1. Impact of the Affordable Care Act on Behavioral Health
March, 2014

2. My Background Medicaid Director
Previously DMH Medical Director – 20 years
Practicing Psychiatrist
CMHCs – 10 years
FQHC – 18 years
Distinguished Professor, Missouri Institute of Mental Health, University of Missouri St. Louis

3. Endorsements
"He is not only dull himself, he is the cause of dullness in others.“-Samuel Johnson
"He uses statistics as a drunken man uses lamp-posts... for support rather than illumination." -- Andrew Lang
"He can compress the most words into the smallest idea of any man I know." -- Abraham Lincoln

4. Today… It’s not just Arkansas Status of our world
Healthcare delivery and payment “change” strategies
Future of specialty behavioral health

5. Our niche: caring for complex, costly patients
Socially vulnerable patients (income, language, race/ethnicity, health disparities)
Clinically vulnerable patients (complex, difficult healthcare needs)
You Are Here
Source: Health Affairs: VA Lewis, et al. “The Promise and Peril of Accountable Care for Vulnerable Populations: A Framework for Overcoming Obstacles.” 2012.
Health Affairs: VA Lewis, et al. “The Promise and Peril of Accountable Care for Vulnerable Populations: A Framework for Overcoming Obstacles.” 2012.

6. Co-morbidities in the Adult Population
Source: Druss & Walker. “Mental disorders and medical comorbidity.” The Robert Wood Johnson Foundation Synthesis Project, February 2011.

7. Opportunities… Defined by Tragedies
2020, behavioral health disorders surpass all physical diseases as major cause of disability
MI most common reason for SSD/SSI
More deaths due to suicide than to accidents, homicides, and war combined
Most mental health treatment is in primary care - medication, poorly managed
Sandy Hook
Tucson
Aurora
Virginia Tech

9. Effective Treatments

10. 62
million people will gain access to coverage that includes MH/SUD at parity
Essential benefits include mental health and substance use treatment
MH and SUD must be offered at parity with medical/surgical benefits
This means…
…Most people will have coverage that includes mental health and substance use treatment
EHB applies to Exchanges, individual market, & individuals newly enrolled in Medicaid

11. Parity
Robust final rule

12. Role of Parity
Essential Health Benefit (EHB) for private insurance must be at parity. What does parity mean?
Medicaid Benchmark Benefit must be at parity.
Parity does extend to all new individual and small group plans beginning in 2014.
What about parity for current Medicaid beneficiaries?

13. State Estimates of the Uninsured
You can access state estimates for the Medicaid Expansion and for the State Health Insurance Marketplace at
Three estimates are provided:
Adults with Serious Mental Illness
Adults with Serious Psychological Distress
Adults with a Substance Use Disorder

14. Essential Benefit Plans (EBP) on the Insurance Exchanges
The plan selected by a state to be its EBP benchmark for ACA may not comply with parity.
States had until exchanges went live to make it comply with parity - then it became an EHB benchmark plan
But so far its unclear if CMS will enforce this – especially since the final ACA rule stated that “We do not intend to require or request states to include specific services within EHB categories offered by their ABP.”
States resisting ACA implementation will not enforce it either
High deductibles and co-pays will be an obstacle

15. Alternative Medicaid Benefit (AMB) for Medicaid Expansion Groups
Wellstone – Domenici Parity does not apply
If the individual meets that states definition for “medically frail” they reverts to the standard Medicaid benefit
Serious Mental Illness and Substance Use Disorders constitute Medically Frail
But - states get to define which diagnosis is “SMI”
Many states are not expanding Medicaid

16. Parity and Case Law Monitoring and reporting…
Anthem Health Plans’ Connecticut rate schedule changes violate the Mental Health Parity and Addiction Equity Act
New York against UnitedHealth Group
California class-action lawsuit against United Behavioral Healthcare for reviews of outpatient treatments
Vermont held Cigna has burden of proving that disparate treatment of mental health and medical surgical justified by clinical standards

