11 Managed Care and Integration May 19, 2011

22 Managed Care and Integration How One Organization Is Approaching This Dynamic Change To Current Practices Robert B. Baker, MD, MMM VPMA, MHS- Indiana Bernard T. Engelberg, MD Medical Director, Cenpatico

3 What is Integrated Care? (Managed Care View) Is Coordinated Care Integrated Care? –What do you think coordination means? Shared information, shared treatment plans, more than one person deals with the patient’s problems How does it actually look? How does it function? Is Co-Location Integrated Care? Where do functional impairments stop and mental impairments begin? Can PH practitioners treat SMI? Can BH practitioners treat PH problems? Medications? Information sharing?

4 Why is this important? Comorbidities are common - >25% Only 5% see a mental health provider 80% see a PMP Disproportionate needs in minority populations Paradoxical decrease usage in refugee populations

5 Importance of Screening According to a NAMI survey: 13% of youth aged 8-15 live with mental illness 21% of youth aged ½ of all cases of mental illness begin by age 14 Average delay of 8-10 years from the onset of symptoms to intervention Fewer than ½ of children with a diagnosable mental illness receive services in a given year

6 What are our goals? Synergistic decrease in utilization (cost) –Cherokee model – 28% decrease in medical utilization –27% decrease in psychiatry visits –34% decrease in psychotherapy –48% decrease in mobile crisis team encounters Improved Health Outcomes –May increase mental health cost for the episode of care –Overall morbidity may decrease –Quality of care can increase

7 Treatment Barriers Substance Abuse Psychological Components of Physical Illness Nonadherence Unhealthy Behaviors Social Support Gaps Hierarchy of Needs Cultural and Linguistic Issues

8 What is the current state of affairs? Not enough mental health providers to supply demands Not enough PMPs – at least 15,000 FTE short in the US for current demand Estimated 50,000 FTE shortage for a fully insured population Staff productivity

9 Cross-Training AHEC interest Expanded curricula UMass program HRSA training and funding Use of mental health grants Use of standardized screening and assessment tools Speaking the same language

10 Documentation EHRs Outcomes measurement (SF-12, others) Health Information exchanges Define shared data sets Improved reimbursement

11 Who are the players? MCEs –Case Managers Integrated Health Systems CMHCs OMPP Medical Homes (co-located, embedded) –Patient Navigators, Care Managers Getting Everyone To Talk With Each Other –In The Weeds –IPHCA

12 What are the barriers to a more integrated system? Promoting co-located care Promoting truly integrated care Credentialing Integrated treatment plans Shared information –Many release forms available

13 What can be done? MCE Level –Case Management –Telephones –Disease Management – stratification of risk –Toolkits –Facilitated follow-up appointments CMC Level –Written Referral Arrangements with FQHCs State Level –Full range covered services

14 Integrated Level Embedded BH practitioner on primary care team Integrated clinical record and treatment plan BH screening of the primary care patient – normalizes the illness Multidisciplinary meetings Clinic redesign Coordination with wrap-around care Seamless transition across settings (e.g. hospital to outpatient) Shared knowledge about resources (parents and patients want this – not just a prescription!) - Binders, handouts, referrals, support groups, community services

15 Financial Barriers Telemedicine Treatment Team Meetings Co-management Brief Consultation Same Day Restrictions on Billing Use of Mid-levels Reimbursing SBIRT

16 Financial Solutions No carve out Determine proper coding, e.g psych vs medical Telemedicine reimbursement Demonstrating ROI

17 Regulatory Solutions State decision on claims policy – modifier codes Privacy concerns

18 Legal Barriers HIPAA interpretations

19 Solutions to Legal Issues Health Coordination forms –Auditing continuity of care

20 …so why integrate? Each year up to 30% of Adults meet criteria for a mental health problem Up to 70% of children and adolescents in need of MH services do not receive them Undiagnosed SA disorders impact PH. MH problems 2-3x more common in chronic medical illnesses Untreated MH issues lead to functional impairment

21 What Needs to Change in Primary Care? Role of CMHCs in a Patient Centered Medical Home Redesign of practices that permit identification of MH/SA issues Monitor MH outcomes Coordinate treatment more closely with MH specialists

22 Role of CMHC Integration; not just collaboration “Stepped Care” matching patient’s needs to services provided Availability – office visits and telephone SA and dual diagnosis solutions Integrated “piggy-back” hand-offs

23 Crucial Links PCPs need tools for MH/SA identification Case managers/Care Coordinators needed for patient success PCPs need to know what help is available upon SA/MH identification EHR availability to all involved parties Education on outcomes measurements Assessment of system efficacy

24 Bringing It Together (MCE view) Health Risk Screening Patient Analysis - leveling tools Intensive Case Management Care Management Payment Strategies