Clinical Quality in Behavioral Health: A TRICARE Perspective October 15, 2010

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1 Clinical Quality in Behavioral Health: A TRICARE Perspective October 15, 2010 RADM C.S. Hunter, MC, USN Deputy Director TRICARE Management Activity

2 TRICARE - Who We Are 9.6 million beneficiaries TRICARE Prime enrollees: 3.7 million in direct care system 1.6 million in contractor networks 1.9 million TRICARE for Life Others are TRICARE Standard/Extra and TRICARE Reserve Select Purchased care managed through regional contracts (North, South, West, Overseas) Retail and mail order pharmacy managed separately via Express Scripts Over 380,000 participating providers and over 60,000 retail pharmacies TRICARE annual cost per beneficiary (FY09) Prime: $4,202 Standard: $3,584 TFL (age 65+): $3,874 (does not include Medicare contribution) 2

3 A Week in the Life of TRICARE 21,800 inpatient admissions 5,000 direct care 16,800 purchased care 1.6 million outpatient visits 737,000 direct care 876,400 purchased care 2,300 births 1,000 direct care 1,300 purchased care 2.5 million prescriptions 910,000 direct care 1.41 million retail pharmacies 223,000 home delivery 179,300 behavioral health outpatient services 46,100 direct care 133,200 purchased care 3.5 million claims processed 12.6 million electronic health record messages Behavioral Health Outpatient Visits Per Year 3

4 Creating Alignment: MHS Quadruple Aim Readiness Pre-, During, and Post-deployment Family Health Behavioral Health Professional Competency/Currency Population Health Healthy service members, families, and retirees Quality health care outcomes A Positive Patient Experience Patient and Family centered Care, Access, Satisfaction Cost Responsibly Managed Focused on value Quadruple Aim as an Enduring Construct for Care 4

5 Predicting Behavioral Health Needs 25,000 Active Active Duty Duty Inpatient Admissions 20,000 15,000 10,000 Purchased Care Direct Care 5, Active Duty Inpatient Admissions Direct Care 7,871 7,878 8,379 9,023 9,429 Cost, Direct Care $ 65,752,332 $ 70,870,362 $ 72,427,608 $ 84,740,203 $ 101,382,912 Purchased Care 5,821 6,207 7,791 9,610 11,227 Cost, Purch Care $ 24,278,856 $ 31,289,100 $ 46,000,274 $ 64,396,363 $ 91,227,905

6 Predicting Behavioral Health Needs 12,000 Pediatric Inpatient Admissions Pediatric Inpatient Admissions 10,000 8,000 6,000 Purchased Care Direct Care 4,000 2, Pediatric Inpatient Admissions Direct Care Cost, Direct Care $ 516,063 $ 974,388 $ 797,466 $ 1,360,614 $ 1,059,208 Purchased Care 10,665 8,859 8,609 9,425 9,893 Cost, Purch Care $ 55,778,141 $ 58,557,727 $ 62,454,507 $ 82,228,475 $ 93,633,068

7 Predicting Behavioral Health Needs 2,500,000 Active Duty Outpatient Active Duty Encounters/Services Inpatient Admissions 2,000,000 1,500,000 1,000,000 Purchased Care - Services Direct Care - Encounters 500, Active Duty Outpatient 2006 Encounters/Services Direct Care - Encounters 885, ,661 1,126,757 1,378,868 1,681,947 Cost, Direct Care $ 232,054,457 $ 264,903,124 $ 306,232,183 $ 399,950,875 $ 506,575,642 Purchased Care - Services 266, , , , ,044 Cost, Purch Care $ 20,510,620 $ 24,402,223 $ 29,373,038 $ 41,111,108 $ 49,400,707

8 Predicting Behavioral Health Needs Pediatric Inpatient Admissions Pediatric Outpatient Encounters/Services 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000, , Purchased Care - Services Direct Care - Encounters Direct Care - Encounters Pediatric Outpatient Encounters/Services , , , , ,572 Cost, Direct Care $ 59,005,103 $ 59,156,027 $ 59,941,275 $ 67,874,690 $ 78,134,881 Purchased Care - Services 1,661,693 1,750,546 1,965,532 2,416,066 3,506,414 Cost, Purch Care $ 79,077,706 $ 85,387,021 $ 95,882,254 $ 112,473,407 $ 144,009,394

9 Personnel Assigned Meeting Demand by Increasing Access Purchased Care Behavioral Health Providers Behavioral Health, FY07-FY10 Services Patients Direct care Up 47% Up 26% Purchased care Up 84% Up 40% 9

10 Valuing Behavioral Health TRICARE programs which assist: Behavioral Health Provider Locator First 8 outpatient visits per year need no authorization TRIAP, intransition Challenges: 31.5% of MTF referrals for network outpatient behavioral health are not activated (improved from 39.1% in 2008) More military children reporting problems (National Military Family Association study) Reserve health coverage continuum Screenings at critical intervals Caregiver behavioral health 10

11 Responding to New Behavioral Health Needs Defined access to care standards for behavioral health as equivalent to those in medical surgical services (2009/10) Ongoing access to care monitoring for behavioral health referrals and appointing Increased access to Psychiatric Partial Hospitalization Programs by streamlining certification requirements Policy changes to substance abuse treatment are under review Regulation change to permit independent practice for Licensed Mental Health Counselors in progress Approved integration of behavioral health into primary care across direct care system 11

12 Enhancing Health and the Patient Experience Patient Centered Medical Home (PCMH) emphasizes: Coordination of Care Access Continuity Preventive Care Disease Management Access to Care Team-Based Healthcare Delivery Population Health Enhances beneficiary s relationship with provider Advanced IT Systems Patient is the Center of the Medical Home Patient-Centered Care Includes all service primary care initiatives Incorporates embedded behavioral health Decision Support Tools Patient & Physician Feedback Refocused Medical Training 12

13 The Next Frontier in MHS Quality Behavioral Health effectiveness Patient Centered Medical Home (PCMH) outcomes The inpatient experience (Obstetrics, OCONUS) Serious preventable events / HACs Radiology imaging (Evidence-based, dosing) Safety of prescription medications for pain High Risk High Volume Problem Prone

14 Implementing High Quality Behavioral Health Care Benefits of Clinical Quality Management System Fosters patient-centered care (e.g. behavioral health (BH) in primary care initiatives) Improves BH care quality and outcomes Reduces costs through prevention and early intervention, greater efficiency in delivery of services and reduced duplication Decreases variations in BH care provided: all will experience same high quality, evidenced-based BH care, regardless of location or provider Puts MHS on cutting edge of movement toward National Clinical Quality Goals Improves Quality Management System for Behavioral Health under Clinical Quality Program MHS-wide In alignment with Quadruple Aim Enhances Force Health and Readiness 14

15 Measuring Effective Outcomes After Process Quality, Provider Quality and Evidence-based Medicine Outcomes of counseling intervention Re-integration index Family wellness Violence, divorce, school performance Behavior indicators for AD wellness Sleep quality Mishaps, infractions, personnel actions Substance abuse Medication use and misuse Key Effectiveness Measures Needed 15

16 Total Force Fitness Quadruple Aim as an Enduring Construct for Care Fitness is state of flexible adaptation in balance with surrounding conditions Holistic and healthy Ready and resilient Meeting challenges and surviving threats Optimal fitness is: Constant awareness of change Continuous pursuit of adaptation Integrity of readiness reporting State of mind vs. physical health Seek new scientific measures of total fitness Learning & Continuous Improvement Maintaining balance with rapidly changing demands Readiness and well-being Emotionally and physically ADM Michael Mullen from Military Medicine, Vol 175, August