17. Four key elements of the Affordable Care Act

18. 2010 Prohibits lifetime benefit limits
Dependent coverage up to age 26 is mandated
Cost-sharing obligations for preventive services are prohibited
Recissions are prohibited
Pre-existing condition exclusions for dependent children (under 19 years of age) are prohibited
Coverage for emergency services at in-network cost-sharing level with no prior-authorization is mandated

19. More 2010
Require coverage of tobacco cessation programs for pregnant women under Medicaid free of cost-sharing
Begin Community Health Centers and National Health Service Corps Fund expanded funding to total $11 billion over five years
Begin Medicaid global payments demonstrations to fund large, safety-net hospitals in five states to alter payment from fee-for-service to a capitated, global payment structure.
Establish Patient-Centered Outcomes Research Institute. Create a private, nonprofit Patient-Centered Outcomes Research Institute to set a national research agenda and conduct comparative clinical effectiveness research.

20. 2011 85% MLR for large group (with refund) is mandated
80% MLR for individual and small group (with refund) is mandated
Primary care physicians and General surgeons in shortage areas begin 10 percent Medicare payment bonus for next 5 years
Medicare adds annual wellness visit with no copayment or deductible and eliminates cost-sharing for evidence-based preventive services

21. 2012
Medicaid starts option funding Health homes for persons with chronic conditions
Prohibit federal payments for Medicaid services related to hospital-acquired conditions.
Begin Medicaid Emergency Psychiatric Care Demonstration Project. to expand the number of emergency inpatient psychiatric care beds available.

22. 2013
Medicaid payment rates to primary care physicians for furnishing primary care services raised no less than 100 percent of Medicare payment rates in 2013 and 2014.
Medicaid coverage of preventive services approved by the U.S. Preventive Services Task Force with no cost-sharing will receive an increased federal funds

23. 2014 Health insurance exchanges established
Guarantee issue is required
Community rating required limits use of age and illness as a rating factor
All annual and lifetime limits prohibited
Essential Benefit established and required to cover MH and SA at Parity
Individual Mandate Starts

24. Insurance Exchanges To Date:
16 states have selected a state-based model,
7 are partnering with the federal government and
26 states have chosen federally-run exchanges.
Current enrollment deadline is March 31, 2014
In non- expansion states low-income individuals may experience more difficulty finding affordable coverage because they are not Medicaid-eligible and do not qualify for federal subsidies in the exchange.

25. ACA Affordable Health Insurance Marketplace
Fact: Enrollment system went live in ALL STATES on October 1, Insurance will became effective on January 1, Scope is all uninsured adults above 133 percent of poverty (plus discounted 5 percent of income).
Overall 25% will have a Behavioral Health Condition. (About 6% will have a Serious Mental Illness and 14% will have a Substance Use Disorder).
KEY ISSUES TO CONSIDER:
Are eligible uninsured persons aware of the opportunity?
Will persons with mental health and substance use conditions actually enroll?
Will the insurance benefits be adequate?

26. 2014 Medicaid Expansion
To date, 26 states are planning to expand coverage in 2014
Some include non-traditional models such as Medicaid premium support.
Decisions to expand Medicaid or discontinue Medicaid expansion in 2015 will impact bids that insurers submit in the spring of 2014 for the 2015 enrollment period.

28. ACA Medicaid Expansion
Fact: For states that choose this option (now 26 + DC), enrollment system went live on October 1, 2013 and coverage began on January 1, Designed for all uninsured adults up to 133 percent of poverty (plus discounted 5 percent of income).
Overall 40% with Behavioral Health Conditions. (About 7% will have a Serious Mental Illness and about 14% will have a Substance Use Disorder).
KEY ISSUES TO CONSIDER:
What is the effect of a State opting out?
Are eligible uninsured persons aware of the opportunity?
Will persons with mental health and substance use conditions actually enroll?

