Impact of the Affordable Care Act on Behavioral Health March,
2014
Slide 2
My Background Medicaid Director Previously DMH Medical Director
20 years Practicing Psychiatrist CMHCs 10 years FQHC 18 years
Distinguished Professor, Missouri Institute of Mental Health,
University of Missouri St. Louis
Slide 3
Endorsements "He is not only dull himself, he is the cause of
dullness in others.-Samuel Johnson "He uses statistics as a drunken
man uses lamp-posts... for support rather than illumination." --
Andrew Lang "He can compress the most words into the smallest idea
of any man I know." -- Abraham Lincoln
Slide 4
Today Its not just Arkansas Status of our world Healthcare
delivery and payment change strategies Future of specialty
behavioral health
Slide 5
Health Affairs: VA Lewis, et al. The Promise and Peril of
Accountable Care for Vulnerable Populations: A Framework for
Overcoming Obstacles. 2012. Our niche: caring for complex, costly
patients Socially vulnerable patients (income, language,
race/ethnicity, health disparities) Clinically vulnerable patients
(complex, difficult healthcare needs) You Are Here Source: Health
Affairs: VA Lewis, et al. The Promise and Peril of Accountable Care
for Vulnerable Populations: A Framework for Overcoming Obstacles.
2012.
Slide 6
Co-morbidities in the Adult Population Source: Druss &
Walker. Mental disorders and medical comorbidity. The Robert Wood
Johnson Foundation Synthesis Project, February 2011.
Slide 7
Sandy Hook Tucson Virginia Tech Aurora 7 2020, behavioral
health disorders surpass all physical diseases as major cause of
disability MI most common reason for SSD/SSI More deaths due to
suicide than to accidents, homicides, and war combined Most mental
health treatment is in primary care - medication, poorly
managed
Slide 8
Slide 9
www.TheNationalCouncil.org 9 Effective Treatments
Slide 10
million people will gain access to coverage that includes
MH/SUD at parity
Slide 11
Parity 11 Robust final rule
Slide 12
Role of Parity Essential Health Benefit (EHB) for private
insurance must be at parity. What does parity mean? Medicaid
Benchmark Benefit must be at parity. Parity does extend to all new
individual and small group plans beginning in 2014. What about
parity for current Medicaid beneficiaries?
Slide 13
State Estimates of the Uninsured You can access state estimates
for the Medicaid Expansion and for the State Health Insurance
Marketplace at http://www.samhsa.gov/healthReform/enrollment.aspx
http://www.samhsa.gov/healthReform/enrollment.aspx Three estimates
are provided: Adults with Serious Mental Illness Adults with
Serious Psychological Distress Adults with a Substance Use
Disorder
Slide 14
Essential Benefit Plans (EBP) on the Insurance Exchanges The
plan selected by a state to be its EBP benchmark for ACA may not
comply with parity. States had until exchanges went live to make it
comply with parity - then it became an EHB benchmark plan But so
far its unclear if CMS will enforce this especially since the final
ACA rule stated that We do not intend to require or request states
to include specific services within EHB categories offered by their
ABP. States resisting ACA implementation will not enforce it either
High deductibles and co-pays will be an obstacle
Slide 15
Alternative Medicaid Benefit (AMB) for Medicaid Expansion
Groups Wellstone Domenici Parity does not apply If the individual
meets that states definition for medically frail they reverts to
the standard Medicaid benefit Serious Mental Illness and Substance
Use Disorders constitute Medically Frail But - states get to define
which diagnosis is SMI Many states are not expanding Medicaid
Slide 16
Monitoring and reporting Anthem Health Plans Connecticut rate
schedule changes violate the Mental Health Parity and Addiction
Equity Act New York against UnitedHealth Group California
class-action lawsuit against United Behavioral Healthcare for
reviews of outpatient treatments Vermont held Cigna has burden of
proving that disparate treatment of mental health and medical
surgical justified by clinical standards Parity and Case Law
Slide 17
Four key elements of the Affordable Care Act
Slide 18
2010 Prohibits lifetime benefit limits Dependent coverage up to
age 26 is mandated Cost-sharing obligations for preventive services
are prohibited Recissions are prohibited Pre-existing condition
exclusions for dependent children (under 19 years of age) are
prohibited Coverage for emergency services at in-network
cost-sharing level with no prior-authorization is mandated
Slide 19
More 2010 Require coverage of tobacco cessation programs for
pregnant women under Medicaid free of cost-sharing Begin Community
Health Centers and National Health Service Corps Fund expanded
funding to total $11 billion over five years Begin Medicaid global
payments demonstrations to fund large, safety-net hospitals in five
states to alter payment from fee- for-service to a capitated,
global payment structure. Establish Patient-Centered Outcomes
Research Institute. Create a private, nonprofit Patient-Centered
Outcomes Research Institute to set a national research agenda and
conduct comparative clinical effectiveness research.
