1. Pitching Value: Negotiating Better Rates by Telling a Compelling Story to Payers
Anna Ratzliff, MD, PhD TCPI National Faculty – Lead Trainer APA-SAN Associate Professor, University of Washington Dept. Psychiatry and Behavioral Sciences Director, AIMS Center & UW ICTP
Part 1
“Behavioral health is a foundational part of healthcare transformation because there is no health without mental health.”

2. Mental Health in Primary Care Settings
Hospital
CMHC Specialty Care
Collaborative Care Brief Behavioral Interventions
Primary Care Patient Self-Management
COORDINATION

3. Outline of Performance Story
Who we are as a high performing practice
Our patient population segments and, for each, the metrics and management approach we are using to drive performance
Our results that makes us high value to payers and patients
As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable
The culture responsible for our high performance

4. Outline of Performance Story
Who we are as a high performing practice
Our patient population segments and, for each, the metrics and management approach we are using to drive performance
Our results that makes us high value to payers and patients
As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable
The culture responsible for our high performance

5. Our Practice State-wide Collaborative Care program
Mental Health Improvement Program (MHIP)
Behavioral Health Improvement Program (BHIP)
State-wide Collaborative Care program
Safety-net practices/FQHCs
Started in 2008
>50,000 patients served to date
UW primary care clinics- now 19
Mixed payer population
Started in 2011
4660 indirect/ 8717 direct patient assessments to date
Part 2

6. Our Practice 1.0 - 3.0 FTE care manager Variable number of PCPs ~3-20
Mental Health Improvement Program (MHIP) Team
Behavioral Health Improvement Program (BHIP) Team
FTE care manager
Variable number of PCPs ~3-20
0.2 FTE psychiatric consultant
1.0 FTE care manager
~ 5.0 FTE PCPs
0.2 FTE psychiatric consultant
Part 2

7. Outline of Performance Story
Who we are as a high performing practice
Our patient population segments and, for each, the metrics and management approach we are using to drive performance
Our results that makes us high value to payers and patients
As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable
The culture responsible for our high performance

8. Population Served
1500 patients PCP with 10% of the population with mental health needs
Insured Population  ~2% enrolled = patients
0.5FTE care manager
0.05FTE psychiatric consultant
Safety-Net Population  ~5% enrolled = patients
1.0FTE care manager
0.1FTE psychiatric consultant

9. Our Metrics
Number of patient with behavioral health needs served with Collaborative Care Model
Depression Remission or Response: % of patients showing response or remission of depression symptoms using the PHQ-9

10. Outline of Performance Story
Who we are as a high performing practice
Our patient population segments and, for each, the metrics and management approach we are using to drive performance
Our results that makes us high value to payers and patients
As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable
The culture responsible for our high performance

11. High Performance Areas: MHIP
Initial results from pilot showing taking a long time for patients to show improvement in depression
Pay for performance on process measures
Complete initial assessment
Meet with psychiatric consultant weekly and obtain indirect assessments on all patients not improving
Half of caseload had to receive 2 contacts per month
Population management target = 50% of patients show improvement on PHQ-9
Part 3 and 4

12. MHIP: Pay-for-performance cut in half the median time to achieve improvement in 50% of patients. We get patients better FAST!
© University of Washington
AFTER P4P:
~ 26 week s to 50% of patients to improve
BEFORE P4P:
~68 week s to 50% of patients to improve
Unützer et al., 2012

13. BHIP: High Performance Areas
Population management target >50% of patients show improvement on PHQ-9
Estimated costs savings: defined as medical care cost savings per patient enrolled

14. BHIP: High Performance over 4 years
2012
2013
2014
2015
Number of Clinics 10 12 15
Number of Patients Enrolled
262
771
763
705
Average PHQ-9 at First Assessment
14.5
13.5
12.9
Indirect
Psychiatric Consultations
231
1505
1087
1417
Face-to-Face
320
2346
2394
3044
Percent of Patients Improved
81%
68%
64%
63%
Estimated Cost Savings
$340,000
$1,002,000
$991,900
$916,500

15. Outline of Performance Story
Who we are as a high performing practice
Our patient population segments and, for each, the metrics and management approach we are using to drive performance
Our results that makes us high value to payers and patients
As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable
The culture responsible for our high performance

16. Effective Collaboration
COLLABORATIVE CARE
© University of Washington
Effective Collaboration
Prepared, Pro-active
Practice Team
Informed,
Active Patient
Outcome
Measures
Treatment
Protocols
Population
Registry
Psychiatric
Consultation
Unützer et al., 2002, 2004

