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MakingtheCaseandMakingIt

Work:IntegratingBehavioral

HealthintoPrimaryCare

KarenW.Linkins,PhD

karen@desertvistaconsulting.com

May18,2016

Whatwe’llcovertoday

• WhyIntegratedBehavioralHealth

• Changingpolicyenvironment

• Whereweareheaded:Collectiveimpactand

AccountableCommunitiesofHealth

TheProblem:Fragmentation

Clinicaldelivery

Payment/financing

Community

expectation

Training/education

Fragmentation

QuickReview:CaseforIntegration

• 5%ofthepopulationuse50%ofthehealthcareresources(the5/50population)

• 1%use20%ofthehealthcareresources• Halfofbothgroupshaveabehavioralhealthdisorder• PrimarycareisthesolesourceofMHtreatmentfor

1/3ofpatientsreceivingcareforaMHcondition

• Depressedpatientsare3timesmorelikelythannon-

depressedpatienttobenon-compliantwith

treatmentrecommendations

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BehavioralHealthisaKeyConcernfor

HealthCare• Disparities:Affectslow-incomepopulations

o Nearlyhalf(49%)ofallMedicaidbeneficiarieswith

disabilitieshaveapsychiatricdiagnosis

o AmongDualeligibles (Medicare/Medicaid),44percent

haveatleastonementalhealthdiagnosis

• Costdrivero Behavioralhealthdisordersareamongthefivemostcostly

conditionsintheU.S.withexpendituresof$57billion

oMooddisorderssuchasdepressionarethirdmost

commoncauseofhospitalizationintheU.Sforbothyouth

andadults

Weonlyspend5%ofourhealthdollarstoaddresswhatcauses60%ofouravoidabledeaths

1 McGinnis et al., The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93.2 Centers for Medicare & Medicaid Services, Office of the Actuary. National health expenditures, by source of funds and type of expenditure. 2013.

10%

30%

5%

40%

15%

EnvironmentBehavior

Social factors Health care

Genetics

Causes of avoidable death in the United States1

95%

5%

Health care

Population-wide approaches to health improvement

United States health expenditures in 20132

Behavioral health preventionChemical dependency preventionMaternal and child health programsPublic health activitiesResearchSchool health programs

EconomicImpactofIntegratedBehavioralHealth• CMSP:reimbursingprimarycareclinicsforupto10mentalhealthvisitsand20substanceabusevisits

peryear resulted inadramatic57%dropinpsychiatricdaysbythetreatedgroup (vs.a71%increaseinthebusiness-as-usualcontrols). However,thiscost-savingswasneutralizedbyanincreaseinoutpatientexpenses.Nonetheless,CMSPhaselectedtocontinuetheprogramwiththeexpectationthattherewillbesavingsoncetheprogramisfurtherunderway.EvaluationoftheCMSPBehavioralHealthPilotProject,Draft FinalReport, preparedforCMSPbytheLewinGroup,February,2011

• Depressionmanagementfordepressedprimarycare clientsresultedina$980costdecreaseforthosewhocomplainedofpsychologicalsymptoms,buttherewasa$1,378costincreaseforthosewhocomplainedofphysicalsymptomsonly.MiriamDickinsonetal.,“RCTofaCareManagerInterventionforMajorDepressioninPrimaryCare:2-YearCostsforPatientsWithPhysicalvsPsychologicalComplaints” AnnalsofFamilyMedicine,2005,3:15-22.

• “Theimpactofpsychologicalinterventionsontheuseofmedicalserviceswasevaluatedbyexaminingtheoutcomeof91studiespublishedbetween1967and1997usingmeta-analytictechniquesandpercentage estimates.Resultsprovidedevidenceforamedicalcost-offseteffect,specificallyinthedomainofbehavioralmedicine.Averagesavingsresultingfromimplementingpsychologicalinterventionswasestimatedtobeabout20%.Aboutonethirdofthearticlesdemonstratedthatdollarsavingscontinuedtobesubstantialevenwhenthecostofprovidingthepsychologicalinterventionwassubtractedfromthesavings.”JeremyA.Chilesetal.TheImpactofPsychologicalInterventionsonMedicalCostOffset:AMeta-analyticReviewClinicalPsychology: ScienceandPractice,June1999,Vol.6.

