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![Page 1: Start-up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the ACT Program Deborah Cohen, PhD, Associate.](https://reader034.fdocuments.in/reader034/viewer/2022051620/56649eff5503460f94c1477f/html5/thumbnails/1.jpg)
Start-up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the ACT Program
Deborah Cohen, PhD, Associate Professor
Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.
Session # G5bOctober 17, 2015
![Page 2: Start-up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the ACT Program Deborah Cohen, PhD, Associate.](https://reader034.fdocuments.in/reader034/viewer/2022051620/56649eff5503460f94c1477f/html5/thumbnails/2.jpg)
Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships during the past 12 months.
![Page 3: Start-up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the ACT Program Deborah Cohen, PhD, Associate.](https://reader034.fdocuments.in/reader034/viewer/2022051620/56649eff5503460f94c1477f/html5/thumbnails/3.jpg)
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Understand and define basic terms used in assessing practice expenditures (e.g., start-up expenses, ongoing expenses, effort cost).
• Identify common start-up, ongoing and effort expenses related to initiating and maintaining and integration program.
• Discuss financial and effort expenditures in their own organizations, and identify the sources of these expenses.
![Page 4: Start-up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the ACT Program Deborah Cohen, PhD, Associate.](https://reader034.fdocuments.in/reader034/viewer/2022051620/56649eff5503460f94c1477f/html5/thumbnails/4.jpg)
References 1. Mclaughlin N, Burke MA, Setlur NP, et al. Timedriven activity-based costing: a driver
for provider engagement in costing activities and redesign initiatives. Neurosrug Focus 2014;37:E3.
2. Grazier KL, Smith JE, Song J, Smiley ML. Integration of depression and primary care: Barriers to adoption. J Prim Care Community Health 2014;5: 67–73.
3. Covell NH, Margolies PJ, Myers RW, et al. Scaling up evidence-based behavioral health care practices in New York State. Psychiatr Serv 2014;65:713–5.
4. Carey TS, Crotty KA, Morrisey JP, et al. Future research needs for evaluating the integration of mental health and substance abuse treatment with primary care. J Psychiatr Pract 2013;19:345–59. 5.
5. Monson SP, Sheldon JC, Ivey LC, et al. Working toward financial sustainability of integrated behavioral health services in a public health care system. Fam Syst health 2012:30:181-6.
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Background
• Behavioral health and primary care integration requires investment to implement and sustain
• Financial support for integration is a critical barrier to wide spread and sustainable adoption
• Published information on the level and type of expenses incurred in undertaking the transformation to integrate primary and behavioral health care is limited
• We report start-up and ongoing expenses across a variety of behavioral health and primary care integration interventions
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Purpose
To provide credible estimates of the start-up and ongoing effort and incremental practice
expenses for behavioral health and primary care integration interventions
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Methods• Practical expenditure data on health care interventions is
sparse in the academic literature
• Expenditures, where reported, typically do not isolate practice expenditures, include start-up expenses, or report expenditures in categories relevant to typical practice activities
• One study - the Prescription for Health program- developed a credible, standardized tool for capturing intervention-related expenditures at the practice level
• We applied this tool, with modest modifications, to the practices in the ACT
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Methods
• Setting: Advancing Care Together (ACT) • Sample: 10 of 11 practices participating in ACT• Study design: Comparative case study• Integration Interventions: Specific
interventions and practice characteristics varied across the ACT practices
• Time period for data collection: 2013-2014
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Methods – Data collection
• Flowcharts of site specific activities were used to create categories of intervention staff and activities
• This study took an intervention perspective– Each intervention attributed to a sponsoring practice
– Some involved joint efforts of separate BH and PC practices that shared resources to accomplish the intervention
– This study focused on expenses related to the start-up or delivery of the interventions regardless of formal organizational boundaries
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Methods – Data Collection• Staff members at each intervention helped with data collection• Staff members received a guidebook and four spreadsheets
– start-up– baseline, and – two for ongoing expenses
• We tailored the data collection instruments to the specific intervention and practice environment within the standardized format
• Data were collected at four points in time: start-up phase, baseline (month), and two times during ongoing intervention (month)
• Practice staff completed data collection tools, and iterated them with our team until they were complete, consistent, and accurate
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Methods - Analysis
