND—Joint Project of DHCS and DMH
CARE MODEL
ELEMENT
DELIVERY
SYSTEM
DESIGN
CHANGE CONCEPT
 Develop cross-consultation
between clients, MH and PC
providers to improve
communication
 Establish and implement
shared guidelines or protocols
TESTABLE IDEA
Medical assistants and peer supporters
o Use non-licensed staff to coordinate care and services
for clients
o Case conferences for joint care planning and
coordination of planned interventions
o Link psychiatrists in MH with PC physicians for
consultation and training
o Develop methods to identify primary care clients
requiring MH and mental health clients requiring PC
o Assist practitioners to triage referrals received to
ensure that the most urgent referrals are seen first
 Develop team-driven care
EXAMPLE
o Standardize information that should accompany a
client referral, such as the results of diagnostic tests
o Allow MH to schedule PCP visit and allow PCP to
schedule visits with MH
o Create a shared formulary
o Adopt/adapt shared care plan
o Organize patient care teams with defined roles that
address the integrated mental health/primary care
plans
o Include peer workforce in teams to enhance client
 PC uses screens for level of MH need:
PHQH providers screen for physical
conditions (e.g. metabolic syndrome)
 MD and PC providers screen for
alcohol/drug use
 "Fast Track" automatic referrals for:
brief psychotherapy group (CBT, DBT,
problem solving therapy, etc.); in
place for depression anxiety,
unexplained physical disorder,
borderline personality disorder
 Psychiatric consultation, crossreferral and crisis MH access
protocols for primary care providers
Establish criteria for shared registry;
include data at time of referral
Driven by DHCS drug list
Create document for shared care plan
to be reviewed and signed by PCP,
MHP, and client as part of joint session
Financing: Paradigms
• How will funds in other systems be integrated to support clinical integration?
• We need a new paradigm—none of the old models (Carve-in or Carve-out)
work for implementing bidirectional integrated care for the whole population
• Lessons from the “field”:
– Medical Home Pilots— case rate in addition to FFS, to cover prevention,
care management of chronic medical conditions (why not build the BHC in
PC role into the case rate?)
– MN—financing the DIAMOND case rate (for BH in PC) out of the
healthcare side (rather than the mental health side) believing that cost and
quality improvements will be there
– WA General Assistance project—explicit stepped care model that finances
both Level 1 (primary care) and Level 2 (specialty) MH/SU benefits;
dedicated financing for Levels 1 and 2; neither draw on dedicated mental
health funding
– Washtenaw Co, MI—global budget for Medicaid population; local
consolidation of medical and behavioral health funding streams
41
Financing: Paradigms
• Assuming that parity will be embedded as a requirement for most health plans
in the final healthcare reform legislation and a broader behavioral health benefit
will be available for most people with coverage, and …
• Drawing on the California Integration Policy Initiative framework of Mild,
Moderate, Serious and Severe Levels of Care, and …
Untangling the MH/SU Funding
Current
Healthcare
Funding
Current
MH/SU
Funding
General Healthcare System Funds
MH/SU Services for Mild &
Moderate Levels of Care (mostly in
Primary Care Settings)
Specialty MH/SU System Funds MH/
SU Services for Serious & Severe
Levels of Care (mostly in Specialty
Care Settings)
For example, the SPD plans should have a MH/SU benefit for primary carebased brief services
42
Financing: SPD Plans
• Ensure that the MH/SU community and consumers know about the
consumer protections proposed in the California Healthcare Foundation
2005 report: Performance Standards for Medi-Cal Managed Care
Organizations Serving People with Disabilities and Chronic Conditions
http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSPDs.as
px
• Consider overall recommendations for SPD Plans
– Capitation rates that cover adequate (e.g., Medicare) reimbursement
rates for primary care FFS
– Capitation rates that include funding for a PMPM case rate payment
to medical homes for care management activities
– Capitation rates that include funding for a PMPM case rate for brief
MH/SU services provided in primary care (e.g., behavioral health
consultant/care manager and consulting psychiatrist )
Part Two
Financing: SPD Plans
• Ensure that the MH/SU community and consumers know about the
consumer protections proposed in the California Healthcare Foundation
2005 report: Performance Standards for Medi-Cal Managed Care
Organizations Serving People with Disabilities and Chronic Conditions
http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSPDs.as
px
• Consider overall recommendations for SPD Plans
– Capitation rates that cover adequate (e.g., Medicare) reimbursement
rates for primary care FFS
– Capitation rates that include funding for a PMPM case rate payment
to medical homes for care management activities
– Capitation rates that include funding for a PMPM case rate for brief
MH/SU services provided in primary care (e.g., behavioral health
consultant/care manager and consulting psychiatrist )
Financing: Paradigms
• Assuming that parity will be embedded as a requirement for most health plans
in the final healthcare reform legislation and a broader behavioral health benefit
will be available for most people with coverage, and …
• Drawing on the California Integration Policy Initiative framework of Mild,
Moderate, Serious and Severe Levels of Care, and …
Untangling the MH/SU Funding
Current
Healthcare
Funding
Current
MH/SU
Funding
General Healthcare System Funds
MH/SU Services for Mild &
Moderate Levels of Care (mostly in
Primary Care Settings)
Specialty MH/SU System Funds MH/
SU Services for Serious & Severe
Levels of Care (mostly in Specialty
Care Settings)
For example, the SPD plans should have a MH/SU benefit for primary carebased brief services
46
IMPACT Lowers Total Health Care Costs
$8,800
$8,400
$ / year
$8,5 88
Study Usual
Care
$8,000
Study
IMPACT
$7,949
$7,600
$7,200
$7,471
Post Study
IMPACT
$6,800
Grypma, et al; General Hospital Psychiatry, 2006
Washington State Studies of SU and Healthcare Costs
•
•
Medicaid medical expenses prior to specialty SU treatment and over a five-year follow
up were compared to Medicaid expenses for the untreated population.