Slide 20
2011 85% MLR for large group (with refund) is mandated 80% MLR
for individual and small group (with refund) is mandated Primary
care physicians and General surgeons in shortage areas begin 10
percent Medicare payment bonus for next 5 years Medicare adds
annual wellness visit with no copayment or deductible and
eliminates cost-sharing for evidence- based preventive
services
Slide 21
2012 Medicaid starts option funding Health homes for persons
with chronic conditions Prohibit federal payments for Medicaid
services related to hospital-acquired conditions. Begin Medicaid
Emergency Psychiatric Care Demonstration Project. to expand the
number of emergency inpatient psychiatric care beds available.
Slide 22
2013 Medicaid payment rates to primary care physicians for
furnishing primary care services raised no less than 100 percent of
Medicare payment rates in 2013 and 2014. Medicaid coverage of
preventive services approved by the U.S. Preventive Services Task
Force with no cost-sharing will receive an increased federal
funds
Slide 23
2014 Health insurance exchanges established Guarantee issue is
required Community rating required limits use of age and illness as
a rating factor All annual and lifetime limits prohibited Essential
Benefit established and required to cover MH and SA at Parity
Individual Mandate Starts
Slide 24
Insurance Exchanges To Date: 16 states have selected a
state-based model, 7 are partnering with the federal government and
26 states have chosen federally-run exchanges. Current enrollment
deadline is March 31, 2014 In non- expansion states low-income
individuals may experience more difficulty finding affordable
coverage because they are not Medicaid-eligible and do not qualify
for federal subsidies in the exchange.
Slide 25
ACA Affordable Health Insurance Marketplace Fact: Enrollment
system went live in ALL STATES on October 1, 2013. Insurance will
became effective on January 1, 2014. Scope is all uninsured adults
above 133 percent of poverty (plus discounted 5 percent of income).
Overall 25% will have a Behavioral Health Condition. (About 6% will
have a Serious Mental Illness and 14% will have a Substance Use
Disorder). KEY ISSUES TO CONSIDER: Are eligible uninsured persons
aware of the opportunity? Will persons with mental health and
substance use conditions actually enroll? Will the insurance
benefits be adequate?
Slide 26
2014 Medicaid Expansion To date, 26 states are planning to
expand coverage in 2014 Some include non-traditional models such as
Medicaid premium support. Decisions to expand Medicaid or
discontinue Medicaid expansion in 2015 will impact bids that
insurers submit in the spring of 2014 for the 2015 enrollment
period.
Slide 27
Slide 28
ACA Medicaid Expansion Fact: For states that choose this option
(now 26 + DC), enrollment system went live on October 1, 2013 and
coverage began on January 1, 2014. Designed for all uninsured
adults up to 133 percent of poverty (plus discounted 5 percent of
income). Overall 40% with Behavioral Health Conditions. (About 7%
will have a Serious Mental Illness and about 14% will have a
Substance Use Disorder). KEY ISSUES TO CONSIDER: What is the effect
of a State opting out? Are eligible uninsured persons aware of the
opportunity? Will persons with mental health and substance use
conditions actually enroll?
