Transcript Depression in Primary Care: Drowning in the Mainstream or

Mental Health and Healthcare
Reform
On the Banks or in the Mainstream?
Harold Alan Pincus, MD
Professor and Vice Chair, Department of Psychiatry
Co-Director, Irving Institute for Clinical and Translational Research
Columbia University
Director of Quality and Outcomes Research
New York-Presbyterian Hospital
Senior Scientist, RAND Corporation
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Agenda
• PCASG/CIBHA
– Where from?
– Where to?
• Healthcare Reform
– Patient Centered Medical Home (PCMH)
– Accountable Care Organizations (ACO)
– Pay for Performance (P4P)
– Comparative Effectiveness Research
• Goals for Today/Tomorrow
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Mental-Health Challenge Emerges
As Victims Face Multiple Traumas
BATON ROUGE, La. –
“…Post-traumatic stress disorder, depression and anxiety are common after major
disasters, mental-health experts say, because disasters frighten people and disrupt their
lives. But Hurricane Katrina poses special challenges…”
“…The hurricane’s upheaval also has exacerbated the symptoms of some people who
suffer from developmental disabilities and mental illnesses such as schizophrenia…”
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Crossing the Quality Chasm
“Quality problems occur typically
not because of failure of goodwill,
knowledge, effort or resources
devoted to health care, but
because of fundamental
shortcomings in the ways care is
organized”
The American health care
delivery system is in need of
fundamental change. The current
care systems cannot do the job.
Trying harder will not work:
Changing systems of care will!
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“Crossing the Quality Chasm”
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Six Aims For Improvement
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Safe
Effective
Patient-centered
Timely
Efficient
Equitable
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Ten Rules for Achieving the Aims
New Rules
Old Rules
1. Care is based upon
continuous healing
relationships.
2. Care is customized to
patient needs and
values.
3. The patient is the
source of control.
4. Knowledge is shared
and information flows
freely.
5. Decision making is
evidence-based.
1. Care is based on visits.
2. Professional autonomy
drives variability.
3. Professionals control
care.
4. Information is a record.
5. Decisions are based
upon training and
experience.
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Ten Rules for Achieving the Aims
Old Rules
New Rules
6. “Do no harm” is an
individual clinician
responsibility.
7. Secrecy is necessary.
6. Safety is a system
responsibility.
7. Transparency is
necessary.
8. Needs are anticipated.
8. The system reacts to
needs.
9. Cost reduction is
sought.
10. Preference for
professional roles over
the system.
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9. Waste is continuously
decreased.
10. Cooperation among
clinicians is a priority.
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Six Problems in the Quality of
M/SU Health Care
• Problem 1: Obstacles to patient-centered care
• Problem 2: Weak measurement and
improvement infrastructure
• Problem 3: Poor linkages across MH/SU/GH
• Problem 4: Lack of involvement in National
Health Information Infrastructure (NHII)
• Problem 5: Insufficient workforce capacity for QI
• Problem 6: Differently structured marketplace
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Crossing the Quality Chasm
Consumer Participation
Leadership
Support
Standardize Practice Elements
– Clinical assessment
– Interventions
– IT infrastructure
Develop Guidelines
– Evidence-based medicine
– Shared decision making
Measure Performance
– For each “6P” level
– Across silos
Improve Performance
– Learn
– Reward
Strengthen Evidence Base
– Evaluate effective strategies
– Translate from bench to
bedside to community
Clinical
Perspectives
Integrative Processes
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“6 P” Conceptual Framework
Patient/
Consumer
• Enhance self-management/participation
• Link with community resources
• Evaluate preferences and change behaviors
Providers
• Improve knowledge / skills
• Provide decision support
• Link to specialty expertise and change behaviors
Practice/
Delivery Systems
• Establish chronic care model and reorganize practice
• Link with improved information systems
• Adapt to varying organizational contexts
Plans
• Enhance monitoring capacity for quality/outliers
• Develop provider/system incentives
• Link with improved information systems
Purchasers
(Public/Private)
• Educate regarding importance/impact of depression
• Develop plan incentives/monitoring capacity
• Use quality/value measures in purchasing decisions
Populations
and Policies
• Engage community stakeholders; adapt models to local needs
• Develop community capacities
• Increase demand for quality care enhance policy advocacy
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Don’t Split Mind and Body
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Evidence-Based Chronic (Planned) Care Approaches
for Treating Depression
Are Effective
Community
Health System
Resources and Policies
Health Care Organization
SelfManagement
Support
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Productive Interactions
Patient-Centered
Informed, Empowered
Patient and Family
Timely and
Efficient
Coordinated
EvidenceBased and Safe
Prepared, Proactive
Practice Team
Improved Outcomes
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Models of Linkage /
Integration
Embedded PCP in BHS
Co-location of BHS in PCP
B
P
P
Unified
B
B
Coordination / Collaboration
P
B
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Top Ten Issues
General Health/Mental Health
Relationships
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Partnerships
Formalize
Accountability
Referral
Consultation/ Evaluation
Information Flow
Money
Quid Pro Quo
Maintenance
Generalize
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PCASG Strategies
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Medical Home
Care Management
Communic-Coordin-Integr-ation
Evidence-Based Practices
Training
Technical Assistance
Quality Incentives
Flexibility
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“Crossing the Quality Chasm”
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Major Mental Health Policy
Questions
• How will healthcare reform incorporate
mental health?
