Integrating Behavioral Health and Primary Care Missouri Health Homes Integrating Behavioral Health and Primary Care

Paving the Way for Health Homes Missouri’s Health Homes Missouri is the first state to amend its Medicaid state plan to implement Health Homes. Statewide 36,000 enrolled Missouri will have three types of Health Homes Primary Care Chronic Conditions Health Home Federally Qualified Health Centers (FQHCs) Rural Health Centers (RHCs) Physician practices Community Mental Health Center Health Home Multi-Payer Person Centered Medical Homes This slide explains that Missouri is amending its Medicaid state plan to provide for the creation of Health Homes. Though we focus on CMHC Health Homes, it is important to recognize that FQHCs and RHCs may also be designated Health Homes since some CMHC consumers receive services from these providers. CMHC consumers will most likely be enrolled in CMHC Health Homes rather than FQHC Health Homes, since they receive the majority of their care from CMHCs. The Department of Mental Health has been working with MO HealthNet to amend the Medicaid state plan to create the opportunity for CMHCs to be designated as Health Homes for individuals with behavioral health problems, and we appear to be among the very first states to take advantage of this opportunity. The Medicaid state plan is also being amended to allow federally qualified health centers, rural health centers and some physicians practices to be designated as Health Homes for individuals with other chronic diseases. CMHCs that have a collaborative relationship with an FQHC/RHC may want to discuss the initiative with the collaborating agency and provide more details for their staff.

Paving the Way for Healthcare Homes Why CMHC Healthcare Homes? Because addressing behavioral health needs requires addressing other healthcare issues Individuals with SMI, on average, die 25 years earlier than the general population. 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases. Second generation anti-psychotic medications are highly associated with weight gain, diabetes, dyslipidemia (abnormal cholesterol) and metabolic syndrome. The next five slides give some of the reasons why it is important for the CMHC’s to become Healthcare Homes. There are a number of reasons it is important for CMHCs to continue to broaden our scope by assuming the responsibilities of a Healthcare Home for the people we serve. First, because we know that we cannot effectively meet the behavioral needs of consumers if we ignore the fact that individuals with SMI, on average die 25 years earlier than the general population, and that 60% of these premature deaths are due to medical conditions, such as cardiovascular disease and pulmonary and infectious diseases that are either going undiagnosed or untreated. In addition, we know that our own treatment approaches can contribute to high risk health conditions: second generation anti-psychotic medications are highly associated with weight gain, diabetes, abnormal cholesterol levels and metabolic syndrome.

Maine Study Results: Comparison of Health Disorders Between SMI & Non-SMI Groups

Principles Physical healthcare is a core service for persons with SMI MH systems have a primary responsibility to ensure: Access to preventive healthcare Management and integration of medical care

Healthcare Homes Expectations: We can meet them Cost Savings Analysis of CMHC Clients Enrolled in CCIP Initial PMPM Cost $1,556 Expected PMPM Cost w/o intervention $1,815 Actual PMPM Cost following enrollment w/ CMHC $1,504 Savings $21 million This slide shows the results of a study of what happened to the individuals enrolled in CCIP and served by the CMHCs. The year before CCIP enrollment, the per member per month cost to Medicaid for these individuals was $1556. Health care analysts projected that without the CMHC intervention, the PMPM costs would rise to $1815 in one year. The actual PMPM cost for consumers served by the CMHC’s after one year was $1504. Note that this is less than the $1556 PMPM for the previous year. But more importantly, it is dramatically less than the project upward trend in cost for these individuals. The difference between the actual PMPM of $1504 and the projected PMPM of $1815 is $311 per member per month. When you multiply $311 times 12 for a year’s cost times the 6757 consumers served, you get a savings off of projected costs of more than $21 million. We know how to do this work, and we can get better at it as well.

CMHC Savings Off Trend Category pre CMHC-CM post CMHC-CM Net Change Percent Change Pharmacy $39,367,496 $30,154,143 ($9,213,352) -23.4% General Hospital $23,140,172 $21,546,466 ($1,593,706) -6.9% CMHC $35,378,951 $37,467,731 $2,088,780 5.9% Other BH $463,069 $144,434 ($318,635) -68.8% Clinic $3,549,715 $4,324,452 $774,738 21.8% Overall $101,899,402 $93,637,226 ($8,262,176) -16.%

Average Medicaid expenditures   Total HealthCare Utilization Per User Per Month Pre and Post Community Mental Health Case Management Months with case management initiated on month 24 Average Medicaid expenditures per month

CMHC Outcomes comparing admission to annual assessments Independent Living increased by 33% Vocational Activity increased by 44% Legal Involvement decreased by 68% Psychiatric Hospitalization decreased by 52% Illegal Substance use decreased by 52% IN ADDITION- Study shows CMHCs services substantially decrease overall medical cost

Out Reach Target Population Analysis of Care Management Out Reach Target Population $25,000 minimum cost for previous 12 months or risk predicted to have high cost A diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or recurrent major depression Not a consumer of public mental health system in previous 12 months Excluded nursing home, developmental disability, hospice and renal failure Average cost of group over $50,000 per year

Physical Health Demographic Analysis of Care Management 35% COPD 34% Asthma 32% Diabetes 11% Congestive Heart Failure (CHF)

Cost Savings Including Cost of Intervention DM 3700 Progress Cost Savings Including Cost of Intervention 1298 clients enrolled for over 6 months $346 PMPM actual cost savings $5.4 Million annualized $619 PMPM trended cost savings $9.6 Million annualized

Opportunities for Federal Policy Improvement Push for Deeper Implementation of Parity Assure that Essential and Benchmark Benefit includes rehabilitation benefit parity Allow Safety Net BH Providers access to 340B pharmaceutical pricing Prohibit States from not paying for a PC visit and a BH visit on the same day Include BH providers in Federal HIT funding

Paving the Way for Health Homes Questions? Website: www.dmh.mo.gov Click on Healthcare Home link Any questions you may receive during your presentation that you either need feedback or would like to share with the rest of the CMHC providers, can be forwarded to Dorn Schuffman, Kathy Brown or myself. Technical assistance will be offered and questions with feedback will be distributed to the CMHCs.