29. Increased competition in MH/SUD
Managed care
Accountable Care Organizations
New MH/SUD coverage under essential benefits
New parity requirements
Unless otherwise noted, all requirements are effective January 1, 2014.
1. Applies to new plans only
2. The ACA requires plans sold in the small group market to cover the Essential Health Benefits (which include MH/SUD). In subsequent rulemaking, HHS clarified that compliance with parity is a requirement of EHB.
3. Already in effect under the 2008 Mental Health Parity and Addictions Equity Act
4. Required to comply with federal parity law on treatment limitations and cost- sharing requirements, but not required to comply with parity law on annual/aggregate limits or in/out-of-network limitations. This is likely because these types of limitations are less applicable to FFS plans than to managed care.

30. EHR Meaningful Use Behavioral Health Quality Measures (Phase 2)
Quality metrics for chronically ill:
Tobacco screening and cessation
Weight screening and counseling
Depression screening and intervention
Hypertension screening
Depression remission rates using PHQ9!
Depression followup using PHQ9
Substance Abuse assessment in Bipolar patients
Alcohol Treatment initiation and Engagement
Maternal depression screening at < 6 month child visit
Suicide assessment for depressed patients

31. Delayed Changes Employer mandate delayed from 2014 to 2015
First reduction of Disproportionate Share Hospital (DSH) funds delayed from 2104 to 2015
Compliance of small business Existing Plans with new Rules
CMS has delayed until September 2015
15 States will permit renewal of non-compliant plans
18 States will not
17 States are undecided

32.
Innovation Waivers
Beginning 2015, states may consider developing proposals to waive portions of the ACA beginning in 2017.
“Innovation Waivers” must cover at least as many people as under the ACA and provide coverage that is at least as comprehensive and affordable, at no extra cost to the federal government.
States that receive waivers may finance their reforms with federal funding that otherwise would have been provided for premium tax credits, cost-sharing reduction and small business tax credits

33. Estimated changes in payer mix
Medicare is included in “other”
Source: The Commonwealth Fund: “Including Safety Net Providers in Integrated Delivery Systems: Issues and Options for Policymakers”

34. 50 Years of Federal Spending
Chart depicting 50 years of federal spending; image taken from NPR.org

36. The future…
The greatest danger in times of turbulence is not the turbulence. It is to act with yesterday’s logic.
Peter Drucker
Contact: |

37. Population based - Health homes…37

38. Health Home Functions: CMHCs are well positioned
CMHC teams already fulfill many Healthcare Home functions:
Providing individualized services and supports
Linking consumers to community and social supports
Hospital admission and discharge follow-up
Communicating with collaterals
CMHCs already serve people with high rates of chronic medical conditions
Many CMHCs have been trained by PBHCI Grant Project
Providing individualized services and supports, linking consumers with community and social supports, or utilizing health information technology to manage care, we are well positioned to serve as a Healthcare Home.

39. Defining Health Homes
Enumerated in Sec of the Social Security Act
Provides states the option to cover care coordination for individuals with chronic conditions through health homes
Intended to improve access and quality of care
Eligible Medicaid beneficiaries have:
Two or more chronic conditions,
One condition and the risk of developing another, or
At least one serious and persistent mental health condition

40. Defining Health Homes Provides 90% FMAP for eight quarters for:
Comprehensive care management
Care coordination
Health promotion
Comprehensive transitional care
Individual and family support
Referral to community and support services
Services by designated providers, a team of health care professionals or a health team

41. What is a Health Home? Not just a Medicaid Benefit
Not just a Program or a Team
A System and Organizational Transformation

42. What is Different about Health Homes?
Treatment as Usual
Health Homes
Individual Practitioner
Episodic Care
Focus on Presenting Problem
Referral to meet other Needs
Managed Care
Manages access to care
Does not change clinical practice
Integrated Primary/Behavioral Health Care Team
Continuous Care
Comprehensive Care Management
Coordinates care across the healthcare system
Data driven population management
Transforms clinical practice
Emphasizes healthy lifestyles and self-management of chronic health problems

