Managed Care and Integration

1. Managed Care and Integration May 19, 2011 1

2. 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

3. 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?

4. 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

5. 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

6. 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

7. Treatment Barriers • Substance Abuse • Psychological Components of Physical Illness • Nonadherence • Unhealthy Behaviors • Social Support Gaps • Hierarchy of Needs • Cultural and Linguistic Issues

8. 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

9. 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

10. Documentation • EHRs • Outcomes measurement (SF-12, others) • Health Information exchanges • Define shared data sets • Improved reimbursement

11. 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

12. 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

13. 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

14. 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

15. Financial Barriers • Telemedicine • Treatment Team Meetings • Co-management • Brief Consultation • Same Day Restrictions on Billing • Use of Mid-levels • Reimbursing SBIRT

16. Financial Solutions • No carve out • Determine proper coding, e.g. 90801 psych vs. 96150 medical • Telemedicine reimbursement • Demonstrating ROI

17. Regulatory Solutions • State decision on claims policy • modifier codes • Privacy concerns

18. Legal Barriers • HIPAA interpretations

19. Solutions to Legal Issues • Health Coordination forms • Auditing continuity of care

20. …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

21. 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

22. 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

23. 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

24. Bringing It Together (MCE view) • Health Risk Screening • Patient Analysis - leveling tools • Intensive Case Management • Care Management • Payment Strategies