acos & chronic care management: opportunities for ... · 55% of medicaid enrollees, and 64% of...
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1© 2017. All Rights Reserved.
www.openminds.com163 York Street, Gettysburg, Pennsylvania 17325Phone: 717-334-1329 - Email: info@openminds.com
The 2017 OPEN MINDS Strategy & Innovation Institute Tuesday, June 6, 2017 | 11:45am – 1:00pm
Steve Ramsland, Ed.D., Senior Associate, OPEN MINDS
ACOs & Chronic Care Management: Opportunities For Behavioral Health Organizations In Population Health Management
2© 2017. All Rights Reserved.
I. The ACO Landscape
II. Opportunities For Behavioral Health In Population Health & Care Management Models
III. Prospect CharterCare Case Study
IV. Questions & Discussion
Agenda
The ACO Landscape
4© 2017. All Rights Reserved.
What Are ACOs?
Groups of health care providers that share mutual responsibility for a population of patients • Improve quality and health outcomes• Reduce health costs and inefficiencies• Reimbursement based on metrics of Quality Care, Patient
Satisfaction, and Reductions in Cost of Care
Population Health Management approach:
• Maintaining and improving people’s health across full continuum of care
5© 2017. All Rights Reserved.
ACO Market Trends – 2013 vs. 2016
412
689
2013
2016
Number Of ACOs
12.1%
2016
Percent Of U.S. Insured Population Covered By An ACO
4.4%
2013
11.9
35.1
2013 2016
Lives Covered (Millions)
6© 2017. All Rights Reserved.
Of ACOs Are Run By Physician Groups
1.60%
2.30%
3.60%
42.50%
47.30%
Federally Qualified Health Center (FQHC)
Health Plan and Provider Organizations
Hospital System and Physician Group
Hospital System
Physician Group
% of Organizations
Type
of O
rgan
izatio
n
ACO Sponsoring Organizations By Type, 2016
7© 2017. All Rights Reserved.
ACOs, By Payer
6.4%11.2%
22.6%
59.8%
MedicaidOnly
Contracts
MultipleContracts
CommercialOnly
Contracts
MedicareOnly
ContractsACO Contract Payer
Accountable Care Organizations By Contract, %, 2016
ACO Contracting Overview, 2016
ACO Contract Payer
Number Of ACOs
Number Of Contracts
Total Beneficiaries
Percent Of Attributed Consumers
Medicare 412 485 14,615,007 41.7%
Medicaid 44 55 3,243,728 9.2%
Commercial 156 229 17,219,745 49.1%
Multiple Contracts
77 - - -
Total 689 769 35,078,480 100%
8© 2017. All Rights Reserved.
Largest ACOs By Population, 2016ACO Name Payer Service Area Sponsoring
OrganizationEnrollment
Catalyst Health Network Commercial Texas Physician Group 3,937,000Delaware Valley ACO Medicare/ Commercial New Jersey/
PennsylvaniaHospital System/ Physician Group
1,728,000
Accountable Care Alliance Of Ventura
Medicare California Physician Group 1,500,000
Accountable Care Coalition Of Greater New York
Medicare New York Hospital System 1,500,000
MetroHealth Care Partners ACO
Medicare Ohio Hospital System 1,500,000
Memorial Hermann Accountable Care Organization
Medicare/ Commercial Texas Hospital System 1,134,430
Banner Health Network Medicare/ Commercial Arizona Hospital System 1,077,100
Health Choice Preferred Commercial Utah Hospital System 1,000,000Brown & Toland Physicians Medicare/
CommercialCalifornia Physician Group 766,000
Heritage California ACO Medicare California Physician Group 700,000
Ten Largest ACOs, By Enrollment
9© 2017. All Rights Reserved.
Utah Has The Highest Percent Of Their Population Attributed To An ACO – 62.9%
Opportunities For Behavioral Health In Population Health & Care Management Models
11© 2017. All Rights Reserved.