43. Apples and Oranges Managed-Care Care Management
Health Home Care Management
Population = most are well most of the time
Population = all have multiple chronic conditions
Most have a few health care providers
Most have many Healthcare providers
Primary focus = avoidable over utilization
Primary focus= inappropriate underutilization
Mostly communicates with providers
Mostly communicates with patients directly
Administrative relationship
Face-to-face personal relationship
Mostly , fax or telephone
Mostly in person communication
Intermittent contact by different care managers
Ongoing contact with stable team
Strangers working together
You know them and they know you
Do not have to provide service to be paid
Have to provide service to receive payment

44. Health Care Home Strategy
Case management coordination and facilitation of healthcare
Primary Care Nurse Care Managers
Disease management for persons with complex chronic medical conditions, SMI, or both
Behavioral Health management and behavior modification as related to chronic disease management for persons with Medical Illness
Preventive healthcare screening and monitoring by MH providers
Integrated Primary Care and Behavioral Healthcare

45. Health Home Strategy
Health technology is utilized to support the service system.
“Care Coordination” is best provided by a local community-based provider.
MH Community Support Workers who are most familiar with the consumer provide care coordination at the local level.
Primary Care Nurse Care Managers working within each Health Home provide system support.
Behavioral Health Consultants in each Primary Care Health Home
Statewide coordination and training support the network of Health Homes.

46. Principles One Team One Treatment Plan for the Whole Person
CMHC’s composed of pre-2012 CPRC staff plus NCM and PC Consultant
PCHH’s composed of new infrastructure and team members
One Treatment Plan for the Whole Person
Rehab Goals
Medical Goals
Healthy Lifestyle Goals
Some Goals and Outcomes reference Health Home Performance Measures
Wrap –Around approach to outside treating PCP, mental health providers, community supports, etc

47. What is a Health Home? Not just a Medicaid Benefit
Not just a Program or a Team
A System and Organizational Transformation

48. What is Different about Health Homes?
Individual Practitioner
Episodic Care
Focus on Presenting Problem
Referral to meet other Needs
Managed Care
Manages access to care
Does not change clinical practice
Integrated Primary/Behavioral Health Care Team
Continuous Care
Comprehensive Care Management
Coordinates care across the healthcare system
Data driven population management
Transforms clinical practice
Emphasizes healthy lifestyles and self-management of chronic health problems
Treatment as Usual
Health Homes

49. Disease Management Diabetes ( 2434 Continuously Enrolled Adults)*
*29% of continuously enrolled adults

50. Hypertension and Cardiovascular Disease
302
3176

51. Improving Diabetes (HbA1c)
7.2% Uncontrolled (too high)
For 51% there are 2 results so we can find the trend
The uncontrolled group average HbA1c decreased from 9.50% to 8.95% (-0.55%)
1% point decrease in HbA1c yields:
21% decrease in Diabetes related deaths
14% decrease in Heart Attacks
37% decrease in micro-vascular complications

52. Improving Cholesterol (LDL)
46.3% Uncontrolled (too high, greater than 100)
For 58% there are 2 results so we can find the trend
The uncontrolled group average LDL decreased from 122 to 115 (-7)
A 10% Cholesterol Reduction yields a 30% reduction in Coronary Heart Disease

53. Improving Hypertension (BP)
23% Uncontrolled (too high, greater than 140/90)
For 61% there are 2 results so we can find the trend
The uncontrolled group average BP decreased from 142/90 to 137/86 (-5/4)
A 6 point reduction yields:
16% reduction in Coronary Heart Disease
42% reduction in Stroke

55. Outcomes Reducing Hospitalization
Primary Care Health Homes
CMHC Healthcare Homes

56. Intial Estimated Cost Savings after 18 Months
Health Homes
43,385 persons total served (includes Dual Eligibles)
Cost Decreased by $51.75 PMPM
Total Cost Reduction $23.1M
DM3700
3560 persons total served (includes Dual Eligibles)
Cost Decreased by $ PMPM
Total Cost Reduction $22.3M

