Implementing Value-Based Sustainable Behavioral Health in Patient-Centered Medical Homes:

Beyond the Co-Located Generalist Model

Rodger Kessler, PhDRoger Kathol, MDFrank deGruy, MD

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # D5a October 17, 2015

Rodger Kessler has no relevant financial relationships or conflicts of interest.

Frank deGruy has no relevant financial relationships or conflicts of interest

Cartesian Solutions, Inc.™

Employment, Direct Relationship Consulting--Direct Relationship

Ownership--Direct Relationship

Case Management Society of America

Chief Medical Office/Board Advisor

Faculty Disclosure

Roger Kathol, M.D.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• List three principles that lead to the successful integration of behavioral healthcare into primary care.

• Identify two common errors in created integrated practices.

• Discuss how the financing structure affects the prospects for successful integration.

Learning Assessment

• We will attempt to answer questions at the end of this presentation.

• In order for this session to qualify for CE credit, it must be evaluated. Please complete an evaluation form at the end of the session.

Introduction

• We know more than we do. There’s lots of room for improvement.

• This is an expensive problem, and addressing it will pay for itself.

• There’s mounting pressure to address this problem.

• It requires changing some long held beliefs

The Problem

• A very small minority of patients with behavioral problems are identified & effectively treated.

• Most PC practices are already overextended.• Most PC practices don’t use evidence-based care.• Most don’t have primary care trained BHC on staff.• Savings don’t accrue to the PC clinic, making this locally

expensive.• Referral out doesn’t work.• Hiring the least expensive BH also professionals doesn’t work.• Resources aren’t matched to problems.

Implementing Value-Based Sustainable BH in PCMHs

(The Business Case)

Cartesian Solutions, Inc.™ ©

Roger Kathol, M.D.President, Cartesian Solutions, Inc.™

Adjunct Professor, University of Minnesota, Minneapolis, MN(roger-kathol@cartesiansolutions.com)

Cartesian Solutions, Inc.™ ©

Post-ACA Healthcare

3.Providers

Med Home

1.Purchasers

Triple Aim: Better Health Care, Better Outcomes, Lower Cost

--Vendors--Organizations

--Regulators--BH “Resources”

Med

Med

--adapted from Kathol & Gatteau, Healing Body AND Mind, 2007

Body

PublicPrivate

BHBH Home

2.Fund

Distributors

Accountable Care Organization

(Mind?)MindBH

3.2.

Clinically Integrated Network

Network IT System, Team Culture, Care Coordination, and Administrative Oversight

Medical Home

Specialty ClinicsHospitals

Ancillary Services

Contracted Vendors

--BH -- Pharmacy -- Lab, X-ray -- Other Cartesian Solutions, Inc.™ ©

Cartesian Solutions, Inc.™ ©

Perceived Value of Separate BH System

• Protects BH funds• Maintains BH autonomy• Retains independent decision

making power• Safeguards privacy• Provides better BH care

Cartesian Solutions, Inc.™ ©

Reality of Separate BH System

• Protects funds greater BH losses during housing bubble, state budget shortfalls, sequestration

• BH autonomy care fragmentation• Decision making insular; parochial to health• Privacy stigma; poor health outcomes• Better care 75% with BH illness receive no

treatment; 13-25 years shorter survival

Seventy-five Percent of BH Patients Are Seen in the Medical Setting

Medical Outpatients

Medical Setting

BH Patients Seen in the BH Sector (25%)

Medical Inpatients

Health Complexity

Chronic Medical Illnesses

BH Patients Seen Primarily or Only in the Medical Sector (75%)

95% BH Providers

Mental Health Sector

Cartesian Solutions, Inc.™ ©

Cartesian Solutions, Inc.™ ©

Health and Cost Impact of Comorbidity & Integrated Care

All Insured $2,920 15% Arthritis $5,220 6.6% 36% $10,710 94% Asthma $3,730 5.9% 35% $10,030 169% Cancer $11,650 4.3% 37% $18,870 62% Diabetes $5,480 8.9% 30% $12,280 124% CHF $9,770 1.3% 40% $17,200 76% Migraine $4,340 8.2% 43% $10,810 149% COPD $3,840 8.2% 38% $10,980 186%

Cartesian Solutions, Inc.™--consolidated health plan claims data

Illness Prevalence

% with Comorbid BH Condition*

Annual Cost with BH Condition

Annual Cost of Care

% Increase with BHl Condition

Patient Groups

*Approximately 10% receive evidence-based BH condition treatment

Cartesian Solutions, Inc.™ ©

Claims Expenditures for Patients With and Without BHCondition Service Use

7,5758,201

2,649

7,284

– Thomas et al, Psych Serv 56:1394-1401, 2005

7,847

5,732

BH Transition Options--The Challenge

Health Outcomes Cost Outcomes

1. Do Nothing

• Poor BH access• Retarded medical illness

improvement due to untreated BH comorbidity

• Unfavorable BH finances• Comorbid medical patients: 1 day longer

ALOS, >$6M for sitters, ~30% higher 30-day readmissions; ~$22M+ in extra service delivery costs

