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Steve  Daviss,  MD,  DFAPA  

Chief  Medical  InformaCon  Officer,  M3  InformaCon,  LLC  

President  &  Co-­‐Founder,  FUSE  Health  Strategies,  LLC  

Clinical  Assistant  Professor,  University  of  Maryland  

steve@m3informaCon.com  

St.  Agnes  Hospital  October  15,  2015  

How  to  reduce  readmissions  and  improve  care:  IntegraCon  of  behavioral  health  care  

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•   IdenCfy  the  clinical  and  financial  impacts  of  behavioral  health  disorders  on  chronic  medical  condiCons.  

•   Describe  the  challenges  involved  in  improving  clinical  and  financial  outcomes  in  paCents  with  chronic  medical  condiCons  who  also  have  behavioral  health  symptoms  and/or  condiCons.  

•   List  three  things  that  can  be  done  to  reduce  hospital  readmissions  in  this  populaCon.  

Learning  ObjecCves  

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Other  Hats  I  Wear  •  Chair,  APA  CommiYee  on  Mental  Health  IT  •  Former  Department  Chair,  BWMC  •  URAC  Health  Standards  CommiYee  •  HIE  Policy  Board,  MHCC  •  Clinical  Advisory  CommiYee,  CRISP  •  Shrink  Rap  blog  -­‐-­‐  My  Three  Shrinks  podcast  •  Book:  Shrink  Rap:  Three  Psychiatrists  Explain  Their  Work  

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Fuse  Health  Strategies  LLC  

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Problems  .  .  .  OpportuniCes  

Sources: NAMI, APA, CMS, Project RED

mood disorders are treated by Primary

Care doctors

35%

Of patients with a chronic illness have a

mental illness

26%

Americans 18 and older suffer from a diagnosable

mental disorder

40million

US adults (18-54) have an anxiety disorder in given

year

2X Costs

Unmanaged patients with mental illnesses

Cost Payers more than double to manage chronic conditions

$3T

Global disease burden for Mental illnesses due to

disability #1 cost for businesses (WHO)

28%

Of patients re-admitted to hospitals related to

mental illness

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Slide  courtesy  of  Ben  Druss  MD   7  

Life expectancy cut by up to 25 years

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Across  these  top  9  chronic  condiCons,  depression  and  anxiety  go  UNDIAGNOSED  85%    of  the  Cme.    

Medical Costs per Disease State

Chronic Medical Condition

PMPM With Behavioral Condition

PMPM Without Behavioral Condition

% Treated For Depression or

Anxiety Expected Depression or

Anxiety Prevalence % Missed Arthritis $871.88 $564.76 7.1% 32.3% 77.9%

Asthma $861.99 $470.05 6.8% 60.5% 88.8%

Cancer (Malignant) $1,180.96 $1,018.45 5.7% 39.8% 85.7%

Chronic Pain $1,210.56 $884.70 5.9% 61.2% 90.4%

Coronary Artery $1,305.00 $958.34 5.7% 48.2% 88.1%

Diabetes $1,110 $828.18 5.2% 30.8% 83.2%

Heart Failure $2,242.85 $1,888.11 7.0% 43.8% 84.1%

Hypertension $880.33 $588.04 5.5% 30.5% 82.0%

Ischemic Stroke $1,461.57 $1,254.68 7.7% 52.4% 85.2%

Source: http://www.ncbi.nlm.nih.gov/

Cost  Burdens  from  unrecognized/undiagnosed/Mental  Health  Cases.

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Mental  Health  Affects  Medical  CondiCons    and  Outcomes  in  a  BIG  WAY    

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Slide  courtesy  of  Wayne  Katon  MD  Mitchell  et  al,  J  Hosp  Med  2010  

Depression increases risk of 30-day readmission by nearly 40%

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2008:  Chronic  condiCons  and  comorbid    psychological  disorders  

For  comorbid  depression,  increased  healthcare  costs  “average  $505  per  comorbid  member  per  month  across  all  chronic  medical  condiCons  we  analyzed,  of  which  nearly  $400  is    higher  medical  costs.”   79%  For  comorbid  anxiety  condiCons,  they  “average  $651  per  comorbid  member  per  month  across  all  chronic  medical  condiCons  we  analyzed,  of  which  nearly  $538  is  due  to    higher  medical  costs.”   83%  

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2008:  Chronic  condiCons  and  comorbid    psychological  disorders  

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Breakdown    of        U.S.        PopulaEon,        EsEmated        Annual        Costs,        and        Cost        ReducEon        from        Managing        Behavioral        Health        CondiEons          

Total      U.S.        PopulaEon  

321,043,000 1  

Total    Adult        U.S.        PopulaEon  

234,000,000   2  

EsEmated  Monthly  

Per      PaEent   Cost        

ReducEon

EsEmated  Total    Annual  

Cost        ReducEon

PopulaEon   Total

PopulaCon   Percentage

PopulaCon   Subtotal Breakdown        by        Chronic        Disease

Diabetes  COPD  CHF  Asthma  Cancer  ArthriCs  Hypertension  Ischemic    Heart        Disease  