57. Intial Estimated Cost Savings after 18 Months
CMHC Health Homes
20,031 persons total served (includes Dual Eligibles)
Cost Decreased by $76.33 PMPM
Total Cost Reduction $15.7 M
PC Health Homes
23,354 persons total served (includes Dual Eligibles)
Cost Decreased by $30.79 PMPM
Total Cost Reduction $7.4 M

58. State Health Home Activity-March 20143 2 2 3 #
*Some states may be in the planning phase.

59. Psychiatrist Shortage Overview
Currently Demand for Psychiatrists exceeds the supply
Demand for psychiatric workforce is increasing
Psychiatric workforce is projected to shrink
The current psychiatric care delivery model is not sustainable
So what can be done differently?
We are going to attempt to first set the stage for the discussion by laying out 1) the current situation in terms of workforce needs and suppiies; 2) projected needs and supply; and then discuss strategies.

60. Drivers of Increased Demand
ACA requires newly covered populations meet the parity requirements of Wellstone Domenici Parity Act
Multiple parts of ACA require or incentivize integration of Behavioral Health and general medical care
Stigma continues to drop releasing pent up demand
In responding to recent press coverage of mass shootings increasing mental health services is more popular than gun control

61. CURRENT SHORTAGE
Best data: Study by University of North Carolina commissioned by Health Resources and Services Administration (HRSA)
Demonstrated shortages for all MH professionals, especially “prescribers”
77% of U.S. Counties have “a severe shortage of prescribers, with over half their need unmet”
96% of US counties have “some unmet need”
There is currently a national shortage of mental health professionals at all levels, especially prescribers. The most detailed data on supply and demand are from a HRSA sponsored study through the University of North Carolina. They used various estimates of prevalence and severity of mental illness, and utilization data to determine need at the level of counties nationally. That showed that over ¾ of all counties in the US had a “severe shortage of prescribers”, defined as greater than half their need unmet, and almost all counties (96%) had some unmet prescriber needs. These estimates are conservative as they only look at outpatient needs (no institutional or hospital services).
Konrad et al, Psych Services, 60: , 2009

62. Current Supply and Need for Psychiatrists
Estimated need of 25.9 psychiatrists/100,000 population
With current population of 300,000,000, this is 78,000.
Current supply is ~ 48,000 (~ 16/100,000)
Current gap = at least 30,000
Much greater supply vs. need gap for child and adolescent psychiatry (~ 7,500 total)
Based on the UNC studies, the current estimated need for psychiatrists is 25.9 / 100,000. Currrently the supply is ~48,000 (detailed in next slide), leaving a gap of 30,000; The gap is much greater for child and adolescent psychiatrists.
Sources: Konrad et al, Psych Services, 60: , 2009

63. Psychiatric Times Series on Psychiatrist Shortage (Summer 2010)
“Psychiatry Job Openings Surge into the Future”: Physician recruitment company, Merritt Hawkins reported a 121% increase in requests for psychiatrists between 2007/2007 and 2009/2010
“45,000 More Psychiatrists, Anyone?”: HRSA commissioned studies considered “very conservative” because of exclusion of many patients with disorders that require some type of treatment (ADHD, Conduct Disorder, Dysthymia)

64. Demand for Psychiatrists Continues to Grow
The Bureau of Health Professions predicts that demand for General Psychiatry services will increase nearly 20% between 1995 and 2020
100% increase in the need for Child and Adolescent Psychiatry

65. Supply of Psychiatrists has been flat for 20+ years
The top graph shows that the number of residents per year in US psychiatric programs has been flat over the past 20+ years. (data from are missing); This is in contrast to a linear increase in the number of physicians overall (bottom graph).
Note: there has been a linear increase in number of physicians overall during this time

66. Current Psychiatrists are Aging Out Fast Percent of MD’s by Specialty over age 55
Off all sub-specialties (35), Psychiatry is second oldest (Second only to Preventive Medicine)
55% of current psychiatrist are > age 55
The aging out phenomenon is of particular concern. Psychiatry is the second oldest of all medical specialties, with more than half of all current psychiatrists over age 55.

