Proving Your Value: Optimizing the Business Case for Integrated Behavioral Health

1. Proving Your Value: Optimizing the Business Case for Integrated Behavioral Health Kent A. Corso, PsyD, BCBA-D and Lesley Manson, PsyD Co-Authors of Integrating BehavioralHealthinto the Medical Home: A Rapid Implementation Guide, 2016, by Greenbranch Publishing Financial Stability and Cost Control - Session #A3 CFHA 18th Annual Conference October 13-15, 2016  Charlotte, NC U.S.A.

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Identify process and outcome improvement metrics which promote sustainable models of integrated care delivery for families and patients. • Describe and discuss data mining options for collecting metrics to demonstrate fidelity, quality improvement, and fiscal sustainability related to integrated care programs. • Identify, evaluate and select tools for effective financial strategic planning and management in integrated care.

4. Bibliography / References 1. Corso, Hunter, Dahl, Kallenberg, and Manson (2016). Integrating behavioral health into the medical home: A rapid implementation guide. Greenbranch: Phoenix, Maryland. 2. Robinson, P. & Reiter, J. (2015). Behavioral Consultation and Primary Care: A Guide to Integrating Services (2nd Edition). Springer International Publishing: Geneva, Switzerland.   3. Savage, A., Lauby, T., & Burkard, J. F. (2014) Examining selected patient outcomes and staff satisfaction in a primary care clinic at a military treatment facility after implementation of the patient-centered medical home. Military Medicine, 178(2):128 – 134. 4. Bendix, J. (2014) RVUs: A valuable tool for aiding practice management. Understanding the basics of the RVU can assist physicians and practice managers in a wide variety of finance and management-related tasks. Med Econ 91(4): 48-51. 5. Kilbourne, A. M., Keyser, D., & Pincus, H. A. (2010). Challenges and opportunities in measuring the quality of mental health care. Canadian Journal of Psychiatry, 55(9), 549-557. 6. Goldman, Spaeth-Rublee, Pincus (2015). Quality indicators for physical and behavioral health care indicators. Journal of the American Medical Association, 314(8):769-770. doi:10.1001/jama.2015.6447

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Overview • Why Bother Proving Your Value? • The Role of Process and Outcome Metrics • Optimizing Your Value: Concepts, Calculations and Demonstrations • Data Mining Options for Demonstrating Fidelity and Quality Improvement • Tools for Financial Strategic Planning and Management for Sustainability • Conclusion

7. Why Bother? • Remaining Current with American Healthcare • Meeting the Triple or Quadruple Aim • Taking advantage of special programs, incentives or healthcare initiatives • Survival • Many funding streams eventually dry up • If you ARE the business side of the house, it’s your job • If you are NOT the business side of the house, they will come knocking eventually • Integrated healthcare IS the standard of care

8. The Role of Outcome and Process Metrics • Outcome Metrics help us answer: • “How we are doing?” • Clinical • Financial • Operational • Process Metrics help us answer: “Why are we doing this well or poorly?”

9. Outcome Metrics (within the Triple Aim)

10. Clinical Outcome Metrics Appropriate for Primary Care

11. Process/Operational Metrics (within the Triple Aim)

12. Process/Operational Metrics (within the Triple Aim)

13. Process/Operational Metrics (within the Triple Aim)

14. Optimizing Your Value: Key Concepts Business Case Analysis (BCA) - A decision support and planning tool that projects the likely financial results and other business consequences of an action. The analysis essentially considers “What happens if we take this or that action?" and answers in business terms—business costs, business benefits, and business risks.

15. BCA

16. Optimizing Your Value: Key Concepts Pro Forma - a method of calculating current or projective fiscal results; describes a presentation of data, in financial terms, where the data reflect the world on an “as-if” basis.

17. Pro Forma

18. Optimizing Your Value: Key Concepts Return on Investment (ROI) - A performance measure used to evaluate the efficiency of an investment or to compare the efficiency of a number of different investments. ROI measures the amount of return on an investment relative to the investment’s cost. To calculate ROI, the benefit (or return) of an investment is divided by the cost of the investment, and the result is expressed as a percentage or a ratio. gain from program—cost of program x 100 = percent of ROI cost of program

19. Data Mining Options for Demonstrating Fidelity and Quality Improvement • Claims data (ROI for insurance companies) • Joint ventures with insurance companies • Registries • Survey Data • Electronic Health Records • HIE (Health Information Exchanges) • HEDIS, UDS, NQF, Physician Quality Reporting • Self-reporting • Other ways?

