Comorbidity in the Dual Eligible Population: Improving Health Status through Behavioral Health Interventions PREPARED FOR THE CALIFORNIA ASSOCIATION OF HEALTH PLANS 2013 SEMINAR SERIES JUNE 25, 2013 BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 1
Agenda 1. Beacon s Point of View 2. Understanding di the Behavioral Health Needs of Dual Eligiblesibl A. Serious Mental Illness and Substance Use Disorder B. Chronic Illness and Behavioral Health Comorbidity 3. CA Duals Model A. Building bridges between Cal MediConnect Plans & County Partners 4. A Few Parting Thoughts BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 2
Beacon is engaged throughout demonstration states to address the behavioral health needs of the dual eligible population DIVERSE GEOGRAPHY AND EXPERIENCE 8.2 million covered lives in 15 states, UK DUALS ELIGIBLE HEALTH PLAN PARTNERS Massachusetts 2.4 million Medicaid members 625,000 ABD and dual enrollees Includes +150,000 SPMI members 10 Medicaid programs: TX, CA, DC, FL, KY, MA, MI, NH, NY, RI California Operating or implementing with 9 health plan partners in 5 demonstration states Readiness with NORC underway: MA, IL, CA Illinois, Virginia and Ohio Rhode Island BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 3
Agenda 1. Beacon s Point of View 2. Understanding the Behavioral Health Needs of Dual Eligibles A. Serious Mental Illness and Substance Use Disorder B. Chronic Illness and Behavioral Health Comorbidity 3. CA Duals Model A. Building bridges between Cal MediConnect Plans & County Partners 4. A Few Parting Thoughts ht BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 4
Serious mental illness and substance use disorder are more prevalent among the dual eligible population than either Medicaid-only or Medicare-only groups PREVALENCE OF SERIOUS MENTAL ILLNESS PREVALENCE OF SUBSTANCE USE DISORDER 30.0% 10.0% 8.0% 20.0% 60% 6.0% 10.0% 4.0% 00% 0.0% <65 65+ Duals Medicare-Only Medicaid-Only 2.0% Duals Medicare-Only 00% 0.0% <65 65+ Medicaid-Only Clark, R.E., Leung, Y.H., Lin, W-C., Little, F.C., O Connell, E., et al (2009). Twelve-Month Diagnosed Prevalence of Mental Illness, Substance Use Disorder, and Medical Comorbidity in Massachusetts Medicare and Medicaid Members Aged 55 and Over, 2005 BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 5
Behavioral health conditions contribute to higher medical and long-term care costs DUAL ELIGIBLE ANNUAL COSTS PER BENEFICIARY $60,000 $51,000 $40,000 $20,000 $0 $19,400 Medicaid $10,800 Medicare $8,600 All Duals $31,000 Medicaid $17,500 Medicare $13,500 1orMoreChronic $38,500 Medicaid $23,200 Medicare $15,300 1 or More Chronic, 1Behavioral Medicaid $32,500 Medicare $18,500 At Least 1BHand1LTSS Source: http://www.kff.org/medicaid/upload/8081.pdf, July 2010 BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 6
Duals with serious mental illness and/or substance use disorder are substantially more likely to be admitted and readmitted inpatient PERCENTAGE OF BENEFICIARIES ADMITTED INPATIENT 30-DAY HOSPITAL READMISSION RATES 100.0% 80.0% 90% 84% 40% 30% 37% 32% 60.0% 40.0% 20.0% 22% 17% 45% 46% Dual Eligib ble Only Medicare 20% 10% 16% 13% 24% 22% 0.0% No SMI SMI SMI & SUD 0% No SMI SMI SMI & SUD SOURCE: SCAN Foundation, DataBrief Series, February 2013, Issue 36 SOURCE: SCAN Foundation, DataBrief Series, Februrary 2013, Issue 37 BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 7
Case Study from Western New York: The community mental health system offers a powerful set of services, if engaged g effectively % OF HIGHEST RISK SERIOUSLY MENTALLY ILL MEMBERS RECEIVING COUNTY SERVICES 40.0% 39.0% 30.0% APPROACH County care management and delivery system retrained on principles of person-centered planning Analytics used to select and prioritize members for engagement and treatment with intensive services Medical necessity criteria developed in concert with community providers inpatient and diversionary services 20.0% 21.0% Integrated Virtual Gateway (SPOA) for social services into clinical management system RESULTS 10.0% 59% decrease in ER utilization 62% decrease in inpatient mental health average length of stay 0.0% Highest Risk Quartile MH only Highest Risk Quartile All BH and Medical 34% decrease in self-harm incidents 32% decrease in physical harm to others 50% decrease in suicide attempts Source: NY Care Coordination Program, 2010 Note: Erie, Monroe and Onandoga Counteis 44% increase in gainful employment BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 8
