Innovation & Coordination UPDATE: The Keys To …...Innovation & Coordination UPDATE: The Keys To...

Innovation & Coordination UPDATE: The Keys To Providing Accountable Care In A World Of Integration

Kevin Scalia Netsmart EVP, Corporate Development July 11, 2013

By the Numbers

1 Parks et al, Morbidity and Mortality in People with Serious Mental Illness 2006 2 Aetna Medicaid, Dispropor�onate Cost for Members with Behavioral Health Comorbidity

A New Brand of Healthcare Behavioral Health, Child and Family Services, I/DD services, and

Addiction Treatment will change more in the next two years than they have in the last two decades.

Care Documentation

Care Delivery

Care Optimization

Care Integration

Care Collaboration

PAST Digitization

PRESENT Semi-Automated Data

FUTURE

Predictive Analytics

MEANINGFUL USE STAGE 1



Copyright ©2010, Netsmart Technologies. All Rights Reserved.

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Questions from Planning & Innovation Institute

  How do we do care management across multiple vendor EHRs?

  How do we integrate the BH / I/DD / CFS / SU EHR data with physical health EHR data?

  How do we connect the various providers in the care continuum together electronically?

  What are some of the lessons learned from actually building a health home?


WHY ALL THIS FUSS?


Dispropor�onate Cost for Members with Behavioral Health Comorbidity

20%

19.5%

5%

78.9%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Member Rank Percen�le Cost Percen�le

25%

50%

1.5 0.9


Medicaid Costs


Dual Eligibles

  8.1 million people

  18% of Medicaid population, 46% of expenditures

  16% of Medicare population, 27% of expenditures

  50% carry a diagnosis of SMI


Impact of Behavioral Health Co-morbidities on Medicaid Costs

$8,000 $9,488 $8,788 $9,498

$15,691 $14,081

$15,257 $15,430 $16,267

$24,693

$15,862 $16,058 $15,634 $18,156

$24,281 $24,598 $24,927 $24,443

$36,730 $35,840

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

Asthma and/or COPD Congestive Heart Failure Coronary Heart Disease Diabetes Hypertension

Ann

ual P

er C

apita

Cos

ts

No Mental Illness and No Drug/Alcohol Mental Illness and No Drug/Alcohol

Drug/Alcohol and No Mental Illness Mental Illness and Drug/Alcohol

Adults with Mental Health Conditions Adults with

Medical Conditions

29% of Adults with Medical Condi�ons Also have Mental Health Condi�ons 68% of Adults with Mental Health Condi�ons Also Have Medical Condi�ons

Robert Wood Johnson, 2011 –Mental Health Comorbidity

Opportunity


Barriers to Solution

  Medicaid now covers more children than private insurance

  Fewer docs taking Medicaid due to low reimbursement rates:   CA: 56% of Medicare   NY: 43% of Medicare   NJ: 37% of Medicare

  Concentration of providers:   25% of physicians provide care to 80% of Medi-Cal patients


Innovations Designed to Improve Care and Reduce Costs

  Health Homes   Integrated Care Organizations   Dual Eligibles

  BH   Elderly   Physically disabled

  I/DD Care Coordination


Potential Savings

  $580 Billion over 25 years

  $1.27 Trillion for Dual Eligibles

Source: UnitedHealth Group Center for Health Reform and Modernization


Federal Health Home Policy

  Created by Section 2703 of ACA   Eligibility:

  Medicaid eligible   Two or more chronic conditions, or   One chronic condition and at risk for another, or   A serious and persistent mental health condition


Eligible Conditions

  Mental health disorder   Substance use disorder   Asthma   Diabetes   Heart disease and overweight (BMI > 25)


Health Home Services

  Defined by Section 1945(h)(4) of ACA:   Comprehensive care management   Care coordination and health promotion   Comprehensive transitional care from inpatient to

other settings including follow-up   Individual and family support   Referral to community and social support services   The use of HIT to link services


Form ACO/PCMH/Health Home/DISCO

Care Delivered to Consumer

Revenue Cycle Mgmt.