Slide 29
Increased competition in MH/SUD Managed care Accountable Care
Organizations New MH/SUD coverage under essential benefits New
parity requirements
Slide 30
EHR Meaningful Use Behavioral Health Quality Measures (Phase 2)
Quality metrics for chronically ill: Tobacco screening and
cessation Weight screening and counseling Depression screening and
intervention Hypertension screening Depression remission rates
using PHQ9! Depression followup using PHQ9 Substance Abuse
assessment in Bipolar patients Alcohol Treatment initiation and
Engagement Maternal depression screening at < 6 month child
visit Suicide assessment for depressed patients 30
Slide 31
Delayed Changes Employer mandate delayed from 2014 to 2015
First reduction of Disproportionate Share Hospital (DSH) funds
delayed from 2104 to 2015 Compliance of small business Existing
Plans with new Rules CMS has delayed until September 2015 15 States
will permit renewal of non-compliant plans 18 States will not 17
States are undecided
Slide 32
2015 - 2017 Innovation Waivers Beginning 2015, states may
consider developing proposals to waive portions of the ACA
beginning in 2017. Innovation Waivers must cover at least as many
people as under the ACA and provide coverage that is at least as
comprehensive and affordable, at no extra cost to the federal
government. States that receive waivers may finance their reforms
with federal funding that otherwise would have been provided for
premium tax credits, cost-sharing reduction and small business tax
credits
Slide 33
Estimated changes in payer mix Source: The Commonwealth Fund:
Including Safety Net Providers in Integrated Delivery Systems:
Issues and Options for Policymakers
Slide 34
50 Years of Federal Spending Chart depicting 50 years of
federal spending; image taken from NPR.org
Slide 35
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36 www.thenationalcouncil.org Contact:
[email protected] | 202.684.7457 The greatest
danger in times of turbulence is not the turbulence. It is to act
with yesterdays logic. Peter Drucker The greatest danger in times
of turbulence is not the turbulence. It is to act with yesterdays
logic. Peter Drucker
Slide 37
37 Population based - Health homes
Slide 38
Health Home Functions: CMHCs are well positioned CMHC teams
already fulfill many Healthcare Home functions: Providing
individualized services and supports Linking consumers to community
and social supports Hospital admission and discharge follow-up
Communicating with collaterals CMHCs already serve people with high
rates of chronic medical conditions Many CMHCs have been trained by
PBHCI Grant Project
Slide 39
Defining Health Homes Enumerated in Sec. 1945 of the Social
Security Act Provides states the option to cover care coordination
for individuals with chronic conditions through health homes
Intended to improve access and quality of care Eligible Medicaid
beneficiaries have: Two or more chronic conditions, One condition
and the risk of developing another, or At least one serious and
persistent mental health condition
Slide 40
Defining Health Homes Provides 90% FMAP for eight quarters for:
Comprehensive care management Care coordination Health promotion
Comprehensive transitional care Individual and family support
Referral to community and support services Services by designated
providers, a team of health care professionals or a health
team
Slide 41
What is a Health Home? Not just a Medicaid Benefit Not just a
Program or a Team A System and Organizational Transformation
Slide 42
Treatment as UsualHealth Homes What is Different about Health
Homes? Individual Practitioner Episodic Care Focus on Presenting
Problem Referral to meet other Needs Managed Care Manages access to
care Does not change clinical practice Integrated
Primary/Behavioral Health Care Team Continuous Care Comprehensive
Care Management Coordinates care across the healthcare system Data
driven population management Transforms clinical practice
Emphasizes healthy lifestyles and self-management of chronic health
problems
Slide 43
Apples and Oranges Managed-Care Care ManagementHealth Home Care
Management Population = most are well most of the timePopulation =
all have multiple chronic conditions Most have a few health care
providersMost have many Healthcare providers Primary focus =
avoidable over utilizationPrimary focus= inappropriate
underutilization Mostly communicates with providersMostly
communicates with patients directly Administrative
relationshipFace-to-face personal relationship Mostly e-mail, fax
or telephoneMostly in person communication Intermittent contact by
different care managersOngoing contact with stable team Strangers
working togetherYou know them and they know you Do not have to
provide service to be paidHave to provide service to receive
payment
Slide 44
Health Care Home Strategy Case management coordination and
facilitation of healthcare Primary Care Nurse Care Managers Disease
management for persons with complex chronic medical conditions,
SMI, or both Behavioral Health management and behavior modification
as related to chronic disease management for persons with Medical
Illness Preventive healthcare screening and monitoring by MH
providers Integrated Primary Care and Behavioral Healthcare
Slide 45
Health Home Strategy Health technology is utilized to support
the service system. Care Coordination is best provided by a local
community-based provider. MH Community Support Workers who are most
familiar with the consumer provide care coordination at the local
level. Primary Care Nurse Care Managers working within each Health
Home provide system support. Behavioral Health Consultants in each
Primary Care Health Home Statewide coordination and training
support the network of Health Homes.
