CHCS WEBINAR Integrating Physical and Behavioral Health ... · B ildi I d S f H l hBuilding an...

CHCS WEBINAR: Integrating Physical and Behavioral Health: An Exploration of State Options

T d N b 15 2 3 30 PM ETTuesday, November 15, 2-3:30 PM ETFor audio, dial: 1-877-668-4490; Meeting/Event Number: 712 359 105 You may also listen to this event online via streaming audio.

A video archive will be posted on www.chcs.org following the event.

This webinar is made possible through support from Kaiser Permanente and the Centers for Medicare & Medicaid Services

State Technical AssistanceState Technical Assistance►The Integrated Care Resource Center was recently established by

CMS t h l t t d l d i l t i t t d d lCMS to help states develop and implement integrated care models for Medicaid beneficiaries with high-cost, chronic needs

►Technical assistance (TA) to help states integrate care for: (1) ( ) p g ( )individuals who are dually eligible for Medicare and Medicaid; and (2) high-need, high-cost Medicaid populations via the Health Homes state plan option as well as other emerging models

►TA coordinated by Mathematica Policy Research and CHCS

►Visit www.integratedcareresourcecenter.org to submit a TA request and/or download useful resources, including policy briefs, tools, state best practice resources, and the latest CMS guidance

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Inclusion of the models in this brief does not signify endorsement by the Centers for Medicare & Medicaid Services; nor do these models necessarily meet the criteria for integrated care under the financial alignment models introduced by CMS’s Medicare-Medicaid Coordination Office in July 2011. For more information, see http://www.cms.gov/smdl/downloads/Financial_Models_Supporting_Integrated_Care_SMD.pdf.

Why Integrate?Why Integrate?

• 5/50► Top 5% drives 50% of Medicaid spending

• 1 out of 2 ► Half of beneficiaries with disabilities have BH comorbidity

• 3 to 4► Addition of mental illness and substance use disorder to chronic► Addition of mental illness and substance use disorder to chronic

medical population is associated with 3-4x increase in costs

• 25Y f l t lif t i t d ith i t l► Years of lost life expectancy associated with serious mental illness, primarily due to physical health issues

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*Sources: RG Kronick et al., “The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions.” Center for Health Care Strategies, October 2009; C. Boyd, et al. “Clarifying Multimorbidity for Medicaid Programs to Improve Targeting and Delivery of Clinical Services.” Center for Health Care Strategies, December 2010.

Impact of Mental Illness & Substance Use Disorders on Cost and Hospitalization for People with Diabeteson Cost and Hospitalization for People with Diabetes

2.5$40,000.00

ar

1 5

2$30,000.00

atio

n Pe

r Yea

Per Y

ear

1

1.5

$20,000.00

Hos

pita

liza

Cap

ita C

ost P

0.5$10,000.00

Per C

apita

Per C

0$-Diabetes Only Diabetes + MI Diabetes + SUD Diabetes + MI + SUD

Beneficiaries with Diabetes

4SOURCE: C. Boyd et al. Faces of Medicaid: Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services. Center for Health Care Strategies, December 2010.

Per Capita Cost Per Year Per Capita Hospitalization Per Year

Who Can Integrate?Who Can Integrate?

• Integration can happen under any deliveryIntegration can happen under any delivery system design

• All states have building blocks to leverageg g• Today’s goal: provide examples of how

integration can be realized under various system g ydesigns

5

Physical and Behavioral Health I t ti O tiIntegration Options

Integrated Care Entity State Example

M d C O i ti (MCO) TManaged Care Organization (MCO) Tennessee

Primary Care Case Management (PCCM) Program Vermont(PCCM) Program

Behavioral Health Organization (BHO) Arizona

MCO/PCCM Partnership with BHO Pennsylvania

6

Key Elements of Integrated ModelsKey Elements of Integrated Models

• Aligned financial incentivesAligned financial incentives• Information exchange• Multidisciplinary care teams accountable forMultidisciplinary care teams accountable for

coordinating the full range of services• Competent provider networksCompetent provider networks• Mechanisms for assessing and rewarding high-

quality care qua ty ca e

7

Managed Care Organization as Integrated Care Entity

Jeanne James, MD, FAAPMedical Director, TennCareMedical Director, TennCare

November 15, 2011

TennCareTennCare

• Tennessee’s Medicaid ProgramTennessee s Medicaid Program• 1115 waiver

i l 2 illi ll• Approximately 1.2 million enrollees• Managed care since January 1, 1994• Integrated physical health and behavioral health since 2007/2008/

Why Integration?Why Integration?