Insurers

Public Health

Behavioral Health

Substance Abuse

Primary Care

Value = Outcomes

Cost


VALUE = Reducing

Cost

Improving Outcomes


Change of Focus Required Element of Change Today Future

Care focus Sick care "Healthcare" wellness and preven�on, disease management

Care management Manage u�liza�on and cost within a care se�ng

Manage ongoing health (and op�mize care episodes)

Delivery Model Fragmented/silos Care con�nuum and coordina�on (right care, right place, right �me)

Care Se�ng In office/hospital In home, virtual (e-‐visits, home monitoring, etc)

Quality measures Process-‐focused, individual Outcomes-‐focused, popula�on-‐based

Payment Fee-‐for-‐service Value-‐based (outcomes, u�liza�on, total cost)

Financial incen�ves Do more, make more Perform be�er on measures, make more

Financial performance

Margin per service, procedure (bed, clinician, etc) Margin per life


Population & Community

Health Management

Primary Care

Integration Information Exchange Clinical

Decision Support Meaningful

Use EHR & Medication

Management

Steps to Driving Accountable Care Im

prov

e O

utco

mes

Clinical Innovation Care Coordination

Red

uce

Cos

t

Business Efficiencies

Del

iver

ing

Acc

ount

able

Car

e

Technology Partners

Managed Services

Revenue Cycle

Management

Hosting & SaaS

Benchmarking Data Analytics

Netsmart Confidential Information

Data Analytics Strategy

Encounter Level Data Predic�ve Analy�cs

Centerstone Research

Institute

Other Research Entities

Netsmart Research Database (20MM People)

New Outcomes Measures/Metrics

Behavioral Pathway Systems (1000’s of Organiza�ons) Aggregate Data Descrip�ve Analy�cs

Enlighten Analytics Enlighten Analytics

Enterprise EHR Avatar | Tier | Evolve | Insight

Enterprise EHR Avatar | Tier | Evolve | Insight


Enlighten Analytics Dashboard



Health Management

Primary Care




Management

Impr

ove

Out

com

es



Information Exchange


INTEGRATION APPROACHES FOR PROVIDERS

Current Offerings

33

Netsmart Clients TIER, Avatar, Insight. MIS

Beacon Community

Integrated Delivery System

Community Practice

Health Information Organization

Health Center Network

Federal Agencies

CareConnect

Non-Netsmart EHRs

Image Source: http://healthit.hhs.gov

CareConnect Vision

Labs


Suncoast

Inpatient

Referrals Physical Health

PEMHS

Tampa Bay 211

CareConnect

Tampa General Hospital


60 BH Orgs

Healthix

Referrals

Physical Health

NS/LIJ

CBC Health Home

Maimonedies

CareConnect

Bronx Lebanon

Behavioral Health BHIX

BH Avatar

BH Avatar

BH Avatar

BH Avatar

BH Avatar

BH Avatar

BH Avatar

BH Avatar

CareConnect Healthix HIE

NYCLIX HIE

Healthix Non-‐Avatar Intersystems

BH Avatar

BH Avatar

BH Avatar

HEALTHIX


Technology to Support New Models

Acute Care Hospitals and Ambulatory Practices

Behavioral Health, Public Health, I/DD


INTEGRATED APPROACHES FOR PRIMARY CARE



Health Management

Primary Care




Management

Impr

ove

Out

com

es



Primary Care Integration


Primary Care and Behavioral Health in One Database


INTEGRATED CARE APPROACHES

The same challenge…Different Approaches


Health Homes HH 1 HH N HH 2

RHIO Primary Care

Acute Care 1

Acute Care N

CareConnect

New York Approach

Optum Health | Magellan | Value Options | NYCCP | CCBH % Clients shared between orgs

BH Provider

SU Provider


Health Homes CMHC 1 CMHC 27

Some Consumers

Shared

CMHC 2

Optum Centpatico Amerigroup

KHIE Primary Care

Acute Care 1

Acute Care N

Kansas Approach

Benchmarking


Massachusetts Approach

Integrated Care Organization Risk

Bearing Entity

Regional Care Center

Primary Care


Primary Care


Primary Care

MHC

Social Services

Hospital

MHC MHC

CMHC


Pennsylvania I/DD Approach

Integrated Care Organization

Risk Bearing Entity

MHC

Social Services

Hospital CMHC


Health Homes Today


Claim Processing

Provider Management

Care Management / Coordina�on

Popula�on Health

Analy�cs

Individual

Primary Care

CareConnect

Public Health Social Services

Substance Abuse

Primary Care

HIEs & RHIOs

Developmental Disabili�es / Behavioral Health

Consum

erP

ortal

Consumer Pharmacies Hospital

Social Services

Substance Use Inpa�ent MH Facility CMHC PCP

Case Management Utilization Management

Enrollment

Assessm

ents

Coordination Plan

Referrals

Analytics

Outcomes

Consent

Authorizations

Outbound C

laims

Clinical R

egistries

Provider Registry

HIEs Insurance

Provider P

ortal

Treatment Guidelines

Population Based

Evidence

Clinical Research

Medicaid Medicare BC/BS MCO

Local Health Dept.