35,314,730  14,742,000  5,100,000  25,683,440  14,483,830  53,118,000  68,094,000  

14,040,000

25.6%  31.3%  36.8%  53.7%  34.1%  25.2%  25.0%  44.7%  

9,040,571  4,614,246  1,876,800  

13,792,007  4,938,986  

13,385,736  17,023,500  

282  412  355  392  163  307  292  207  

30,603,055,674  22,795,667,229  7,989,312,384  64,867,672,000  9,631,615,437  49,332,326,884  59,709,585,780  

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11  11     6,275,880 11   15,581,001,758  

Total    for        Top        8        Diseases  

230,576,000 *   70,947,726   *             260,510,237,146   *            

Costs        to        Treat  

As    %        of        Costs  

Cost    to        Treat  

                    PotenEal  Savings  

Milliman    EsCmate  Unutzer    CollaboraCve        Model        EsCmate  

16.00%  10.00%  

41,681,637,943          *  26,051,023,715          *  

          $218,828,599,203  $234,459,213,432  

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*   Actual    amounts        are        less        because        some        paEents        have        more        than        one        chronic        condiEon.  

PopulaCon    Clock,        U.S.        Census        Bureau,        Retrieved        March        6,        2015  Chronic    Disease        Overview,        Center        for        Disease        Control        and        PrevenCon  U.S.    Diabetes        Rate        Levels        off        in        2011,        Gallop.com,        December        16,        2011,        Retrieved        May        8,        2013  

6.3%    of        U.S.        Adults        Report        Having        COPD,        Center        for        Disease        Control        and        PrevenCon        (only        includes        reported        cases)  Heart        Failure        Fact        Sheet,        Centers        for        Disease        Control        and        PrevenCon  Asthma        StaCsCcs,        American        Academy        of        Allergy        Asthma        &        Immunology  Cancer    Prevalence:        How        Many        People        Have        Cancer?,        American        Cancer        Society  CDC:    Center        for        Disease        Control        and        PrevenCon;        (ArithiCs:        2010-­‐-­‐-­‐2012        -­‐-­‐-­‐        Data        and        StaCsCcs)  

Center    for        Disease        Control        and        PrevenCon;        Hypertension        among        adults        in        the        United        States;        NaConal        Health        and        NutriCon        ExaminaCon        Survey,        October        2013  CDC:    Center        for        Disease        Control        and        PrevenCon;        (Morbidity        and        Mortality        Weekly        Report:        October        14,        2011)  Based    on        OptumHealth        Report:        Co-­‐-­‐-­‐Morbid        Behavioral        Health        CondiCons        in        PCP        PracCce  Milliman,    2013.        Economic        impact        of        integrated        medical-­‐-­‐-­‐behavioral        healthcare  

Unutzer,    2008.        American        Journal        of        Managed        Care  

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ConfidenCal    Property        of        M-­‐3        InformaCon,        LLC.                Do        not        distribute        or        reproduce        without        permission.  

Undiagnosed        Behavioral  Health      CondiEons  

This  is  a  BIG  number  in  COST  SAVINGS.      

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Source: Cartesian Solutions, consolidated health claims data

Increased  costs  of  chronic  medical  condiCons  when  mental  illness  co-­‐exists  

Dollars  

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Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011

None +MH +SU +MH+SU

CHF

Rel

ativ

e R

isk

Sou

rce:

Hill

top

Inst

itute

, 201

2

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Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011

None +MH +SU +MH+SU

HIV

Rel

ativ

e R

isk

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Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011

None +MH +SU +MH+SU

Epilepsy

Rel

ativ

e R

isk

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Relative risk of medical admission with & without MH and SU comorbidity

None +MH +SU +MH+SU

Diabetes

Rel

ativ

e R

isk

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-- Maryland Medicaid Adults, 2011

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None +MH +SU +MH+SU

COPD Asthma Pneumonia NOS Bronchitis

Rel

ativ

e R

isk

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-- Maryland Medicaid Adults, 2011 Relative risk of medical admission with & without MH and SU comorbidity

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None +MH +SU +MH+SU

Cellulitis Septicemia

Rel

ativ

e R

isk

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Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011

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2008:  Chronic  condiCons  and  comorbid    psychological  disorders  

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Behavioral Health Co-Morbidities Have Significant Impact on Healthcare Costs

$8,000   $9,488   $8,788   $9,498  

$15,691  

$24,598   $24,927   $24,443  

$36,730   $35,840  

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  Abuse  

With  Undiagnosed    and/or  Untreated    MI  and  Drug/Alcohol  Abuse  

Impact  on  Chronic  Healthcare  Costs  

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Melek,  Norris,  &  Paulus.  Economic  impact  of  integrated  medical-­‐behavioral  healthcare:  ImplicaCons  for  Psychiatry.  Milliman,  2014     23  

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Increased  readmissions  for  COPD,  CVA  

Pooler  &  Beech,  2014  

Abrams  2011:  22%  more  (COPD)  Dossa  2011:  44%  more  (CVA)  ChwasCak  2014:  24%  more  (DM)  Prina  2015:  36%  more  (all)  

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Meaningful  Use  2015-­‐2017  