Plans must partner with the SMI system of care to bring managed care insight to a more traditional public system mentality 1. Community Mental Health Centers (CMHCs) provide highly impactful services, but often without regard to risk, appropriate p tenure, or overall capacity needs A. LA County Example: 45 55k SMI; 16k+ engaged with county rehab option services 2. Substance use services are particularly variable, particularly fragmented and in some cases may not even exist in the Medicaid program (FL, CA) 3. Behavioral health services remain carved out in a number of demonstrations (CA, MA, MI), not withstanding grand objectives regarding alignment 4. Provider politics always matter (SNFs, PCAs, homecare, etc.), but the SMI advocates are especially organized and effective A. Care management efforts by duals plans cannot be seen as weakening the existing safety net B. Must leverage installed base CMHC care management services i. Limited experience with managed care and limited medical capability ii. Health Home (ACA Section 2703) or behavioral health homes, etc. - OH, NY, RI BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 9
A few additional takeaways for the under 65 SMI population 1. Delegation of care management and effective oversight are acquired skills 2. Out-of-plan benefits cannot be out of sight, out of mind 3. Developing a large-scale peer support program is a key programmatic objective for the advocacy and provider community Evidence suggests that this is a good idea Effective means of finding and engaging this population 4. Housing, housing, housing BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 10
Behavioral health co-morbidity is relatively high among the >65 population, though probably understated PREVALENCE OF BH COMORBIDITY BY RATE CELL 100% 88.4% 80% 60% 62.5% 40% 40.1% BH Co-Morbid 20% 14.0% 0% Community Well Nursing Home Eligible Institutional ADCMI SOURCE: Beacon client data prior to Beacon engagement g BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 11
In the over 65, costs are also about mental health as an accelerator, not a primary condition PMPM SPENDING DIFFERENTIAL TOTAL COST OF CARE (BH COMORBID VS. NON) 1.3x $10,000 $8,521 $8,000 1.8x $6,387 $6,000 $5,206 2.0x $4,000 $2,844 $2,061 $2,000 Chronic Mental Illness $1,037 $0 Community Well Nursing Home Eligible Institutional SOURCE: Beacon client data prior to Beacon engagement g BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 12
Behavioral health conditions complicate transitions, and contribute to far higher costs within non-bh categories of service PMPM SPENDING DIFFERENTIAL BY CATEGORY OF SERVICE (BH COMORBID VS. NON) 17.2x $2,000 $1,864 $1,500 3.9x $1,000 $1,047 1.9x 3.0x $500 $0 $269 $290 $321 $108 $152 $82 Hospital SNF/LTC Professional DME SOURCE: Beacon client data prior to Beacon engagement g BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 13
The SPMI population among duals has a greater co-morbidity burden at an earlier age. High likelihood of nursing home placement with no ADLs DUALS WITH 5 OR MORE CHRONIC ILLNESSES 60.0% 54.4% 58.8% 40.0% 20.0% 13.0% 31.0% 16.2% 41.0% 26.2% 33.9% BH Populat tion SMI + Chronic 0.0% 55-64 65-74 75-84 85 vclark, R.E., Leung, Y.H., Lin, W-C., Little, F.C., O Connell, E., et al (2009). Twelve-Month Diagnosed Prevalence of Mental Illness, Substance Use Disorder, and Medical Comorbidity in Massachusetts Medicare and Medicaid Members Aged 55 and Over, 2005 BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 14
Good news: notwithstanding diagnostic challenges, HCC scores allow investment in behavioral health services and management AVERAGE MEDICARE RISK SCORE 2.0 1.8 1.5 1.0 0.8 1.1 1.2 0.5 0.0 Non-BH, Non-Chronic BH Only Chronics BH + Chronic SOURCE: Beacon client data prior to Beacon engagement g BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 15
