1. Implementing Value-Based Sustainable Behavioral Health in Patient-Centered Medical Homes: Beyond the Co-Located Generalist Model Rodger Kessler Ph.D. ABPP Associate Chair for Research Associate Professor Doctor of Behavioral HealthFamily Medicine Arizona State UniversityUniversity of Vermont College of Medicine Thanks to Frank DeGruy M.D. University of Colorado Denver Roger Kathol M.D. Cartesian Solutions Parts of this presentation was presented with above authors at CFHA 2015

2. 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

3. 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.

4. Post-ACA Healthcare CARTESIAN SOLUTIONS, INC.™ © 3. Providers Med Home 1. Purchasers Triple Aim: Better Health Care, Better Outcomes, Lower Cost --Vendors --Organizations --Regulators --BH “Resources” Med --adapted from Kathol & Gatteau, Healing Body AND Mind, 2007 Body PublicPrivate BH 2. Fund Distributors Accountable Care Organization (Mind?) Mind BH 3.2.

5. Clinically Integrated Network CARTESIAN SOLUTIONS, INC.™ © Network IT System, Team Culture, Care Coordination, and Administrative Oversight Medical Home Specialty Clinics Hospitals Ancillary Services Contracted Vendors -- BH -- Pharmacy -- Lab, X-ray -- Other Contracted Vendors -- BH -- Pharmacy -- Lab, X-ray -- Other

6. 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.™ ©

7. 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 CARTESIAN SOLUTIONS, INC.™ ©

8. What Our Patients and the Health System Experiences --The Opportunity-- CARTESIAN SOLUTIONS, INC.™ ©

9. 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.™ ©

10. BH Spending as a Part of the Health Budget in 2003 CASE MANAGEMENT SOCIETY OF AMERICA & CARTESIAN SOLUTIONS, INC.™© Total Health Spending--2003 $ 1.6 trillion Mark TL et al, Psych Serv, 58:1041-1048, 2007 BH Spending--2003 $ 83 billion (5.1% of Total Health*) *does not include BH services provided by non-BH professionals

11. Health and Cost Impact of Comorbidity & Integrated Care CARTESIAN SOLUTIONS, INC.™ © All Insured $2,92015% Arthritis $5,2206.6%36%$10,710 94% Asthma $3,7305.9%35%$10,030 169% Cancer$11,6504.3%37% $18,870 62% Diabetes $5,4808.9%30%$12,280 124% CHF $9,7701.3%40%$17,200 76% Migraine $4,3408.2%43%$10,810 149% COPD $3,8408.2%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

12. Claims Expenditures for Patients With and Without BH Condition Service Use CARTESIAN SOLUTIONS, INC.™ © 7,575 8,201 2,649 7,284 – Thomas et al, Psych Serv 56:1394-1401, 2005 7,847 5,732

13. Benchmark Data on Chronic Illness & BH Comorbidity (Cost Saving Opportunity) CARTESIAN SOLUTIONS, INC.™ © MDC Illness Category%BHΔ ALOS Δ Total Cost for AdmissionsΔ Total Gain/Loss AMI34%1.3$1,089,346($689,946) Arthritis42%1.6$3,688,176*($2,309,407) Asthma37%1.9$2,336,520*($2,437,978) Back Pain41%1.6($412,668)($1,180,978) CAD26%1.3$1,192,695*($1,119,291) Cancer24%2.2$5,621,349($762,043) CHF38%0.9($22,393)($386,457) COPD48%1.4($668,800)($167,538) Diabetes30%1.6$1,635,198*($1,204,304) Pneumonia40%2.4$1,232,453*($336,095) Renal Failure39%1.1$239,615($708,891) Stroke30%1.6$266,105($2,309) *considered targeted opportunities

14. BH Transition Options--The Challenge Health OutcomesCost 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.™ ©

15. Desired Post-ACA Infrastructure CARTESIAN SOLUTIONS, INC.™ © 3. Providers Med Home 1. Purchasers Triple Aim: Better Health Care, Better Outcome, Lower Cost --Vendors --Organizations --Regulators Med/BH --adapted from Kathol & Gatteau, Healing Body AND Mind, 2007 Body/Mind PublicPrivate 2. Fund Distributors Health Delivery Networks

16. Referral Medical Practice Behavioral Practice Medical Practice BH Behavioral Practice Med Medical & Behavioral Practice Model 1: “Cross-Referral” Model 2: “Bidirectional” Model 3 “Integrated” Patient sorting (75% of BH Patients) Specialty BH Settin g (10% of BH Patients) (90% of BH Patients) Manderscheid & Kathol, AIM:160, 61-65, 2014 CARTESIAN SOLUTIONS, INC.™ ©

17. 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.

18. “When a subject becomes totally obsolete we make it a required course.” Peter Drucker

19. 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.

20. Seven Principles of Integrated Care 1 Make BH clinicians part of medical team. Pay for them with medical benefits.

21. Seven Principles of Integrated Care 2 Use a common EHR, registries, and claims data. One panel. Pull complex patients from that registry.

22. Seven Principles of Integrated Care 3 If possible, create teams, or subteams. Construct teams with skillsets that match problems in subpopulations.

23. Seven Principles of Integrated Care 4 Match levels of clinicians to severity of problems, then step care up if improvement doesn’t occur.

24. Seven Principles of Contemporary Integrated Care 5 Prospectively define desired health outcomes and treat to target, evaluating frequently.

25. Seven Principles of Integrated Care 6 Use evidence-based algorithms and protocols as standard of care.

26. Seven Principles of Integrated Care 7 Use care coordinators to create a whole-person care plan.

27. 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.

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

29. 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

30. 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

31. 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

32. The The 2 Diabetes integrated Pathway AT Berlin Family Health AN ON THE GROUND EXAMPLE

33. Health Behavior Integration Clinical Protocol

34. Health Behavior Integration Clinical Protocol continued…

38. Initial Analysis Two Years of E H R Data * ~ 55% of Patients seen are “At Risk”

39. The future will be Population level of complex, high cost, multi morbid patient populations Data generated and driven algorithms Minimal referrals, behavioral clinician contact will be stepped and data driven Care algorithms will flow through HER Bioinformatics has a large role in the future of integration

40. 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

41. Bibliography / Reference 1.Kathol, deGruy, Rollman, 2014, AFM 12(2):172-175 2.Grembowski, Martin, Patrick et al., 2002, JGIM 17(4):258-269 3.Bower, Knowles, et al. Cochrane Rev, 2011, 9:CD001025 4.Kathol, Melek, et al., 2008, Psych Clin NA, 31(1):11-25 Thank you! Rodger.Kessler@ASU.edu Rodger.Kessler@ASU.edu Rodger.Kessler@uvm.edu