20. Understand Your Data and Sources • Forms of Data: How to choose? • Claims • Chunking • Small amounts • Analytical vs. Clinical • Volume of Data • How to understand it? • How is it relevant?

21. Data Points • Clinical Indicators • Mortality • Health status • Biometrics • Disease prevalence • Disability status • Health Maintenance • Health assessments (screening tools) • ED visits • Re-admission • PHM • Standardization • HEDIS • UDS / NQF / CMS  • Annual QI Goals • RVUs/Productivity • Fiscal ROI • NCQA PCMH • Organizational • Employee wellness • Job satisfaction • employment sustainment • Satisfaction • Model • Length of session • CPT coding • Diagnosis coding • Visit type • Productivity • Huddles • Communication • Documentation

22. Think We Can Make Fidelity and Quality Great Again?

23. PQRS • PQRS - the quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. • As of 2015, the program applies a negative payment adjustment to individual EPs and PQRS group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013. • Those who report satisfactorily for the 2015 program year avoid the 2017 PQRS negative payment adjustment.

24. PQRS There are several PQRS criteria that could be evaluated or considered as measures of your clinical outcomes. If you have Medicare providers and do not currently monitor these quality data for reporting, you may already be losing money. A few examples relevant to IBH are listed below. PQRS #9 – Anti-depressant Medication Management • PQRS#1 - Diabetes Hemoglobin A1c Poor Control • PQRS #106 – Adult Major Depression Disorder • PQRS #370 – Depression Remission at Twelve Months • PQRS #173 – Unhealthy Alcohol Use • PQRS #131 – Pain Assessment and Follow Up • PQRS #247 – Substance Abuse Disorders • PQRS #128 – Preventative Care and Screening: Body Mass Index Screening and Follow – Up Plan • PQRS #317 – Preventative Care and Screening: High Blood Pressure and Follow-Up with Lifestyle Modifications • PQRS #134 (NQF 0418) – Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (National Quality Strategy Domain: Community/Population Health) • www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

25. PQRS Integrated Care Targets by Domain Effective Clinical Care Measures: • Adult Major Depressive Disorder • Suicide Risk • Substance Use Population Health Measures: • Body Mass • Pain • Depression • Tobacco Safety Measures: Medication Reconciliation / Monitoring Elder Maltreatment

26. Under PQRS, an eligible professional (EP) is defined as one of the following types of professionals: 1. Medicare physicians Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic 2. Practitioners Physician Assistant Nurse Practitioner* Clinical Nurse Specialist* Certified Registered Nurse Anesthetist* (and Anesthesiologist Assistant) Certified Nurse Midwife* 2. Practitioners (continued) Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologists *Includes Advanced Practice Registered Nurse (APRN) 3. Therapists Physical Therapist Occupational Therapist Qualified Speech-Language Therapist

27. HEDIS • Psychiatric hospitalization (e.g., 7 and 30-day follow-up) • Antidepressant medication adherence (e.g., 6 month treatment duration) • Others include: treatment adherence for ADHD in children and schizophrenia in adults, treatment engagement for chemical dependency • Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults • Depression Remission, Response or Treatment Adjustment for Adolescents and Adults • Depression Screening and Follow-up for Adolescents and Adults • Emergency Department Utilization

28. Fidelity Measures • Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ)  Bheeleret al., Translational Behavioral Medicine 2013 Dec;3(4):379-91. • Care Management / Collaborative Care Model (3CM Model)  Oxmanet al., Med Care 2006;44: 1030–1037.

29. Calculating and Demonstrating Your Value • Direct Revenue: dollars • Indirect Revenue (e.g., productivity, operational efficiency, etc.) • Cost Savings: cost management without sacrificing the quality of care; doing more with what you have and doing more without spending more money on resources or time. • Cost Offset: occurs when general healthcare savings are identified as exceeding the cost of the integrated care intervention.

30. Financial Strategic Planning and Management for Sustainability

36. Conclusions If you don’t feel compelled to prove your value, someone will ask you to do it, eventually. Regarding metrics…just ensure you ask “good” questions and the data will give you “good” answers. Outcomes tell us “what” and process/operational metrics help us understand “why.” There are many ways to demonstrate ROI and they may not be in direct revenue. There are many options when it comes to measuring quality; while there are fewer options for fidelity measurement, that doesn’t make it any less important. If your “success story” is not sustainable, consider developing a new story. Plan, implement, evaluate, iterate, repeat

37. Session Evaluation Please complete and return the evaluation form before leaving this session. Thank you!