1. Economic Impact of An Integrated Behavioral Health Program Kenneth Kushner, PhD Professor, University of Wisconsin Department of Family Medicine Neftali Serrano, PsyD Director of Clinical Training, Center of Excellence for Integration, North Carolina Foundation for Advanced Health Programs Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # C1 October 16, 2015

2. Faculty Disclosure The presenters of this session currently have or have had the following relevant financial relationships (in any amount) during the past 12 months. –Lead consultant, primarycareshrink.com primarycareshrink.com

3. Learning Objectives At the conclusion of this session, the participant will be able to:  Describe the impact of insurance status on patient utilization of healthcare resources  Describe the main conclusions of our study in terms of the effect of integrated behavioral health on overall inpatient and outpatient utilization  Discuss the policy implications of the results of our study in the context of the larger literature on cost offset for mental health services

4. Bibliography / Reference  Egede et al. Impact of Mental Health Visits on Healthcare costs in Patients with Diabetes and Comorbid Mental Health Disorders. PLoS One, 2014  Park et al. Examining the Cost Effectiveness of Interventions to Promote the Physical Health of People with Mental Health Problems: A Systematic Review. Public Health, 2013  Salvador-Carulla, L & Hernandez-Pena, P. Economic Context Analysis in Mental Health Care. Usability of Health Financing and Cost of Illness Studies for International Comparisons. Epidemiology and Psychiatric Services, 2011.  Serrano, N. and Monden, K.The effect of behavioral health consultation on the care/ Wisconsin Medical Journal, 2011. Reiss-Brennan, B. Cost and quality impact of Intermountain's mental health integration program. Journal of Healthcare Management, 2010

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Does Integrated Behavioral Health Result in Cost Savings? 6

7. Medical Cost Offset “At some point, the reduction in medical costs may offset the cost of providing mental health services” Pallak, Cummings et al (1993) 7

8. Cummings and Follett (1967) Found that overall utilization of (non- psychiatric) inpatient and outpatient medical services declined significantly among patients who received psychotherapy in a pre-paid health plan. Declines persisted after the initial interview, most significantly 2 years afterwards. Control patients, who did not receive psychotherapy, showed no decrease utilization. 8

9. Cummings and Follette (1976) Found the overall costs of medical care of patients who received 1 to 8 managed mental health treatments declined significantly, compared to matched controls, in the year following the treatments. The declines persisted after 5 years. 9

10. Pallak, Cummings et al (1993) Tracked medical costs for Medicaid enrollees in Hawaii. They found declines in overall medical costs for those who received managed mental health services, but not for those receiving traditional, unmanaged mental health intervention. 10

11. Pallak, Cummings et al (1993-Cont.) Declines in the managed mental health care group were attributable to decreases in: Inpatient medical services Outpatient medical services Drug prescription ED visits 11

12. Subsequent Studies Chronic illness (Schlesinger et al, 1983) Anxiety and Depression (Fifer et al, 2003; Goldberg et al, 1996; Korff et al, 1998) Cancer (Carlson and Butz, 2004) Substance abuse (Polen et al, 2006) Diabetes (2014) 12

13. Reviews Cummings, O’Donahue and Ferguson (2002) Mumford et al (1998) Olfson, Sing and Schlesinger (1999) Shemo (1995) 13

14. Meta-analysis Chiles, Lambert and Hatch (1999). Found that the average savings resulting from psychological intervention to be 20%. In 1/3 of the articles, the savings were “substantial” even after the costs of providing psychological services were factored in. 14

15. Cost Offset and Integrated Behavioral Health? 15

16. Study Parameters 12,300 Patients From Four Medical Homes Selected based on having at least one encounter in a medical home with a mood disorder diagnosis between 2004-2012 Data obtained from three area hospitals and several specialty mental health providers The analysis segmented utilization into four categories: emergency department, inpatient psychiatry, inpatient medical, outpatient specialty mental health The final analysis used three years of utilization pre/post, following patients from the initial three year period into the subsequent period 16

17. Sample Demographics 17 Clinics ArmN Age 2012 (sd) % Female Afr. Am.Am. Ind.WhiteHispanicNoneCommercialMedicaidMedicare NortheastC2089 50.2 (15.0) 71.213.21.978.23.86.466.013.8 ACHC-SI900 46.7 (13.2) 70.327.612.744.631.435.227.328.78.8 ACHC-EI816 46.5 (12.8) 67.523.14.558.819.534.729.729.06.6 WingraI1458 48.1 (13.8) 71.125.24.860.015.211.952.724.011.3 Demographics Insurance

