ACOs & Chronic Care Management: Opportunities For Behavioral Health Organizations In Population Health Management The 2017 OPEN MINDS Strategy & Innovation Institute Tuesday, June 6, 2017 11:45am 1:00pm Steve Ramsland, Ed.D., Senior Associate, OPEN MINDS 1 www.openminds.com 163 York Street, Gettysburg, Pennsylvania 17325 Phone: 717-334-1329 - Email: info@openminds.com 2017. All Rights Reserved.
Agenda I. The ACO Landscape II. III. IV. Opportunities For Behavioral Health In Population Health & Care Management Models Prospect CharterCare Case Study Questions & Discussion 2 2017. All Rights Reserved.
The ACO Landscape
What Are ACOs? Groups of health care providers that share mutual responsibility for a population of patients Improve quality and health outcomes Reduce health costs and inefficiencies Reimbursement based on metrics of Quality Care, Patient Satisfaction, and Reductions in Cost of Care Population Health Management approach: Maintaining and improving people s health across full continuum of care 4 2017. All Rights Reserved.
ACO Market Trends 2013 vs. 2016 Percent Of U.S. Insured Population Covered By An ACO 2016 689 2016 12.1% 2013 412 Number Of ACOs 2013 4.4% Lives Covered (Millions) 35.1 11.9 5 2017. All Rights Reserved. 2013 2016
Of ACOs Are Run By Physician Groups ACO Sponsoring Organizations By Type, 2016 Physician Group 47.30% Type of Organization Hospital System Hospital System and Physician Group Health Plan and Provider Organizations 3.60% 2.30% 42.50% Federally Qualified Health Center (FQHC) 1.60% % of Organizations 6 2017. All Rights Reserved.
ACOs, By Payer ACO Contracting Overview, 2016 ACO Contract Payer Number Of ACOs Number Of Contracts Total Beneficiaries Percent Of Attributed Consumers Accountable Care Organizations By Contract, %, 2016 59.8% Medicare 412 485 14,615,007 41.7% Medicaid 44 55 3,243,728 9.2% 6.4% 11.2% 22.6% Commercial 156 229 17,219,745 49.1% Multiple Contracts 77 - - - Medicaid Only Contracts Multiple Contracts Commercial Only Contracts ACO Contract Payer Medicare Only Contracts Total 689 769 35,078,480 100% 7 2017. All Rights Reserved.
Ten Largest ACOs, By Enrollment Largest ACOs By Population, 2016 ACO Name Payer Service Area Sponsoring Enrollment Organization Catalyst Health Network Commercial Texas Physician Group 3,937,000 Delaware Valley ACO Medicare/ Commercial New Jersey/ Pennsylvania Accountable Care Alliance Of Ventura Accountable Care Coalition Of Greater New York Hospital System/ Physician Group 1,728,000 Medicare California Physician Group 1,500,000 Medicare New York Hospital System 1,500,000 MetroHealth Care Partners Medicare Ohio Hospital System 1,500,000 ACO Memorial Hermann Medicare/ Commercial Texas Hospital System 1,134,430 Accountable Care Organization Banner Health Network Medicare/ Commercial Arizona Hospital System 1,077,100 Health Choice Preferred Commercial Utah Hospital System 1,000,000 Brown & Toland Physicians Medicare/ California Physician Group 766,000 Commercial Heritage California ACO Medicare California Physician Group 700,000 8 2017. All Rights Reserved.
Utah Has The Highest Percent Of Their Population Attributed To An ACO 62.9% 9 2017. All Rights Reserved.
Opportunities For Behavioral Health In Population Health & Care Management Models
History Of Separate Financing & Delivery Of Behavioral Health Since the time of the HMO Act of 1973, benefits have been separate In 2001, 80% of health plans had a carve-out their behavioral health benefits 33% Magellan 19% Cigna 13% United Behavioral Health 11% MHN 3% ValueOptions New model emerging with integration at the individual consumer level 11 2017. All Rights Reserved.
States With Traditional Primary Medicaid Behavioral Health Carve-Outs Decreasing Primary Carve-Outs To Public CMOs, 2016 1. California 2. Michigan (at risk of ending) 3. North Carolina (ending) 4. Pennsylvania 5. Utah Primary Carve-Outs To Private CMOs, 2016 1. Arizona 2. Colorado (ending) 3. Hawaii 4. Idaho 5. Massachusetts 6. Washington (ending) 12 2017. All Rights Reserved.
