Darren Urada, Ph.D.UCLA Integrated Substance Abuse Programs

CADPAAC / ADP Quarterly MeetingIntegration Learning Collaborative

May 29, 2013

Integration of SUD services with Primary Care

Lessons Learned from around the World

AcknowledgementsUCLA team: Jeff Annon, Valerie Antonini, MPH, Desiree Crevecoeur-

MacPhail, Ph.D., Thomas Freese, Ph.D., Sherry Larkins, Ph.D., Brandy Oeser, MPH, Howard Padwa, Ph.D., Diego Ramirez, Beth Rutkowski,

MPH, Cheryl Teruya, Ph.D., Elise Tran, Richard Rawson, Ph.D.

Research funded by:California Department of Alcohol and Drug Programs

Kern County

The authors’ views and recommendations do not necessarily represent those of the funders, UCLA, or the UCLA Integrated Substance Abuse Programs.

Topics to be covered

• Financing / Workforce• Chronic Pain• Performance – lessons from Britain• “Hot-spotting”• Coming to an exchange near you…

Financing / Workforce• With ACOs, currently non-billable BH staff like SUD

counselors will essentially be “billable” if the team is credentialed. Rules still in progress and will vary from state to state.

• There are 150 “pioneer” medicare ACOs right now, and CMS is awaiting data from them. At first look, not finding huge cost savings.

Source: Capobioanco & Kenerson (National Council), 2013

Financing / Workforce• FQHC/BH partnership example: BH center was seeing lots

of people very briefly for meds only and were getting paid $17-$34 because billing was based on time.

• In FQHCs, the National encounter rate avg is: $143/encounter. 

• BH center and FQHC partnered, moved the med-only BH patients over to the FQHC.  Partnership brings in more $$.

Source: Reynolds, 2013

Financing / Workforce• FQHCs can contract with BH and still have enough left over

to pay their own expenses.• The “sell”: Doctor wants to hand off the crying patient to BH

rather than that patient taking up all of the doctor’s time. For bottom line, FQHCs need to see as many pts as possible.

• With BH, Doctor hands off, moves to the next patient, but the crying patient still gets quality care.

• Partner.“If you’re not at the table, you’re on the table.”

Source: Reynolds, 2013

Workforce

• In Nebraska, licensed mental health practitioners can bill at FQHCs. This includes social workers, MFTs, and COUNSELORS.

• http://dhhs.ne.gov/publichealth/Pages/crl_mhcs_mental_lmhprequire.aspx

Source: Capobioanco & Kenerson, 2013

Financing/Workforce

• Next steps• Rosenberg, Gauthier on financing.• CATES meetings (finance)• SARC Meeting, September 11, 2013

(workforce).

CATES follow up WebinarsTopic Date

Integrating Services with Primary Care June 19

Marketing June 26

Contract Negotiations July 2

Financing Strategies July 10

Developing Payer Relations July 17

Marketing July 18

Integrating Services with Primary Care July 23

Contract Negotiations July 31

Financing Strategies August 7

Developing Payer Relations August 14

Chronic Pain &Prescription Drugs

Source: Fishman (2013)

Source: Fishman (2013)

Suggestions for Reframing the Goals of Treatment

• Function is primary• Happiness is important• Goal of complete analgesia is unrealistic• In fact, pain relief is not high on the list at all

“You’re taking all the pain meds known to man, and are still in pain with miserable side effects. We can’t possibly do worse. Let’s try something different.”

• Not helpful to use the term “addiction”

Source: Fishman (2013)

Source: Fishman (2013)

Source: Fishman (2013)

Lessons from Britain

Listen to people who use our services

• ‘In Your Shoes’ sessions for staff to listen to experiences of service users and their carers

• Feedback cards – simple postcard sized feedback from service users and carers

• Observations of care – by staff or carers

Source: Ardley, 2013

Feedback from Patients

Source: Ardley, 2013

Source: Ardley, 2013

Source: Ardley, 2013

Performance• Net promoter score. Required across National Health Service. 