History Of Separate Financing & Delivery Of Behavioral Health
Since the time of the HMO Act of 1973, benefits have been separate
In 2001, 80% of health plans had a carve-out their behavioral health benefits– 33% Magellan
– 19% Cigna
– 13% United Behavioral Health
– 11% MHN
– 3% ValueOptions
New model emerging with integration at the individual consumer level
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Primary Carve-Outs To Private CMOs, 20161. Arizona2. Colorado (ending)3. Hawaii4. Idaho5. Massachusetts6. Washington (ending)
States With Traditional Primary Medicaid Behavioral Health Carve-Outs Decreasing
Primary Carve-Outs To Public CMOs, 20161. California2. Michigan (at risk of ending)3. North Carolina (ending)4. Pennsylvania5. Utah
13© 2017. All Rights Reserved.
Pre-existing condition coverage and parity have driven use of new strategies
Consumers with behavioral disorders
are often ‘super-utilizers’ of health care
resources
Undiagnosed and/or untreated behavioral
health conditions hinder the treatment
of a wide range of medical conditions
Consumers with behavioral disorders
and comorbid chronic medical conditions
have higher average cost than those
consumers without comorbid conditions
Lack of coordination care management results in poorer
outcomes and higher cost per consumer
14© 2017. All Rights Reserved.
Consumers With Behavioral Disorders Are Often ‘Super-Utilizers’ Of Health Care Resources
1. 5% of Americans consume half of all health care resources
2. Much of this is due to frequent and preventable use of expensive health care settings
3. This group of consumers is often referred to as “superutilizers” - individuals with multiple illnesses whose care is uncoordinated and fragmented, resulting in high resource use
More than 80% of Medicaid superutilizers have a comorbid mental illness
In 44% of Medicaid super-utilizers, mental illness is in the form of a ‘serious mental illness’
Mental health and addictive disorders were among the ‘top ten’ principal diagnoses for super-utilizers aged 1 to 64 years, regardless of payer
15© 2017. All Rights Reserved.
Consumers With Behavioral Disorders & Comorbid Medical Conditions Have Higher Average Costs
1. Mental health and addictive disorder comorbidities increase average health care costs by up to 200%
2. Individuals with these comorbidities often experience gaps in care management, leading to avoidable utilization of expensive health care settings
Asthma&/OrCOPD
CHF CHD Diabetes Hyper-tension
No MH/SUD $8,000 $9,488 $8,788 $9,498 $15,691MH $14,081 $15,257 $15,430 $16,267 $24,693SUD $15,862 $16,058 $15,634 $18,156 $24,281MH and SUD $24,598 $24,927 $24,443 $36,730 $35,840
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
Annu
al P
er C
apita
Hea
lth C
osts
16© 2017. All Rights Reserved.
Undiagnosed Behavioral Health Conditions Have Human & Economic Tolls
1. Each year, one in four Americans experience some mental illness
2. The presence of a mental health or addictive disorder comorbidity can increase a person’s chances of hospital admissions by up to 300%
The Impact Of Depression1.Mood disorders like
depression are the third most common cause of hospitalization among non-elderly adults
2.60% of individuals suffering from chronic depression have not received treatment within the last year
17© 2017. All Rights Reserved.
Strategies To Optimize Behavioral Health
Use Of Analytics In Identification & Early Intervention Of High-Risk Consumers With Behavioral Conditions
Strategies Focused On Improving Consumer
Access To Care
Strategies For Improving Consumer
Engagement
Improved Coordination Of Care For Consumers
With Behavioral Conditions
Strategies ToEnsure Quality Of Behavioral Health Care
Creating Partnership Models With Behavioral Health Provider Organizations
18© 2017. All Rights Reserved.
Identification of High-Risk Consumers To Optimize Population Health Management Strategies
Goal is to identify consumers who are likely to use high levels of resources - to support targeted use of mitigation strategies
Individual-level data that is aggregated for population-level analysis
Requires timely access to integrated data set including physical and behavioral health, pharmacy, social determinants of health, and other factors that impact wellbeing
Supporting consumer care planning and event surveillance –
– Enrollment in specific programs
– Matching referrals of high-risk consumers to provider organizations with special expertise and demonstrated proficiency
– Tracking consumer adherence to recommended treatment plans, emergency department visits, and hospital admissions
19© 2017. All Rights Reserved.
