“Healthcare Reform”Preparing for the Change

Mental Health Association of New York StateOctober 26, 2011

“To mind one's P's and Q's; to be attentive to the main chance.”

The Dictionary of the Vulgar Tongue

Francis Grose, 1785 ed.

Ps & Qs

1. Pillars2. People3. Players & Plans4. Promotion5. Questions

Ps & Qs

1. Pillars of

Healthcare

Healthcare Reform Why Now?

Cost --Contain costsQuality -- focused on

outcomesAccess -- timely, right service

at the right time

Pillars of Healthcare

Spending on mental illness grew faster than for heart disease, cancer, trauma-linked disorders & asthma Americans seeking treatment for mental health conditions almost doubled, from 19M to 36M Treatment cost for mental disorders rose from $35B to nearly $58B between 1996 and 2006 Antidepressant use among U.S residents almost doubled from 1996 to 2005.

AHRQ data (HHS Agency for Healthcare Research and Quality-August 2009.

August 6, 2009 — Anne Ziegler (Fierce Health)

Cost

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Cost of Health & Mental Health

Among the most expensive 1% of Medicaid beneficiaries (acute care only)

Almost 83% have three or more chronic conditions

Over 60% have five or more chronic conditions

And most of them are in unmanaged fee-for-service

Source: Kronick RG, Bella M, Gilmer TP, Somers SA, “The Faces of Medicaid II: Recognizing the Care Needs of People with Multiple Chronic Conditions.” Center for Health Care Strategies, Inc. October 2007

Purchasers (employers or government) seek value for health care expenditure & managed care companies to deliver: Member satisfaction Positive clinical outcomes and recovery Timely access to needed services Controlling the rate of cost increases Targeting scare health care dollars to the

High Risk/High Cost/High Need members.

Quality

Timely Culturally responsive Right service, right time, right

LOS, right reason

Access

Quality

20 Years:Research to Practice

18 Months: Technology Change(Data)

“ …knowing which treatments work won’t matter unless we know how to target the interventions to the people who will benefit most….In the absence of such knowledge we risk treatment decisions guided by accessibility to resources rather than patient needs.”

Psychological scientists Varda Shoham, Ph.D., and Thomas R. Insel, M.D.Perspectives on Psychological Science.

Source: Association for Psychological Sciencehttp://psychcentral.com/news/2011/09/14/mental-health-care-reform-urged-by-top-

scientists/29412.html

Cost, Quality & Access

Practice Models: what types of interventions work — and for whom

Healthcare Reform Why Now?

2. People

1 in 4 Americans has a diagnosable mental disorder 6% of Americans have a serious mental illness, e.g. Bi-polar disorder or schizophrenia 50 million children and adults in this country are diagnosed every year with mental illness People with diabetes, heart disease, asthma & cancer are at greater risk of becoming depressed.

http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_862051.html

Incidence of Mental Illness & Medical Conditions

If you are depressed & have asthma, diabetes, heart disease or cancer your are:

2X as likely to develop cardiovascular disease and stroke, 4X more likely to die within six months of a heart attack 3X more likely to be non-compliant with your treatment.

http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_862051.html

The Case for Health Homes

Healthcare Reform Why Now?

3. Players & Plans

DOB & DOH OMH & OASAS Managed Care Companies Providers Counties Peers/Recipients All are advocates

Who Are They

In challenging economic times States move more aggressively to manage costs. States have 3 ways to manage costs

Restrict eligibility, which is prohibited under the federal health care reform initiative

Cut benefits-vision, dental, pharmacy, etc. Cut provider payments

Managing State Medicaid Costs

The Economist-April 2011

Managed Care Health Homes ACOs Service Limits Regulatory Reform

Addressing System Stressors

CA & NY are moving the elderly and disabled into a managed care system

Second step in Managed Care - integrate the dual eligibles into MC

Dual eligibles account for 40% of Medicaid’s cost and just 15% of the population.

Future of Medicaid

The Economist-October 2012

If the managed care system works as designed, doctors (health care professionals) can monitor all aspects of care, in contrast to the fragmented fee for service system.

If states do not draft their contracts properly or fail to be vigilant in monitoring patient’s health, their experiment in managed care could be a disaster.

Future of Medicaid

The Economist-October 2012

To limit the financial exposure of the state Design and manage systems of care To bring together health care financing and health care service delivery into one operating system Manages data for quality monitoring, to track & trend utilization, etc. Use of clinical outcome measures and use of standardized measures to track progress

Why States Use Managed Care

Health Homes & ACOsNCCBH -http://www.thenationalcouncil.org/galleries/default-file/ACOs%20and%20Health%20Homes%20Exec%20Summary.pdf

Health Homes & ACOs are responsible for providing the full range of healthcare services needed by the populations they serve

Goals are to improve quality, patient experience, & reduce costs

MH/SU providers are urged to prepare for participation in the larger healthcare field

Ensure IT readiness of providers

ACOs

Final Federal Regulations published Oct 20 Decreased quality measures from 65 to33 Re: ACO regulations,

"But fundamentally, most health systems continue to struggle with the fact that their present operations are oriented toward billing per service, and not taking on risk and responsibility for quality."

Dan Mendelson, CEO Washington-based consulting firm Avalere Health

Oct 20, 2011

Life improvements, e.g. community tenure, education, jobs, housing, etc.

Services in least restrictive settings Decreased use of ER & avoidable

inpatient and residential stays Customer satisfaction with personal

goal achievement

Quality Outcomes

4. Promotion

Healthcare Reform Why Now?

Components of Managed Care

Benefits designed by the purchaser, e.g. the state in Medicaid or the insurance company with approval by the employer group

Networks are built for Access & to: Meet geo-access requirements Provide timely access to ambulatory

services, e.g. medication management Provide the “right” level of care to

support recovery & build on strengths

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Services not Programs

Services Individual Therapy Group Therapy Medication Therapy Detox Case Management Care Coordination Peer Support

Interventions Assessment Treatment Planning Discharge Planning Medication

Therapy/Education/Monitoring

Verbal Therapies Assistance with ADLs Safety Planning

Services & Interventions vary by: frequency, duration & location of care--in other words, the program

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Members & Money in Managed Care

Members: Who is in Adults Adults with SMI Children Dual Eligibles

Who gets served

Money: What is in Medicaid Grant Dollars Other State & Local

Money

Preserve the base funding

Less about the Models: Carve In or Carve Out

People Pillars: Cost, Quality & Access Players & Plans

Services not Programs Evidence based practices Measurable outcomes Care coordination Recovery Follow the Money not the Model

Opportunities

What MHA knows….

Questions

Ann Boughtin615-498-4398

boughtin@boughtinandorndoff.comwww.boughtinandorndoff.com