67. Projected Supply and Demand of All Physicians 2010 - 2025
There is currently less of a gap between need and supply across all physicians, than there is in psychiatry or other mental health professionals However, projections clearly suggest that need will outpace supply for all physicians over the next few decades.– This is the expected gap between supply and demand for physicians across all specialties over the next 15 years.
Source: AAMC Center for Workforce Studies, June 2010 Analysis

68. Anticipated Supply and Demand of Psychiatrists?
Anticipated Demand
The concern for mental health professionals, especially psychiatrists, is that the increase in demand is going to be steeper, and the supply is going to be flat, at best. Indeed there is a real concern that if recruitment does not improve, that supply will DECREASE rather than remain flat. ?
Anticipated Supply
Time

69. So, what to do… There is NO one magic bullet
More and larger “help wanted” signs won’t work
Warm bodies with prescription pads won’t work
Locums Tenens isn’t “the solution”
Tele-psychiatry isn’t “the solution”

70. Collaboration Models Clearly must change the way we do business
Primary Care Physicians with Consulting Psychiatrist
Advanced Practice Nurse Practitioners as LIPs with Collaborating Psychiatrists (practice agreements or prescriptive agreements)
Psychologists with Supervising Psychiatrists
Physician Assistants as psychiatrists’ extenders

71. Potential Options and Concerns
Primary Care Physicians take on more psychiatric patients – already overloaded and not doing the best job in treating people with psychiatric problems
Train more Psychiatrist – $100,000 per residency slot (times 45,000 = $4.5B)
Train more APRNs and Physician Assistants in Psychiatry – very little training in psychology or psychotherapy
Psychologists Prescribing Authority – What is “adequate training” in basic science medicine and clinical science medicine to prescribe?

72. Benefits of Co-Location and Integration
Patients prefer it
Percent complying with a referral rises from 15-20% to 40-60%
Builds personal relationships – the foundation of any enduring arrangement
Allows more accurate understanding of each other’s incentives, methods and constraints
Opportunities for informal consultation
Single clinical record reduces errors
Facilitates converting BH clinicians into consultants to PCPs

73. Integration with Primary Care Expands Access to Psychiatry
Another Pilot Program with a N of 1

74. Background
More Psychiatric Medications are prescribed in primary care than in Specialty BH clinics
Community Health Centers (CHC = FQHC)
1200 CHCs serve 20M patients of whom 38% are minorities and including 20% of all uninsured
All must have a plan to meet BH needs, 71% provide BH services totaling 4.7 M visits annually
Primary focus has been Depression
Static or shrinking Psychiatrist workforce and increasing demand
Health Care Reform emphasizes on Primary Care

75. University Clinic & CMHC Practice
Over 10 years duration
Patient Volume – small and static
Never saw PCP or Patients-in-waiting
Model
Initial Evaluation all in one visit of min
Med visit w/ a little therapy
20-39 minute duration
Every 1-4 weeks
Termination criteria - death or disappearance

76. Phase 1 –Co-Location Into the FQHC
Two years duration
Model
Got my office in the corner
PCP refers them, I evaluate and keep them
Evaluations 60 min, return visits 20 min
Outcomes
Patient volumes a little larger but still static
Get to regularly come across PCPs and Patients-in-Waiting who are unhappy about lack of access
3 month wait list and 30 % no-show rate

77. Talk a different language with unfamiliar colleagues

78. Phase 2 Desperation Duration – 1 year
Method – Squeeze Down the appt times
Initial Eval 30 min – Learn and do just enough to get to a 2nd visit
Return Visits 15 Mins
Outcomes
33% increase in caseload
Case load static again 6 months later
Running really fast but not getting ahead