• Collaborativecare,implementedthroughbriefcognitive-behavioraltherapyandenhancedpatienteducationinprimarycare,increaseddepressiontreatmentcosts,butimprovedthecost-effectivenessoftreatment forpatientswithmajordepression.Acostoffsetinspecialtymentalhealthcosts,butnotmedicalcarecosts,wasobserved.VonKorff,“Treatmentcostoffsetsandcost-effectivenessofcollaborativemanagementofdepression”,PsychosomaticMedicine,1998,60.

• Whenclientswithdiabetesanddepressionreceiveddepressioncollaborativecare(adepressioncaremanager offered education,behavioralactivation,andachoiceofproblem-solvingtreatmentorsupportofantidepressantmanagementbytheprimarycarephysician),anincrementalnetbenefitof$1,129wasfoundovertwoyears.Thestudyconcludedthatthisinterventionis“ahigh-valueinvestmentforolderadultswithdiabetes;itisassociatedwithhighclinicalbenefitsatnogreatercostthanusualcare.”WayneKaton etal.“Cost-EffectivenessandNetBenefitofEnhancedTreatmentofDepressionforOlderAdultswithDiabetesandDepression.”DiabetesCare29:265-270,2006.

• Whenfamilyphysiciansworkedcollaborativelywithmentalhealthprofessionalstotreatpersonsonshort-term mentalhealthdisabilityleave,theirpatientsreturnedtoworkathigherrates thanthosetreated byphysiciansalone.Theaveragecostsavingstoemployerswas$503perpatient.CarolynDewaet al.“Cost,EffectivenessandCost-Effectivenessof a CollaborativeMentalHealth CareProgram forPeopleReceivingShort-Term Disability BenefitsforPsychiatricDisorders”, CanadianJournalofPsychiatry, 54(6),2009.

• Over24months,clientshavingbothdiabetesanddepressionwhowereassignedtoastepped-caredepressiontreatment programhadoutpatienthealthservicescoststhataveraged $314lesscomparedtothosewhoreceivedcareasusual.Theauthorsconcludethat“foradultswithdiabetes,systematicdepressiontreatment appearstohavesignificanteconomicbenefitsfromthehealthplanperspective.”Gregory Simonetal.,“Cost-effectivenessofSystematicDepressionTreatmentAmongPeopleWithDiabetes Mellitus”,ArchivesofGeneralPsychiatry,January,2007,Vol.64,No.1.

• AstudyofMedicaidrecipientsdiagnosedaschemicallydependentfoundthatthosenotusingmentalhealthservicesincreasedtheir medicalcostsby91%duringthestudyperiod,comparedtodecreasedcostsforrecipientsofmentalhealthtreatment.Inthefirsttwelvemonthsaftertreatment, someinterventionsproducednetdecreasesofapproximately$514perperson.N.,Cummings,etal.“Theimpactofpsychologicalinterventiononhealthcareutilizationandcosts”.Biodyne Institute,1990.

• Acollaborativecare interventionforprimarycareclientswithpanicdisorder,includingsystematicpatienteducationandapproximatelytwovisitswithanon-siteconsultingpsychiatrist,resultedinnosignificantdifferencesintotaloutpatientcosts,andananalysissuggestsa70%probabilitythattheinterventionledtolowercostsandgreatereffectiveness comparedwithusualcare.WayneJ.Katon,“Cost-effectiveness andCostOffsetofaCollaborativeCareInterventionforPrimaryCarePatientswithPanicDisorder”, ArchGenPsychiatry. 2002;59.

