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Managed Care and Integration

May 19, 2011

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Managed Care and Integration

How One Organization Is Approaching This Dynamic Change To Current

Practices

Robert B. Baker, MD, MMMVPMA, MHS- Indiana

Bernard T. Engelberg, MDMedical Director, Cenpatico

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What is Integrated Care? (Managed Care View)

• Is Coordinated Care Integrated Care?– What do you think coordination means?

• Shared information, shared treatment plans, more than one person deals with the patient’s problems

• How does it actually look? How does it function?

• Is Co-Location Integrated Care?• Where do functional impairments stop and mental impairments

begin?• Can PH practitioners treat SMI?• Can BH practitioners treat PH problems?• Medications?• Information sharing?

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Why is this important?

• Comorbidities are common - >25%• Only 5% see a mental health provider• 80% see a PMP• Disproportionate needs in minority

populations• Paradoxical decrease usage in refugee

populations

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Importance of Screening

According to a NAMI survey:• 13% of youth aged 8-15 live with mental illness• 21% of youth aged 13-18• ½ of all cases of mental illness begin by age 14• Average delay of 8-10 years from the onset of

symptoms to intervention• Fewer than ½ of children with a diagnosable

mental illness receive services in a given year

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What are our goals?• Synergistic decrease in utilization (cost)

– Cherokee model – 28% decrease in medical utilization– 27% decrease in psychiatry visits– 34% decrease in psychotherapy– 48% decrease in mobile crisis team encounters

• Improved Health Outcomes– May increase mental health cost for the episode of care– Overall morbidity may decrease– Quality of care can increase

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Treatment Barriers

• Substance Abuse• Psychological Components of Physical Illness• Nonadherence• Unhealthy Behaviors• Social Support Gaps• Hierarchy of Needs• Cultural and Linguistic Issues

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What is the current state of affairs?

• Not enough mental health providers to supply demands

• Not enough PMPs – at least 15,000 FTE short in the US for current demand

• Estimated 50,000 FTE shortage for a fully insured population

• Staff productivity

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Cross-Training

• AHEC interest• Expanded curricula• UMass program• HRSA training and funding • Use of mental health grants• Use of standardized screening and

assessment tools• Speaking the same language

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Documentation

• EHRs• Outcomes measurement (SF-12, others)• Health Information exchanges• Define shared data sets• Improved reimbursement

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Who are the players?

• MCEs– Case Managers

• Integrated Health Systems• CMHCs• OMPP• Medical Homes (co-located, embedded)

– Patient Navigators, Care Managers• Getting Everyone To Talk With Each Other

– In The Weeds– IPHCA

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What are the barriers to a more integrated system?

• Promoting co-located care• Promoting truly integrated care• Credentialing• Integrated treatment plans• Shared information

– Many release forms available

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What can be done?• MCE Level

– Case Management– Telephones– Disease Management – stratification of risk– Toolkits– Facilitated follow-up appointments

• CMC Level– Written Referral Arrangements with FQHCs

• State Level– Full range covered services

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Integrated Level• Embedded BH practitioner on primary care team• Integrated clinical record and treatment plan• BH screening of the primary care patient – normalizes

the illness• Multidisciplinary meetings• Clinic redesign• Coordination with wrap-around care• Seamless transition across settings (e.g. hospital to

outpatient)• Shared knowledge about resources (parents and

patients want this – not just a prescription!) - Binders, handouts, referrals, support groups, community

services

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Financial Barriers

• Telemedicine • Treatment Team Meetings• Co-management• Brief Consultation• Same Day Restrictions on Billing• Use of Mid-levels• Reimbursing SBIRT

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Financial Solutions

• No carve out• Determine proper coding, e.g. 90801 psych

vs. 96150 medical• Telemedicine reimbursement• Demonstrating ROI

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Regulatory Solutions

• State decision on claims policy – modifier codes

• Privacy concerns

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Legal Barriers

• HIPAA interpretations

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Solutions to Legal Issues

• Health Coordination forms– Auditing continuity of care

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…so why integrate?

• Each year up to 30% of Adults meet criteria for a mental health problem

• Up to 70% of children and adolescents in need of MH services do not receive them

• Undiagnosed SA disorders impact PH.• MH problems 2-3x more common in chronic

medical illnesses• Untreated MH issues lead to functional

impairment

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What Needs to Change in Primary Care?

• Role of CMHCs in a Patient Centered Medical Home

• Redesign of practices that permit identification of MH/SA issues

• Monitor MH outcomes• Coordinate treatment more closely with MH

specialists

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Role of CMHC

• Integration; not just collaboration• “Stepped Care” matching patient’s needs to

services provided• Availability – office visits and telephone• SA and dual diagnosis solutions• Integrated “piggy-back” hand-offs

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Crucial Links

• PCPs need tools for MH/SA identification• Case managers/Care Coordinators needed

for patient success• PCPs need to know what help is available

upon SA/MH identification• EHR availability to all involved parties• Education on outcomes measurements• Assessment of system efficacy

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Bringing It Together (MCE view)

• Health Risk Screening• Patient Analysis - leveling tools• Intensive Case Management• Care Management• Payment Strategies