Pre-existing condition coverage and parity have driven use of new strategies Consumers with behavioral disorders are often superutilizers of health care resources Consumers with behavioral disorders and comorbid chronic medical conditions have higher average cost than those consumers without comorbid conditions Undiagnosed and/or untreated behavioral health conditions hinder the treatment of a wide range of medical conditions Lack of coordination care management results in poorer outcomes and higher cost per consumer 13 2017. All Rights Reserved.
Consumers With Behavioral Disorders Are Often Super-Utilizers Of Health Care Resources 1. 5% of Americans consume half of all health care resources 2. Much of this is due to frequent and preventable use of expensive health care settings 3. This group of consumers is often referred to as superutilizers - individuals with multiple illnesses whose care is uncoordinated and fragmented, resulting in high resource use More than 80% of Medicaid superutilizers have a comorbid mental illness In 44% of Medicaid superutilizers, mental illness is in the form of a serious mental illness Mental health and addictive disorders were among the top ten principal diagnoses for super-utilizers aged 1 to 64 years, regardless of payer 14 2017. All Rights Reserved.
Consumers With Behavioral Disorders & Comorbid Medical Conditions Have Higher Average Costs 1. Mental health and addictive disorder comorbidities increase average health care costs by up to 200% 2. Individuals with these comorbidities often experience gaps in care management, leading to avoidable utilization of expensive health care settings Annual Per Capita Health Costs $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 Asthma &/Or COPD CHF CHD Diabetes Hypertension No MH/SUD $8,000 $9,488 $8,788 $9,498 $15,691 MH $14,081 $15,257 $15,430 $16,267 $24,693 SUD $15,862 $16,058 $15,634 $18,156 $24,281 MH and SUD $24,598 $24,927 $24,443 $36,730 $35,840 15 2017. All Rights Reserved.
Undiagnosed Behavioral Health Conditions Have Human & Economic Tolls 1. Each year, one in four Americans experience some mental illness 2. The presence of a mental health or addictive disorder comorbidity can increase a person s chances of hospital admissions by up to 300% The Impact Of Depression 1.Mood disorders like depression are the third most common cause of hospitalization among nonelderly adults 2.60% of individuals suffering from chronic depression have not received treatment within the last year 16 2017. All Rights Reserved.
Strategies To Optimize Behavioral Health Use Of Analytics In Identification & Early Intervention Of High-Risk Consumers With Behavioral Conditions Strategies Focused On Improving Consumer Access To Care Strategies For Improving Consumer Engagement Improved Coordination Of Care For Consumers With Behavioral Conditions Strategies To Ensure Quality Of Behavioral Health Care Creating Partnership Models With Behavioral Health Provider Organizations 17 2017. All Rights Reserved.
Identification of High-Risk Consumers To Optimize Population Health Management Strategies Goal is to identify consumers who are likely to use high levels of resources - to support targeted use of mitigation strategies Individual-level data that is aggregated for population-level analysis Requires timely access to integrated data set including physical and behavioral health, pharmacy, social determinants of health, and other factors that impact wellbeing Supporting consumer care planning and event surveillance Enrollment in specific programs Matching referrals of high-risk consumers to provider organizations with special expertise and demonstrated proficiency Tracking consumer adherence to recommended treatment plans, emergency department visits, and hospital admissions 18 2017. All Rights Reserved.
Addressing Untreated Behavioral Health Conditions Through Consumer Access Improvement 1. Consumers with unrecognized/asymptomatic depression had health care expenditures $2,000 to $3,000 per year than those without depression 1 2. Patient with symptomatic depression had health care expenditures $5,000 per year higher than those without depression 1 3. 59% of Americans with insurance do not get the behavioral health services they need 3 4. Strategies to improve access must address three issues: a. Easy access to health care system b. Ready availability of locations where needed services are provided c. Matching consumers with a professional they view as trustworthy and easy to communicate with 2 19 2017. All Rights Reserved.
Improving Consumer Engagement To Drive Health Plan Performance 1. A significant portion (more than 40%) of readmissions have significant consumer engagement-related causes such as lack of support, inability to navigate the health care system, and inability to comprehend and follow instructions 1 2. Members' level of engagement with their health plan and the health plan s provider network is directly related to their disenrollment and satisfaction behavior 3. Complicating factors to engagement specific to the behavioral health are that consumers may not become engaged due to stigma surrounding mental illness, or perceived lack of diversity and cultural competence among professionals 4 20 2017. All Rights Reserved.