80. Phase 3 – Enhancing Access by Consultation
Duration 3 years
Two New Consult Access Methods
Interrupt me if it’s urgent and brief
Separate Wait Lists
Rapid access to one time consult visit
Regular wait list for ongoing care
Outcomes
Moderately larger patient volumes
Consult service turns over constantly

81. Phase 4 – The PCPs Catch on to Me
Duration 2 years
The Power of See One- Do One- Teach One
PCPs see my usual prescribing pattern by diagnosis in our common EMR
PCPs practice implementing my recommendations
PCPs see me interview during interruptive consults
Outcomes
PCPs decide that they will try my 1st 3 moves before referral
Referral pressure drops
I get more phone calls for curbside advice

83. Phase 5 - We Leave the Nest
Duration 3 years
Method
Add a collaborative Psychiatric APN
Convert to Open Access Scheduling
Refer all ongoing patients back to APN or PCPs unless acutely unstable or scary to APN and PCPs
Outcome
2-3 week wait max
can always fit urgent in next week
Much higher patient volume
No Shows down to 10%

84. Breath vs. Depth Choices Which Patients do You have a Duty To?
Give the best to a few
Give minimally adequate to many
Which Patients do You have a Duty To?
The ones on your case load now
The rest in your community waiting to get in

85. Psychiatrist View of Working in Primary Care Clinics
Advantages
Can treat many more patients
Working more often at top of their expertise
Immediate access to MD records of prior treatment
Lots more support of practice
Nurses – verbal orders, refill protocols, do EKGs, 1st on call
PCP - consults, handles CS refills, reads EKG, 2nd on call
Labs, pulse-ox, EKGs, scheduling specialty referrals
Problems
Intermittent Consultant, not an ongoing relationship
New Culture – interruptions and variable appt times
Less access to CMHC specialty services and BH colleagues
PCPs start controlled substances then refer to Psychiatrist

86. Consumer View of Getting BH Services in Primary Care Clinics
Advantages
Easier Access, more available appts, shorter waits
Attention to the Medical causes of BH symptoms
Getting Medical Care including healthy lifestyle advice
Relation ship less fear based than with psychiatrist
Problems
Know less about Dx & Tx of BH illness other than Depression and Anxiety
Medical Culture, Not familiar with Recovery concepts
Less awareness of and access to non-Med interventions
Don’t use comprehensive Bio-Psycho-Social Assessment

87. When you make a choice, you change the future. Status of our world…
Status of our world…
When you make a
choice, you change
the future.
Deepak Chopra
Contact: |

88. Because we know that the healthcare system of the near future will not look much like the present.
And the implications for our members and those they serve are enormous.

91. Struggles…
Moving from special silo status to equality; from incremental improvement to fast paced change
Disconnected from the rest of the healthcare ecosystem
Small independent organizations with small margins
Not effectively addressed divide between
mental health and substance use
Image of not having timely access to care
Limited capital for new service lines and HIT infrastructure

92. Fee for Service is headed towards extinction
Health Care Home models are beginning with a 3-layer funding design with the goal of the FFS layer shrinking over time
Being replaced with case rate or capitation with a pay for performance layer
Payment mechanisms will be tied to these measures in a variety of ways. Bundled payments that only pay for part of potentially avoidable complications (PACs) will penalize providers that have higher error rates. CBHOs that don’t have structures and staffing to provide effective prevention and early intervention services and manage chronic health conditions will not be eligible for case rates and capacity-based payments to fund that work. CBHOs that don’t hit performance measure targets will not earn their bonuses.
A related issue from above is whether existing carve-out plans that have worked closely with CBHOs to develop innovative payment mechanisms such as sub-capitation, case rates, risk corridors with bonuses, etc. will still be in business in the near future. Should CBHO groups and existing behavioral health carve-outs look to align/merge with health plans such as members of the Association for Community Affiliated Plans? What other strategies could be used to ensure their survival?