Slide 46
Principles One Team CMHCs composed of pre-2012 CPRC staff plus
NCM and PC Consultant PCHHs composed of new infrastructure and team
members One Treatment Plan for the Whole Person Rehab Goals Medical
Goals Healthy Lifestyle Goals Some Goals and Outcomes reference
Health Home Performance Measures Wrap Around approach to outside
treating PCP, mental health providers, community supports, etc
Slide 47
What is a Health Home? Not just a Medicaid Benefit Not just a
Program or a Team A System and Organizational Transformation
Slide 48
Treatment as UsualHealth Homes What is Different about Health
Homes? Individual Practitioner Episodic Care Focus on Presenting
Problem Referral to meet other Needs Managed Care Manages access to
care Does not change clinical practice Integrated
Primary/Behavioral Health Care Team Continuous Care Comprehensive
Care Management Coordinates care across the healthcare system Data
driven population management Transforms clinical practice
Emphasizes healthy lifestyles and self-management of chronic health
problems
Improving Diabetes (HbA1c) 7.2% Uncontrolled (too high) For 51%
there are 2 results so we can find the trend The uncontrolled group
average HbA1c decreased from 9.50% to 8.95% (-0.55%) 1% point
decrease in HbA1c yields: 21% decrease in Diabetes related deaths
14% decrease in Heart Attacks 37% decrease in micro-vascular
complications
Slide 52
Improving Cholesterol (LDL) 46.3% Uncontrolled (too high,
greater than 100) For 58% there are 2 results so we can find the
trend The uncontrolled group average LDL decreased from 122 to 115
(-7) A 10% Cholesterol Reduction yields a 30% reduction in Coronary
Heart Disease
Slide 53
Improving Hypertension (BP) 23% Uncontrolled (too high, greater
than 140/90) For 61% there are 2 results so we can find the trend
The uncontrolled group average BP decreased from 142/90 to 137/86
(-5/4) A 6 point reduction yields: 16% reduction in Coronary Heart
Disease 42% reduction in Stroke
Slide 54
Slide 55
Outcomes Reducing Hospitalization Primary Care Health HomesCMHC
Healthcare Homes
Slide 56
Intial Estimated Cost Savings after 18 Months Health Homes
43,385 persons total served (includes Dual Eligibles) Cost
Decreased by $51.75 PMPM Total Cost Reduction $23.1M DM3700 3560
persons total served (includes Dual Eligibles) Cost Decreased by
$614.80 PMPM Total Cost Reduction $22.3M
Slide 57
Intial Estimated Cost Savings after 18 Months CMHC Health Homes
20,031 persons total served (includes Dual Eligibles) Cost
Decreased by $76.33 PMPM Total Cost Reduction $15.7 M PC Health
Homes 23,354 persons total served (includes Dual Eligibles) Cost
Decreased by $30.79 PMPM Total Cost Reduction $7.4 M
Slide 58
58 State Health Home Activity-March 2014 *Some states may be in
the planning phase. 2 2 2 # 3 3
Slide 59
Psychiatrist Shortage Overview Currently Demand for
Psychiatrists exceeds the supply Demand for psychiatric workforce
is increasing Psychiatric workforce is projected to shrink The
current psychiatric care delivery model is not sustainable So what
can be done differently?