Improved Care Coordination For Consumers With Behavioral Conditions 1. More than 90% of consumers treated for behavioral health conditions have at least one comorbid medical condition, and more than half have four or more. 4 2. Lack of coordinated, person-centered care management for individuals with comorbid mental health conditions leads to missed diagnoses, poor follow-up, and gaps in care 1 3. HEDIS measures show that more than 47% of commercially-insured individuals, 55% of Medicaid enrollees, and 64% of Medicare enrollees did not receive follow-up care within seven days of discharge from hospitalization due to mental illness 2 4. People with psychotic disorders and bipolar disorder are 45 percent and 26 percent less likely, respectively, to have a primary care doctor than those without mental disorders 2 21 2017. All Rights Reserved.
Improving Effectiveness By Improving The Quality of Behavioral Health Care 1. There is a lack of consensus on tools for measuring quality of care in behavioral health sector, although efforts to develop a standardized set of quality measures is in process a. For example, National Quality Forum 3 has 55 currently identified measures include 11 addressing depression, 16 addressing medical conditions in psychiatric populations plus 3 about tobacco use, and 9 relating to medications 2. Despite this current lack of consensus, health plans are using a range of quality measures for behavioral health, including measures of symptom level and functional status 4 22 2017. All Rights Reserved.
Reshaping Network Design With Partnerships For Gainsharing & Aligned Incentives 1. Models for management of behavioral health benefits moving beyond traditional specialty carve-outs 2. The need for integration of care coordination for consumers with complex needs is driving new designs 3. Integrated care coordination (and integrated service delivery) are not possible without reimbursement realignment which is resulting in the creation of new gainsharing arrangements 23 2017. All Rights Reserved.
ACOs & Complex Consumers 24 2017. All Rights Reserved.
Opportunities for Specialist Organizations Are Many Behavioral health service system sub-capitation Specialty care coordination for consumers with behavioral disorders Specialty center of excellence programs for acute conditions Behavioral health consultation in officebased service locations live or via telehealth Management of specific acute episodes or chronic conditions via case rate or episodic/bundled payment Management of shortterm inpatient psychiatric and addiction treatment programs Psychiatric consultation live or via telehealth in hospital emergency rooms Behavioral health consultation program for inpatient programs live or via telehealth Hospital diversion programs Specialty behavioral health ER/crisis stabilization Hospital readmission prevention programs Community-based/mobile crisis response Home-based service delivery Specialty primary care 25 2017. All Rights Reserved.
Business Model Transition For Provider Organizations Payer Policy = Pay For Cost Or Volume Payer Policy = Pay For Value What is paid for is good for the consumer - - and doing more is the business model A revolution in performance management required Giving the consumer (and their payer) what they want and need is the business model Good outcome at low cost conveniently 26 2017. All Rights Reserved.
Prospect CharterCARE Case Study Rebecca Plonsky, LICSW, Vice President of Development for Integrated Behavioral Health-East and Southwest Region, Prospect CharterCARE, LLC
ACOs & Chronic Care Management Opportunities: The Prospect CharterCARE, LLC Case Study Rebecca Plonsky, LICSW Vice President of Integrated Behavioral Health June 6, 2017 28
Becoming an ACO Built Continuum of Care Expanded continuum of care to meet requirements of ACO Enhanced BH and medical integration at all points of care Convened Key Stakeholder Meetings Convened series of Executive meetings to discuss launching an ACO model of care Secured Approval from State & Payer(s Formerly submitted application that demonstrated meeting ACO requirements Secured Approval and Executed contracts with payers Health Care Transformation Began Focused efforts on patient retention, population health, and engagement Focused on quality and enhanced reporting Began to track leading indicators 29
Our ACO Types Current State in RI: Medicaid ACO Medicare Next Gen ACO Medicare ACO like Commercial ACO like Future State: Commercial ACO like by Q1 2018 to include BH and medical management Of Note: RI Community Mental Health Centers (CMHCs) are eligible to be certified as an ACO for patients with SPMI Prospect CharterCARE, LLC has deep partnerships with 2 CMHCs and has fully executed MOU s with each 30