• Prior to 2007, had separate behavioral health organizations or BHO’sorganizations, or BHO s

• Patients are “integrated” – often have physical h l h d b h i l h l hhealth concerns and behavioral health concerns, and conditions impact each other in i li i l limportant ways – clinical examples

Why Integration at the MCO Level?Why Integration at the MCO Level?

Many integration models at the provider levelMany integration models at the provider level• Integrated delivery team• Co‐located providersp• “visiting” providers• Established referral patterns

Need to establish an environment to allow local preferences to develop and flourish

Contractor Risk Agreement includes requirements

Benefits of IntegrationBenefits of Integration

• Simplifies contracting negotiations for integratedSimplifies contracting negotiations for integrated and co‐located provider groups (contract with MCO rather than MCO and BHO))

• Alleviates possibility of “turf wars” over which conditions are covered as physical health orconditions are covered as physical health or behavioral health

• Allows providers to work with MCO to innovateAllows providers to work with MCO to innovate and customize at local care delivery setting

Benefits of Integration for MCOBenefits of Integration for MCO• Opportunity for integrated, complex caseOpportunity for integrated, complex case rounds, with input from physical health and behavioral health clinicians

• Disease management can address patients with multiple conditions

• Cross‐training of care management staff improves patient coaching

• “Local solutions” to fit local delivery system• Quality metrics ‐ HEDISQuality metrics HEDIS

Next StepsNext Steps

• Develop measurement tools for integrationDevelop measurement tools for integration• Consider how integration could help combat stigma of mental health in some communitiesstigma of mental health in some communities

• Leverage behavioral health expertise in approach to chronic physical healthapproach to chronic physical health conditions, such as diabetes and obesity, to encourage long‐term health improvement

• Have now integrated long‐term‐care services, considering approach to dual eligibles

Questions?Questions?To submit a question please click the question mark icon located in the floating toolbar at the lower right side of g gyour screen. Your questions will be viewable only to CHCS staff and the panelists.p

Answers to questions that cannot be addressed due to time constraints will be posted online after the webinarconstraints will be posted online after the webinar.

A video archive of this event will be available on our website, at www.chcs.org/events.

Department of Vermont Health Access

Vermont Blueprint for Health

B ildi I d S f H l hBuilding an Integrated System of Health

Integrating Physical and Behavioral Health: eg a g ys ca a d e a o a eaAn Exploration of State Options

Center for Health Care Strategies, Inc.Webinar November 15, 2011

Beth Tanzman, MSW

Assistant Director, Blueprint for Health

www.hcr.vermont.govwww.hcr.vermont.gov

[email protected]


Vermont’s Foundation

Advanced Primary Care Practices(Medical Homes)

Community Health Teams

All i t fAll-insurer payment reforms

Learning Health System: IT Infrastructure

Evaluation & Reporting SystemsEvaluation & Reporting Systems

Quality Improvement

Specialized & TargetedS i

Continuum of Health Services - General

HigherAcuity &

Complexity

• Specialty Care• Advanced Assessments• Advanced Treatments

Community HealthTeams

Services

Level

• Advanced Treatments• Advanced Case Management• Social Services• Economic Services• Community Programs

Advanced PrimaryCare Practice

• Support Patients & Families• Support Practices• Coordinate Care• Coordinate Servicesl of N

eed

• Health Maintenance• Prevention• Access• Communication

• Self Management Support• Public Health Programs

Care Practice • Referrals & Transitions• Case Management

o Medicaid Care Coordinatorso Senior Services Coordinators

• Self Management SupportC li

LowerAcuity &

• Communication• Self Management Support• Guideline Based Care• Coordinate Referrals• Coordinate Assessments

• Counseling• Population Management

11/21/2011 18

Acuity &Complexity

Locus of Service & Support

• Panel Management


Multi‐insurer Payment Reforms•Medicaid

Insurers

Medicaid•Commercial Insurers•Medicare

•Community Health Teams•Shared costs as core resource

•Patient Centered Medical Home•Payment to practicesC i t t i

•Fee for Service•UnchangedAll titi + + •Consistent across insurers

•Minimizes barriers•Consistent across insurers•Promotes quality

•Allows competition•Promotes volume

+

•Based on NCQA PPC‐PCMH Score•$1.20 ‐ $2.49 PPPM•Based on active case load

•5 FTE / 20,000 people•$ 350,000 per 5 FTE•Scaled based on population


Community Health Teams


Advanced

Hospitals A foundation of medical homes and community health teams that can Advanced

