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Health Care Reform: What is it? Why are we doing it? How will it affect psychiatry? Wisconsin Psychiatric Association Annual Meeting December 2014 Robert.

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Presentation on theme: "Health Care Reform: What is it? Why are we doing it? How will it affect psychiatry? Wisconsin Psychiatric Association Annual Meeting December 2014 Robert."— Presentation transcript:

1 Health Care Reform: What is it? Why are we doing it? How will it affect psychiatry? Wisconsin Psychiatric Association Annual Meeting December 2014 Robert N. Golden, MD Dean, School of Medicine and Public Health Vice Chancellor for Medical Affairs Robert Turell Professor in Medical Leadership Professor of Psychiatry University of Wisconsin-Madison

2 US Health Care “Brain Trust”

3 What is Health Care Reform?

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5 Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily Efficiency – Greater percentage of GDP spent on health care with worse outcomes Fiscal Sustainability – Health care costs rising faster than real GDP growth Health Care Reform: Why?

6 CMS, April 2010 Health Care Reform

7 Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily Efficiency – Greater percentage of GDP spent on health care with worse outcomes Fiscal Sustainability – Health care costs rising faster than real GDP growth Health Care Reform: Why?

8 Total Health Expenditures as Proportion of GDP – 2009

9 Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily Efficiency – Greater percentage of GDP spent on health care with worse outcomes Fiscal Sustainability – Health care costs rising faster than real GDP growth Health Care Reform: Why?

10 Big future deficits projected by Congressional Budget Office are largely a result of growth in health care spending and, to a lesser extent, in Social Security. Projections assume that other forms of spending will shrink as a share of GDP. Sources: Congressional Budget Office; Center on Budget and Policy Priorities Growth of Federal Spending

11 The Wedges of Waste Berwick, JAMA (14)

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13 A transition to outcomes-focused reimbursement Operating efficiency will replace revenue growth as driver of profitability Total cost management will supplant fee- for-service incentives in the health system business model Actualization of the Triple Aim

14 Rewards in clinical practice will focus on coordination, chronic disease management, and population health Bundled payments and other reimbursement innovations will make specialty care more rare and less profitable Information-driven care, not simply information technology adoption, will become a competitive differentiator Actualization of the Triple Aim

15 As of January 1, 2014, all U.S. residents are required to maintain minimum essential coverage unless the individual falls into an exemption Individuals are required to maintain essential coverage each month or pay a penalty Penalty equals greater of flat dollar amount or percentage of individual’s income:  $95 in 2014 or 1% of taxable income  $325 in 2015 or 2% of taxable income  $695 in 2016 or 2.5% of taxable income Individual Coverage Mandate

16 Non-grandfathered, individual and small group plans, inside and outside of the new Health Insurance Marketplace, must cover a core package of items and services, known as Essential Health Benefits Result: These standards help consumers become more confident when comparing and selecting health plans Essential Health Benefits

17 Ambulatory Care Emergency Care Hospitalization Lab Services Maternity and Newborn Care Mental Health and Substance Abuse Pediatric Services (Oral and Vision) Prescription Drugs Rehabilitative and Habilitative Services Wellness and Disease Management Essential Health Benefits

18 Are We Built for the Job? “The effectiveness of ACOs will depend on the centralization of the administration of medical care, whereas clinical departments in medical schools operate on a decentralized model.” - Kastor, NEJM, 2/2/2011

19 Preferred Health Plan Features

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21 Insurance Reform Delivery Reform IntegratedCare BetterCoverage QualityFocus MorePeople Innovation Medicaid Expansion Exchanges Guaranteed Issue Prevention Benefits Cost: MLR, Rate Review, M’Care Adv. Care Transitions Dual Eligibles ACOs, Bundles Prescription Drugs Prevention Funds Fraud and Abuse Transparency, Data Sharing Value-Based Payment CMMI Pricing Reforms FQHCs Kids < 26 Don Berwick, GPIN, Boston, MA, Oct. 17, 2012 (Partial) Structure of ACA