Slide 60
Drivers of Increased Demand ACA requires newly covered
populations meet the parity requirements of Wellstone Domenici
Parity Act Multiple parts of ACA require or incentivize integration
of Behavioral Health and general medical care Stigma continues to
drop releasing pent up demand In responding to recent press
coverage of mass shootings increasing mental health services is
more popular than gun control
Slide 61
CURRENT SHORTAGE Best data: Study by University of North
Carolina commissioned by Health Resources and Services
Administration (HRSA) Demonstrated shortages for all MH
professionals, especially prescribers 77% of U.S. Counties have a
severe shortage of prescribers, with over half their need unmet 96%
of US counties have some unmet need Konrad et al, Psych Services,
60: 1307-14, 2009
Slide 62
Current Supply and Need for Psychiatrists Estimated need of
25.9 psychiatrists/100,000 population With current population of
300,000,000, this is 78,000. Current supply is ~ 48,000 (~
16/100,000) Current gap = at least 30,000 Much greater supply vs.
need gap for child and adolescent psychiatry (~ 7,500 total)
Sources: Konrad et al, Psych Services, 60: 1307-14, 2009
Slide 63
Psychiatric Times Series on Psychiatrist Shortage (Summer 2010)
Psychiatry Job Openings Surge into the Future: Physician
recruitment company, Merritt Hawkins reported a 121% increase in
requests for psychiatrists between 2007/2007 and 2009/2010 45,000
More Psychiatrists, Anyone?: HRSA commissioned studies considered
very conservative because of exclusion of many patients with
disorders that require some type of treatment (ADHD, Conduct
Disorder, Dysthymia)
Slide 64
Demand for Psychiatrists Continues to Grow The Bureau of Health
Professions predicts that demand for General Psychiatry services
will increase nearly 20% between 1995 and 2020 100% increase in the
need for Child and Adolescent Psychiatry
Slide 65
Supply of Psychiatrists has been flat for 20+ years Note: there
has been a linear increase in number of physicians overall during
this time
Slide 66
Current Psychiatrists are Aging Out Fast Percent of MDs by
Specialty over age 55 Off all sub-specialties (35), Psychiatry is
second oldest ( Second only to Preventive Medicine) 55% of current
psychiatrist are > age 55
Slide 67
Projected Supply and Demand of All Physicians 2010 - 2025
Source: AAMC Center for Workforce Studies, June 2010 Analysis
Slide 68
Anticipated Supply and Demand of Psychiatrists? Anticipated
Supply Anticipated Demand Time ? ?
Slide 69
So, what to do There is NO one magic bullet More and larger
help wanted signs wont work Warm bodies with prescription pads wont
work Locums Tenens isnt the solution Tele-psychiatry isnt the
solution
Slide 70
Collaboration Models Clearly must change the way we do business
Primary Care Physicians with Consulting Psychiatrist Advanced
Practice Nurse Practitioners as LIPs with Collaborating
Psychiatrists (practice agreements or prescriptive agreements)
Psychologists with Supervising Psychiatrists Physician Assistants
as psychiatrists extenders
Slide 71
Potential Options and Concerns 1.Primary Care Physicians take
on more psychiatric patients already overloaded and not doing the
best job in treating people with psychiatric problems 2.Train more
Psychiatrist $100,000 per residency slot (times 45,000 = $4.5B)
3.Train more APRNs and Physician Assistants in Psychiatry very
little training in psychology or psychotherapy 4.Psychologists
Prescribing Authority What is adequate training in basic science
medicine and clinical science medicine to prescribe?