For the Supplemental Security Income (SSI) population, Washington studied the
Medicaid cost differences for those who received treatment and those who did not.
– Average monthly medical costs were $414 per month higher for those not receiving
treatment, and with the cost of the treatment added in, there was still a net cost offset of
$252 per month or $3,024 per year.
– The net cost offset rose to $363 per month for those who completed treatment.
– Providing treatment for stimulant (methamphetamine) addiction resulted in higher net cost
savings ($296 per month) than treatment for other substances. For SSI recipients with
opiate-addiction, cost offsets rose to $899 per month for those who remain in methadone
treatment for at least one year.
•
In the SSI population, average monthly Emergency Department (ED) costs were lower
for those treated—the number of visits per year was 19% lower and the average cost
per visit was 29% lower, almost offsetting the average monthly cost of treatment.
– For frequent ED users (12 or more visits/year) there was a 17% reduction in average visits
for those who entered, but didn’t complete SU treatment and a 48% reduction for those who
did complete treatment.
Kaiser Permanente Northern California Studies
•
•
•
•
The setting was an internally operated outpatient and day treatment SU program in
which primary care was added
Kaiser tracked a subgroup of patients with Substance Abuse-Related Medical
Conditions (SAMCs) which included: depression, injury and poisonings/overdoses,
anxiety and nervous disorders, hypertension, asthma, psychoses, acid-peptic
disorders, ischemic heart disease, pneumonia, chronic obstructive pulmonary disease,
cirrhosis, hepatitis C, disease of the pancreas, alcoholic gastritis, toxic effects of
alcohol, alcoholic neuropathy, alcoholic cardiomyopathy, excess blood alcohol level,
and prenatal alcohol and drug dependence
– Many of these are among the most costly conditions to the health plan
Focusing on the SAMC subgroup, they found that SAMC integrated care patients had
significantly higher abstinence rates than SAMC independent care patients
SAMC integrated care patients demonstrated a significant decrease in inpatient rates
while average medical costs (excluding addiction treatment) decreased from $470.39
PMPM to $226.86 PMPM.
Align with 1115 Concept Paper
Population Focus
•
Medi-Medi (FFS) 977,000; 14%
Medi-Cal ABD (FFS) 379,000; 5%
Medi-Medi & Medi-ABD (Mg Care)
434,000; 6%
•
•
Medi-Cal - Other
Medi-Cal Other
(Managed Care)
(Fee for Service)
3,399,000; 48%
1,846,000; 26%
•
Key Objectives
Bring the majority of
Duals and ABD(SPD)
now in FFS into
Managed Care
Bring the CCS Youth
into Managed Care
Bring the Rest of TANF
into Managed Care
Expand the Medi-Cal
“box” by bringing more
Indigent/ Uninsured into
Managed Care
Note: Most of the costs
are in the FFS Dual &
FFS ABD boxes
50
Align with 1115 Concept Paper
Four Area of Fragmentation
• Managed Care population:
fragmentation between
health, MH and SU
Medi-Medi & Medi-ABD (Mg Care)
434,000; 6%
Medi-Cal - Other
(Managed Care)
3,399,000; 48%
Medi-Medi (FFS) 977,000; 14%
Medi-Cal ABD (FFS) 379,000; 5%
• FFS population: no
integration of primary,
acute, SU, MH, social
& long-term care; mix
of services paid and
administered by
different systems
Medi-Medi (FFS) 977,000; 14%
Medi-Medi & Medi-ABD (Mg Care)
434,000; 6%
• Medi-Medi
fragmentation
Medi-Cal Other
(Fee for Service)
1,846,000; 26%
• CCS (Youth)
fragmentation
51
Align with 1115 Concept Paper
Organized Delivery Systems of Care
Key Objectives
• Rely on existing Managed Care
Medi-Medi (FFS) 977,000; 14%
Plans “provided such plans can
Medi-Cal ABD (FFS) 379,000; 5%
meet the needs of the population
Medi-Medi & Medi-ABD (Mg Care)
and achieve the State’s
434,000; 6%
performance standards”
• Bring in new Managed Care plans
“as necessary and appropriate the
Medi-Cal - Other
Medi-Cal Other
meet diverse geographic and
population needs”
(Managed Care)
(Fee for Service)
• Translation: If you’re in a county
3,399,000; 48%
1,846,000; 26%
with high Mg Care penetration, start
coordinating and/or partnering; If
you’re in a county with little or no
Mg Care, join the planning process
The MH/SU systems have an important
to make it happen ASAP
contribution to make to this process!