22 Delivery/Payment Reform: Goal “Improve Medicare beneficiary health outcomes and experience of care by using payment incentives and transparency to encourage higher quality, more efficient professional services.” --> Value = Quality/Cost U.S. Department of Health & Human Services. Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services. Issues Paper [accessed 15 Nov 2012] Payment/PhysicianFeeSched/Downloads/PhysicianVBP-Plan-Issues-Paper.pdf Payment/PhysicianFeeSched/Downloads/PhysicianVBP-Plan-Issues-Paper.pdf

23 Tertiary/ Quaternary Care Secondary Care Primary Care Market Segments

24 Strategy: Bundled Care & Payment Diagnostic Services Procedure Outpatient Follow-up Diagnostic Services Procedure Outpatient Follow-up $ Diagnostic Services Procedure Outpatient Follow-up $ $ $ $ $ $ $ $ $ Bundled Care & Payments: Care processes provided and paid for as a bundle; Promotes coordination, quality & efficiency Fee for Service: Care processes provided and paid for independently; Promotes silos and more services

25 Delivery System & Payment Reform Movement is toward paying for Value –Highest quality care at the lowest cost Increasingly, providers will be assuming financial risk for the care of different sets of populations Learn to think about (and manage) populations and episodes of care

26 Impact on Health Insurers Macro Impacts on Health Insurance Industry in 2014 Regulatory approval of premium rate filings – federal and state Health insurers required to pay out 80 or 85% of premium dollars as claims New premium setting methods: increase premium rates for people under age 40 while lowering rates for people over age 40 Health reform restricts ability to underwrite  Guaranteed issue of policy to any insured  No pre-existing condition limitations at time of application Individual states must introduce a Health Insurance Exchange or be subject to Federal Insurance Exchange

27 New Value Creation NCQA and consumers are judging health plans on the delivery of health care services Healthcare Effectiveness Data and Information Set (HEDIS) scores become important (104 clinical measures) Consumer Awareness of Health Plan Survey (CAHPS) scores become important with consumer purchasing:  Rating of All Health Care  Getting Care Quickly  Shared Decision Making  Rating of Personal Physician  Rating of Specialist Seen Most Often

28 Mechanisms of Acquiring Health Insurance Coverage under the Affordable Care Act (ACA) Blumenthal D, Collins SR. N Engl J Med 2014;371:

29 Categories of Expanded Health Insurance Coverage under the Affordable Care Act (ACA) Blumenthal D, Collins SR. N Engl J Med 2014;371:

30 Health Care Reform and Psychiatry: Oil and Water? -or- Salad Dressing? Payment streams for psychiatric and substance use care are distinctive and poorly understood Scope of the relative sectors - public, commercial, direct state expenditures, self pay - are unique Substantial impact of medical and psychiatric co-morbidity on total cost of all medical care

31 Percentages of U.S. Spending on Mental Health Care, Substance Abuse Services, and All Health Care That Were Covered by Various Types of Payers, 2005 Barry CL, Huskamp HA. N Engl J Med 2011;365:

32 Medicaid Mental Health Bending the Medicaid cost curve through financially sustainable medical behavioral integration Steve Melek Milliman July 2012

33 Public-Private Payer MH Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment SAMHSA, 2008

34 SA Expenditures Public–Private Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment SAMHSA, 2008

35 Health Care Reform and Psychiatry Payer environment is problematic Payment differentials are discriminatory The impact of commoditization and stigma on the marginal value of psychiatric services is of particular importance There is a larger psychiatric self-pay population

36 How Psychiatric Practice Differs Avik Roy: Health Tracking Study Physician Survey

37 Co-Morbidity and Cost: The Impact of “Psychiatric” Illness on “Medical” Illness Outcomes

38 Medical Psychiatric Co-Morbidity Druss BG and Walker ER. Mental Disorders and Medical Comorbidity. Robert Wood Johnson Foundation, Research Synthesis Report No 21, February

