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Managed Care and Integration. May 19, 2011. 1. Managed Care and Integration . How One Organization Is Approaching This Dynamic Change To Current Practices Robert B. Baker, MD, MMM VPMA, MHS- Indiana Bernard T. Engelberg, MD Medical Director, Cenpatico. 2.

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Managed Care and Integration

How One Organization Is Approaching This Dynamic Change To Current Practices

Robert B. Baker, MD, MMM

VPMA, MHS- Indiana

Bernard T. Engelberg, MD

Medical Director, Cenpatico


what is integrated care managed care view
What is Integrated Care? (Managed Care View)
  • Is Coordinated Care Integrated Care?
    • What do you think coordination means?
      • Shared information, shared treatment plans, more than one person deals with the patient’s problems
      • How does it actually look? How does it function?
  • Is Co-Location Integrated Care?
  • Where do functional impairments stop and mental impairments begin?
  • Can PH practitioners treat SMI?
  • Can BH practitioners treat PH problems?
  • Medications?
  • Information sharing?
why is this important
Why is this important?
  • Comorbidities are common - >25%
  • Only 5% see a mental health provider
  • 80% see a PMP
  • Disproportionate needs in minority populations
  • Paradoxical decrease usage in refugee populations
importance of screening
Importance of Screening

According to a NAMI survey:

  • 13% of youth aged 8-15 live with mental illness
  • 21% of youth aged 13-18
  • ½ of all cases of mental illness begin by age 14
  • Average delay of 8-10 years from the onset of symptoms to intervention
  • Fewer than ½ of children with a diagnosable mental illness receive services in a given year
what are our goals
What are our goals?
  • Synergistic decrease in utilization (cost)
    • Cherokee model – 28% decrease in medical utilization
    • 27% decrease in psychiatry visits
    • 34% decrease in psychotherapy
    • 48% decrease in mobile crisis team encounters
  • Improved Health Outcomes
    • May increase mental health cost for the episode of care
    • Overall morbidity may decrease
    • Quality of care can increase
treatment barriers
Treatment Barriers
  • Substance Abuse
  • Psychological Components of Physical Illness
  • Nonadherence
  • Unhealthy Behaviors
  • Social Support Gaps
  • Hierarchy of Needs
  • Cultural and Linguistic Issues
what is the current state of affairs
What is the current state of affairs?
  • Not enough mental health providers to supply demands
  • Not enough PMPs – at least 15,000 FTE short in the US for current demand
  • Estimated 50,000 FTE shortage for a fully insured population
  • Staff productivity
cross training
  • AHEC interest
  • Expanded curricula
  • UMass program
  • HRSA training and funding
  • Use of mental health grants
  • Use of standardized screening and assessment tools
  • Speaking the same language
  • EHRs
  • Outcomes measurement (SF-12, others)
  • Health Information exchanges
  • Define shared data sets
  • Improved reimbursement
who are the players
Who are the players?
  • MCEs
    • Case Managers
  • Integrated Health Systems
  • CMHCs
  • OMPP
  • Medical Homes (co-located, embedded)
    • Patient Navigators, Care Managers
  • Getting Everyone To Talk With Each Other
    • In The Weeds
    • IPHCA
what are the barriers to a more integrated system
What are the barriers to a more integrated system?
  • Promoting co-located care
  • Promoting truly integrated care
  • Credentialing
  • Integrated treatment plans
  • Shared information
    • Many release forms available
what can be done
What can be done?
  • MCE Level
    • Case Management
    • Telephones
    • Disease Management – stratification of risk
    • Toolkits
    • Facilitated follow-up appointments
  • CMC Level
    • Written Referral Arrangements with FQHCs
  • State Level
    • Full range covered services
integrated level
Integrated Level
  • Embedded BH practitioner on primary care team
  • Integrated clinical record and treatment plan
  • BH screening of the primary care patient – normalizes the illness
  • Multidisciplinary meetings
  • Clinic redesign
  • Coordination with wrap-around care
  • Seamless transition across settings (e.g. hospital to outpatient)
  • Shared knowledge about resources (parents and patients want this – not just a prescription!)

- Binders, handouts, referrals, support groups, community services

financial barriers
Financial Barriers
  • Telemedicine
  • Treatment Team Meetings
  • Co-management
  • Brief Consultation
  • Same Day Restrictions on Billing
  • Use of Mid-levels
  • Reimbursing SBIRT
financial solutions
Financial Solutions
  • No carve out
  • Determine proper coding, e.g. 90801 psych vs. 96150 medical
  • Telemedicine reimbursement
  • Demonstrating ROI
regulatory solutions
Regulatory Solutions
  • State decision on claims policy
    • modifier codes
  • Privacy concerns
legal barriers
Legal Barriers
  • HIPAA interpretations
solutions to legal issues
Solutions to Legal Issues
  • Health Coordination forms
    • Auditing continuity of care
so why integrate
…so why integrate?
  • Each year up to 30% of Adults meet criteria for a mental health problem
  • Up to 70% of children and adolescents in need of MH services do not receive them
  • Undiagnosed SA disorders impact PH.
  • MH problems 2-3x more common in chronic medical illnesses
  • Untreated MH issues lead to functional impairment
what needs to change in primary care
What Needs to Change in Primary Care?
  • Role of CMHCs in a Patient Centered Medical Home
  • Redesign of practices that permit identification of MH/SA issues
  • Monitor MH outcomes
  • Coordinate treatment more closely with MH specialists
role of cmhc
Role of CMHC
  • Integration; not just collaboration
  • “Stepped Care” matching patient’s needs to services provided
  • Availability – office visits and telephone
  • SA and dual diagnosis solutions
  • Integrated “piggy-back” hand-offs
crucial links
Crucial Links
  • PCPs need tools for MH/SA identification
  • Case managers/Care Coordinators needed for patient success
  • PCPs need to know what help is available upon SA/MH identification
  • EHR availability to all involved parties
  • Education on outcomes measurements
  • Assessment of system efficacy
bringing it together mce view
Bringing It Together (MCE view)
  • Health Risk Screening
  • Patient Analysis - leveling tools
  • Intensive Case Management
  • Care Management
  • Payment Strategies