Pitching Value: Negotiating Better Rates by Telling a Compelling Story to Payers Anna Ratzliff, MD, PhD TCPI National Faculty – Lead Trainer APA-SAN Associate Professor, University of Washington Dept. Psychiatry and Behavioral Sciences Director, AIMS Center & UW ICTP annar22@uw.edu Part 1 “Behavioral health is a foundational part of healthcare transformation because there is no health without mental health.”

Mental Health in Primary Care Settings Hospital CMHC Specialty Care Collaborative Care Brief Behavioral Interventions Primary Care Patient Self-Management COORDINATION

Outline of Performance Story Who we are as a high performing practice Our patient population segments and, for each, the metrics and management approach we are using to drive performance Our results that makes us high value to payers and patients As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable The culture responsible for our high performance

Outline of Performance Story Who we are as a high performing practice Our patient population segments and, for each, the metrics and management approach we are using to drive performance Our results that makes us high value to payers and patients As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable The culture responsible for our high performance

Our Practice State-wide Collaborative Care program Mental Health Improvement Program (MHIP) Behavioral Health Improvement Program (BHIP) State-wide Collaborative Care program Safety-net practices/FQHCs Started in 2008 >50,000 patients served to date UW primary care clinics- now 19 Mixed payer population Started in 2011 4660 indirect/ 8717 direct patient assessments to date Part 2

Our Practice 1.0 - 3.0 FTE care manager Variable number of PCPs ~3-20 Mental Health Improvement Program (MHIP) Team Behavioral Health Improvement Program (BHIP) Team 1.0 - 3.0 FTE care manager Variable number of PCPs ~3-20 0.2 FTE psychiatric consultant 1.0 FTE care manager ~ 5.0 FTE PCPs 0.2 FTE psychiatric consultant Part 2

Outline of Performance Story Who we are as a high performing practice Our patient population segments and, for each, the metrics and management approach we are using to drive performance Our results that makes us high value to payers and patients As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable The culture responsible for our high performance

Population Served 1500 patients 1 PCP with 10% of the population with mental health needs Insured Population  ~2% enrolled = 30 patients 0.5FTE care manager 0.05FTE psychiatric consultant Safety-Net Population  ~5% enrolled = 75 patients 1.0FTE care manager 0.1FTE psychiatric consultant

Our Metrics Number of patient with behavioral health needs served with Collaborative Care Model Depression Remission or Response: % of patients showing response or remission of depression symptoms using the PHQ-9 https://www.ncqa.org/hedis/measures/depression-remission-or-response-for-adolescents-and-adults/

Outline of Performance Story Who we are as a high performing practice Our patient population segments and, for each, the metrics and management approach we are using to drive performance Our results that makes us high value to payers and patients As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable The culture responsible for our high performance

High Performance Areas: MHIP Initial results from pilot showing taking a long time for patients to show improvement in depression Pay for performance on process measures Complete initial assessment Meet with psychiatric consultant weekly and obtain indirect assessments on all patients not improving Half of caseload had to receive 2 contacts per month Population management target = 50% of patients show improvement on PHQ-9 Part 3 and 4

MHIP: Pay-for-performance cut in half the median time to achieve improvement in 50% of patients. We get patients better FAST! © University of Washington AFTER P4P: ~ 26 week s to 50% of patients to improve BEFORE P4P: ~68 week s to 50% of patients to improve Unützer et al., 2012

BHIP: High Performance Areas Population management target >50% of patients show improvement on PHQ-9 Estimated costs savings: defined as medical care cost savings per patient enrolled

BHIP: High Performance over 4 years 2012 2013 2014 2015 Number of Clinics 10 12 15 Number of Patients Enrolled 262 771 763 705 Average PHQ-9 at First Assessment 14.5 13.5 12.9 Indirect Psychiatric Consultations 231 1505 1087 1417 Face-to-Face 320 2346 2394 3044 Percent of Patients Improved 81% 68% 64% 63% Estimated Cost Savings $340,000 $1,002,000 $991,900 $916,500

Outline of Performance Story Who we are as a high performing practice Our patient population segments and, for each, the metrics and management approach we are using to drive performance Our results that makes us high value to payers and patients As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable The culture responsible for our high performance

Effective Collaboration COLLABORATIVE CARE © University of Washington Effective Collaboration Prepared, Pro-active Practice Team Informed, Active Patient Outcome Measures Treatment Protocols Population Registry Psychiatric Consultation Unützer et al., 2002, 2004