Perspectives

Inbound C

laims

Dashboard  Alerts  Missed Medica�on Refills  Missed Appointments  Arrests


CASE STUDY: COORDINATED BEHAVIORAL CARE

New York City Health Home

Coordinated Behavioral Care


Phased Implementation

managing scope

Mutual Agreement Netsmart and CBC agreed on scope

changing requirements

Project Management Increased frequency of project meetings to support aggressive timeline

7/12 12/12 01/13 2/13

GO-LIVE Initial Screening

SF-12 Provider Connect

HIE Integration Events

Measures

CBC Implementa�on Timeline

CBC

Install Requirements Capture

Team Training

Build

End-User Training

30 days

Inspiring Success

HEALTH • DISABILITIES │HOME CARE │ HOUSING │ EMPLOYMENT • WORKFORCE │ EDUCATION │ YOUTH • FAMILIES

PLANNING & POSITIONING FOR A CHANGING HEALTHCARE LANDSCAPE: Presented by: Boris Vilgorin

Vice President Managed Care & Business Development

Youth and Families

Education

§  Established in 1934 §  Serving 110,000 New Yorkers Annually §  $280 Million Operating Budget §  Workforce of 7,500

§  1.7 Million Square Feet of Space §  350 Locations §  16 Subsidiaries (non-‐‑profit & for-‐‑profit) §  15 Successfully Completed Mergers,

Acquisitions and Receiverships of New York City Non-‐‑Profits

§  Provider of Technical Assistance & Management Consulting to non-‐‑profit & for profit entities.

CORE OPERATING AREAS

Health

Disabilities

Housing

Homecare

OVERVIEW FEGS HEALTH & HUMAN SERVICES

FEGS HEALTH & HUMAN SERVICES 3

Employment/ Workforce

Development

NEW YORK STATE POPULATION

OVERVIEW, CHALLENGES AND

STRATEGIC DIRECTIONS

FEGS HEALTH & HUMAN SERVICES

NEW YORK STATE HIGH NEED POPULATION

  All Other Chronic Conditions

 306,087 Recipients  $698 PMPM

  Mental Health and/or Substance Abuse  408,529 Recipients

 $1,370 PMPM

  Long Term Care

 209,622 Recipients  $4509 PMPM

  Developmental Disabilities

 52,118 Recipients  $10,429 PMPM

$6.5 Billion 50% Dual 10% MMC

$10.7 Billion 77% Dual

18% MMC

$2.4 Billion 20% Dual

69% MMC

$6.3 Billion 16% Dual 61% MMC

Total Complex N=976,356

$2,338 PMPM 32% Dual

51% MMC

FEGS HEALTH & HUMAN SERVICES Informa�on provided by New York State Department of Health

NEW YORK STATE MEDICAID CHALLENGE

§ Medicaid Accounts for 40% of NYS State Budget and Deficit

§ Federal ““Affordable Care Act ““ Promotes Change § Governor Appoints Medicaid Redesign Team of all Stakeholders

§  Shrink Medicaid (i.e. Growth Curve)

§  Integrate Health, Behavioral Health, Substance Use Services

§  Mandate Managed Care for All Medicaid and M/M by 2014

§  Don’’t Pay Hospitals for Readmits for Same Disorder < 30 Days

§  Fund ““Health Homes”” for Complex Cases, esp. Mentally Ill

§  Apply Quality Measures, Outcomes and Incentives

§  Use Federal IT Revolution and RHIOs for Standardization


PLANNING FOR ANTICIPATED CHANGES IN

CARE INDUSTRY AND PLANS TO ESTABLISH

CARE MANAGEMENT ENTITY


COORDINATED BEHAVIORAL CARE

HEALTH HOME IMPLEMENTATION


Care Management

Accessing Shared Infrastructure Services

& IT Resources Through CBC

Lead Nassau County Health Home

CBC Designated Co-‐‑Lead Bronx Health Home

Co-‐‑ Manager Suffolk County Health Home

Partner in Manha�an and Brooklyn Health Homes

Downstream Service Provider


FEGS HEALTH HOME PARTICIPATION

WHY HEALTH HOMES?