• Comprehensivecollaborativeandstructuredmentalhealthservicesprovidedtohighutilizersofmentalhealthservicesresultedina65%reductionincommunityhospitaldays.NancyAnderson,“MedicalCostOffsetsAssociatedwithMentalHealthCare”ABriefReview,WashingtonStateDept.ofSocialandHealthServices, December, 2002.

• Useofmanagedmentalhealthcare(structured, targeted, focusedandbrieftreatment)forMedicaidenrolleesreducedmedicalservicescostsandutilizationby23to40percentrelativetocontrolgroups.Forenrolleeswithchronicmedicaldiagnoses,managedtreatmentreducedmedicalcostsby28to47percent.Forenrolleeswithoutchronicmedicaldiagnoses,traditionalfee-for-servicealsoreducedmedicalcostsbyabout20%butusedthreetimesasmanyoutpatientvisits.Costsofmanagedtreatmentwere recovered in6to24months.Themanagedmentalhealthgroupspentfewerdaysinthehospitalandusedtheemergencyroomless.MSPallak etal.,“Medicalcosts,Medicaid,andmanagedmentalhealthtreatment:theHawaiistudy”, ManagedCareQ, 1994Spring;2(2).

• Aneight-sessionmind/bodyeducationprogramforpeoplepronetosomatizationandaneightsessionchronicpainmanagementprogram“decreasedmedicalofficevisitsbyabout35%”.DanielBruns etal.,“TheImplementationofIntegratedPrimaryCareatKaiserPermanente”:An InterviewwithRogerJohnson,Dec.,1998.

• Primarycare clientsassignedtoenhancedcarefordepressionnotonlyexperiencedsignificantlymoredepression-free dayscomparedwithusualcareclients,butcostthehealthplansignificantlyless($568vs-$12inincrementalcosts;P<.001).KatherineRost,“Cost-EffectivenessofEnhancingPrimaryCareDepressionManagementonanOngoingBasis”,2005,AnnalsofFamilyMedicine3:2005.

• “JohnsHopkinsHealthCareexaminedthefirst12monthsofclaimshistoriesof603adultMedicaidenrolleeswhofrequentlyusedmedicalservicesandhadarecenthistoryofsubstanceabuse.Aninterventiongroupof400wastargetedformanagement bysubstanceabusecoordinatorsandnursecaremanagerswhoreceivedtrainingintheintegrationofmedicalcasemanagementandsubstanceabuseservices.Thetrainingincludedmockinterviews,lectures,andcaseconferencesonsubstanceabusetopics.Acomparisongroupof203membersreceived routinecareintheformofseparateoutreach fromsubstanceabusecoordinatorsandcaremanagers. Early resultsindicatethattheinterventiongroupreducedmedicalcostsby$122permemberpermonthascomparedtoanincreaseinthecomparisongroup.Theinterventiongroup’scostreductionswererealizedthroughadecrease of288admissionsper1,000membersaswellasadecreasein92daysadmittedper1,000members.Moreover,theinterventiongroupexperiencedincreasedenrollmentinsubstanceabusetreatment andcasemanagement,whichappropriatelyoffsetsomeofthesavingsfromhospitalutilization.Inall,thePMPMcostreductionsamonginterventiongroupmemberstotaled$503,616throughthefirstyearoftheprogram,relative tobaseline.”see JohnsHopkinsHealthcare:DemonstratingaReturnonInvestmentforIntegrated Substance AbuseandTreatment

• Thoughtheaprimarycaredepressionmanagementinterventionaddedtothetotalcarecoststhefirstyearofoperation,thesecostswerelargely off-setbygeneral healthcaresavingsduringthesecondyear.Theinterventionproducedhealthandmentalhealthimprovementswithoutasignificantincreaseincosts.WayneKaton etal.,“Cost-effectivenessofImprovingPrimaryCareTreatment of Late-LifeDepression”,ArchivesofGeneral Psychiatry,2005,62.