• How should we pay for mental health
care? How much?
• Who will provide mental health care?
• What is the role of the public sector?
• Where will new scientific findings/
technologies come from?
• Can mental health cross the “quality
chasm”?
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?
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Future Policy Initiatives
• Healthcare Reform
– Patient Centered Medical Homes (PCMH)
– Accountable Care Organizations (ACO)
– Pay for Performance (P4P)
– Center for Medicare/Medicaid Innovation
• Health Information Technology
• Comparative Effectiveness Research
– Concepts/Buckets/Questions
• Mental Health Specific Initiatives
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Healthcare Reform Innovations
• Two Populations
– General/Primary Care
– Severe/Persistent Behavioral Health
Conditions
• Two Strategies
– Mainstream
– Separate Specialty Adaptations
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Patient Centered Medical Home
and Behavioral Health
• Mainstream Strategy (augmentation)
– Accreditation
• BH one of three conditions
• Require BH condition as fourth
• Integrate BH care for all three conditions
– Payment
• Blended FFS and PM/PM
• Pricing incremental BH costs
• Risk Adjustment
– Accessing BH Specialty care
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Patient Centered Medical Home
• BH Specialty “Health Homes”
– In ACA (Sec. 2703)
– SAMHSA Demonstration- 50+ Sites
– Accessing General Health Care
• Buy or Own?
– Pricing Issues
– Quality Measurement
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Accountable Care Organizations
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Networks of Hospital, PCPs, VNS, etc.
Bundled Payment
Shared Savings/Accountability for Quality
BH Accountability?
BH Care Management Expertise
– Buy or Own?
• BH ACOs for SPB populations?
– Option 1: Maintain in Mainstream w MBHO
Partner
– Option 2: BH ACO with Full Accountability
– Option 3: BH ACO with Limited Scope
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Quality Measurement
• “You can’t improve what you don’t measure”
• Develop quality metrics (indicators)
- Structure
- Process
- Outcomes
• Across silos of MH/SU/GH
• At each “P” level
• Multiple activities/No stewardship
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Improve Performance
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Guideline Dissemination
Provider Training/Education/CME
Certification/Accreditation/Licensure
Provider Reminder Systems/Decision Support
Patient Education/Reminders
Quality Measurement
Quality Improvement- PDSA/Six Sigma/IHI
Public Reporting
Financial Incentives/P4P
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P4P in Behavioral Health
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Early study by Bremer, Pincus, et al
23 programs identified
11 targeting primary care providers
10 focused on depression
Movement to go beyond “black box” of visit
to specific PHQ measures
• Longitudinal implementation of structure,
process, outcomes measurement e.g.
Minnesota DIAMOND project
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Pay for Performance
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Stewardship for BH Field
Measure Development
Risk Adjustment
“Market Basket” Problem
Multi Payer
Joint Accountability
Process-Outcomes Link
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Comparative Effectiveness Research
Issues for Behavioral Health and
Wellness
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CER Definitions
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CER Questions:
– Who, What, Where, When, Why
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Why Now?
