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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 1335099

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


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
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


Documentation
Documentation

  • 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