• PatientsparticipatingintheIMPACTprogramfortreatingdepressioninprimarycarehadlowermeantotalhealthcare coststhanusualcarepatientsduringafouryearperiod.JurgenUnutzeretal.,“Long-termCostEffects ofCollaborativeCareforLate-life Depression”,AmericanJournalofManagedCare,Vol.14,No.2,2008

• “Patientswhoreceivecare fordepressioninprimarycareclinicswithroutinementalhealthintegrationteamsandcareprocesseswere 54%lesslikelytousehigher-orderemergencydepartmentservices.”BrendaReiss-Brennanetal.,“CostandQualityImpactofIntermountain’sMental HealthIntegrationProgram”,JournalofHealthcareManagement,55:2,2010.

• Primarycare patientswithdiabetesandmajordepressionassignedtoaninterventionprogramincludingeducationaboutdepression,behavioralactivationandand achoicebetweenanti-depressantmedicationorproblem-solvingtherapyhad improveddepressionoutcomescomparedtotheusualcaregroupwithnoevidenceofgreater long-termcosts.Wayne Katon etal.,“Long-TermEffectsonMedicalCostsofImprovingDepressionOutcomesin PatientswithDepressionandDiabetes:, DiabetesCare,Vol.31,2008

• Whencomparingclientswiththehighestriskscoresenrolledinpatient-centered healthhomes(PCHM)vs.thosenotenrolled,thePCMHmodelwasshowtohaveasignificantreductionintotalcostsinthefirsttwoyears andsignificantlylowerclientadmissionsinthethreeyearsstudied.SusannahHigginsetal.,March,2014. Publishedon-line

TheSolution

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Primary Care

IntegratedCareDefinition

• Integrationofbehavioralhealthandphysicalhealthcarereferstotheintentional,ongoing,and

committedcoordinationandcollaborationamong

allprovidersandtheindividualintreatment.

Providersrecognizeandappreciatethe

interdependencetheyhavewitheachotherand

thepatient/clienttopositivelyimpacthealthcare

outcomes.(AgencyforHealthCareResearchandQuality(AHRQ))

Differenttypesofmodelsforintegrated

behavioralhealthhavechallenges

BH Med

BH Medical

BH

Medical

Referral

Coordination/partnership

Colocation

KeyFeaturesofSuccessfulModels

• Communication:Warmhandoffsvs.referrals

• Shiftinscopeandapproachtopractice: e.g.,Consultingpsychiatristvs.extendedevaluationwith

caseload

• Coordination: e.g.,PCPprescribingvs.twoprescribers

• EngagementandActivation: Recoveryorientationandpatientselfmanagementskills

• Datadrivencare: e.g.,Dataanddocumentation

sharing;outcometracking

TwoRolesofBHProviders

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Food MartMH/SU

BehavioralHealthinPrimaryCare

Embeddedmentalhealthandsubstanceuseservicesinaprimarycareclinicwiththeabilitytoaddressneedsofpersonswithmildto

moderatebehavioralhealthdisorders

PC

Food Mart

MH/SU

BehavioralHealthSpecialtyCentersofExcellence

Apartnerwithmedicalhomes,providinghighvalue,wholehealth-

oriented,specialtycaretoindividualswithcomplex

behavioralhealthconditions

PC

IntegratedCareisMovingintheRightDirection,but

hasChallenges

• Lackofknowledgeandexperiencewithvaluebasedpurchasing(ratherthanvolume)andconnectionto

outcomes

• Disconnectbetweenbeliefinrecoveryphilosophyandexpectationsforpatientoutcomes

• Perceivedandrealbarrierstodatasharing• Stigmatowardspatientswithmentalillnessand

addictionpersistsamongmedicalproviders– creating

barrierstoaccessandtreatmentfollowthrough

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NewModelsofCareareChangingFasterthan

WorkForceSupply&Preparedness

• Mostprovidersreceivelimitedtrainingonworkinginteams;

happens“onthejob”

• MHprovidershortages– CAruralcounties(OSHPD,2011)

• DemandforMH/SUsocialworkersisprojectedtoincrease

by22.8percentand35.4percent,respectively,from2006to

2016(CaliforniaEmploymentDevelopmentDepartment)

• MedicalandBHfieldshavedistinctlydifferenttraining

programs,professionalcultures,andtreatmentapproaches.