• Study designed to provide information on type and distribution of expense levels that might be found in “real world” practices seeking to integrate care
• No a priori expectation that expense levels should converge on a mean
• Describe and explore the extent and nature of expenditure variation across different integration efforts and settings
– We present findings at the individual intervention level– As the means of interventions above and below the median (high /
low expense groups)– Overall, sample mean
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Analysis
• Start-up– General– Developmental
• Expenses– Ongoing– Incremental– Effort– Direct staff– Administrative staff– Non-staff direct– Overhead
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Analysis
• Start-up and ongoing expenses calculated and reported separately
• Start-up expenses were reported in total and the percentage of total that were developmental
• Ongoing expenses were reported as the average of the two sample ongoing months of data collection
• For each expense type, effort and incremental expenditures were calculated and reported
• Incremental overhead expense was estimated by calculating the ratio of new staff to total staff salaries and assigning that portion of non-staff overhead expenses as incremental
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Analysis• For each general expense category we calculated
and reported the following expenses:– Total– Staff (direct / indirect)– Non-staff (direct / indirect)
• Start-up expenses reported on a “cash” basis without asset depreciation
• Ongoing expenses are reported on an accrual basis (with depreciation of assets) and on a per patient basis to allow for more standardized comparison
• No adjustments were made for time or inflation
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Results
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Key practice characteristics
• Whether intervention employed systematic identification of need for BH or relied on clinical discretion
• Number of direct FTE involved
• Whether new staff were hired for the intervention
• Whether the intervention involved substantial capital asset purchase (e.g., IT, physical space investments)
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Results – Start-up expenses
• Start-up effort expenses for all practices and five highest/lowest start-up expenses were $44,076, $80,848, and $7,304– Difference in non-staff expenses and /or– Length of start-up
• Start-up incremental expenses for all practices and five highest/lowest start-up expenses were $20,788, $39,956, and $1,621– Difference in non-staff expenses
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Results – Start-up expenses
• Incremental start-up expenses where ~50% of total start-up for total and high start-up $ practices, <25% for low $ group
• Developmental start-up expenses represented ~40% of total start-up expenses for total/high/low start-up expense practices– Practices with highest proportion of
developmental expenses (>50%) had longest start-up period
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Results – Ongoing Expenses
• Ongoing effort expenses for all practices and five highest/lowest start-up expenses were $44.39, $62.89, and $17.88 per patient– Clinician discretion (high) vs. systemic (low) screening – Scale effects – more patients in systemic – Density of post-screening intervention activity – higher in clinician
discretion interventions • Incremental ongoing expenses for all practices and five
highest/lowest start-up expenses were $4.58, $8.19, and $0.03 per patient – New staff expenses key difference – Only 11%, 13%, and 0.2% of effort costs
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Limitations
• Self-reported data• Generalizability• Capturing incremental and
overhead costs
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Conclusions: Start-up
• Costs may be daunting or modest• Actual additional costs (incremental)
underestimate practice effort• Knowledge transfer mechanisms – learning
collaboratives, standardized interventions – could lower developmental and thus total start-up costs considerably
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Conclusions: Ongoing
• Incremental costs per patient do not likely to overwhelm system
• Effort costs are much more substantial• Payers will need to recognize and support
both to get wide spread adoption• Value based -as opposed to typical
incremental cost based- reimbursement may be best option
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Co-authors
• Neal T. Wallace, PhD; lead author and health economist
• Rose Gunn, M.A. • Arne Beck, Ph.D. • Steve Melek, MSA FAAA• Donald Bechtold, MD • Larry A. Green, MD
Wallace NT, Cohen DJ, Gunn R, et al. Start-up and ongoing practice expenses of behavioral health and primary care integration interventions in the Advancing Care Together (ACT) program. J Am Board Fam Med 2015;28:S86 –S97.
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Others we’d like to acknowledgePam Wise Romero, PhDMatt Engel, MPHShannon Tyson Poletti, MDMichele StewardGlenn Kotz, MDCandice TalkingtonJulie DeSaireCarol SchlageckCheryl Young, MA, LMFTLori Bryan, PhDLaura Engleman, MPHKatrin Seifert, PsyDCaitlin Barba, MPH
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Session Evaluation
Please complete and return theevaluation form to the classroom
monitor before leaving this session.
Thank you!