Organized Delivery Systems of Care
52
Payment Reform Models Link to the Ability to
Demonstrate Outcomes and Manage Costs
• New funding mechanisms will be
utilized to fund services that
manage total healthcare
expenditures
• Many PCMHs will be funded with a
3-layer model—now being piloted
Case Rate
 Prevention, Early Intervention, Care
Management for Chronic Medical Conditions
Fee for Service/
PPS
 Per Service Payment
 Prospective Payment System (PPS)
Settlement (FQHC model) to cover shortfalls
Bonus
 Share in Savings from Reduced Total
Healthcare Expenditures (bending the
curve)
• Payment for inpatient care will
bundle hospital and physician
services that only pay for part of
Potentially Avoidable Complications
(PACs)
• Bundled payments may include all
costs in the 30 days post an inpatient
stay, including any return to the
hospital
53
Management Models to Consider
• Acknowledging that all healthcare is local, we have identified
three models of integration that build on existing designs in the
California Counties
– Single County Organized Health System Model (8 counties)
– County Organized Health System + Private Health Plan Model (9
counties)
– Small County Collaboration Model (31 counties)
• All three models are organized around
the idea that each county would have
an integrated design for the four
Priority Populations (at a minimum)
identified in the Waiver Concept
Paper, bringing current MediCal FFS populations into managed
care and expanding coverage for indigent uninsured
54
Management Model Assumptions
• Each Model assumes that:
– Structures are put in place to support and ensure that the clinical
activities mirror the healthcare reform goals of Improving Quality
and managing Total Healthcare Expenditures
– Substance use, mental health and primary care services will be
clinically integrated and the financial and management structure
will support clinical integration, versus hinder it (e.g., pay for
same day services, etc.)
– Services will be provided through an “Organized Delivery System
of Care” (managed care) that operates within a quality
improvement and performance measurement structure using the IPI
Continuum as the framework for developing a collaborative delivery
system that includes all levels of care
– The Management Structure will seamlessly manage both
Medicaid and non-Medicaid funds and services
55
Single County Organized Health System Model
Mental Health
MISP
PEMMCP
Alcohol &
Drug
Delivery System
- Hospitals
- Primary Care Clinics/FQHCs
- Medical Specialists
- Mental Health Providers
- Substance Use Providers
- etc.
• 8 Counties - Yolo, Monterey, Santa Cruz, Santa Barbara, San Luis
Obispo, Orange, Merced, and San Mateo
• Current components could support an integration effort involving the
County Mental Health Department, Alcohol & Drug Program, Medically
Indigent Service Program (MISP) and Public Entity Medi-Cal Managed
Care Plan (PEMMCP)
• Could serve as an organized system of care for the priority populations
(at a minimum) to address their healthcare, mental health and
substance use needs in an integrated manner
56
Single County Organized
Health System Model
Mental Health
MISP
PEMMCP
Alcohol &
Drug
• These counties could create an integrated clinical design based on
person-centered healthcare home principles
• And develop one of the following financial and management designs
A Single, Integrated, Healthcare, Mental Health and Substance Use
Managed Care Entity serving Medi-Cal and Indigent, Uninsured
Residents
Option A: “Virtually” integrated Managed Care Entity via MOUs
PEMMCP
MOU
Behavioral
Health (MH
& SU)
MISP
MOU
Option B: “Virtually” integrated Managed Care Entity via MOUs
PEMMCP
MOU
Mental
Health
MOU
Alcohol
& Drug
MOU
MISP
57
All of the Models...