Source: Ardley, 2013

Performance• "Net Promoter Score (NPS") - Those scoring

services with 9 or 10 are promoters, those scoring 0-6 are detractors and those between 7-8 are passively satisfied or neutral. The NPS is the difference between the percentage of users who would recommend your services minus the percentage of those who would not.

• 75% or above is considered quite high. • If scores go down, a regulator comes in. If scores are

good, they’re left alone.

Source: http://www.nta.nhs.uk/

“Hot Spotting”

“Hot Spotting”

• Hotspots.  Identify high cost users. Who are they, where are they? Looked at home addresses of patients from 5 years of data.  Costs are highly concentrated geographically.

Source: Jeffrey Brenner, M.D.

Source: Brenner, 2013

One patient, two hospitals running the same tests. Insurers, docs, pts all complain about each other. It’s the system.Source: Brenner, 2013

Source: Gawande, 2013

Atul Gawande: Video about treating the needs of a high-cost patient. See: 1hr 13min -1hr 17 min mark.http://www.livestream.com/nationalcouncil/video?clipId=pla_27872969-949e-44b0-873e-5e65b663ddfc

“Hot Spotting”• Why do hospitals like hot spotting?  Doesn’t

identifying, addressing high-cost patients take away revenue? 

1.“You’re going to go off the cliff in the next 5-10 yrs.  How will you succeed in the ACO world?”

2.“We can influence doctors the most by getting patients to stop driving them crazy.” High cost patients are not always good for their processes.

Source: Brenner, 2013

Camden, NJ

Exchanges

Exchanges

• 8 regional exchanges, with different plans.• Outreach - $200 million for marketing,

outreach, promotion. More from foundations.• See: Coveredca.com

Source: Peter Lee, Director, Covered California. Insure the Uninsured Project (ITUP) conference, 2/5/2013

Will people buy insurance?Penalties for not doing so:• 2014: $95 per adult or 1.0% of (income minus

10k indiv/20k family), whichever is greater• 2015: $325 or 2%• 2016 $695 or 2.5% • Confused?  Here’s a penalty calculator:http://www.healthinsurance.org/learn/obamacare-penalty-calculator/

Final Note• “It is important to remember that January

1, 2014 is an important day, but it is just one day; it will be tough day, month and year.”

Source: Alan Weil, Executive Director, National Academy for State Health Policy. Feb 5, 2013, ITUP Conference

ReferencesArdley, J. (2013). Perspectives from Great Britain: Creating the customer

focused culture. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, 2013. Powerpoint available at:http://nationalcouncil.info/natcon2013/handouts/TLunch3-Ardley-1.pdf

Brenner, J. (2013). “Hot Spotting” - Ideas for psychiatrists working with high utilizers of health care. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, 2013. Powerpoint available at: http://nationalcouncil.info/natcon2013/handouts/TLT3-Brenner-1.pdf

Capobianco, J., & Kennerson, J. (2013). Building the integrated healthcare workforce of the future. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 7, 2013. (no powerpoint available)

Fishman, M. (2013). Chronic Pain and Prescription DrugAbuse: Intertwined Epidemics. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, 2013. Powerpoint available at: http://nationalcouncil.info/natcon2013/handouts/B1-Fishman-1.pdf

ReferencesGawande, A. (2013). Better: Lowering Costs and Improving Health Care.

Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, 2013. Video available at: http://www.livestream.com/nationalcouncil/video?clipId=pla_27872969-949e-44b0-873e-5e65b663ddfc

Reynolds, K. (2013). Show Me the Money! Designing a Sustainable Financing Model for Integration. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, 2013. Powerpoint available at: http://nationalcouncil.info/natcon2013/handouts/A2-Reynolds-2.pdf

Richardson, J. (2013). Show Me the Money! Designing a Sustainable Integration Financing Model. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, 2013. Powerpoint available at: http://nationalcouncil.info/natcon2013/handouts/A2-Richardson-1.pdf

CONTACT

Darren Urada, Ph.D.UCLA Integrated Substance Abuse Programs durada@ucla.edu