Primary Care

Community Health TeamNurse Coordinator

Specialty Care & Disease Management Programs

ysupport coordinated care and linkages with a broad range of services

Multi Insurer Payment Reform that Social, Economic, & Advanced PrimaryNurse Coordinator

Social WorkerHealth Coach

MH/SA ClinicianMCAID Care Coordinators

SASH Team

ysupports a foundation of medical homes and community health teams

A health information infrastructure Mental Health &

Substance Abuse

, ,Community Services

Primary Care

Advanced Primary

C

P bli H lth

that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry

Programs

Healthier Living Workshops

Care

Advanced Primary

Care

H l h IT F k

Public Health Programs & Services

g y

An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement,

Health IT Framework

Evaluation Framework

, g q y p ,and determine program impact

11/21/2011 21

Advanced Model of Primary CareyA Foundation for integrated services

Targ Economic Servicesgeted Serv Case Management

Social ServicesSub

PopulationSub

P l ti

vices

Specialty Care

Disease Management ProgramsPopulation

SubPopulation

Community Health TeamAP

C

Patient Centered Medical Homes

Multi-insurer payment reform

C Foundat General population

Health Information Infrastructure

Evaluation Infrastructure

tion


$3.00 All insurers pay enhanced payment based on a practices

$2.00

$2.50

vide

r

score as a patient centered medical home

NCQA PCMH standards and

$1.50

$

M p

er p

rov

scoring methods are used to score practices as a medical home

Payment changes with each 5

$0.50

$1.00

$ P

PP

M

Requires 5 of 10 M st Pass

Requires 5 of 10 Must Pass Elements

point change in the NCQA PCMH score (score ranges from 0 – 100 points)

$0.000 10 20 30 40 50 60 70 80 90 100

NCQA PCMH Score

Must Pass Elements Designed to incent ongoing

iterative improvement, and to provide a disincentive for moving backwards

Continuum of Health Services - General

C i H l h

Specialized & TargetedServices

• Specialty Care• Advanced Assessments• Advanced Treatments• Advanced Case Management• Social ServicesAdvanced Primary

Community HealthTeams

• Support Patients & Families• Support Practices• Coordinate Care

• Health Maintenance• Prevention• Access

C i ti

• Economic Services• Community Programs• Self Management Support• Public Health Programs

Care Practice• Coordinate Care• Coordinate Services• Referrals & Transitions• Case Management

o Medicaid Care Coordinatorso Senior Services Coordinators

• Communication• Self Management Support• Guideline Based Care• Coordinate Referrals• Coordinate Assessments• Panel Management

• Self Management Support• Counseling• Population Management

Panel Management

• Fee for Service • Costs shared by insurersPayment ?11/21/2011 24

• $PPPM based on NCQA score

• No co-pays or prior authorizations

Payment Reforms ?


Payment Based on Shared Interests: PCPs & SpecialistsAdjustable outcomes based payment – ongoing refinement

Continue current FFS Decreased FFS

Total new FFS + $PPPM > baseline FFS

Measure results Measure results

First shared interest$PPPM payment

Adjust Pa ment Dials

Second shared interest$PPPM payment$PPPM payment Payment Dials$PPPM payment

6 moBaseline 12 mo


Vermont Blueprint TeamCraig Jones, MD, Director

Lisa Dulsky Watkins, MD, Associate Director

Pat Jones, MS, Assistant Director

Jenney Samuelson MPA Assistant DirectorJenney Samuelson, MPA, Assistant Director

Beth Tanzman, MSW, Assistant Director

Diane Hawkins, Executive Assistant

Terri Price, Administrative Assistant

Julie Trottier, Milbank Fellow

Maricopa County RBHA with SMI Health Homes

Integrated Care Resource Center

State Options for Integrating Physical and B h i l H lth CBehavioral Health Care

November 15, 2011

K r i s t i n F r o u n f e l k e r D r . L a u r a N e l s o n B e h a v i o r a l H e a l t h A d m i n i s t r a t o r D i r e c t o r o f B e h a v i o r a l H e a l t h A H C C C S A r i z o n a D e p t . o f H e a l t h S e r v i c e s

Overview of AHCCCS

1115 WaiverOversee 10 managed care contractsgMCO’s are reimbursement through capitated payments (PMPM)Behavioral Health services carved out for acute members- Department of Behavioral Health Services

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Integration/Alignment31

Integration-Payer, Clinical, Coordination of Benefits

Maricopa County- Average 12,000 actively enrolled individuals with serious mental illness

47% have Medicare- AHCCCS seeking alignment

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First Steps in Planning for Integrated Care32

