1. LPHI/CIBHA Conference February3-4, 2011 1 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

2. Agenda PCASG/CIBHAPCASG/CIBHA –Where from? –Where to? Healthcare ReformHealthcare Reform –Patient Centered Medical Home (PCMH) –Accountable Care Organizations (ACO) – Pay for Performance (P4P) –Comparative Effectiveness Research Goals for Today/TomorrowGoals for Today/Tomorrow LPHI/CIBHA Conference February3-4, 2011 2

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9. 9 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…”

10. LPHI/CIBHA Conference February3-4, 2011 10 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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12. LPHI/CIBHA Conference February3-4, 2011 12 “Crossing the Quality Chasm”

13. Six Aims For Improvement SafeSafe EffectiveEffective Patient-centeredPatient-centered TimelyTimely EfficientEfficient EquitableEquitable 13 LPHI/CIBHA Conference February3-4, 2011

14. 14 Ten Rules for Achieving the Aims Old Rules 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. New 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.

15. LPHI/CIBHA Conference February3-4, 2011 15 Ten Rules for Achieving the Aims Old Rules 6.“Do no harm” is an individual clinician responsibility. 7.Secrecy is necessary. 8.The system reacts to needs. 9.Cost reduction is sought. 10.Preference for professional roles over the system. New Rules 6. Safety is a system responsibility. 7. Transparency is necessary. 8. Needs are anticipated. 9. Waste is continuously decreased. 10. Cooperation among clinicians is a priority.

16. LPHI/CIBHA Conference February3-4, 2011 16 Six Problems in the Quality of M/SU Health Care Problem 1: Obstacles to patient-centered careProblem 1: Obstacles to patient-centered care Problem 2: Weak measurement and improvement infrastructureProblem 2: Weak measurement and improvement infrastructure Problem 3: Poor linkages across MH/SU/GHProblem 3: Poor linkages across MH/SU/GH Problem 4: Lack of involvement in National Health Information Infrastructure (NHII)Problem 4: Lack of involvement in National Health Information Infrastructure (NHII) Problem 5: Insufficient workforce capacity for QIProblem 5: Insufficient workforce capacity for QI Problem 6: Differently structured marketplaceProblem 6: Differently structured marketplace

17. LPHI/CIBHA Conference February3-4, 2011 17 Crossing the Quality Chasm 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 Consumer Participation Leadership Support Clinical Perspectives Integrative Processes

18. LPHI/CIBHA Conference February3-4, 2011 18 “6 P” Conceptual Framework Patient/ Consumer Practice/ Delivery Systems Purchasers (Public/Private) Enhance self-management/participation Link with community resources Evaluate preferences and change behaviors Improve knowledge / skills Provide decision support Link to specialty expertise and change behaviors Establish chronic care model and reorganize practice Link with improved information systems Adapt to varying organizational contexts Enhance monitoring capacity for quality/outliers Develop provider/system incentives Link with improved information systems 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 Providers Plans

19. LPHI/CIBHA Conference February3-4, 2011 19 Don’t Split Mind and Body

20. LPHI/CIBHA Conference February3-4, 2011 20 Evidence-Based Chronic (Planned) Care Approaches for Treating Depression Are Effective Prepared, Proactive Practice Team Informed, Empowered Patient and Family Productive Interactions Patient-Centered Coordinated Timely and Evidence- Efficient Based and Safe Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Community Health Care OrganizationResources and Policies

21. LPHI/CIBHA Conference February3-4, 2011 21 Models of Linkage / Integration Embedded PCP in BHSCo-location of BHS in PCP Embedded PCP in BHSCo-location of BHS in PCP B P Unified Coordination / Collaboration B P B BP P

22. LPHI/CIBHA Conference February3-4, 2011 22 Top Ten Issues General Health/Mental Health Relationships 1.Partnerships 2.Formalize 3.Accountability 4.Referral 5.Consultation/ Evaluation 6.Information Flow 7.Money 8.Quid Pro Quo 9.Maintenance 10.Generalize

23. LPHI/CIBHA Conference February3-4, 2011 23 PCASG Strategies Medical HomeMedical Home Care ManagementCare Management Communic-Coordin-Integr-ationCommunic-Coordin-Integr-ation Evidence-Based PracticesEvidence-Based Practices TrainingTraining Technical AssistanceTechnical Assistance Quality IncentivesQuality Incentives FlexibilityFlexibility

24. LPHI/CIBHA Conference February3-4, 2011 24 “Crossing the Quality Chasm”

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26. 26 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”? LPHI/CIBHA Conference February3-4, 2011

