Transcript IndianaManagedCareIntegration

Managed Care
and
Integration
May 19, 2011
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Managed Care and Integration
How One Organization Is Approaching
This Dynamic Change To Current
Practices
Robert B. Baker, MD, MMM
VPMA, MHS- Indiana
Bernard T. Engelberg, MD
Medical Director, Cenpatico
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What is Integrated Care?
(Managed Care View)
• Is Coordinated Care Integrated Care?
– What do you think coordination means?
• Shared information, shared treatment plans, more than one
person deals with the patient’s problems
• How does it actually look? How does it function?
• Is Co-Location Integrated Care?
• Where do functional impairments stop and mental impairments
begin?
• Can PH practitioners treat SMI?
• Can BH practitioners treat PH problems?
• Medications?
• Information sharing?
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Why is this important?
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Comorbidities are common - >25%
Only 5% see a mental health provider
80% see a PMP
Disproportionate needs in minority
populations
• Paradoxical decrease usage in refugee
populations
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Importance of Screening
According to a NAMI survey:
• 13% of youth aged 8-15 live with mental illness
• 21% of youth aged 13-18
• ½ of all cases of mental illness begin by age 14
• Average delay of 8-10 years from the onset of
symptoms to intervention
• Fewer than ½ of children with a diagnosable
mental illness receive services in a given year
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What are our goals?
• Synergistic decrease in utilization (cost)
– Cherokee model – 28% decrease in medical
utilization
– 27% decrease in psychiatry visits
– 34% decrease in psychotherapy
– 48% decrease in mobile crisis team encounters
• Improved Health Outcomes
– May increase mental health cost for the episode of
care
– Overall morbidity may decrease
– Quality of care can increase
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Treatment Barriers
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Substance Abuse
Psychological Components of Physical Illness
Nonadherence
Unhealthy Behaviors
Social Support Gaps
Hierarchy of Needs
Cultural and Linguistic Issues
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What is the current state of
affairs?
• Not enough mental health providers to supply
demands
• Not enough PMPs – at least 15,000 FTE
short in the US for current demand
• Estimated 50,000 FTE shortage for a fully
insured population
• Staff productivity
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Cross-Training
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AHEC interest
Expanded curricula
UMass program
HRSA training and funding
Use of mental health grants
Use of standardized screening and
assessment tools
• Speaking the same language
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Documentation
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EHRs
Outcomes measurement (SF-12, others)
Health Information exchanges
Define shared data sets
Improved reimbursement
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Who are the players?
• MCEs
– Case Managers
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Integrated Health Systems
CMHCs
OMPP
Medical Homes (co-located, embedded)
– Patient Navigators, Care Managers
• Getting Everyone To Talk With Each Other
– In The Weeds
– IPHCA
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What are the barriers to a more
integrated system?
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Promoting co-located care
Promoting truly integrated care
Credentialing
Integrated treatment plans
Shared information
– Many release forms available
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What can be done?
• MCE Level
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Case Management
Telephones
Disease Management – stratification of risk
Toolkits
Facilitated follow-up appointments
• CMC Level
– Written Referral Arrangements with FQHCs
• State Level
– Full range covered services
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Integrated Level
• Embedded BH practitioner on primary care team
• Integrated clinical record and treatment plan
• BH screening of the primary care patient – normalizes
the illness
• Multidisciplinary meetings
• Clinic redesign
• Coordination with wrap-around care
• Seamless transition across settings (e.g. hospital to
outpatient)
• Shared knowledge about resources (parents and
patients want this – not just a prescription!)
- Binders, handouts, referrals, support groups, community
services
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Financial Barriers
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Telemedicine
Treatment Team Meetings
Co-management
Brief Consultation
Same Day Restrictions on Billing
Use of Mid-levels
Reimbursing SBIRT
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Financial Solutions
• No carve out
• Determine proper coding, e.g. 90801 psych
vs. 96150 medical
• Telemedicine reimbursement
• Demonstrating ROI
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Regulatory Solutions
• State decision on claims policy
– modifier codes
• Privacy concerns
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Legal Barriers
• HIPAA interpretations
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Solutions to Legal Issues
• Health Coordination forms
– Auditing continuity of care
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…so why integrate?
• Each year up to 30% of Adults meet criteria
for a mental health problem
• Up to 70% of children and adolescents in
need of MH services do not receive them
• Undiagnosed SA disorders impact PH.
• MH problems 2-3x more common in chronic
medical illnesses
• Untreated MH issues lead to functional
impairment
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What Needs to Change in
Primary Care?
• Role of CMHCs in a Patient Centered Medical
Home
• Redesign of practices that permit
identification of MH/SA issues
• Monitor MH outcomes
• Coordinate treatment more closely with MH
specialists
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Role of CMHC
• Integration; not just collaboration
• “Stepped Care” matching patient’s needs to
services provided
• Availability – office visits and telephone
• SA and dual diagnosis solutions
• Integrated “piggy-back” hand-offs
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Crucial Links
• PCPs need tools for MH/SA identification
• Case managers/Care Coordinators needed
for patient success
• PCPs need to know what help is available
upon SA/MH identification
• EHR availability to all involved parties
• Education on outcomes measurements
• Assessment of system efficacy
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Bringing It Together (MCE view)
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Health Risk Screening
Patient Analysis - leveling tools
Intensive Case Management
Care Management
Payment Strategies
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