Slide 72
Benefits of Co-Location and Integration Patients prefer it
Percent complying with a referral rises from 15-20% to 40-60%
Builds personal relationships the foundation of any enduring
arrangement Allows more accurate understanding of each others
incentives, methods and constraints Opportunities for informal
consultation Single clinical record reduces errors Facilitates
converting BH clinicians into consultants to PCPs
Slide 73
Integration with Primary Care Expands Access to Psychiatry
Another Pilot Program with a N of 1
Slide 74
More Psychiatric Medications are prescribed in primary care
than in Specialty BH clinics Community Health Centers (CHC = FQHC)
1200 CHCs serve 20M patients of whom 38% are minorities and
including 20% of all uninsured All must have a plan to meet BH
needs, 71% provide BH services totaling 4.7 M visits annually
Primary focus has been Depression Static or shrinking Psychiatrist
workforce and increasing demand Health Care Reform emphasizes on
Primary Care Background
Slide 75
University Clinic & CMHC Practice Over 10 years duration
Patient Volume small and static Never saw PCP or
Patients-in-waiting Model Initial Evaluation all in one visit of
90-120 min Med visit w/ a little therapy 20-39 minute duration
Every 1-4 weeks Termination criteria - death or disappearance 20-39
minute duration Every 1-4 weeks
Slide 76
Phase 1 Co-Location Into the FQHC Two years duration Model Got
my office in the corner PCP refers them, I evaluate and keep them
Evaluations 60 min, return visits 20 min Outcomes Patient volumes a
little larger but still static Get to regularly come across PCPs
and Patients-in- Waiting who are unhappy about lack of access 3
month wait list and 30 % no-show rate
Slide 77
Talk a different language with unfamiliar colleagues
Slide 78
Phase 2 Desperation Duration 1 year Method Squeeze Down the
appt times Initial Eval 30 min Learn and do just enough to get to a
2 nd visit Return Visits 15 Mins Outcomes 33% increase in caseload
Case load static again 6 months later Running really fast but not
getting ahead
Slide 79
Slide 80
Phase 3 Enhancing Access by Consultation Duration 3 years Two
New Consult Access Methods Interrupt me if its urgent and brief
Separate Wait Lists Rapid access to one time consult visit Regular
wait list for ongoing care Outcomes Moderately larger patient
volumes Consult service turns over constantly
Slide 81
Phase 4 The PCPs Catch on to Me Duration 2 years The Power of
See One- Do One- Teach One PCPs see my usual prescribing pattern by
diagnosis in our common EMR PCPs practice implementing my
recommendations PCPs see me interview during interruptive consults
Outcomes PCPs decide that they will try my 1 st 3 moves before
referral Referral pressure drops I get more phone calls for
curbside advice
Slide 82
Slide 83
Phase 5 - We Leave the Nest Duration 3 years Method Add a
collaborative Psychiatric APN Convert to Open Access Scheduling
Refer all ongoing patients back to APN or PCPs unless acutely
unstable or scary to APN and PCPs Outcome 2-3 week wait max can
always fit urgent in next week Much higher patient volume No Shows
down to 10%
Slide 84
Breath vs. Depth Choices Give the best to a few Give minimally
adequate to many Which Patients do You have a Duty To? The ones on
your case load now The rest in your community waiting to get
in
Slide 85
Advantages Can treat many more patients Working more often at
top of their expertise Immediate access to MD records of prior
treatment Lots more support of practice Nurses verbal orders,
refill protocols, do EKGs, 1st on call PCP - consults, handles CS
refills, reads EKG, 2 nd on call Labs, pulse-ox, EKGs, scheduling
specialty referrals Problems Intermittent Consultant, not an
ongoing relationship New Culture interruptions and variable appt
times Less access to CMHC specialty services and BH colleagues PCPs
start controlled substances then refer to Psychiatrist Psychiatrist
View of Working in Primary Care Clinics
Slide 86
Advantages Easier Access, more available appts, shorter waits
Attention to the Medical causes of BH symptoms Getting Medical Care
including healthy lifestyle advice Relation ship less fear based
than with psychiatrist Problems Know less about Dx & Tx of BH
illness other than Depression and Anxiety Medical Culture, Not
familiar with Recovery concepts Less awareness of and access to
non-Med interventions Dont use comprehensive Bio-Psycho-Social
Assessment Consumer View of Getting BH Services in Primary Care
Clinics
Slide 87
87 www.thenationalcouncil.org Contact:
[email protected] | 202.684.7457 When you make
a choice, you change the future. Deepak Chopra When you make a
choice, you change the future. Deepak Chopra Status of our
world
Slide 88
Slide 89
Slide 90
Slide 91
Moving from special silo status to equality; from incremental
improvement to fast paced change Disconnected from the rest of the
healthcare ecosystem Small independent organizations with small
margins Not effectively addressed divide between mental health and
substance use Image of not having timely access to care Limited
capital for new service lines and HIT infrastructure 91
Struggles
Slide 92
Fee for Service is headed towards extinction Health Care Home
models are beginning with a 3-layer funding design with the goal of
the FFS layer shrinking over time Being replaced with case rate or
capitation with a pay for performance layer
Slide 93
Shared Savings Full Risk Partial Risk Shared Savings Bundled
Payments Traditional Fee-for-Service Pay-for- Performance
MinimalSavings Potential for Health Plans and CustomersSubstantial
Episodic Cost Accountability Total Cost Accountability Source: The
Advisory Board Company: Accountable Care Forum-Briefing for Health
Plan Executives 93
Slide 94
Behavioral Health Organizations Integrated Practice Units treat
disease and all related conditions, complications and circumstances
Outcomes Based Care measure full set of outcomes and costs for
every patient Bundled Payments acute care cycle; yearly care for
chronic condition Expand Across Geography affiliations, mergers and
acquisitions = volume Integrate Across Facilities determine scope
of service; and standardize care across sites Enabling Technology
Platform enable measurement; new reimbursement approaches; tie
delivery system together 94
Slide 95
Organize into Integrated Practice Units 95
Slide 96
www.TheNationalCouncil.org Monopoly Economy 96 Merge and
Consolidate
Slide 97
Produce measurable outcomes Episodic care Treat to target
Solution-focused therapy British CBT Use of standardized tools to
measure improvement in symptoms, functioning, resilience and
recovery Dont be afraid to embrace new approaches to
treatment!
