"Integration Can Work! Demonstrating Cost Effectiveness

and Marketing It in the Real World"Natasha Gouge, PhD

Psychologist, MSMG Pediatrics, Kingsport TNJodi Polaha, PhD

Associate Professor, Department of Psychology, East Tennessee State University

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session # G2b Friday, October 11, 2013

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Objectives

• Learn a method of assessing cost effectiveness of behavioral health integration within a primary care clinic

• Obtain results from a study assessing cost effectiveness of behavioral health integration within a primary care clinic

• Identify strategies for disseminating and marketing cost effectiveness results to administrators and third party payers

• Discuss applications of this case study to a wide array of clinics and styles of integration

Learning Assessment

Audience Question & Answer

Overview

• Rationale• Study aim• Methods• Results• Marketing• Q & A

Rationale

Study Aim• evaluate the cost effectiveness of an integrated

care model in a pediatric private practice clinic

• A barrier cited by PC administrators in integrating BH is financial risk

• Fee-for-service billing mechanisms remain complex and there is little empirical guidance on cost-effective models

• indirect benefits of hiring a Behavioral Health Consultant have been demonstrated in large health care industry but not in small, stand-alone practices

Method

• Procedure– BHC is available one full day per week– Case consultation– Warm hand-offs– Follow-up referrals– Located near nurse pods

Method

• Overall comparison BHC vs non-BHC days– Total # of patients seen– Time spent by staff and providers in DPC– Billing codes/levels used– Reimbursement received– Prorate revenue generated on BHC days for

possible cost offset

Method

• Additional output– Concerns raised– % of concerns addressed– Utilization of BHC services– Insurance providers– % of reimbursement rates

Hypotheses

• More patients seen on BHC days• More revenue generated on BHC days• Incorporation of BHC is cost effective

• 669 complete appointments– 277 Non-BHC Day– 392 BHC Day

• 63 BHC-patient contacts

• 59% Medicaid• 49% Commercial• 1% Self Pay

• Data was obtained for 92% of all visits– 8% accounted for participation refusal

• 30% of data used for inter rater reliability– score of 96%

Visits & BHC Contacts

Type Uncomplicated

Complicated TOTAL

Acute 328 0 68 1 396 1

Well 132 1 48 1 180 2

Chronic 2 0 2 0 4 0

Psychiatric 20 4 68 48 88 52

Concerns# Presented Frequency # Addressed

0 80

100%1 268

2 181

3 95

4 31

5 9

6 2

7 2

Concerns

Top

Concerns

Presented

Medical

Behaviora

l

BHC used

Medical

Behaviora

l

BHC used

• BHC averages 6 pts/day• 7-57 minute appts• Average appt = 27 minutes

• Primarily complicated psychiatric referrals

Visits by Clinic DayType Uncomplicat

edComplicated TOTAL

N-BHC Y-BHC N-BHC Y-BHC N-BHC

Y-BHC

Acute 150 178 26 42 176 220

Well 54 78 30 18 84 96

Chronic 1 1 0 2 1 3

Psychiatric 6 14 10 58 16 72

Hypothesis 1:

115 more pts on BHC days; 42% increase in volume

Time SavingsBHP Day in General•Patients

– Increase in direct care– Off-site earlier– 5 minutes less of wait

times•Providers

– Save 3 minutes per patient

• @ 15 pts = 45 extra available minutes

• @ 20 pts = 60 extra available minutes

BHP Contacts•Patients

– 22 additional min of direct care– Onsite 10 minutes longer – 10 minutes less in non-care– 4 minutes less in waiting room

•Providers – Save 5-50 minutes per BHP

patient– Highest savings from complicated

well visits and psychiatric visits

Reimbursement: Visit Type/Day Calculations

Non-BHC Day BHC Day

Ave. $

Paid

Time spen

t

# of Appts / day

$ MINU

TE

Day Total

$

Time Spen

t

# of Appts

/ day

$ MINUT

E

Day Total

$

BHC Day Addition

al Revenue

U-ACUTE

$64 12.14 15 $5.67 $960 12.07 18 $5.68 $1,152 $192

C-ACUTE

$94 19.04 3 $4.89 $282 16.61 4 $5.60 $376 $94

U-WELL

$183

19.54 5 $10.05

$915 17.00 7 $11.53 $1,281 $366

C-WELL

$156

28.58 3 $5.15 $468 28.28 3 $5.25 $468 $0

U-PSYC

$76 19.33 1 $3.79 $76 12.79 3 $5.54 $228 $152

C-PSYC

$79 31.40 1 $2.61 $79 11.69 5 $7.04 $395 $316

TOTAL $2,780 $3,900 $1,120

Hypothesis 2:

Hypothesis 3:

• Yearly stipend $10,000• @ 1 day a week for 52 weeks• $193/day

• Current data shows additional revenue generated on BHC days = $1,120– $927 average daily profit

• $48, 204 annually

Discussion points• All hypotheses confirmed

– 42% increase in patient volume across all visit types

– Increase in revenue generated because of more pts seen, and time saved

– Increase revenue generated is more than adequate to cover current BHC costs

– Differences remain statistically significant even when controlling for pre-scheduled BHC appts

Consider…• Areas to get at maximum cost effectiveness

– Increase BHC coverage– Increase BHC on WCC and Psych appts– Remember Acute and Psychiatric visits have the

highest reimbursement ratio– Use BHP strategically before/after drs and

primary/secondary to NPs– Increase compliance with co-pays– Continue monitoring data

Using the DataJodi Polaha, Ph.D.Associate Professor, PsychologyETSU

Rationale

Further growth of integrated care movement.

Create jobs for graduates of ETSU’s doctoral program.

Build needed workforce in rural Appalachia.

Non-BHC Day BHC Day

Ave. $

Paid

Time spen

t

# of Appts / day

$ MINU

TE

Day Total

$

Time Spen

t

# of Appts

/ day

$ MINUT

E

Day Total

$

BHC Day Addition

al Revenue

U-ACUTE

$64 12.14 15 $5.67 $960 12.07 18 $5.68 $1,152 $192

C-ACUTE

$94 19.04 3 $4.89 $282 16.61 4 $5.60 $376 $94

U-WELL

$183

19.54 5 $10.05

$915 17.00 7 $11.53 $1,281 $366

C-WELL

$156

28.58 3 $5.15 $468 28.28 3 $5.25 $468 $0

U-PSYC

$76 19.33 1 $3.79 $76 12.79 3 $5.54 $228 $152

C-PSYC

$79 31.40 1 $2.61 $79 11.69 5 $7.04 $395 $316

TOTAL $2,780 $3,900 $1,120

Taking the Data on the Road

Taking the Data on the Road

Mountain View Pediatrics Interested in nuanced

aspects to data. Caused reflection on

practice habits. Underscored utility of

student BHC Led credence to “gut

feeling” Resulted in efforts to

make job offer/increase student hours on site

Mountain States Medial Group Pediatrics

Providers trained in integrated careProviders rally administrationResulted in a full-time hire

Mountain States Medial Group Pediatrics

In the world of pediatrics, revenue is ALWAYS  going to come down to one keything:  numbers.  I don't care what anyone says.  Numbers are what makes money in peds.  So if you can offer a service that increases your numbers, you can't gowrong.  That this type of service makes us more productive and gets much neededservices to our patients makes hiring a BHP a no-brainer to me.  I've been begging for something

like this for years. It’s all about numbers. Time savings make a huge impact in peds.  You try to ask a mom to only give you their top two

concerns and schedule a future appointment for the rest, and she will be looking for another pediatrician.  We get new patients all the time because they feel like their current provider isn't giving them enough time and attention.  That is what every concerned parent wants when they walk in the door:  time and attention.  And we give it, because it is important and it hurts your practice if you don't, but quite frankly it costs us a great deal of money and productivity because we can't get reimbursed for that.

Mountain States Medial Group Pediatrics

I love that this model doesn't include psychiatric billing, and the cost savings is still demonstrated.  I think billing for the service would actually deter patients from using it.  If there is a way to maximize the time savings piece and do other things for our wealthier self-pay patients like cash for service appts, flat fees for groups, or camps in the summer, I think that is actually the best way to go here.  Parents get frustrated when they get a bill because you charged for cleaning out their child's ear in the office and come in pitching a fit, so the more of this type of service that can be offered without relying on direct billing the better probably.   Marketing this as a free service that we offer our patients will ultimately get us more patients, which gets us more money.  Plain and simple, really.

ETSU Pediatrics (Residency Program)

Agreed with utility (service/training) and value for patients

Unconvinced BHC could “save time” given precepting model.

Wondered about BHC impact on “quality of life” for residents/ preceptors, impact medical errors/fatigue etc.

ETSU Family Medicine (Residency)

Cost savings would not be realized due to strength in setting agenda.

Still: “After (considering data) I propose we consider having one of your doctoral candidates—isn’t that the level of learner in her study?—come to our clinic a couple of half-days/month.

BlueCare (Third Party Payer)

Estimate #s patients served who might need services if you had more to offer. Children vs. Adults?

List high risk populations (chronic pain, pregnant moms, opioid users). Add as outcome “closing HEDIS gaps in care”. Add as outcome “reduction of acute care and ED with projection of $$

saved”

Marketing the Data Audience X Data match Implications for future research Thoughts about Dissemination

Dissemination

Q & A