1. Consumers with unrecognized/asymptomatic depression had health care expenditures $2,000 to $3,000 per year than those without depression1
2. Patient with symptomatic depression had health care expenditures $5,000 per year higher than those without depression1
3. 59% of Americans with insurance do not get the behavioral health services they need3
4. Strategies to improve access must address three issues: a. Easy access to health care system
b. Ready availability of locations where needed services are provided
c. Matching consumers with a professional they view as trustworthy and easy to communicate with2
Addressing Untreated Behavioral Health Conditions Through Consumer Access Improvement
20© 2017. All Rights Reserved.
Improving Consumer Engagement To Drive Health Plan Performance
1. A significant portion (more than 40%) of readmissions have significant consumer engagement-related causes such as lack of support, inability to navigate the health care system, and inability to comprehend and follow instructions1
2. Members' level of engagement with their health plan and the health plan’s provider network is directly related to their disenrollment and satisfaction behavior
3. Complicating factors to engagement specific to the behavioral health are that consumers may not become engaged due to stigma surrounding mental illness, or perceived lack of diversity and cultural competence among professionals4
21© 2017. All Rights Reserved.
1. More than 90% of consumers treated for behavioral health conditions have at least one comorbid medical condition, and more than half have four or more.4
2. Lack of coordinated, person-centered care management for individuals with comorbid mental health conditions leads to missed diagnoses, poor follow-up, and gaps in care1
3. HEDIS measures show that more than 47% of commercially-insured individuals, 55% of Medicaid enrollees, and 64% of Medicare enrollees did not receive follow-up care within seven days of discharge from hospitalization due to mental illness2
4. People with psychotic disorders and bipolar disorder are 45 percent and 26 percent less likely, respectively, to have a primary care doctor than those without mental disorders2
Improved Care Coordination For Consumers With Behavioral Conditions
22© 2017. All Rights Reserved.
1. There is a lack of consensus on tools for measuring ‘quality of care’ in behavioral health sector, although efforts to develop a standardized set of quality measures is in process
a. For example, National Quality Forum3 has 55 currently identified measures include 11 addressing depression, 16 addressing medical conditions in psychiatric populations plus 3 about tobacco use, and 9 relating to medications
2. Despite this current lack of consensus, health plans are using a range of quality measures for behavioral health, including measures of symptom level and functional status4
Improving Effectiveness By Improving The Quality of Behavioral Health Care
23© 2017. All Rights Reserved.
1. Models for management of behavioral health benefits moving beyond traditional specialty carve-outs
2. The need for ‘integration” of care coordination for consumers with complex needs is driving new designs
3. Integrated care coordination (and integrated service delivery) are not possible without reimbursement realignment – which is resulting in the creation of new gainsharing arrangements
Reshaping Network Design With Partnerships For Gainsharing & Aligned Incentives
24© 2017. All Rights Reserved.
ACOs & Complex Consumers
25© 2017. All Rights Reserved.
Opportunities for Specialist Organizations Are Many
Behavioral health service system sub-capitation
Specialty care coordination for consumers with behavioral disorders
Specialty ‘center of excellence’ programs for
acute conditions
Behavioral health consultation in office-
based service locations –live or via telehealth
Management of specific acute episodes or chronic conditions via case rate or episodic/bundled payment
Management of short-term inpatient psychiatric and addiction treatment
programs
Psychiatric consultation –live or via telehealth – in
hospital emergency rooms
Behavioral health consultation program for inpatient programs – live
or via telehealth
Hospital diversion programs
Specialty behavioral health ER/crisis stabilization
Hospital readmission prevention programs
Community-based/mobile crisis response
Home-based service delivery Specialty primary care
26© 2017. All Rights Reserved.