Slide 98
Most multisite organizations are not true delivery systems, at
least thus far, but loose confederations of largely stand-alone
units that often duplicate services. To achieve true system
integration, organizations must grapple with four related sets of
choices: defining the scope of services, concentrating volume in
fewer locations, choosing the right location for each service line,
and integrating care for patients across locations. Integrate Care
Delivery Systems
Slide 99
Hospital groups, physician groups and commercial payers most
common 99 Medicare Shared Savings Program Medicare Shared Savings
Program Pioneer Program Pioneer Program Commercial Payers
Commercial Payers Public Sector Private Sector 25 to 31 MILLION
Americans currently receive healthcare through ACOs 2.4 MM in
Medicare ACOs 15MM non-Medicare patients of Medicare ACOs 8 to 14
MM Patients of non-Medicare ACOs Sources: Market Trends in ACO
formation, OPTUM; The ACO Surprise, Oliver Wyman Accountable Care
Organizations
Slide 100
Other emerging trends Elimination of Safety Net Funding For
Uninsured Decrease of Fee-For-Service Rates Medicaid or Medicare
Coverage of SPMI Moved To Managed Care or ACOs Expanding Role of
Urgent Care Clinics in Community Payers Increase Coverage of
E-Health Services & Remote Monitoring Responsibility for Health
Outcomes and Costs of Defined Populations Mandatory Adoption of EBP
Via Comparative Effectiveness Research Medication Assisted
Treatments for Addictive Disorders Widespread Adoption of Neurotech
(Scans, Avatars, Cognitive Retraining)
Slide 101
Medicaid Emergency Psychiatric Demonstration Project Section
2707 of ACA Allows IMDs to bill Medicaid at usual rate for persons
19-64 y.o. $75 M Federal funds plus usual state match 12 states
with 27 IMDs participating Planned to run 3 years began July 2012,
Authorization ends Dec, 2015 December 2013 Mandated Report (18
months) Status 3458 admissions, 2791 patients, 84% had 1 admission
Ave LOS = 7 days, 84% discharged home Ave per diem $911 Way under
budget half way through allotted time has used 25% of funding
December 2013 Mandated Report (18 months) Recommendations Too
little data to recommend expanding Extend Demonstration past
December, 2015
Slide 102
DSH REDUCTION CRISIS in ADULT PSYCHIATRIC INPATIENT BEDS: FOUR
MISSOURI COMMUNITY HOSPITAL EXAMPLES 102 Hospital # of Total
Hospital Beds # of Adult Psychiatric Inpatient Beds % of all
Hospitals Patients who are Uninsured % of Adult Psychiatric
Patients who are Uninsured % of Hospitals Total Indigent Care Days
Accrued on Adult Psych Units Cox Health- Springfield
646429.0%30.9%23.8% SSM St. Joseph Health Center-St.
Charles/Wentzville 331619.4%28.8%58.2% Truman Medical
Center-Lakewood 3102817.9%23.7%46.7% Twin Rivers Regional Medical
Center- Kennett 116126.7%18.2%52.2%