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28. LPHI/CIBHA Conference February3-4, 2011 Future Policy Initiatives Healthcare ReformHealthcare Reform –Patient Centered Medical Homes (PCMH) –Accountable Care Organizations (ACO) –Pay for Performance (P4P) –Center for Medicare/Medicaid Innovation Health Information TechnologyHealth Information Technology Comparative Effectiveness ResearchComparative Effectiveness Research –Concepts/Buckets/Questions Mental Health Specific InitiativesMental Health Specific Initiatives 28

29. Healthcare Reform Innovations Two PopulationsTwo Populations –General/Primary Care –Severe/Persistent Behavioral Health Conditions Two StrategiesTwo Strategies –Mainstream –Separate Specialty Adaptations LPHI/CIBHA Conference February3-4, 2011 29

30. Patient Centered Medical Home and Behavioral Health Mainstream Strategy (augmentation)Mainstream Strategy (augmentation) –Accreditation BH one of three conditionsBH one of three conditions Require BH condition as fourthRequire BH condition as fourth Integrate BH care for all three conditionsIntegrate BH care for all three conditions –Payment Blended FFS and PM/PMBlended FFS and PM/PM Pricing incremental BH costsPricing incremental BH costs Risk AdjustmentRisk Adjustment –Accessing BH Specialty care LPHI/CIBHA Conference February3-4, 2011 30

31. Patient Centered Medical Home BH Specialty “Health Homes”BH Specialty “Health Homes” –In ACA (Sec. 2703) –SAMHSA Demonstration- 50+ Sites –Accessing General Health Care Buy or Own?Buy or Own? –Pricing Issues –Quality Measurement LPHI/CIBHA Conference February3-4, 2011 31

32. Accountable Care Organizations Networks of Hospital, PCPs, VNS, etc.Networks of Hospital, PCPs, VNS, etc. Bundled PaymentBundled Payment Shared Savings/Accountability for QualityShared Savings/Accountability for Quality BH Accountability?BH Accountability? BH Care Management ExpertiseBH Care Management Expertise –Buy or Own? BH ACOs for SPB populations?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 LPHI/CIBHA Conference February3-4, 2011 32

33. LPHI/CIBHA Conference February3-4, 2011 33 Quality Measurement “You can’t improve what you don’t measure”“You can’t improve what you don’t measure” Develop quality metrics (indicators)Develop quality metrics (indicators) - Structure - Process - Outcomes Across silos of MH/SU/GHAcross silos of MH/SU/GH At each “P” levelAt each “P” level Multiple activities/No stewardshipMultiple activities/No stewardship

34. LPHI/CIBHA Conference February3-4, 2011 34 Improve Performance Guideline DisseminationGuideline Dissemination Provider Training/Education/CMEProvider Training/Education/CME Certification/Accreditation/LicensureCertification/Accreditation/Licensure Provider Reminder Systems/Decision SupportProvider Reminder Systems/Decision Support Patient Education/RemindersPatient Education/Reminders Quality MeasurementQuality Measurement Quality Improvement- PDSA/Six Sigma/IHIQuality Improvement- PDSA/Six Sigma/IHI Public ReportingPublic Reporting Financial Incentives/P4PFinancial Incentives/P4P

35. LPHI/CIBHA Conference February3-4, 2011 35 P4P in Behavioral Health Early study by Bremer, Pincus, et alEarly study by Bremer, Pincus, et al 23 programs identified23 programs identified 11 targeting primary care providers11 targeting primary care providers 10 focused on depression10 focused on depression Movement to go beyond “black box” of visit to specific PHQ measuresMovement to go beyond “black box” of visit to specific PHQ measures Longitudinal implementation of structure, process, outcomes measurement e.g. Minnesota DIAMOND projectLongitudinal implementation of structure, process, outcomes measurement e.g. Minnesota DIAMOND project

36. Pay for Performance Stewardship for BH FieldStewardship for BH Field Measure DevelopmentMeasure Development Risk AdjustmentRisk Adjustment “Market Basket” Problem“Market Basket” Problem Multi PayerMulti Payer Joint AccountabilityJoint Accountability Process-Outcomes LinkProcess-Outcomes Link LPHI/CIBHA Conference February3-4, 2011 36

37. LPHI/CIBHA Conference February3-4, 2011 Comparative Effectiveness Research Issues for Behavioral Health and Wellness CER Definitions CER Questions: – – Who, What, Where, When, Why 37

