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Health Planning Council Meeting 10 Advisory Committee Meeting 7 Joint Meeting

Health Planning Council Meeting 10 Advisory Committee Meeting 7 Joint Meeting. Madeleine Biondolillo, MD Associate Commissioner Department of Public Health July 23, 2014. Agenda. Approve minutes of May 20, 2014 meeting Review planning work to date Review utilization d ata and analysis

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Health Planning Council Meeting 10 Advisory Committee Meeting 7 Joint Meeting

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  1. Health Planning Council Meeting 10 Advisory CommitteeMeeting 7 Joint Meeting Madeleine Biondolillo, MD Associate Commissioner Department of Public Health July 23, 2014

  2. Agenda • Approve minutes of May 20, 2014 meeting • Review planning work to date • Review utilization data and analysis • Review Issue Briefs to date • Next steps

  3. Timeline • Reminder of Timeline

  4. Timeline Reminders • Service Mapping – Complete • Service Definitions – Complete • Needs Framework – Complete • Inventory: Beds, Licensed Programs and Contracts – Complete • Analytic Approach for Utilization Data – Complete • Utilization Data, Analysis and Report – July 23 • Projection of Need – July 23

  5. Research Questions Overarching research questions have been developed to organize and frame the analysis. As outlined in previous presentations, the data completeness and reliability will vary by type of service. Research questions address need, demand, use, inventory, capacity and include a gap analysis. The analysis is supplemented with issue briefs. We begin to address these questions through the data presented in May and in this meeting, through the Issue Briefs and through recommendations for future work.

  6. Analytic Road Map and Framework – Report Demand Sought Treatment Need Prevalence Use Provider Inventory and Capacity • Needs are estimated using national prevalence and survey data. The framework and the overall need data were shared last meeting. Projections of need are presented today. • Demand for services in behavioral health is highly elastic and data such as wait lists are not readily available. Many people meeting diagnostic criteria are not “ready” for treatment. • Provider inventory is available primarily for licensed programs and is covered in this presentation. • Use data came from five primary sources: DPH-BSAS; DMH; MassHealth; Medicare 5%; APCD commercial data.

  7. Estimation of Need

  8. Need: Prevalence Data for Mental Health Conditions Mental Health Conditions NSDUH and National Health Information Survey Youth 4-17 Any Emotional and Behavioral Difficulty: 19.7%* - 197,310*** Adults 18+ Any Mental Illness: 17.1%** - 894,313*** Serious Emotional and Behavioral Difficulties: 5.3%* - 53,083*** Adults Serious Mental Illness: 3.9%** - 203,966*** * National Health Information Survey 2011 ** National Survey of Drug Use and Health 2008-11 (rev 10/13) and 2012 ***2014 population projections from UMass Donahue Institute Any Mental Illness(AMI): having (currently or at any time in the past year) a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within the DSM-IV, regardless of functional impairment. Serious Mental Illness(SMI): having a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within the DSM-IV that has resulted in serious functional impairment, which substantially interferes with or limits one or more major life activities. Minor and Serious Emotional and Behavioral Difficulties: Based on parent responses to the Strengths and Difficulties Questionnaire. Serious emotional or behavioral difficulties may be similar to but do not equate with the Federal definition of serious emotional disturbances (SED), used by the Federal government for planning purposes.  

  9. Need: Prevalence Data for Substance Dependence& Abuse Substance Dependence and Abuse (MA) (2008-11 and 2012 NSDUH Combined) Overall: 10.1% of the Target Population (≥12 years old) - 577,087* Alcohol Dependence or Abuse 8.1%* - 462,813 Illicit Drug** Dependence or Abuse 2.9% - 165,698 * ** 188,276*** With co-occurring disorders *Dependence or Abuse Past Year Ages 12+ – NSDUH 2008-11 (rev 10/13) and 2012 **Illicit Drugs include cocaine, heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics and marijuana used non-medically ***NSDUH 2012 2014 population projections from UMass Donahue Institute Dependence or Abuse is based on definitions found in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Substance Use Disorders include both Abuse and Dependence

  10. Half of People with Any Mental Illness (AMI) Did Not Get Treatment and Did Not Report an Unmet Need Unmet Need? Received Treatment? • Respondents who were identified as having AMI were asked “was there any time when you needed mental health treatment or counseling for yourself but didn’t get it?” • 9% did not get treatment and yet they reported an unmet need • Half of people reporting a mental illness did not get treatment, and did not report an unmet need (despite being identified with a mental illness) • 12% got treatment, and reported an unmet need • 29% who met the criteria for any mental illness were receiving treatment with no unmet need. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2011 and 2012 http://www.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/MHDT/NSDUH-MHDetTabsSect1peTabs2012.htm - Tables 1.1A , 1.24A , 1.39A Source on Massachusetts: Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: Massachusetts, 2013. HHS Publication No. SMA-13-4796MA. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, p.9

