Medicaid Matters: Depression and other Psychiatric Illnesses Jorge Cortina, MD DFAPA West Virginia Medicaid Behavioral Health Medical Director for UniCare an Anthem Company

Cost of Chronic Mental Illnesses Human suffering costs are incalculable Those with serious mental illness die 25 years earlier Suicide is 10th leading cause of death and 2 or 3rd in teens/young adults Mood disorders are 3rd highest cause of hospitalization under age 44 $11,000-21,000 annual costs for those with schizophrenia Medicaid members with BH or SUD Diagnosis 3X higher costs Lost productivity and wages (193 billion annually-2008) Uninsured & Mental illness is 19% in non expansion states vs. 13% in expansion states Chapel. Prevalence and Medical Costs of Chronic Diseases Among Adult Medicaid Beneficiaries (2017) https://www.hcup-us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_report_2009.pdf retrieved 8/27/18 http://www.mentalhealthamerica.net/issues/2017-state-mental-health-america-ranking-states retrieved 8/27/18 https://www.nami.org/learn-more/mental-health-by-the-numbers retrieved 8/27/18

Mental Health of West Virginians WV highest rates of Opioid Used Disorder and complications (NAS, infections and overdose) 2nd highest rate of depression (nearly 1 in 4) Most common in middle aged low income 2nd highest rates of smoking (25%) 11th highest rate of mental illness or substance abuse http://www.wvdhhr.org/bph/hsc/pubs/brfss/2016/BRFSS2016.pdf retrieved 8/27/18 http://www.mentalhealthamerica.net/issues/2017-state-mental-health-america-ranking-states retrieved 8/27/19

Interaction between chronic physical and mental conditions and Social Determinants of Health Physical illness and conditions such as diabetes, heart disease, COPD increase the risk of depression and depression hinders good self care Those with Psychiatric and Substance Use Disorders Higher prevalence of medical illnesses such as COPD, heart disease and diabetes Less likely to get their conditions diagnosed and treated More likely to be impoverished, malnourished, homeless, exposed to unhealthy environments Alexandria, VA: Parks, J., et al. Morbidity and Mortality in People with Serious Mental Illness (2006)

Bill 48 Schizophrenia Smokes (60% with his DX do) Antipsychotics Diabetes Homeless No transportation

Mary 56 Single Many adverse childhood experiences Unskilled unsteady work Smokes, has bronchitis Anxious and depressed Obese Shops at the convenience store Heats with wood stove

Two Major Challenges (and Opportunities) Care delivered in silos, no coordination between medical and BH care Providing expensive health for preventable conditions that could be prevented by addressing social determinants of health

Integrated Care for Physical and Behavioral Disorders Levels of integration 1 2 3 Coordination (different settings occasionally sharing information and plans) Colocation (greater opportunity for coordination and collaboration) Integration (merged, collaborative, single record, strong relationships, frequent contact and informal consultation) https://www.integration.samhsa.gov/about-us/CIHS_Integration_101_FINAL.pdf retrieved 8/27/18

Healthy People 2020 Examples of Social Determinants of Health Safe and affordable housing Education Public safety Access to healthy foods Local emergency/health services Area free of life-threatening toxins https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Successful Disease Management Size matters Simplicity Patient centered Ability to collect data easily and analyze results Quality (HEDIS, Satisfaction) Costs (utilization) Incentives for provider, patient, and others https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/how-to-design-a-successful-disease-management-program retrieved 8/27/18

Medicaid Initiatives to address SDOH and Promote Integrated Care Partnering with Area Agencies for Aging to address SDOH Paramedicine visiting frequent users of ER Health Homes Care management and coordination Health promotion Transitions Referrals to community and social support Home and Community Based Services Health Home providers (teams)

Questions?