93. Episodic Cost Accountability Total Cost Accountability
Full Risk
Partial
Risk
Shared Savings
Bundled Payments
Traditional
Fee-for-Service
Pay-for-Performance
Shared Savings
Minimal
Savings Potential for Health Plans and Customers
Substantial
Source: The Advisory Board Company: Accountable Care Forum-Briefing for Health Plan Executives

94. Behavioral Health Organizations
Integrated Practice Units – treat disease and all related conditions, complications and circumstances
Outcomes Based Care – measure full set of outcomes and costs for every patient
Bundled Payments –acute care cycle; yearly care for chronic condition
Expand Across Geography – affiliations, mergers and acquisitions = volume
Integrate Across Facilities – determine scope of service; and standardize care across sites
Enabling Technology Platform – enable measurement; new reimbursement approaches; tie delivery system together 94

95. Organize into Integrated Practice Units95

96. Merge and Consolidate
Monopoly Economy

97. Produce measurable outcomes
Episodic care
Treat to target
Solution-focused therapy
British CBT
Use of standardized tools to measure improvement in symptoms, functioning, resilience and recovery
Don’t be afraid to embrace new approaches to treatment!

98. Integrate Care Delivery Systems
Most multisite organizations are not true delivery systems, at least thus far, but loose confederations of largely stand-alone units that often duplicate services.
To achieve true system integration, organizations must grapple with four related sets of choices:
defining the scope of services,
concentrating volume in fewer locations,
choosing the right location for each service line, and
integrating care for patients across locations.

99. Accountable Care Organizations
Medicare Shared
Savings Program
Pioneer
Program
Commercial
Payers
Public Sector
Private Sector
Hospital groups, physician groups and commercial payers most common
25 to 31 million
Americans currently receive healthcare through ACOs
2.4 MM
in Medicare ACOs
15MM
non-Medicare patients of Medicare ACOs
8 to 14 MM
Patients of non-Medicare ACOs
Sources: Market Trends in ACO formation, OPTUM; The ACO Surprise, Oliver Wyman

100. Other emerging trends
Elimination of ‘Safety Net’ Funding For Uninsured
Decrease of Fee-For-Service Rates
Medicaid or Medicare Coverage of SPMI Moved To Managed Care or ACOs
Expanding Role of Urgent Care Clinics in Community
Payers Increase Coverage of E-Health Services & Remote Monitoring
Responsibility for Health Outcomes and Costs of Defined Populations
Mandatory Adoption of EBP Via Comparative Effectiveness Research
Medication Assisted Treatments for Addictive Disorders
Widespread Adoption of Neurotech (Scans, Avatars, Cognitive Retraining…)

101. Medicaid Emergency Psychiatric Demonstration Project
Section 2707 of ACA
Allows IMDs to bill Medicaid at usual rate for persons y.o.
$75 M Federal funds plus usual state match
12 states with 27 IMDs participating
Planned to run 3 years –began July 2012, Authorization ends Dec, 2015
December 2013 Mandated Report (18 months) – Status
3458 admissions , 2791 patients, 84% had 1 admission
Ave LOS = 7 days, 84% discharged home
Ave per diem $911
Way under budget – half way through allotted time has used 25% of funding
December 2013 Mandated Report (18 months) Recommendations
Too little data to recommend expanding
Extend Demonstration past December, 2015

102. DSH REDUCTION CRISIS in ADULT PSYCHIATRIC INPATIENT BEDS: FOUR MISSOURI COMMUNITY HOSPITAL EXAMPLES
# of Total Hospital Beds
# of Adult Psychiatric
Inpatient Beds
% of all Hospital’s Patients who are Uninsured
% of Adult Psychiatric Patients who are Uninsured
% of Hospital’s Total Indigent Care Days Accrued on Adult Psych Units
Cox Health-Springfield
646 42
9.0%
30.9%
23.8%
SSM St. Joseph Health Center-St. Charles/Wentzville
331 61
9.4%
28.8%
58.2%
Truman Medical Center-Lakewood
310 28
17.9%
23.7%
46.7%
Twin Rivers Regional Medical Center-Kennett
116 12
6.7%
18.2%
52.2%