Business Model Transition For Provider Organizations
Payer Policy = Pay For Cost Or Volume
Payer Policy = Pay For Value
What is paid for is good for the consumer -
- and doing more is the
business model
Giving the consumer (and
their payer) what they want and need is the business model
Good outcome at low cost –
conveniently
A revolution in performance management
required
Prospect CharterCARECase Study
Rebecca Plonsky, LICSW, Vice President of Development for Integrated Behavioral Health-East and Southwest Region, Prospect CharterCARE, LLC
ACOs & Chronic Care Management Opportunities:
The Prospect CharterCARE, LLC Case Study
Rebecca Plonsky, LICSWVice President of Integrated Behavioral Health
June 6, 2017 28
Becoming an ACO
29
Built Continuum of Care
Convened Key Stakeholder
Meetings
Secured Approval from
State & Payer(s
Health Care Transformation
Began
• Expanded continuum of care to meet requirements of ACO
• Enhanced BH and medical integration at all points of care
• Convened series of Executive meetings to discuss launching an ACO model of care
• Formerly submitted application that demonstrated meeting ACO requirements
• Secured Approval and Executed contracts with payers
• Focused efforts on patient retention, population health, and engagement
• Focused on quality and enhanced reporting
• Began to track leading indicators
Our ACO Types
30
Current State in RI:
Medicaid ACO Medicare Next Gen ACO Medicare ACO “like” Commercial ACO “like”
Of Note:
RI Community Mental Health Centers (CMHCs) are eligible to be certified as an ACO for patients with SPMI
Prospect CharterCARE, LLC has deep partnerships with 2 CMHCs and has fully executed MOU’s with each
Future State:
Commercial ACO “like” by Q1 2018 to include BH and medical management
Prospect Population Under Management Growth
3,688 4,786 7,657
29,941 33,546
50,028 64,982
- 10,000 20,000 30,000 40,000 50,000 60,000 70,000
Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17
14-Jul 15-Jan 15-Jul 16-Jan 16-Jul 17-Jan 17-JulBCBSRI MA 3,688 3,986 6,807 7,385 7,823 8,300 8,300Tufts Commercial 800 850 1,056 1,200 1,700 1,700BCBSRI Commercial 14,000 17,023 17,796 18,000United Medicaid Pilot 3,800 3,800 5,600 5,600NHPRI Medicaid Pilot 3,700 3,700 7,300 7,300CIGNA Commercial 2,200 2,200United Commercial 8800United Medicare Advantage 4450Next Gen ACO 7,132 7,132Tufts Medicaid 1,500
3,688 4,786 7,657 29,941 33,546 50,028 64,982
Our ACO Population Health Approach
32
Addiction Medicine
• Medication Assisted Treatment Case Rates
– Allowed treatment flexibility based on acuity of symptoms
• Enhancing connectivity between primary care and Addiction Medicine Services
Serious and Persistent Mental Illness
• Partner and Coordinated Care for Patients In Integrated Health Homes
• Engage patients who are not affiliated with CMHC
• Focus on patients who decline care management
Geri Psychiatric
• Nursing Home Initiative with 24/7 Access Line
• Exceptional medical team has been nationally recognized for providing exceptional medical and bh treatment for highly complex patients
Long Term Behavioral Health Care
• Built best practice programming focused on recovery and community Integration
• Programming also included Peer Recovery Services and AA
• Improved Effective and Successful Discharge Planning to the community
Introduction to CharterCARE Health Partners Integrated Continuum of Care- Outpatient
1. Addiction Services Center on the Roger Williams Medical Center Campus
Multi-disciplinary team including: (Peer Specialist Q2 2017) Offer same day appointments for co-occurring disorders and/or co morbid conditions Short and Long term counseling Suboxone treatment from induction phase to maintenance Early Recovery Groups Partial Hospital Program (PHP) and an Intensive Outpatient Program (IOP)
2. Outpatient Programs on the Our Lady of Fatima Hospital Campus
MH and Dual Diagnosis IOP and PHP General Outpatient Counseling opened in February 2017
3. St Joe’s Health Center
LICSW fully integrated within primary care team Warm hand offs, brief interventions Evidence based routing screenings PHQ 2/9, Gad 2/7 SBIRT go live in Q2 2017
33
CharterCARE Health Partners Integrated Continuum of Care-Inpatient
We offer comprehensive individual and group interventions including early recovery and building effective coping skills for varying levels of needs across our 110 Inpatient Beds.