Improving behavioral health treatment for mild to moderate conditions requires a more flexible provider network model 1. Provider network of LTSS, BH-focused services must deepen Home based BH therapy Mobile assessment, rapid response and stabilization capability to any setting Training and continued awareness to the family and caregivers 2. Clear ROI on spending the money to have BH fully involved in the interdisciplinary team Inside care management team Field-based care team 3. Demand and contract for BH competency in the provider setting 4. BH training of low-skill, high touch work force Homemaker, care attendant, transportation, etc. 5. Jury is out on the best way to infuse primary care into the existing BH delivery system. Key source of innovation and testing in wave 1 Beacon uses nurse supervisors and NPs in the pod, but that s still unproven BH Health Homes BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 16
Agenda 1. Beacon s Point of View 2. Understanding the Behavioral Health Needs of Dual Eligibles A. Serious Mental Illness and Substance Use Disorder B. Chronic Illness and Behavioral Health Comorbidity 3. CA Duals Model A. Building bridges between Cal MediConnect Plans & County Partners 4. A Few Parting Thoughts ht BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 17
Cal MediConnect Implementation Bridge with county BH PROVIDING SEAMLESS ACCESS TO CARE 1. Alameda County A. Alameda Alliance for Health B. Anthem Blue Cross Alameda County Behavioral Health Care Services 2. Los Angeles County Beacon A. LA Care B. CareMore C. Care 1st LA County Dept of Mental Health LA County Dept of Public Health BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 18
Division of Medicare and Medi-Cal Behavioral Health Benefits CAL MEDICONNECT PLAN BENEFITS SPECIALTY MEDI-CAL CARVED OUT BENEFITS 1. Inpatient psychiatric care 1. Mental health services (rehabilitation and 2. Psychiatric testing/assessment care plan development) 3. Outpatient psychiatry 2. Day treatment intensive and day rehabilitation 4. Therapy (group and individual) 5. Partial hospitalization program and intensive outpatient program (IOP) 6. Pharmacy 3. Crisis intervention and crisis stabilization 4. Adult Residential treatment services 5. Crisis residential treatment services 6. Targeted Case Management 7. Alcohol misuse counseling in primary care 7. Crossover claim for psychiatric inpatient 8. Alcohol and/or drug services in intensive hospital services outpatient treatment center 8. Methadone maintenance therapy 9. Detoxification 9. Day care rehabilitation 10. Naltrexone treatment for narcotic 10. Outpatient individual and group counseling dependence 11. Perinatal residential services BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 19
Cal MediConnect BH Coordination BH COORDINATION LOCAL MOU 1. Roles and responsibilities 2. Care coordination Behavioral Health Care Management Team (BHCMT) Interdisciplinary Care Team 3. Process for information i exchange 4. Shared financial accountability strategies BEACON S ROLE 1. Assessment and lead care management for primary BH members 2. Collaboratively develop individual care plans. 3. Credential & Contract with networks (including county & countycontracted CBOs) 4. Authorize services & pay claims 5. Coordinated care teams and lead data exchange with county BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 20
Agenda 1. Beacon s Point of View 2. Understanding the Behavioral Health Needs of Dual Eligibles A. Serious Mental Illness and Substance Use Disorder B. Chronic Illness and Behavioral Health Comorbidity C. Understanding the Full Scale of MR/DD Involvement in the Demo 3. A Few Parting Thoughts ht BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 21
Ensuring improved behavioral health management under the Duals demonstration requires a multi-faceted approach LESSONS FOR IMPLEMENTATION OF DUALS DEMONSTRATIONS 1. Focus BH is only one of many areas in which health plans must execute Disproportionate importance with regard to complexity and cost Identify BH leadership, ensure they are at the table 2. Collaboration and Scale Providers have limited bandwidth for engagement Consistency breeds strong outcomes Group purchasing may provide a simple solution and mitigate adverse selection 3. Local Knowledge Every local system of care has its own providers, services, and capacity Variation state-to-state to and often county-to-county to One-size does not fit all 4. Pace: Crawl, Walk, Run BEACON HEALTH STRATEGIES beaconhealthstrategies.com June 26, 2013 22