39 Depression Rates in Medically Ill Patients Medical IllnessPrevalence % Cardiac Disease17-27 Cerebrovascular14-19 Alzheimer’s30-50 Parkinson’s4-75 Epilepsy Recurrent20-55 Controlled3-9 Diabetes Self Reported26 Diagnostic Interview 9 Cancer22-29 HIV/AIDS5-20 Pain Obesity General Population After Evans, DL et al Biol Psychiatry 2005; 58:

40 Frasure-Smith N et al. Psychosom Med. 1999;61: Depression and 1-Year Post-Myocardial Infarction (MI) Cardiac Mortality N = 896Odds Ratio = 3.4 ( ) P <.001

41 Copyright © 2012 American Medical Association. All rights reserved. From: The State of US Health, : Burden of Diseases, Injuries, and Risk Factors JAMA. 2013;():-. doi: /jama Number of Years Lived With Disability by Age for 20 Broad Groups of Diseases and Injuries in the United States in 2010 for Both Sexes Combined

42 Copyright © 2012 American Medical Association. All rights reserved. From: The State of US Health, : Burden of Diseases, Injuries, and Risk Factors Top 20 Causes of Years Lost to Disability in the United States JAMA. 2013;():-. doi: /jama

43 Cost of Physical & Mental Illness

44 Medicaid Medical Admission Risk Stratified by Psychiatric/Substance Use and None Source: Steve Daviss, MD

45 Models of Medical Psychiatric Integration

46 Integrating Medical & Psychiatric Care – Institute of Medicine Health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body Improving the Quality of Health Care for Mental Health and Substance-Use Conditions: Institute of Medicine 2006

47 Core Principles of Effective Collaborative Care Patient-Centered Care Teams Team-based care: effective collaboration between PCPs and Behavioral Health Providers. Nurses, social workers, psychologists, psychiatrists, licensed counselors, pharmacists, and medical assistants can all play an important role. Population-Based Care Behavioral health patients tracked in a registry: no one ‘falls through the cracks.’ Population-based screening Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for each patient Treatments are actively changed until the clinical goals are achieved Evidence-Based Care Treatments used are ‘evidence-based’ AIMS Center 2011 From Lori Raney MD

48 IMPACT Study Multi-site randomized controlled trial Assessed effects of collaborative care compared to usual care in 1,801 depressed primary care patients >60 years old Patients with depression were identified using the Scl-20 and followed-up with PHQ-9 Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care Feb;14(2):

49 IMPACT Study Design Intervention (n = 906 ) Access to depression care manager who provided: Education Behavioral Activation Support of self-care Problem solving treatment Screening and follow up Usual Care ( n = 895 ) Encouraged to follow up with PCP for treatment. Eligible to receive all treatments:  Antidepressants  Supportive counseling  Self-or physician- referral to mental health specialist Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care Feb;14(2):

50 Clinical Results At 12 months: – 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants Compared to UC, intervention pts had: –  rates dep tx –  rates of satisfaction –  functional impairment –  quality of life Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care Feb;14(2):

51 IMPACT Study Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care Feb;14(2):

52 Psychiatry and the U.S. Mental Health Workforce: 1972 Total MH workforce =40,000 From: DHHS CMHS 2004, chap 18 Source: Ben Druss MD

53 Psychiatry and the U.S. Mental Health Workforce: 2006 Total n for MH workforce =549,000 From: DHHS MH United States 2010 CMHS 2011 Source: Ben Druss MD

54 Barriers and Next Steps Psychiatrists are more disconnected from existing payer systems and appear to be less likely to be in large groups or employed Delivery systems should apply the insights from research in medically co-morbid illness and models of care in planning for their future Training and education for all physicians both currently in practice and in training will be needed

55 Guiding Principles for Reform: The Triple Aim Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of health care The Long Term Costs of Health Care – Public and Private are Unsustainable

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