§  90% FMAP for 2 Years

§ Reduced Healthcare Costs by Improving Outcomes, Including:

  Lowered Rates of Emergency Room Admissions

  Reduced Hospital Re-‐‑Admissions (& admissions)

  Reduced Polypharmacy

  Decreased Reliance on Long-‐‑Term Care Facilities

  Improved Wellness, Access, Quality of Life

  Improve HEDIS indicators


WHAT IS A HEALTH HOME?

§  Not a Residence or Building §  A Care Management Model

§  A Formal Network of Providers, including medical, mental health and substance abuse, social services which form an integrated system of care

§  The Provider Network is Linked by IT §  The Health Home takes primary responsibility for a client in assuring that

essential health and social needs are met.

§  The Care Coordination is the one Medicaid Funded Service


WHICH CLIENTS ARE ELIGIBLE FOR A HEALTH HOME?

§ People with Medicaid who have:

§ At least two chronic medical conditions

-‐‑ OR –

§ One chronic medical condition and at risk for another

-‐‑ OR -‐‑

§ One serious and persistent mental health condition

CHRONIC CONDITIONS INCLUDE:

§  Mental Illness

§  Substance Use Disorder §  Asthma

§  Diabetes §  Heart disease §  Obesity/ Overweight (BMI over 25) §  HIV/AIDS §  Hypertension


HEALTH HOME IT REQUIREMENTS

§  Structured Information Systems

§  Systematic process to follow-‐‑up on tests, treatments, services and, and referrals which is incorporated into the patient’s plan of care.

§  Health Record System allowing plan of care to be accessible to the interdisciplinary team

§  Use of HIT and RHIO data. §  Structured Interoperable Health Information Technology Systems

§  Join RHIO or qualified health IT entities for data exchange §  Supports the use of evidence based clinical decision making tools

§  Comply with the current and future version of the Statewide Policy Guidance


LESSONS LEARNED

§  Governance/Decision Making Process

§  Be�er Process of Identifying and Enrolling Clients §  Simple Tracking System

§  Payment Alignment for Network Providers

§  Hospital Participation/Cooperation §  Policy and Procedure Management

§  Network Management

§  IT Development

§  Data Management


TRENDS, PLANNING & OPERATIONAL CONSIDERATIONS

§  Emergence of Care Management As Major Core Competency In Health Care Delivery

§  Care and Services will be Fully Integrated §  Coordination and Collaboration Will Be Essential with hospital networks and

provider networks

§  Increased emphasis on data analytics to assess medical acuity of client population, and manage financial risk

§  Sharing/Coordination of Health Information through Regional and Other IT Networks

§  Negotiate Capitated Rates with Managed Care Companies

§  Integrated IT Strategy Is Essential


TRENDS DRIVING FUTURE SERVICE DELIVERY & PLANNING

Service Integration

Quality

Measuring Outcomes/ Data Management

Managing Outcomes/Performance

Leveraging Human Capital

Collaboration/Partnerships

Technology

Care Management Competency

INFRASTR

UCTURE Managing Financial Risk

Program Innovation

Building Scale

OPPORTUNITY

SERVICE

5

NEW HEALTHCARE PARTNERSHIPS/DIRECTIONS

NYS Medicaid Program

(NYS DOH)

Managed Care Organizations

Payment for Care Management Services

Behavioral Health Developmental Disabilities Homecare

BEHAVIORAL HEALTH

HEALTH HOMES (LIBA and CBC)

DD-‐‑ DISCO’’s (Alliance Care Network)

MLTC (SinglePoint Care

Network)

IPA

Medical Budget Risk Arrangement Medical Budget Risk Arrangement Medical Budget Risk Arrangement

Medical Budget Risk Arrangement

Payment for Care Management Services

Service Provider

Service Provider

Service Provider

Service Provider

Service Provider



  Boris Vilgorin Vice President Managed Care & Business

Development FEGS [email protected]

Thank You! Contact Information

  Kevin Scalia Executive Vice President Netsmart Technologies [email protected] Twitter: @kscalia

Innovation & Coordination UPDATE: The Keys To …...Innovation & Coordination UPDATE: The Keys To...

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