38. LPHI/CIBHA Conference February3-4, 2011 Why Now? “Only a limited amount of evidence is available about which treatments work best for which patients…” - Peter Orszag 38

39. LPHI/CIBHA Conference February3-4, 2011 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 39

40. LPHI/CIBHA Conference February3-4, 2011 40 BOGSAT Model

41. LPHI/CIBHA Conference February3-4, 2011 41 Economic Model

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43. LPHI/CIBHA Conference February3-4, 2011 43 Evidence-Based PracticesEvidence-Based Practices –specific interventions –medications, psychotherapies, team-based, etc. –appropriateness/fidelity measurement –training, supervision Measurement-Based Care (MBC)Measurement-Based Care (MBC) –clinical measures (e.g. HA1c, PHQ-9) –systematic, consistent, longitudinal –action-oriented Best Practices/ContextBest Practices/Context –accessibility –therapeutic alliance –patient centeredness –cultural competence

44. LPHI/CIBHA Conference February3-4, 2011 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.” 44

45. LPHI/CIBHA Conference February3-4, 2011 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…” 45

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47. LPHI/CIBHA Conference February3-4, 2011 CER Questions WhoWho WhatWhat WhereWhere WhenWhen HowHow WhyWhy 47

48. LPHI/CIBHA Conference February3-4, 2011 Who Identifying and characterizing participantsIdentifying and characterizing participants Diagnoses (within/beyond DSM)Diagnoses (within/beyond DSM) Co-morbidity (MH, SUD and GMC)Co-morbidity (MH, SUD and GMC) Gender, Age, EthnicityGender, Age, Ethnicity Severity/FunctioningSeverity/Functioning Preferences/ExpectationsPreferences/Expectations 48

49. LPHI/CIBHA Conference February3-4, 2011 What MedicationsMedications Other Somatic TreatmentsOther Somatic Treatments PsychotherapiesPsychotherapies Other Psychosocial InterventionsOther Psychosocial Interventions –ACT, Supported Employment, etc. Combinations/”Cocktails”/AlgorithmsCombinations/”Cocktails”/Algorithms Systems/Policy/Economic InterventionsSystems/Policy/Economic Interventions 49

50. LPHI/CIBHA Conference February3-4, 2011 Where Academic SettingsAcademic Settings Primary Care ClinicsPrimary Care Clinics Mental Health ClinicsMental Health Clinics Community HospitalsCommunity Hospitals LTC, Home Care, Clubhouses, OtherLTC, Home Care, Clubhouses, Other Private PracticePrivate Practice Multiple Clinical DisciplinesMultiple Clinical Disciplines 50

51. LPHI/CIBHA Conference February3-4, 2011 When AssessmentAssessment Acute/Short-termAcute/Short-term IntermediateIntermediate Long-termLong-term Longitudinal/Chronic Care ManagementLongitudinal/Chronic Care Management 51

52. LPHI/CIBHA Conference February3-4, 2011 Why It’s the patient, stupid It’s the patient, stupid 52

53. LPHI/CIBHA Conference February3-4, 2011 HCR and U.S. Alphabet Soup CER ONCHIT CMS AHRQ DM/EAP EHR PQRI RHIO NICE PCORI ACA ACO PCMH CMI NQF NCQA/HEDIS JCAHO/TJC ACGME LCME T1/T2/T3…..T/12 53

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55. LPHI/CIBHA Conference February3-4, 2011 55 You are the mammals!

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58. CIBHA Agenda February 3-4, 2001 What did we do?What did we do? What did we learn?What did we learn? –Clinical –Systems/Economics –Collaborations –Workforce What’s coming?What’s coming? –And what do we need to do? LPHI/CIBHA Conference February3-4, 2011 58

59. LPHI/CIBHA Conference February3-4, 2011 59 Top Ten Issues General Health/Mental Health Relationships 1.Partnerships 2.Formalize 3.Accountability 4.Referral 5.Consultation/ Evaluation 6.Information Flow 7.Money 8.Quid Pro Quo 9.Maintenance 10.Generalize

60. 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 LPHI/CIBHA Conference February3-4, 2011 60

61. CIBHA Challenges 1.Economics/Incentives/Sustainability 2.Technology 3.Substance Use Disorders 4.Accountability –6 Ps/Local-State-National 5.Measurement –S/P/O-Quality/Costs-Clinical/Policy 6.Prediction- who should get what? 7.Information/Communication 8.Workforce –Amount/Competencies/Training/Consistency 9.Stigma/Language/Culture 10.Leadership LPHI/CIBHA Conference February3-4, 2011 61