Our compliment of beds focus on meeting the demands of our patient community
1. Our Lady of Fatima Hospital (71 Beds)
2 South – Long Term Behavioral Health Unit: 20 beds 2 Center – Adult General Psych: 30 beds 3 South – Geri/Psych: 21 beds
2. Roger Williams Medical Center (39 Beds)
West 4 – Geri/Psych: 12 beds West 3 – Dual Diagnosis: 12 beds Center 1 – Detox: 15 beds
34
Key Elements in Advancing Our ACO and Integration
Rhode Island has made significant strides to move toward integrated care across the delivery system through the following:
Strong statewide commitment across providers
Payer Accountability and Partnership
Behavioral Health State wide Work Groups focused on Integrated Health Homes
Care Transformation Collaborative (CTC)/ Patient Centered Medical Home
Prospect CharterCARE’s Strategic Goals to Strengthen Integration include:
A member centric, holistic, “whole person” approach with a focus on recovery and integrated care
Member access to broad networks of specialized care
Coordination & collaboration of care through multi-disciplinary behavioral health and medical teams with ease of access
Promotion of high quality, innovative payment structures, & evidence based best practices that are outcome driven
Ensure rate adequacy via actuarial soundness35
Key Elements in Advancing ACOs and Integration cont.
Member signs Release of information
Share Information
MeasureOutcomes
Case Consultation
• Routine Bi-Directional Communication
• Share treatment plan, medication dosing, & goals• 80% of Medicaid
members have co morbid medical & BH Issues
• Implement Standardized Outcome measures: HEDIS, total cost of care, & quality of life measures
36
COORDINATEDKey Element:
Communication
CO-LOCATEDKey Element:
Physical Proximity
INTEGRATEDKey Element:
Practice Change
LEVEL 1:Minimal Collaboration
LEVEL 2:Basic Collaboration at a
Distance
LEVEL 3:Basic Collaboration
Onsite
LEVEL 4:Close Collaboration Onsite with Some System Integration
LEVEL 5:Close Collaboration
Approaching an Integrated Practice
LEVEL 6:Full Collaboration in
a Transformed/Merged Integrated
Practice
Heath B, Wise Romero P, and Reynolds K from SAMHSA-HRSA (2013) proposed a Standard Framework for 6 Levels of Integrated Healthcare.
Key Components:
RI CTC July 14 Survey Results from at least 14 Practice Sites: Screening for BH Problems
What it Tells Us…
Practices are very good at screening for depression and smoking Not systematically screening for anxiety, overall substance use, pain, or
domestic violence
3
Of patients with serious mental illness like schizophrenia or bipolar disease:
About 1/3 of the practices believe they manage the physical health of these patients less well than they manage the physical health of other patients
Where We’re Going in CY 2017 & Beyond• Across our ACO continuum of we have adopted a coordinated regional care model (CRC)
which is built on the foundation of the Collaborative Care Model (CCM).• CCM an evidence-based practice endorsed by SAMHSA and the American Psychological
Association. • It is proven to have positive outcomes for patients with depression, anxiety, PTSD,
diabetes, heart disease, and cancer. Advance practice sites use screening and brief interventions (like SBIRT) for SUD.
• The collaborative care model can include a care manager, a medical assistant, a psychiatric consultant (typically by phone or video link), and an LICSW, psychologist, or RN. It is led by a PCP.
In a CCM an impact study, findings indicate that for every $1 spent, $6 was saved.