  11. Majority of People with SUD in the US Do Not Feel a Need for Treatment • Only 11% of people reporting an SUD received treatment • Of the remaining 89%, most of these (95%) did not “feel the need for treatment” (awareness). A very small number (<2%) tried to get treatment and failed (access). • Highlights from other data not shown: • Top reasons reported by those who felt the need, tried, and failed to get treatment were not having health insurance (38%), not being ready to stop using (26%), and had health coverage that did not cover treatment or did not cover cost (10%). • Need to build awareness in addition to capacity, e.g. for binge drinkers. Source on Need for Treatment: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2011 and 2012 - Table 5.51A , Table 5.53A - http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH-DetTabsSect5peTabs1to56-2012.htm Source on Reasons for not receiving treatment (annual averages 2009-12):Table 5.56B - http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUH-DetTabsSect5peTabs1to56-2012.htm#Tab5.56B. Source on Receipt of Treatment (not shown): Table 5.44A ,Table 5.47A ,Table 5.48A ,Table 5.50A Source on Massachusetts: Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: Massachusetts, 2013. HHS Publication No. SMA-13-4796MA. Rockville, MD: Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, p.15 and 17.

  12. Population Growth Source: UMass Donahue Institute – Special Analysis for Health Planning Council November 2013.

  13. Population Growth • The Donahue Institute at UMass Boston developed population projections for Massachusetts that projected a modest 1.8% overall increase in the state’s population over the next 6 years (in 2020 - see next page). • Metro Boston showed the highest growth rate at 3.6% over that period, while the Cape and the Islands showed a minor decrease in population. • Data were not readily available for racial and ethnic groups for the HPC regions and for utilization data. This warrants attention in the future. • These estimates have a very small impact on the capacity projections and the regional variation is also very small. • The impact of an increasingly aging population is also not clear though improvements in health and wellness for people with serious mental illness and substance use disorders may in fact lengthen the lives of people served and the number of years of long term services and supports in the community.

  14. What is the capacity of Massachusetts’ behavioral healthcare system to serve those in need?

  15. The Framework: Service Definitions The Health Planning Workgroup organized services into eight major service categories that could include all mental health and substance abuse services provided in the state. These service categories, which differ only slightly between mental health and substance abuse, provided a framework for thinking about the state’s inventory and the utilization of services.

  16. Inventory

  17. Inpatient Mental Health Inventory Inpatient Psychiatric Beds in Free-Standing Psychiatric Hospitals, General Hospitals and State-Operated Units, 2010 and 2014 From 2010 to 2014, bed capacity has grown 5% among the free-standing hospitals and 2% among all hospitals. Free-standing hospital bed growth of 5% over the last four years contrasts with no growth for general acute hospital psychiatric beds that may provide care for more complex, medically involved cases. Total Acute Beds 2010 – 2388 2014 - 2431 There are a total of 67 acute hospitals or psychiatric units across the state, with 2,431 acute beds across different hospital groups. • These facilities include 15 free-standing acute psychiatric hospitals, 50 psychiatric units in general hospitals, and two psychiatric units in state mental health facilities. Of the 2,431 beds, 43% are in free-standing hospitals, 56% in general hospitals, and 1% in state facilities. • These 2,431 beds receive clients from a statewide population of 6.6 million residents, for a ratio of beds to population of 37 beds per 100,000 population. • For age groups, 10% of beds are for children and adolescents, 73% of beds are for adults, 17% of the beds are in specialized geriatric units.

  18. Substance Abuse Inpatient and Other Acute Services Inpatient and other acute substance abuse services inventory includes a total of 1,399 beds. These 1,399 beds receive clients from a statewide population of 5.6 million residents 13 years and older, for a ratio of beds to population of 25 beds per 100,000 population. A variety of acute substance abuse care beds serves people with different levels of need. The medically managed (hospital) and medically monitored (ATS) beds involve the highest level of medical oversight. ATS means acute treatment services. Section 35 is the state statute for court-ordered treatment of substance abuse conditions. CSS means clinical stabilization services. Note that Sec. 35 CSS programs preferentially admit Section 35 ATS discharges for longer term stabilization services.

  19. MH Inpatient Beds: 8 Regions Inpatient mental health beds are distributed across regions of the state with varied numbers of beds per 100,000 population. All acute hospital locations (may or may not include MH beds)

  20. SA Inpatient and Other Acute Service Beds All acute hospital locations (may or may not include SA beds) Bed density based upon MA population data for ages 13+. Central Mass and Cape Cod have the highest concentration of beds while Metro-West region is the lowest.

