Improving Chronic Care: Integrating Mental Health and Physical Health Care in State Programs Barbara Coulter Edwards bedwards@healthmanagement.com NCSL Winter CHAPS Meeting December 4, 2006 Overview Current State Spending The Reality and Cost! - of Co-Morbidity The Call for Integration Working Models Barriers to Integration Mental Health Spending Public dollars accounted for 63% of all mental health and substance abuse spending in 2001 1
Behavioral Health Spending by Payer, 2001 Out-of-Pocket 12% Private Insurance 20% Other Private 3% Medicare 7% MH/SA = $$103.7 billion; 63% is public Other State and Local 26% Other State and Local Other Federal Medicaid Medicare Medicaid 26% Other Federal 6% Other Private Private Insurance Out-of-Pocket Source: National Expenditures for Mental Health Services and Substance Abuse Treatment 1991-2001, SAMHSA Public MH Spending Medicaid has become the largest source of funding in the public MH system States have refinanced many state and locally funded services through Medicaid to draw federal match funds Medicaid and Mental Health 2001 MH (Excludes SA) Public Expenditures Medicare 12% Medicaid 44% Other State & Local 37% Other Federal 7% 2001 MH Public = $53.6 B Source: National Expenditures for Mental Health Services and Substance Abuse Treatment 1991-2001, SAMHSA 2
Medicaid and Mental Health Medicaid is projected to account for two thirds of all state and local mental health spending by 2017 Federal MH services block grant provides fewer than 2 cents of every dollar spent by state and local governments on mental health! Medicaid controls more MH spending than state mental health authorities Medicaid Enrollees and MH 4% of Medicaid enrollees qualify because of a mental disorder/disability 13% of Medicaid enrollees rely on Medicaid for MH services 36% of those receiving MH benefits qualify as disabled 32% are children who qualify under family income, not disability 29% are pregnant women and adult caretakers of eligible children Source: Jeffrey A. Buck et al, Mental Health Services in Ten State Medicaid Programs, October 28, 2004 Who Relies on Medicaid for MH? Children in child welfare system 35-85% have been found to have moderate to severe psychological problems Medicare s MH benefit is limited dually eligible enrollees turn to Medicaid Commercial coverage is often inadequate for those with serious mental illness People with mental disorders made up approx 34% of SSI beneficiaries 3
Medicaid Mental Health Benefits More comprehensive than commercial plans: Rx, hospital, psychiatrists, other professionals, plus respite care, transportation, case management Includes intensive community services (Rehabilitation Services option) Includes long term care EPSDT broad benefits for children No or limited cost sharing No pre-existing condition exclusions or waiting periods The Cost of Co-Morbidity For Medicaid consumers receiving MH/SA services, spending for non-mental health services is larger than spending for mental health services! 10 state survey in 2003: 7-13% Medicaid enrollees used MH/SA 11% of total spending was for MH/SA services 28% of total spending was for MH/SA users Source: Jeffrey A. Buck et al, Mental Health Services in Ten State Medicaid Programs, October 28, 2004 2006 IOM Report Improving Quality of Health Care for Mental Health and Substance Abuse Conditions Co-morbidity is common: MH/SA illnesses frequently accompany conditions like diabetes, heart disease, neurologic illness, cancers 4
Co-morbidity Depression and anxiety - strongly associated with somatic symptoms like headache, fatigue, dizziness and pain, which are leading causes of outpatient medical visits 1 in 5 patients hospitalized for heart attack suffers from major depression; post-heart attack depression increases the risk of death (3x) Persons with MH/SA illnesses often have increased prevalence of cardiovascular disease, high blood pressure, diabetes, arthritis, digestive disorders, asthma Unrecognized or Under-treated A majority of people with MH needs seek services in primary care In many states, access to public MH services is restricted to serious and persistent MI IOM study finds absent or poor linkages between MH/SA and physical health systems Providers in both physical health and mental health/substance abuse treatment fields often fail to detect and treat, or detect, refer, and collaborate in the coordinated care of these patients. Historically, Integration Has NOT Been the Goal in States: Medicaid Managed Care arrangements often carve out some or all MH/SA services Some MH services (community MH/SA, state MH hospitals) are generally planned/administered by state or local mental health authorities, others by the Medicaid agency (Rx, psychiatrists, general hospital admissions, long term care) Dually eligible consumers also have Medicare in the mix! 5
Models of Integration RWJ Depression in Primary Care pilots IMPACT model for identifying and treating depression in older adults Wagner s Model: Chronic Care Quality Improvement HRSA-sponsored Collaboratives (Federally Qualified Health Centers) NCCBH Four Quadrant Integration Model Quadrant II Hi BH Low PH Quadrant I Low BH Low PH Quadrant IV Hi BH Hi PH Quadrant III Low BH Hi PH (Barbara J. Mauer, National Council for Community Behavioral Healthcare) Range of Approaches Shared tools and information, IT facilitated Cleveland, Ohio pediatricians Care management models (HMOs) ColoradoAccess Washington Medicaid pilot Co-location (in primary care settings, in mental health settings) SSTAR, Massachusetts Vermont Medicaid Blended funding + co-location Washtenaw County, Michigan 6
ColoradoAccess Received 2 Medicaid capitations: physical health and mental health care for ABD, parents/children Prior claims data analysis: 40% of adult Medicaid enrollees had received MH diagnosis on a claim but only 33% of those diagnosed had been treated by a MH specialist This group had 2.24 times higher health care costs; 1.77 times higher medical costs ColoradoAccess RWJ Depression in Primary Care pilot Targeted enrollees already selected for case management due to their physical health care conditions; screened for depression Found 46-54% of targeted enrollees had previously received a depression diagnosis and/or received an antidepressant Agreed to pay primary care for MH/SA office visits HMO s case management team coordinated care across providers, facilitated access, monitored patients Colorado Access Results Clinical improvements in depression severity Reduced ER visits, hospital admissions Savings=$2040 per year per patient Source: Marshall R. Thomas, M.D., V.P. of Medical Services/CMO Colorado Access 7
System Barriers to Integration Delivery of care for MH/SA is typically separate from general health care both financially and organizationally (and even from each other!) More dependence on governmental programs for MH/SA, requiring coordination across public (state and local) and private sectors Non-health care sectors (education, child welfare, juvenile and criminal justice systems) also separately arrange for MH/SA services Source: IOM Improving Quality of Health Care for Mental Health and Substance Abuse Conditions What Does It Take? More routine screening (all systems) Providers should anticipate co-morbidity Create linking mechanisms to foster collaborative planning and treatment: co-location of providers shared patient records care/case management formal agreements across providers, committing to collaborative activities Organizational leadership at provider level Source: IOM Improving Quality of Health Care for Mental Health and Substance Abuse Conditions Purchaser and Public Policy Leadership Contracts that establish clear expectations for sharing information, collaboration and coordination Allow primary care to bill for MH/SA treatments Quality oversight focused on improved integration Federal and state level collaboration and coordination in policy-making! Source: IOM Improving Quality of Health Care for Mental Health and Substance Abuse Conditions 8
Medicaid Reality Elderly=9% Disabled=17% Elderly=23% Adults=26% Disabled=46% Children=48% Adults=13% Children=19% Enrollees Expenditures 2006 U.S. Total = $59.7 m 2006 U.S. total = $299 b Note: expenditure distribution based on spending for medical services only and excludes DSH, supplemental provider payments, vaccines for children and administration. Source: HMA estimates based on CBO Medicaid Baseline, March 2006. 9