“Only a limited amount of evidence is
available about which treatments work
best for which patients…”
- Peter Orszag
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Uncertainty, CER and Health Reform
In situations where the right thing to do is well established,
physicians from high- and low-cost cities make the same
decisions. But in cases where the science is more
unclear, some physicians pursue the maximum possible
amount of testing and procedures; some pursue the
minimum. And what kind of doctor they are depends on
where they came from. In case after uncertain case,
more was not necessarily better.
Dr. Atul Gawande
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BOGSAT Model
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Economic Model
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• Evidence-Based Practices
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specific interventions
medications, psychotherapies, team-based, etc.
appropriateness/fidelity measurement
training, supervision
• Measurement-Based Care (MBC)
– clinical measures (e.g. HA1c, PHQ-9)
– systematic, consistent, longitudinal
– action-oriented
• Best Practices/Context
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accessibility
therapeutic alliance
patient centeredness
cultural competence
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Institute of Medicine Report
Definition of Comparative
Effectiveness Research (CER)
• “The generation and synthesis of evidence that
compares the benefits and harms of alternative
methods to prevent, diagnose, treat and monitor
a clinical condition or to improve the delivery of
care. The purpose of CER is to assist patients,
clinicians, purchasers, policy makers, and the
public to make informed decisions that will
improve health care at both the individual and
population levels.”
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Federal Coordinating Council
Report Definition of CER
• “CER is the conduct and synthesis of research
comparing the benefits and harms of different
interventions and strategies to prevent, diagnose,
treat and monitor health conditions in ‘real world’
settings. The purpose of this research is to improve
health outcomes by developing and disseminating
evidence-based information to patients, clinicians,
and other decision-makers, responding to their
expressed needs, about which interventions are
most effective for which patients under specific
circumstances…”
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CER Questions
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Who
What
Where
When
How
Why
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Who
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Identifying and characterizing participants
Diagnoses (within/beyond DSM)
Co-morbidity (MH, SUD and GMC)
Gender, Age, Ethnicity
Severity/Functioning
Preferences/Expectations
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What
•
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•
Medications
Other Somatic Treatments
Psychotherapies
Other Psychosocial Interventions
– ACT, Supported Employment, etc.
• Combinations/”Cocktails”/Algorithms
• Systems/Policy/Economic Interventions
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Where
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Academic Settings
Primary Care Clinics
Mental Health Clinics
Community Hospitals
LTC, Home Care, Clubhouses, Other
Private Practice
Multiple Clinical Disciplines
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When
•
•
•
•
•
Assessment
Acute/Short-term
Intermediate
Long-term
Longitudinal/Chronic Care Management
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Why
It’s the patient, stupid
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HCR and U.S. Alphabet Soup
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CER
ONCHIT
CMS
AHRQ
DM/EAP
EHR
PQRI
RHIO
NICE
PCORI
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ACA
ACO
PCMH
CMI
NQF
NCQA/HEDIS
JCAHO/TJC
ACGME
LCME
T1/T2/T3…..T/12
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You are the mammals!
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CIBHA Agenda
February 3-4, 2001
• What did we do?
• What did we learn?
– Clinical
– Systems/Economics
– Collaborations
– Workforce
• What’s coming?
– And what do we need to do?
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Top Ten Issues
General Health/Mental Health
Relationships
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Partnerships
Formalize
Accountability
Referral
Consultation/ Evaluation
Information Flow
Money
Quid Pro Quo
Maintenance
Generalize
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CIBHA Lessons Learned
1. Systematic data (removes myths)
2. K.I.S.S.
3. Relationships are key
–
Formal and informal connections
4. Communication is essential
–
In all directions (360 degrees)
5. Culture/Environment makes a difference
6. Tools usher in behavior (e.g.,PHQ-9)
7. Relentless follow-up gets results (longitudinality)
8. Training for competence and reinforcement
9. Quality improvement is your friend
10. Flexibility in roles, time, structure, workflow
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CIBHA Challenges
1.
2.
3.
4.
Economics/Incentives/Sustainability
Technology
Substance Use Disorders
Accountability
– 6 Ps/Local-State-National
5.
Measurement
– S/P/O-Quality/Costs-Clinical/Policy
6.
7.
8.
Prediction- who should get what?
Information/Communication
Workforce
– Amount/Competencies/Training/Consistency
9. Stigma/Language/Culture
10. Leadership
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