Would be built around an
integrated clinical design
based on person-centered
healthcare home principles
combined with one of the
financial and management
designs and a shared
savings pool across
medical, MH and SU
A Single, Integrated, Healthcare, Mental Health and Substance Use
Managed Care Entity serving Medi-Cal and Indigent, Uninsured
Residents
Option A: “Virtually” integrated Managed Care Entity via MOUs
PEMMCP
MOU
Behavioral
Health (MH
& SU)
Option B: “Virtually” integrated Managed Care Entity via MOUs
PEMMCP
MOU
Mental
Health
Untangling the Behavioral Health Funding
Current
Healthcare
Funding
Current
BH
Funding
MISP
MOU
General Healthcare System Funds
BH Services for Mild & Moderate
Levels of Care (mostly in Primary
Care Settings)
Specialty BH System Funds BH
Services for Serious & Severe Levels
of Care (mostly in Specialty Care
Settings)
MOU
Alcohol
& Drug
MOU
MISP
Case Rate
 Prevention, Early Intervention, Care
Management for Chronic Medical Conditions
Fee for Service/
PPS
 Per Service Payment
 Prospective Payment System (PPS)
Settlement (FQHC model) to cover shortfalls
Bonus
 Share in Savings from Reduced Total
Healthcare Expenditures (bending the
curve)
58
Integration Pilots
California 1115 Waiver
Pilot for MH/SU Integration with Healthcare
Pilot Project Abstract
Date:
Geographic Service Area (e.g., county, region): Cascade County
Target Populations to be Served (check all that apply):
Seniors and Persons with Disabilities
Dual-eligible beneficiaries
Adults with severe mental illness and/or substance use disorders
Children and Families not currently enrolled in organized delivery systems
Children with special healthcare needs
Type of Project (check all that apply):
Clinical integration
Management integration
Management integration via MOUs
Financing integration
Goals this Project will Address (check all that apply):
Strengthen safety net, including DSH hospitals
Reduce number of uninsured individuals
Increase FFP
Promote efficient use of state and local funds
Improve health care quality and outcomes
Promote home and community-based care
X
X
X
X
X
X
X
X
59
Project Description:
Cascade County proposes the following components:
 Inclusion of the SPD population in the County Health Plan, and expansion of the coverage initiative to
include 75% of indigent uninsured clients served for >1 year by the MH and/or SU system (approximately
2500 individuals). Adoption of a long range plan for types of MH/SU services, sites of service and payment
models, to be implemented by MOUs among the three managing entities.
 Contracting with CHCs and private practice clinics in Cascade County to develop the patient-centered
medical home (PCMH) model for enrollees in the County Health Plan, with a PMPM case rate for care
management in addition to regular FFS claims. The case rate will be calculated to include primary carebased MH and SU interventions and implemented through partnerships with community-based MH and SU
providers.
 Redesign of Cascade County primary care clinics to the PCMH model, including primary care-based MH
and SU interventions implemented through partnership with county and/or community based MH and SU
providers. While building this integration model, we will use data to identify individuals in Quadrant IV, with
multiple, co-morbid conditions, for a focused care management initiative.
 Initiation of basic health screening in all MH and SU programs, connection to and coordination with PCMHs.
 As a second phase, incorporation of basic primary care services into higher volume MH and SU services
sites.
Project Partners (Names of Organizations)
Service Providers: Cascade County Mental Health Services, Cascade County Substance Use Services,
subcontracted service providers for MH/SU services, Cascade County Health System (Hospital and Clinics),
CHCs and private practice clinics located in Cascade County
Management Entities: Cascade County Mental Health Services, Cascade County Substance Use Services,
Cascade County Health Plan/Coverage Initiative
Payor Sources: Medicaid capitation payments to the Health Plan, Medicaid general fund match (SU), local
general fund CPE (current level of health, MH, and SU financing), FFP, MHSA
60
California 1115 Waiver
Pilot for MH/SU Integration with Healthcare
Pilot Project Matrix
This matrix summarizes the potential California pilots that would advance MH/SU integration with healthcare in support of the Waiver Goals. The
notation in the matrix shows the geographic service area the pilot. The attached pilot abstracts provide detail regarding each of the pilots.
Target Populations Seniors and Persons
with Disabilities
Waiver Goals
Strengthen safety net,
including DSH
hospitals
Reduce number of
uninsured individuals
Dual-eligible
beneficiaries
Adults with severe
mental illness and/or
substance use
disorders
Children and Families
not currently enrolled
in organized delivery
systems
Children with special
healthcare needs
Cascade County
Increase FFP
Cascade County
Cascade County
Promote efficient use
of state and local
funds
Cascade County
Cascade County
Improve health care
quality and outcomes
Cascade County
Cascade County
Promote home and
community-based
care
61
Contact Information:
Barbara J. Mauer, MSW CMC
[email protected]
206-613-3339
62