2016  Guidelines  1.  Pop  Health  Mgt    

2.  Care  CoordinaCon    

3.  PaCent  Engagement  

4.  Clinical  Decision  Support            

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2013  NaConal  Survey  of  ACOs,  n=257  

…we  found  that  the  decision  to  pursue  integrated  models  depends  powerfully  on  the  design  of  the  ACO  payment  model,  details  of  contracts,  and  the  quality  measures  used  in  contracts.  “                                                                                        ”  

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Slide:  Courtesy  of  Jurgen  Unutzer  MD  

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Effect  of  CollaboraCve  Care  for  Depression  on  Risk  of  Cardiovascular  Events:    Data  From  the  IMPACT  Randomized  Controlled  Trial  

28  Stewart,  Perkins,  &  Callahan,  PsychosomaCc  Med  2014  76:129  

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N=551  depressed  pts  60+  yrs  >  randomized  

Reference   29  

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CollaboraCve  Care  Model  

Source:  Unutzer,  UW   30  

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Bipolar  disorder  idenCfied  in  22%  of  depression-­‐posiCve  screens  in  postpartum  women  

Source:  Wisner  2014  JAMA   32  

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Gaynes  et  al,  Ann  Fam  Med  2010  

Anxiety  disorders  are    twice  as  common  as  depression  in    primary  care.  Anxiety  

Depression  

Bipolar  

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Risks of not addressing multidimensional behavioral health: misdiagnosis – mistreatment - cost - safety

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  M3  Checklist  validated  in  2009  UNC  study  

  Published  in  March  2010  Annals  of  Family  Medicine  

  n=647  adults  in  an  academic  family  medicine  clinic  

  29  items  

  validated  against  the  MINI  

  overall  sensiCvity  &  specificity  =  0.83  &  0.76    -­‐Depr  =  0.84  &  0.80    -­‐Bip  =  0.88  &  0.70    -­‐Anx  =  0.82  &  0.78    -­‐PTSD  =  0.88  &  0.76  

  3-­‐5  minutes  to  complete  

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“…none  of  the  screens  posed  a  significant  Cme  burden  on  paCents.  In  the  one  study  that  conducted  an  implementaCon  evaluaCon,  both  paCents  and  providers  found  use  of  the  screening  tool  helpful  and  acceptable,  and  that  it  facilitated  discussion  of  mental  health  issues  in  the  clinical  encounter.”  

“…only  three  of  the  fiveen  studies  were  methodologically  rigorous  enough  to  warrant  Level  I  raEngs.”  

“The  likelihood  raCos  for  the  detecCon  of  PTSD,  both  posiCve  and  negaCve,  for  the  M-­‐3  indicated  that  the  M-­‐3  performed  beYer  than  the  GAD-­‐7  at  idenCfying  probable  cases  of  PTSD.”  

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Self-monitoring of mood and anxiety symptoms via iTunes/Android app, or via whatsmym3.com.

whatsmym3.com  

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Telecollaboration

Telepsychiatry

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Consulting Psychiatrists Help Providers Treat Behavioral Health Patients

“The vast majority of people who are living with mental disorders are not able to access psychiatric treatment. So we are looking for different ways of providing the things we know work, so we can spread out more broadly.”15

Dr. Daniel Z. Lieberman of George Washington University Hospital

Consulting Psychiatrists We also enable curbside consultations with top psychiatrists, and a new way of practicing collaborative care.

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Mobile App - Member Secure Check-Ins, Texts, and Calls

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Mobile App – Case Manager Predictive Analytics Enables Population Management

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Based  on  this  paCent’s  personalized  profile  …  Find  the  most  similar  paCents  (or  dynamic  cohort)  from  enCre  populaCon  Analyze  what  happened  with  the  cohort  and  reasons  why  (30,000+  dimensions)  Predict  the  probability  of  the  desired  outcome  for  this  paCent  Create  personalized  care  plan  based  on  unique  needs  of  this  paCent    

Summary  View  of  How  Similarity  and  At-­‐Risk  AnalyCcs  Work  

Desired  Outcomes  

Historical  ObservaCon  Window   PredicCon  Window  

This  PaCent’s  Longitudinal  Data   Predicted  Outcome  For  This  PaCent  

Dynamic  Cohort  Longitudinal  Data  with  Outcomes  

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Steve  Daviss,  MD,  DFAPA          steve@m3informaCon.com  

How  to  reduce  readmissions  and  improve  care:  IntegraCon  of  behavioral  health  care.      

Resources  

•   m3informaCon.com  –  M3  website  •   whatsmym3.com  –  M3  Self-­‐tracking  •   bit.ly/m3appstore  –  WhatsMyM3  in  iTunes  App  Store  •   bit.ly/m3validaCon1  –  Annals  of  Family  Medecine  2010  •   integraCon.samhsa.gov  –  SAMHSA  IntegraCon  Page  •   bit.ly/m3aims  –  AIMS  CollaboraCve  Care  Center  •   fusehealth.org  –  Fuse  Health  Strategies  website  •   mindoula.com  –  Mindoula  care  coordinaCon  

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