• BHproviderslagbehindmedicalprovidersintheircapacity

totracktreatmentoutcomesandusedataforclinical

decisionmaking

Consumersfeelstigmatizedbyhealth

providers

• Orientationofprimarycareisreactive– which

detersclientsreluctantorunabletoseekhelp

• Physiciansinexperiencedinwithmentalhealth

workmayresistgettingfurtherinvolvedwitha

clientbynotactivelyaskingaboutsymptoms(M.

Phelan,2001)

• Crampedschedulescanlimit timephysicianshave

todiscussbehavioralhealthissueswithclients

• Subtleornotsosubtlejudgmentsand

communicationaboutpatients’mentalhealthand

substanceuseissues

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Whystigmashouldmatterto

providers

• Issueswithmedicationadherence

• Drop-outsandnoshows• Access• Poorphysicalhealthoutcomes

• PatientExperience:Keycomponentandmeasurein

theTripleAim

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IBHaKeyStrategyforImprovingPatientExperience

• Researchevidence:IBHisaneffectivestrategytoreducestigmaandimproveaccesstobehavioral

healthservices,especiallyforvulnerable

populations

• A2005IOMreportconcludedthattheonlywayto

achievetruequalityandequality inthehealthcaresystemistointegratedprimarycarewithmental

healthandsubstanceuseservices

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*Ivbijaro,G.&Funk,M.(2008.)Nomentalhealthwithoutprimarycare.MentalHealthinFamilyMedicine,5(3),

September,127-128.

*Kautz C,Mauch D,andSmithS.ReimbursementofMentalhealthservicesinprimarycaresettings.Rockville:

CenterforMentalHealthServices,SubstanceAbuseandMentalHealthServicesAdministration,2008.

ChangingPolicyLandscape

HealthReformisPushingforSystemRealignmentto

ReduceCosts

Prevention,EarlyIntervention,

PrimaryCare,andBehavioralHealth

Inpatient&Institutional

NeededResourceAllocation

AllthingsInpatientandInstitutional

Prevention,PrimaryCare,BH

CurrentResourceAllocation

$$

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ExamplesofChangingIntegratedBehavioralHealth

PolicyLandscape

• Medi-CalExpansion:ExpandedroleofMCOsand

expandedpopulation

• ACASection2703HealthHome– Practice

Transformation

• CAMedi-Cal1115Waiver

• AccountableCommunitiesforHealth

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Medi-CalExpansionandExpandedBenefit

• Startedin2014,butsystemsarestilladjusting

• Newrelationshipsatthecountylevel– CountyBehavioralHealth,HealthPlans,Managed

BehavioralHealthOrganizations(e.g.,Beacon),

FQHCsandCHCs

• Emphasisplacedoncaretransitionsand

maintainingcontinuityofcare– e.g.,hospitalto

community

• Accelerationofnewintegratedcaredeliverymodels,e.g.team-basedcare

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ACAà PracticeTransformation

• Integrated,CoordinatedCare,e.g.Patient-CenteredMedicalHome(section2703)

o Growingawarenessoftheconsequencesofuntreatedmental

healthandSUDneeds

o RecognitionofneedforIntegration/Person-Centered/Whole

PersonCaretoachieveTripleAim

o Increasedrecognitionoftheroleofhousing;needtodevelop

newpartnershipswithnon-medicalproviders(HousingFirst)

o Parity

• ImplementationdelayedinCAuntil2018,butit’sstill

importanttoinvestincapacityandinfrastructure

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Medi-Cal1115WaiverComponents