  21. Inpatient Capacity: MH and SA • SA inpatient and other acute services: • 917 Level 4 and Level 3.7 beds or 16.5 beds/100,000. • This does not include the 284 CSS beds and the 198 Section 35 beds (both of which are mostly purchased by BSAS). Total including CSS and Section 35 beds is 1399 or 25 beds/100,000 (≥13 years old). • The widespread use of non-hospital levels of care in MA for detoxification makes state to state comparisons difficult. SAMHSA NSSAT data for hospital use are not directly comparable. Other studies report much lower bed/100,000 counts including 3 per/100,000 in a California study. (http://www.slocounty.ca.gov/Assets/DAS/San+Luis+Obispo+County+Detoxification+Services+Report.pdf) ACEP Data * MH inpatient capacity based on 2,431 total inpatient beds or 37 acute beds per 100,000. ** The American College of Emergency Physicians 2014 State by State report card REPORTED benchmarks in NY (31.3), MD (29.4), North Carolina (21.9) and IL (21.1). Note that MA in this report was 27.4/100,000. (Data were from the American Hospital Association, AHA Annual Survey, FY 2011) *** A 2013 study by the California Hospital Association found CA had 16.7 beds per 100,000, with county levels ranging from 0 to 39. **** The World Health Organization (WHO) in 2011 reported the U.S. rate of psychiatric beds per 100,000 as 14.4.

  22. Utilization

  23. Data Sources and Methods Utilization data was collected from five main sources: MassHealth; Medicare; Commercial All Payer Claims Data; DMH and BSAS. The sample was limited to claims with primary diagnosis codes shown in the list. This range of codes includes the dementias, even though these disorders are generally thought of as neurological conditions rather than mental illness. Data from 2010-2012 was analyzed. Data was de-identified as specified in the data use agreements

  24. Data Methods: Inclusion Criteria & Population Definitions Note that there are significant differences in coverage and benefits, and case mix severity across the plan types. The inclusion criteria used for the MA Behavioral Health Analysis were as follows: • Claims: • ICD9-CM primary diagnosis codes in the range of 290 – 316; • Year of service equal to 2010, 2011, or 2012 • Eligibility: • Residence of MA, as defined by MA zip code

  25. Payor Groups: Data Sources and Definitions Medicare: • Data from Medicare 5% sample were used. Data were limited to FFS only (as defined by Medicare Parts A & B eligible without Medicare HMO participation). Medicare county utilization data were allocated to HPC regions proportionately according to the total population crosswalk between Counties and HPC regions. • Enrollment was defined by member months and available from an eligibility feed. Medicaid • Data were requested and received from MassHealth. Utilization data were provided by three digit zip code for the enrollees; these data were allocated to HPC regions proportionately according to the three digit zip code to HPC region crosswalk of total population data. • Data included claims where Medicaid was the primary insurer; in addition, third party liability claims were included to capture all service use associated with Medicaid patients.  Crossover claims were attributed to Medicare (the primary insurer) and therefore excluded from Medicaid. • Enrollment (i.e., member months by gender and age group) was provided by MassHealth. Commercial (All Payor Claims Database) • Data were requested and received from the Center for Health Information & Analysis (CHIA). • Top 17 commercial carriers were identified based on # of behavioral health service users in 2012. • Data from Medicaid, Medicare, & Medigap plans were excluded. • Enrollees aged 65 and over were excluded. Enrollment (i.e., member months) was obtained from CHIA’s eligibility file.

  26. Commercial – APCD Top 17

  27. Data Limitations • The analysis of commercial care focused on the top 17 health plans (ranked by number of behavioral health clients); this approach captured 92% of APCD’s 2012 commercial enrollment. • Medicare data are based on a random 5% sample of FFS utilization. Medicare Advantage enrollees (~200,000 in 2012) were not included. MediGap data was also not included. Small cell size in the Medicare under-65 population (which is an important population from the perspective of behavioral health service utilization) may be statistically unstable. • MassHealth data includes data for members for whom MassHealth may be a partial or third party payer, which could skew utilization results. • Data included ICD9-CM diagnosis codes 290 – 316 and did not include E-codes (i.e., suicides, suicide attempts, injuries, and overdoses), thus potentially understating the overall level of substance use disorder-related utilization in MA. • Because claims were selected based on diagnosis code, changes in coding practices (for example, requirements for entering a diagnosis code for certain claim types) could be a factor in explaining an increase in utilization. • Differences across payers in how data fields are populated on claims could result in inaccuracies in the reported utilization.

  28. Enrollment Totals – Payer Groups The 2012 data from the three sources above cover an estimated population of 5,852,795 MA residents, or 89% of the 2014 population. All enrollment is expressed as member months divided by 12 to standardize the rates and minimize duplication between plans.