Behavioral Health Services Available Assessment and treatment planning by team Indirect case-reviews by psychiatric consultant Tele-video assessment as needed by psychiatric consultant Care Planning Patient tracking of all active patients by care manager Relapse prevention planning by care manager Facilitated referral to specialty mental health by care manager Care Management Primary care provider prescribes medications Supported by psychiatric consultant and care manager Medication Prescribing Psychosocial support delivered by care manager Brief behavioral interventions delivered by care manager Psychotherapy Intervention

Outline of Performance Story Who we are as a high performing practice Our patient population segments and, for each, the metrics and management approach we are using to drive performance Our results that makes us high value to payers and patients As a service delivery system, what we have in place or have put into place that is most responsible for producing high value performance that is sustainable The culture responsible for our high performance

Using Data to Manage Performance Registry tool allows practice to track patient data and response to treatment Visits Indirect assessments Graphs of measures Clinic level data Caseload number Processes ( ex. Completed clinical assessment) Outcomes (ex current number of patient with clincial improvement)

Individual Patient Records: Measurement-Based Treatment to Target Part 5 Regular use of behavioral health measures to track response to treatment Use of psychiatrists to help intensify treatment Stepped care makes efficient use of behavioral health resources

Caseload Registry: Population Based Treatment

Clinic Level Summary: Continuous Quality Improvement Care Manager 1 Manager 2 © University of Washington Part 5 This example shows is summary data from a web-based registry which shows aggregate data from two different care manager caseloads, Care Manager 1 and Care Manager 2. In this particular situation, the team was regularly reviewing the data and making observations. If you call your attention to the red box, both of these care managers were having a positive impact on their patient populations with respective improvement rates of 49% and 68%. Although both of these are good numbers, it is notable that Care Manager 2 was able to obtain higher improvement rates than Care Manager 1. So the clinic manager sat down with these two care managers and looked at the data with them. One of the things that the clinic manager noticed was that Care Manager 2 was having almost twice as many follow-up contacts as Care Manager 1. This was a really important observation. In digging a little bit deeper, the clinic manager found that Care Manager 2 conducted a lot more phone contacts than Care Manager 1. One hypothesis was that the increased availability and frequency of engagement with the patients might be driving some of those higher outcomes. When the team reviewed this information and spoke to Care Manager 2, what they found was that every time Care Manager 2 had a cancellation or a no-show patient, she would pick up the phone and make 2-3 phone calls to patients that hadn’t come in. By doing this, she was getting in a lot more phone contacts with those patients that were falling through the cracks: she was able to deliver PHQ-9 screeners, and she was also able to engage patients in both coming back in and assessing how their treatment was going. So a typical quality improvement effort that you might be able to implement when you see data like this is to train up Care Manager 1 to follow the same protocol, and then you could observe over time: is Care Manager 1 able to have more phone visits, and does that in fact drive better patient outcomes? This example illustrates the commitment to regularly using data to look at the care delivered and commit to continuously looking for opportunities to improve it. This idea can be useful no matter what type of practice you are currently working in.

Data Workflow Individual Patient Records Care Manger Caseload Registries Clinic Level Summaries

More than 50% of our patients enrolled in CoCM experience depression response or remission This meets national and published standards. We can deliver this care for over 700 patients a year. We can track and report these results using our robust data workflow strategy and registry.

Example Assertion “Readmission rate for our patients is at 8 percent.” Clarification of the Number 2,000 of our 30,000 patients were admitted and discharged from the hospital in 2017. Their 30-day readmission rate was 8 percent of all discharged patients. (160 readmitted) Assertion of Exemplary Performance Our 8 percent readmission rate is consistently at a State benchmark level for our patient population. Rates at other hospitals in the State range from 12 percent to 15 percent for the age groups represented. Our Care Transition Program consistently produces this low rate. In 2017, we had 80 fewer readmissions than we would have expected with a 12 percent rate. That represents an estimated $800,000 in avoided billing. Our quality improvement program verifies that about 90 percent to 100 percent of the current 8 percent readmission cases are not avoidable. We are close to as low as one can go.

Additional Tips Focus on results rather than the journey. Develop first person stories that are compelling and exciting . Use population targets that set benchmarks, not simply a level of improvement. Make the numerical statements of performance clear and complete. Note patient ownership of and satisfaction with performance.

Other Types of Performance Process Outcomes Close follow-up (Minimum 2 contacts/month) Regular use of behavioral health measures (PHQ-9) Psychiatric consultation if patient not improved Clinical Outcomes PHQ-9 (depression measure for screening and tracking) GAD-7 (anxiety measure for screening and tracking)

Other Value Propositions Patients Why should patients seek care at your organization? Providers Why should a provider want to work in your organization? Community Why should the community partner with your organization?

Think about the Quadruple Aim Better Patient Experience Better Patient Outcomes/Population Health Better Provider Experience Reduced costs/Responsible Spending

Questions?