Nurturing the dialogueg gCHCs, FQHCs, Tribes—many have been providing integrated care for decadesExisting partnerships between Regional Behavioral Health Authorities (RBHAs) and AHCCCS Health PlansMilbank Memorial Fund Conference in January 2011Other states and national experts

Identifying key system partnersMembers and Family members via St. Luke’s Health InitiativeT/RBHAsT/RBHAsHealth PlansBehavioral Health and Physical Health Care Providers


First Steps in Planning for Integrated Care33

Awarded Section 2703 Planning Grant

Obtained support and commitment from Executive Branch

Developed structure to drive change—Interagency Steering Committee:Steering Committee:

ADHS/DBHS and AHCCCS are co-leadsEstablished foundational principlesEstablished vision for RBHA with SMI Health Homes Utilizing consultants as necessary (research, data analysis stakeholder input )


analysis, stakeholder input…)

Foundational Principles34

Stakeholder EngagementStakeholder Engagement

System TransformationSystem Transformation

Improved Coordination of Health CareImproved Coordination of Health Care

Improved Health OutcomesImproved Health Outcomes

R d d H lth C C t


Reduced Health Care Costs

Vision for Maricopa County RBHA35

One (1) or more at-risk managed care organizations (MCOs) to act as an integrated RBHA with SMI Health Homes

Become a Medicare Special Needs Plan (SNP)Start with Maricopa County (begin October 1, 2013)

Expanded responsibility for Title XIX adults with SMI Fully integrate at administrative and service delivery levelProvide all medically necessary behavioral health and physical health care services through the use of health homes and designated team of providersMeet all CMS requirements for health homesCoordinate and manage benefits for dual eligible Title XIX members with SMIC di t i l t i h lth d d h lth i f ti Coordinate care using electronic health records and health information technology (HIT) which provides information to measure system and member-level outcomes


Health Homes vs. PCMHs36

“Health Home” is a health care delivery approach that includes enhanced coordination of care services for individuals with chronic conditions including expansion of community services.community services.Health Homes have a designated team of providers and new payment mechanisms.PCMHs are models of care provided by physician led practices that seek to strengthen the doctor-patient relationship by replacing episodic care with coordinated relationship by replacing episodic care with coordinated care for all life stages.


Vision for SMI Health Homes37

A h id l l l idi i li i ibl At the provider level a multidisciplinary team is responsible for delivering physical and behavioral health services

Multidisciplinary team is responsible for both member andpopulation outcomes

Evidenced based practices used for screening, prevention, wellness, care management, disease management and Recovery programs

Care coordinated through technology and information sharing systems


g y

Vision for SMI Health Homes38

•Use of evidenced based practices • Routine screening, prevention, whole health and wellness focus

• Care management, chronic disease management and recovery programs

Primary Care

Behavioral Health• Shared medical records

Multidisciplinaryteam

Housing Support

Specialty Care

Employment Support

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Peer SupportEmployment Support

Community & Social Support

Planning Activities….39

D l iData analysisAcute care + behavioral health care + Medicare dataUtilization patterns and profiling p p gDiagnostics & demographics of the population

Stakeholder inputM b d f il bMembers and family membersBehavioral health and physical health providersManaged care organizations

RFI submissions and presentationsOther system partners


The Next 6 Months…40

Establish requirements/definitions for SMI q /health homes

Services Team membersBest/promising practices to be usedOutcomesInformation technology

Consider stakeholder input/recommendationsOngoing guidance from CMSConsultation with SAMHSA


The Next 12 Months and beyond…41

RFPState Plan AmendmentPoliciesCosts; billing codes; reimbursementConfidentiality; HIPAA regulations

id / kfProvider/workforceLicensing; credentialing; privilegingProvider network development

TrainingEHR/EMR/HIE; technology; sharing of data


Throughout This Process…42

Preserve RecoveryyPeer and Family voice and participation in program designMaintain strong and effective communication

TransparencySeek public buy-in and supportInclusion


THANK YOU FOR YOUR PARTICIPATION TODAYPARTICIPATION TODAY

[email protected]

www.azahcccs.gov

[email protected]

WWW.AZDHS.GOV

frounfelker

For More InformationFor More Information• Download practical resources to improve the quality and

t ff ti f M di id icost-effectiveness of Medicaid services.

• Subscribe to e-mail Updates to learn about new programs and resources.

• Learn about cutting-edge efforts to improve care for Medicaid’s highest-need, highest-cost beneficiaries.

www.chcs.orgwww.integratedcareresourcecenter.orgg g

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CHCS WEBINAR Integrating Physical and Behavioral Health ... · B ildi I d S f H l hBuilding an...

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