ACO CRC Opportunities in 2017 support:– Tracking member progress over time– Provider effectiveness– Meeting agreed upon performance targets– Informing population management strategies
38
• We Have Strengthened our Core Competencies and Mission– Broadened and provided better clinical care and outcomes– Increased patient engagement in their treatment and recovery– Committed to reducing total cost of care– Strengthened our network and deepened critical partnerships across the state and
have received recognition
• Made Meaningful and Smart Investments– Integrating behavioral and physical healthcare across our primary care network,
convene meetings with CMHCs to coordinate care, hired revenue generating clinicians and prescribers
– Revamped physical space– Optimized EHR platform and reporting to flag at risk patients and to track and trend
leading indicators
• Received Approval from payers for Case Rates and to accept further risk– Pilot programs focused on highly specialized care for high-risk populations
• Serious and Persistent Mental Illness (SPMI)• Addiction Medicine• Depression in Primary Care
39
Our Experience as an Accountable Care Organization to Date
Partnering with Insurers4 Levers of Our ACO Success
40
Robust Continuum of Care
Commitment to Quality
Willingness to Accept Financial Downside Risk
Develop Strong Partnership with
Insurers and State Leaders
Lever 1: Robust Continuum of Care
Our Strong Network is Critical
Demonstrated our organization has a full compendium of services; committed to Coordinated Regional Care Model
Demonstrated deep partnerships with community providers through contracts; (preferably not MOUs or affiliation agreements)
Committed to PCMH advancement and integration
Started small, Deploy onsite clinicians in primary care
Ensured our providers are paid within fair market value
Moved prescribers to wRVUs to demonstrate productivity
Offered Telehealth 41
Lever 2: Commitment to Quality
Improve both patient and provider outcomes
Committed to full adoption of standardized and validated outcomes Demonstrated an interest in implementing an insurance driven outcome tool e.g. On Track GAD 2 and 7 PHQ 2 and 9 SBIRT Moved the needle on HEDIS measures e.g. MH After Care Follow Up
Committed to training and innovation Launched a monthly joint operating committee Convened Grand Rounds focused on Integrated Care Launched Integrated Behavioral Health Internship program Partnered with Colleges Shared best practices
Committed to provider and patient satisfaction 42
Lever 3: Willingness to Accept Financial Downside Risk
1. Committed to winning together or losing together
2. Proposed a 1 year pilot on a specialty population
3. Conveyed willingness to accept varying degrees of risk which may include: Accepting 5-10% of downside risk Quality Withholds Joint participation in shared savings
4. When accepting risk, we asked for full delegation
43
Lever 4: Develop Strong Partnerships with Insurers and State Leaders
44
• ACO BH CEO• Senior BH Leader
• Insurer Chief Medical Officer
• Senior BH Leader• Senior Contract
Administrator
• Community Partners e.g. CMHCs
• ACO Vice President
• State Director (May include multiple departments)• BH Chief Medical Officer• Senior State Contract Administrator
• Governor and/or Senator
Health System Transformation is Possible
Member Centric
Approach
Network Adequacy(PCP &
Pediatric)EMR/
Shared Medical Records
Care Managementfor Complex
Needs
MaximizeTreatment Adherence
CrisisIntervention
Community Support
Preventative Care
Health Education
AfterCare Follow
Up
Quality & Outcome
Real Time Data &
Analytics
InnovativePayment
Structures
Holistic, Whole Person Approach
45
Our Lessons Learned to Date
46
Transformation is possible but we cannot move faster than the systems will allow
We were able to clearly answer the question to insurers, “What is in it for me?”
We had to be flexible and nimble when establishing terms of ACO; Heard what the insurers were asking and modified our position as
needed Optimized our EHR
Leveraged our IPA comprised of 500 Specialists and PCPs to further medical integration
Learned over time, we needed to be conservative with ramp up time lines
Questions & Discussion
47
Table Talk Discussion Questions
1. How do you begin to work through current constraints to partner with or become an ACO?
2. What are the 3 most significant challenges for your organization to advance integrated medical care and behavioral health?
3. What are 3 successful innovations that have been implemented over the past 12 months to promote integrated care across your delivery system?
48
www.openminds.com 163 York Street, Gettysburg, Pennsylvania 17325 717-334-1329 info@openminds.com
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