• Shiftfromfee-for-servicetoGlobalPayment

Programforservicestotheuninsuredindesignated

publichospitalsystems

• Deliverysystemtransformationandalignment

incentiveprogramforpublicandmunicipal

hospitals

• WholePersonCarePilots totargetmoreintegrated

careforhigh-risk,vulnerablepopulations

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ChallengesintheNewPracticeEnvironment

• SignificantprogressinpracticeandsystemtransformationinCAandnationallythatprovidestrongevidencebase,BUT thereareissueswithsustainabilityandspread• Infrastructureandworkforce(andpracticeculture)challengesinachieving:

² Integrated,teambasedcarewithallmembersworkingtothetopoftheirlicense,delegatingactivitiestodifferentteammembers,asappropriate

² Improvedpopulationmanagement² BetterimplementationanduseofHIT,e.g.,QItrackingof

treatmentoutcomes

² Paymentreform(e.g.,valuebasedpurchasing)

² Shiftingfromdatacollectionforcompliancetousingdataforaccountability

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KeyReformIngredientà OutcomesMeasurement

• USbehavioralhealthsystemismovingfrom50states

(50setsofrules)toanationalqualityframeworkfor

BH

• BUT– therearecurrentlymanydifferentquality

measuresrelevanttoBH(noclearconsensus):

o116 indraftNBHQFo64inMeaningfulUseset

o44inthePhysicianQualityReportingSystemo37intheSAMHSAStateURSset

o28intheFQHCUDSset

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ChangingtheFrame:Collective

Impact

TheCollective

ImpactFoundation

• CollectiveImpactisthecommitmentofa

groupofactorsfrom

differentsectorstoa

commonagendafor

solvingaspecificsocial

problem,usinga

structuredformof

collaboration.

Kania &Kramer,CollectiveImpact,

StanfordSocialInnovationReview,2011

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IsolatedImpact:TheCollectiveImpactFoundation

• Whatweknow…

• IsolatedImpact:

o TheprevailingmodelofhealthandhumanservicesintheUS.

o Historicallypromotedbypayorsandfunders.

o Hasresultedinthedevelopmentofover1millionUSnonprofitorganizationsdevotedtoisolatedimpact.

• IsolatedImpactDefinition:Effortstoeffectivelyaddressahealthorsocialproblembycontractingwithorganizationsthatspecializeinthatparticularproblem.

• Problem:ComplexSystemswithmanyinterconnectedcomponentsdoNOTrespondwelltoisolatedimpact.

• Reality:Thepeople,families,andcommunitiesyouworkwitharetheposterchildofComplexSystems.

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5CollectiveImpactComponents

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AccountableCommunitiesforHealth

• Emergingstrategyforimprovingpopulationhealth

• ACHsintegratemedicalcare,behavioralhealthcare,andsocialservicesupportstoimprovethesocialdeterminantsthatshapehealthandwellbeinginageographicalarea

• Collectivelyengagemajorhealthcareprovidersacrossageographicareatooperateaspartnersratherthancompetitors

• Focusesonthehealthofallresidentsinageographicarearatherthanjustapatientpanel

• NewInitiative:TheCaliforniaAccountableCommunitiesforHealthInitiative(CACHI)willassessthefeasibility,effectiveness,andpotentialvalueofamoreexpansive,connectedandprevention-orientedhealthsystem

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Prevention EarlierIntervention

ModerateConditions

HighNeed/ChronicConditions

Commun

ityClinical Screening

ACES

SBIRT

PHQ-9

Primary,Coordinated

Care

CommunityPrograms(schools,

CBOs)

PrimaryandSecondaryPreventionWellness

Interventions–Smoking,Food

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ChronicHealth/HighUtilizers

SnapshotofInterventions,EntryPoints,&PopulationHealth

Upstream Downstream

AsthmaandDiabetes

TheWorkYouDoisEssential…

• Allofthisisnewandnobodyhasthealltheanswers!• Theonusisonallofustoadvanceintegratedprimary

care,mentalhealth,substanceuse,andotherperson-

centeredservices(e.g.,dental,socialservices,and

housingsystemofcare).

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