Prospect Population Under Management Growth 70,000 60,000 50,000 40,000 30,000 20,000 10,000-64,982 50,028 29,941 33,546 3,688 4,786 7,657 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 14-Jul 15-Jan 15-Jul 16-Jan 16-Jul 17-Jan 17-Jul BCBSRI MA 3,688 3,986 6,807 7,385 7,823 8,300 8,300 Tufts Commercial 800 850 1,056 1,200 1,700 1,700 BCBSRI Commercial 14,000 17,023 17,796 18,000 United Medicaid Pilot 3,800 3,800 5,600 5,600 NHPRI Medicaid Pilot 3,700 3,700 7,300 7,300 CIGNA Commercial 2,200 2,200 United Commercial 8800 United Medicare Advantage 4450 Next Gen ACO 7,132 7,132 Tufts Medicaid 1,500 3,688 4,786 7,657 29,941 33,546 50,028 64,982
Our ACO Population Health Approach Addiction Medicine Medication Assisted Treatment Case Rates Allowed treatment flexibility based on acuity of symptoms Enhancing connectivity between primary care and Addiction Medicine Services Geri Psychiatric Nursing Home Initiative with 24/7 Access Line Exceptional medical team has been nationally recognized for providing exceptional medical and bh treatment for highly complex patients Serious and Persistent Mental Illness Partner and Coordinated Care for Patients In Integrated Health Homes Engage patients who are not affiliated with CMHC Focus on patients who decline care management Long Term Behavioral Health Care Built best practice programming focused on recovery and community Integration Programming also included Peer Recovery Services and AA Improved Effective and Successful Discharge Planning to the community 32
Introduction to CharterCARE Health Partners Integrated Continuum of Care- Outpatient 1. Addiction Services Center on the Roger Williams Medical Center Campus Multi-disciplinary team including: (Peer Specialist Q2 2017) Offer same day appointments for co-occurring disorders and/or co morbid conditions Short and Long term counseling Suboxone treatment from induction phase to maintenance Early Recovery Groups Partial Hospital Program (PHP) and an Intensive Outpatient Program (IOP) 2. Outpatient Programs on the Our Lady of Fatima Hospital Campus MH and Dual Diagnosis IOP and PHP General Outpatient Counseling opened in February 2017 3. St Joe s Health Center LICSW fully integrated within primary care team Warm hand offs, brief interventions Evidence based routing screenings PHQ 2/9, Gad 2/7 SBIRT go live in Q2 2017 33
CharterCARE Health Partners Integrated Continuum of Care- Inpatient We offer comprehensive individual and group interventions including early recovery and building effective coping skills for varying levels of needs across our 110 Inpatient Beds. Our compliment of beds focus on meeting the demands of our patient community 1. Our Lady of Fatima Hospital (71 Beds) 2 South Long Term Behavioral Health Unit: 20 beds 2 Center Adult General Psych: 30 beds 3 South Geri/Psych: 21 beds 2. Roger Williams Medical Center (39 Beds) West 4 Geri/Psych: 12 beds West 3 Dual Diagnosis: 12 beds Center 1 Detox: 15 beds 34
Key Elements in Advancing Our ACO and Integration Rhode Island has made significant strides to move toward integrated care across the delivery system through the following: Strong statewide commitment across providers Payer Accountability and Partnership Behavioral Health State wide Work Groups focused on Integrated Health Homes Care Transformation Collaborative (CTC)/ Patient Centered Medical Home Prospect CharterCARE s Strategic Goals to Strengthen Integration include: A member centric, holistic, whole person approach with a focus on recovery and integrated care Member access to broad networks of specialized care Coordination & collaboration of care through multi-disciplinary behavioral health and medical teams with ease of access Promotion of high quality, innovative payment structures, & evidence based best practices that are outcome driven Ensure rate adequacy via actuarial soundness 35
Key Elements in Advancing ACOs and Integration cont. Heath B, Wise Romero P, and Reynolds K from SAMHSA-HRSA (2013) proposed a Standard Framework for 6 Levels of Integrated Healthcare. COORDINATED Key Element: Communication CO-LOCATED Key Element: Physical Proximity INTEGRATED Key Element: Practice Change LEVEL 1: LEVEL 2: Minimal Collaboration Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/ Merged Integrated Practice Key Components: Member signs Release of information 80% of Medicaid members have co morbid medical & BH Issues Share Information Share treatment plan, medication dosing, & goals Measure Outcomes Case Consultation Routine Bi-Directional Communication Implement Standardized Outcome measures: HEDIS, total cost of care, & quality of life measures 36
RI CTC July 14 Survey Results from at least 14 Practice Sites: Screening for BH Problems What it Tells Us Practices are very good at screening for depression and smoking Not systematically screening for anxiety, overall substance use, pain, or domestic violence Of patients with serious mental illness like schizophrenia or bipolar disease: About 1/3 of the practices believe they manage the physical health of these patients less well than they manage the physical health of other patients 3