18. PrePostNPrePostN Integrated Care Control None 2.913.107742.342.251346.5%-3.8% Commercial 1.521.7412571.111.23137814.5%10.8% Medicaid 3.833.678453.413.74289-4.2%9.7% Medicare 3.193.602982.432.7328812.9%12.3% Total combined 2.632.7631741.691.8520894.9%9.5% Integrated Care Control % Change EMERGENCY DEPARTMENT UTILIZATION * *

19. PrePostN% Change None 3.553.08348-13.2% Commercial 1.351.3815382.2% Medicaid 5.164.75700-7.9% Medicare 2.933.3033012.6% Total combined 2.702.612916-3.3% Integrated Care Control % Change EMERGENCY DEPARTMENT UTILIZATION Wingra Clinic Only, Pre/ Post *

20. PrePostNPrePostN Integrated Care Control None 2.954.977743.513.9213468.47%11.7% Commercial 3.324.5712574.134.79137837.65%16.0% Medicaid 4.815.48456.086.8828912.27%13.2% Medicare 7.18.292987.1310.2728816.76%44.0% Total combined 3.985.2431744.785.78208931.66%20.9% Integrated Care Control % Change INPATIENT HOSPITAL UTILIZATION Non-Psychiatric * * * *

21. PrePostN% Change None 4.105.6834838.5% Commercial 3.564.01153812.6% Medicaid 5.806.8470017.9% Medicare 7.167.613306.3% Total combined 4.575.29291615.8% Integrated Care Control INPATIENT HOSPITAL UTILIZATION Wingra Clinic Only, Pre/ Post

22. UTILIZATION COMPARISONS Higher Overall ED UtilizationLower Overall Inpatient Utilization

23. 23

24. Financial Impact, ED Medicaid 24 Integrated CareControl Pre3.833.41 Post3.673.74 (Savings) Cost(-$162,000)$334,600 Estimate over a three year period, assuming per ED visit mean cost of $1200, with equivalent samples of 845 patients *Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $1200 or the mean ED visit cost.

25. Financial Impact, ED Overall 25 Integrated CareControl Pre2.631.69 Post2.761.85 (Savings) Cost$495,144$609,408 Estimate over a three year period, assuming per ED visit mean cost of $1200, with equivalent samples of 3174 patients *Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $1200 or the mean ED visit cost.

26. Financial Impact, Hospital Medicaid 26 Integrated CareControl Pre4.816.08 Post5.46.88 (Savings) Cost$1,944,345$2,636,400 Estimate over a three year period, assuming per hospital stay mean cost of $3900, with equivalent samples of 845 patients *Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $3900 or the mean inpatient daily stay cost.

27. Financial Impact, Hospital Medicare 27 Integrated CareControl Pre7.17.13 Post8.2910.27 (Savings) Cost$1,383,018$3,649,308 Estimate over a three year period, assuming per hospital stay mean cost of $3900, with equivalent samples of 298 patients *Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $3900 or the mean inpatient daily stay cost.

28. Financial Impact, Hospital Overall 28 Integrated CareControl Pre3.984.78 Post5.245.78 (Savings) Cost$15,597,036$12,378,600 Estimate over a three year period, assuming per hospital stay mean cost of $3900, with equivalent samples of 298 patients *Cost/Savings estimates obtained by establishing the difference in visits (with equalized samples using the highest sample size of the two groups) between pre and post and multiplying that difference in visits by $3900 or the mean inpatient daily stay cost.

29. More Questions Than Answers 29

30. Why? Why did the control group do better with the uninsured and the commercial population whereas the intervention group did slightly better with the Medicaid and Medicare groups? Are there differences between the medical home patient samples that were not captured by the data? Are sample sizes and risk exposure different between the groups? As a medical home grows and it achieves greater samples of these insurance subgroups does utilization regress to the mean? Why is there some evidence for mitigation of ED visits and increased hospital visits? 30

31. Factors To Consider The medical homes overall have different proportions of the different payer status subgroups It is possible that the intervention group medical homes had more dual eligible patients represented in the Medicare subgroup It is also possible that the commercial and uninsured populations differed between the medical homes due to the nature of the underserved population of the FQHC 31 Do medical homes develop “orientations”? Are there ways to quantify “harder" patients? Is a commercial patient at an FQHC different than a commercial patient elsewhere?

32. What Does This All Mean? Don’t trust utilization outcomes research that does not identify medical home composition, especially insurance status The impact of integrated care programs appear to have differential impact on patient groups and perhaps medical homes Financial significance does not always equal statistical significance There appears to be a mitigating impact of integrated care on ED utilization, especially in high utilizing subgroups like Medicaid but no impact on hospital utilization (medical only) Significant implications for payment reforms based on quality outcomes 32

33. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!