2. Buy Traditional

BH

• BH access• Small impact on medical sector

outcomes

• More unfavorable BH finances• Similar cost outcomes to above since

value-added BH not possible in medical setting

3. Build BH into Medical

• BH access in medical setting• Medical/BH provider

communication; patient satisfaction

• inpatient and outpatient care coordination and medical and BH outcomes

• Better payment for BH services from medical benefits

• Gap closure on ALOS, sitter use, 30-day readmissions, cost/net margin for general medical patients with BH comorbidity

Cartesian Solutions, Inc.™ ©

Cartesian Solutions, Inc.™ ©

The Transition to Non-Traditional BH Care and Care Support

3.Med/BH

Med Home

1.Purchasers

Health CareOutcome Change

--Vendors--Organizations

--Regulators

Med/BH

Body

PublicPrivate

BH

2.Fund

Distributors

Accountable Care Organization

Mind2. contracting for BH services as part of medical benefits; 3. BH clinicians part of medical provider network; Patients--integrated medical and BH services

Referral

Medical Practice

Behavioral Practice

Medical Practice

BHBehavioral

PracticeMed

Medical & Behavioral Practice

Model 1: “Cross-Referral”

Model 2: “Bidirectional”

Model 3 “Integrated”

Patient sorting

(75% of BH Patients)

(75% of BH Patients)

Specialty BH Setting(10% of BH Patients)

(90% of BH Patients)

Manderscheid & Kathol, AIM:160, 61-65, 2014 Cartesian Solutions, Inc.™ ©

The Problem

• A very small minority of patients with behavioral problems are identified & effectively treated.

• Most PC practices are already overextended.• Most PC practices don’t use evidence-based care.• Most don’t have BHC on staff.• Savings don’t accrue to the PC clinic, making this locally

expensive.• Referral out doesn’t work.• Hiring the least expensive BH also professionals doesn’t work.• Resources aren’t matched to problems.

Recommendations

• Reconsider which services for which patients.– First casefinding efforts for high-risk, high-cost

patients. Comorbidity, high utilizers, rather than universal screening.

– Deploy resources in a fully integrated fashion. More on this later.

– Employ BH clinicians with the skill and training to handle the most difficult problems.

– Stepped care.

Seven Principles of Integrated Care 1

Make BH clinicians part of medical team. Pay for them with medical benefits.

Seven Principles of Integrated Care 2

Use a common EHR, registries, and claims data. One panel. Pull complex patients from that registry.

Seven Principles of Integrated Care 3

If possible, create teams, or subteams. Construct teams with skillsets that match problems in subpopulations.

Seven Principles of Integrated Care 4

Match levels of clinicians to severity of problems, then step care up if improvement doesn’t occur.

Seven Principles of Integrated Care 5

Prospectively define desired health outcomes and treat to target, evaluating frequently.

Seven Principles of Integrated Care 6

Use evidence-based algorithms and protocols as standard of care.

Seven Principles of Integrated Care 7

Use care coordinators to create a whole-person care plan.

Implications

• Single budget, single source of accountability for overall health.• Targeted screening, stepped care—biggest steps for efficiency.• Whole team—whole person care. Avoids mishaps of fragmented

care (ED, etc.)• Effective clinicians are less expensive in the long run.• Biggest savings with most expensive patients.• Evidence-based care best chance of improving.• Care managers heal fragmentation.

But!

It all depends on a new kind of contract with plans or payers and embracing a new care model

The change in care model

• Behavioral case-finding and treatment resources focus on patients with chronic medical conditions, eg, diabetes mellitus, asthma, coronary artery disease, and those patients with high health care costs, rather than conduct universal screening of all patients for behavioral problems

The change in care model

• Treatment resources should be deployed in a fully integrated fashion rather than collocated practices providing specialty mental health and substance use care

The change in clinical focus

• Behavioral clinicians involved in care and PCMH care support need training and experience to deliver evidence-based behavioral treatments proven effective at improving targeted conditions

Summary• Payment needs to be integrated or PCMH targets cannot

be met• EHR screening is used to identify high-need, high-cost,

and “complex” patients • Team care to reduce both behavioral and medical issues• Behavioral clinicians need to have expertise to provide evidence-based care• Use limited resources to focus on patients with

expensive, reversible conditions• This is not behavioral health care, it is behavioral care. • Trained cross-disciplinary care managers need to

coordinate care across the medical-behavioral continuum

Session Evaluation

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monitor before leaving this session.

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