Where We re Going in CY 2017 & Beyond Across our ACO continuum of we have adopted a coordinated regional care model (CRC) which is built on the foundation of the Collaborative Care Model (CCM). CCM an evidence-based practice endorsed by SAMHSA and the American Psychological Association. It is proven to have positive outcomes for patients with depression, anxiety, PTSD, diabetes, heart disease, and cancer. Advance practice sites use screening and brief interventions (like SBIRT) for SUD. The collaborative care model can include a care manager, a medical assistant, a psychiatric consultant (typically by phone or video link), and an LICSW, psychologist, or RN. It is led by a PCP. In a CCM an impact study, findings indicate that for every $1 spent, $6 was saved. ACO CRC Opportunities in 2017 support: Tracking member progress over time Provider effectiveness Meeting agreed upon performance targets Informing population management strategies 38
Our Experience as an Accountable Care Organization to Date We Have Strengthened our Core Competencies and Mission Broadened and provided better clinical care and outcomes Increased patient engagement in their treatment and recovery Committed to reducing total cost of care Strengthened our network and deepened critical partnerships across the state and have received recognition Made Meaningful and Smart Investments Integrating behavioral and physical healthcare across our primary care network, convene meetings with CMHCs to coordinate care, hired revenue generating clinicians and prescribers Revamped physical space Optimized EHR platform and reporting to flag at risk patients and to track and trend leading indicators Received Approval from payers for Case Rates and to accept further risk Pilot programs focused on highly specialized care for high-risk populations Serious and Persistent Mental Illness (SPMI) Addiction Medicine Depression in Primary Care 39
Partnering with Insurers 4 Levers of Our ACO Success Robust Continuum of Care Commitment to Quality Willingness to Accept Financial Downside Risk Develop Strong Partnership with Insurers and State Leaders 40
Lever 1: Robust Continuum of Care Our Strong Network is Critical Demonstrated our organization has a full compendium of services; committed to Coordinated Regional Care Model Demonstrated deep partnerships with community providers through contracts; (preferably not MOUs or affiliation agreements) Committed to PCMH advancement and integration Started small, Deploy onsite clinicians in primary care Ensured our providers are paid within fair market value Moved prescribers to wrvus to demonstrate productivity Offered Telehealth 41
Lever 2: Commitment to Quality Improve both patient and provider outcomes Committed to full adoption of standardized and validated outcomes Demonstrated an interest in implementing an insurance driven outcome tool e.g. On Track GAD 2 and 7 PHQ 2 and 9 SBIRT Moved the needle on HEDIS measures e.g. MH After Care Follow Up Committed to training and innovation Launched a monthly joint operating committee Convened Grand Rounds focused on Integrated Care Launched Integrated Behavioral Health Internship program Partnered with Colleges Shared best practices Committed to provider and patient satisfaction 42
Lever 3: Willingness to Accept Financial Downside Risk 1. Committed to winning together or losing together 2. Proposed a 1 year pilot on a specialty population 3. Conveyed willingness to accept varying degrees of risk which may include: Accepting 5-10% of downside risk Quality Withholds Joint participation in shared savings 4. When accepting risk, we asked for full delegation 43
Lever 4: Develop Strong Partnerships with Insurers and State Leaders ACO BH CEO Senior BH Leader ACO Vice President Insurer Chief Medical Officer Senior BH Leader Senior Contract Administrator Community Partners e.g. CMHCs State Director (May include multiple departments) BH Chief Medical Officer Senior State Contract Administrator Governor and/or Senator 44
Health System Transformation is Possible Holistic, Whole Person Approach Network Adequacy (PCP & Pediatric) EMR/ Shared Medical Records Innovative Payment Structures Care Management for Complex Needs Real Time Data & Analytics Member Centric Approach Maximize Treatment Adherence Quality & Outcome Crisis Intervention After Care Follow Up Community Support Health Education Preventative Care 45
Our Lessons Learned to Date Transformation is possible but we cannot move faster than the systems will allow We were able to clearly answer the question to insurers, What is in it for me? We had to be flexible and nimble when establishing terms of ACO; Heard what the insurers were asking and modified our position as needed Optimized our EHR Leveraged our IPA comprised of 500 Specialists and PCPs to further medical integration Learned over time, we needed to be conservative with ramp up time lines 46
Questions & Discussion 47
Table Talk Discussion Questions 1. How do you begin to work through current constraints to partner with or become an ACO? 2. What are the 3 most significant challenges for your organization to advance integrated medical care and behavioral health? 3. What are 3 successful innovations that have been implemented over the past 12 months to promote integrated care across your delivery system? 48
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