  29. Percent of Members Accessing Any MH or SA Service MH SA MH SA MH SA Overall penetration rates ranged from 13% to 23% for mental health and 1% to 5% for substance abuse. Commercial penetration rates were the lowest and MassHealth had the highest penetration or access rates. Medicare and MassHealth have 1.7x and 1.8x higher mental health utilization rates than Commercial plans, respectively. Those equivalent numbers for SA were 2.8x (Medicare) and 4x (MassHealth) higher than Commercial rates. * Utilization rates are shown as the number of clients accessing BH services who have a diagnosis, divided by the number of enrollees (member months divided by 12).

  30. MH and SA Inpatient and ER Service Users per 1,000 Enrollees Medicare FFS had the highest rates of utilizers/1000 for inpatient care and emergency room visits for both mental health and substance abuse. MassHealth utilization rates for mental health inpatient services were 5 times the Commercial rates.

  31. Inpatient and Acute Treatment Services: 2010-2012 Utilization of MH and SA inpatient days decreased over the three-year period, though the magnitude varied across payor groups. Slide 31

  32. Emergency and Crisis Services: 2010-2012 Utilization of ER visits appeared to increase among Medicare enrollees; this trend was not seen among MassHealth and Commercial enrollees.

  33. Inpatient & ER Utilizers/1,000 by Age Group, 2012

  34. Inpatient/ER Service Users by Gender, 2012

  35. MH Service Users/1,0002012 Regional Variation

  36. Substance Abuse Service Users/ 1,000 2012 Regional Variation

  37. DMH and BSAS Utilization Both agencies reported on the number of clients served for most services. DMH payment methods and their data systems do not permit the agency to easily track clients’ utilization of multiple services. Most of the clients reported by DMH and BSAS are likely to also be reported in other client counts from MassHealth, Medicare or Commercial coverage. The majority of services reported by each agency are active rehabilitative treatment, long-term services and supports or step-down levels of care (e.g., ATS, CSS and TSS services) that are not fully funded by most other payers. BSAS also pays for services for the uninsured.

  38. DMH / BSAS Utilization:Client Use of Services by Year BSAS DMH

  39. DMH and BSAS: Clients by Gender, Race and Age, CY2013

  40. Acute Bed Capacity Mental Health: • Total licensed psychiatric beds x 365 = Bed day capacity. Does not include DMH Continuing Care beds unless paid through Medicare or other payors • Free standing occupancy rates average slightly less than 84% while Acute General Rates are not clear from CHIA Data • Current MA capacity appears adequate for MA utilization, though: this reflects average utilization, not utilization at a given point in time or season; this does not capture populations with specific needs; data subject to the limitations previously specified; and data do not include out-of-state payers Substance Abuse: • A similar analysis is not available for SA beds because BSAS does not capture data by payor and it was not possible to distinguish the specific Detox provider type from the claims for Medicare, MassHealth and Commercial payors. • BSAS provides some funds for roughly 60% of ATS and CSS detox services directly. Total Licensed Bed Day capacity is 887,315 bed days

  41. Conclusions DMH and BSAS clients receive an extensive array of supports in the community that are not available from most other payers. Services funded by these agencies are available to anyone meeting the need for services. This is one of the first instance of using the HPC regions for health planning. Historically neither DMH or BSAS have used these regions, but future work will benefit from the use of these consistent regions. Inpatient MH capacity appears to be high relative to other benchmarks but relevant comparison points for substance abuse bed capacity are not available. MH and SA bed-day capacity rates are substantially higher than measured use rates, though this analysis is subject to a number of limitations. The low proportion of licensed clinics with co-located behavioral health and medical services (17%) suggests a potential area of focus for improving the integration of health services. Obtaining reliable data on the inventory, capacity, and utilization of outpatient services remains challenging (in part because data sources include claims, contracted and funded services) and further work is needed in this area.

  42. Conclusions (2) Inpatient MH capacity appears high relative to other states and showed a slight increase from 2010-2012, but measures of utilization suggests a decline. Measured Medicare MH emergency room and crisis utilization increased significantly. Understanding the cause of this increase will be helpful for understanding whether there is a need for diversionary services or other programs. 18-25 year olds have disproportionately high utilization levels for inpatient and crisis services compared to other age groups for Medicare and Commercial plans. Consistent with national prevalence data, males are 60% or more of the substance abuse treatment utilization population. Regional variation did not show a consistent pattern.

  43. Conclusions (3) • The Health Planning Council’s work has produced a first-of-its-kind baseline for MH and SA service inventory, need and utilization across all payers. • These data cover 89% of the population and all licensed facilities/programs/clinics. • This report will serve as a baseline for future analyses and establishes a framework for the Determination of Need Program to utilize to evaluate applications.

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