17. Behavioral Health Services Available
Assessment and treatment planning by team
Indirect case-reviews by psychiatric consultant
Tele-video assessment as needed by psychiatric consultant
Care Planning
Patient tracking of all active patients by care manager
Relapse prevention planning by care manager
Facilitated referral to specialty mental health by care manager
Care Management
Primary care provider prescribes medications
Supported by psychiatric consultant and care manager
Medication Prescribing
Psychosocial support delivered by care manager
Brief behavioral interventions delivered by care manager
Psychotherapy Intervention

18. Outline of Performance Story
Who we are as a high performing practice
Our patient population segments and, for each, the metrics and management approach we are using to drive performance
Our results that makes us high value to payers and patients
As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable
The culture responsible for our high performance

19. Using Data to Manage Performance
Registry tool allows practice to track patient data and response to treatment
Visits
Indirect assessments
Graphs of measures
Clinic level data
Caseload number
Processes ( ex. Completed clinical assessment)
Outcomes (ex current number of patient with clincial improvement)

20. Individual Patient Records: Measurement-Based Treatment to Target
Part 5
Regular use of behavioral health measures to track response to treatment
Use of psychiatrists to help intensify treatment
Stepped care makes efficient use of behavioral health resources

21. Caseload Registry: Population Based Treatment

22. Clinic Level Summary: Continuous Quality Improvement
Care
Manager 1
Manager 2
© University of Washington
Part 5
This example shows is summary data from a web-based registry which shows aggregate data from two different care manager caseloads, Care Manager 1 and Care Manager 2.
In this particular situation, the team was regularly reviewing the data and making observations. If you call your attention to the red box, both of these care managers were having a positive impact on their patient populations with respective improvement rates of 49% and 68%. Although both of these are good numbers, it is notable that Care Manager 2 was able to obtain higher improvement rates than Care Manager 1.
So the clinic manager sat down with these two care managers and looked at the data with them. One of the things that the clinic manager noticed was that Care Manager 2 was having almost twice as many follow-up contacts as Care Manager 1. This was a really important observation. In digging a little bit deeper, the clinic manager found that Care Manager 2 conducted a lot more phone contacts than Care Manager 1. One hypothesis was that the increased availability and frequency of engagement with the patients might be driving some of those higher outcomes. When the team reviewed this information and spoke to Care Manager 2, what they found was that every time Care Manager 2 had a cancellation or a no-show patient, she would pick up the phone and make 2-3 phone calls to patients that hadn’t come in. By doing this, she was getting in a lot more phone contacts with those patients that were falling through the cracks: she was able to deliver PHQ-9 screeners, and she was also able to engage patients in both coming back in and assessing how their treatment was going.
So a typical quality improvement effort that you might be able to implement when you see data like this is to train up Care Manager 1 to follow the same protocol, and then you could observe over time: is Care Manager 1 able to have more phone visits, and does that in fact drive better patient outcomes?
This example illustrates the commitment to regularly using data to look at the care delivered and commit to continuously looking for opportunities to improve it. This idea can be useful no matter what type of practice you are currently working in.

23. Data Workflow Individual Patient Records
Care Manger Caseload Registries
Clinic Level Summaries

24. More than 50% of our patients enrolled in CoCM experience depression response or remission
This meets national and published standards.
We can deliver this care for over 700 patients a year.
We can track and report these results using our robust data workflow strategy and registry.

25. Example Assertion “Readmission rate for our patients is at 8 percent.”
Clarification of the Number
2,000 of our 30,000 patients were admitted and discharged from the hospital in Their 30-day readmission rate was 8 percent of all discharged patients. (160 readmitted)
Assertion of Exemplary Performance
Our 8 percent readmission rate is consistently at a State benchmark level for our patient population. Rates at other hospitals in the State range from 12 percent to 15 percent for the age groups represented. Our Care Transition Program consistently produces this low rate.
In 2017, we had 80 fewer readmissions than we would have expected with a 12 percent rate. That represents an estimated $800,000 in avoided billing.
Our quality improvement program verifies that about 90 percent to 100 percent of the current 8 percent readmission cases are not avoidable. We are close to as low as one can go.

26. Additional Tips Focus on results rather than the journey.
Develop first person stories that are compelling and exciting .
Use population targets that set benchmarks, not simply a level of improvement.
Make the numerical statements of performance clear and complete.
Note patient ownership of and satisfaction with performance.

27. Other Types of Performance
Process Outcomes
Close follow-up (Minimum 2 contacts/month)
Regular use of behavioral health measures (PHQ-9)
Psychiatric consultation if patient not improved
Clinical Outcomes
PHQ-9 (depression measure for screening and tracking)
GAD-7 (anxiety measure for screening and tracking)

28. Other Value Propositions
Patients
Why should patients seek care at your organization?
Providers
Why should a provider want to work in your organization?
Community
Why should the community partner with your organization?

29. Think about the Quadruple Aim
Better Patient Experience
Better Patient Outcomes/Population Health
Better Provider Experience
Reduced costs/Responsible Spending

30. Questions?