1

How far we’ve come

Integrating Primary & Behavioral

Healthcare

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

3

Life Expectancy

No Mental Disorder Any Mental Disorder General Population

Any Mental Disorder Public Sector

40

45

50

55

60

65

70

75

80

Bar 1 & 2: Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011 June;49(6):599-604

Bar 3; Daumit GL, Anthony CB, Ford DE, Fahey M, Skinner EA, Lehman AF, Hwang W, Steinwachs DM. Pattern of mortality in a sample of Maryland residents with severe mental illness. Psychiatry Res. 2010 Apr 30;176(2-3):242-5

What are the Causes of Morbidity and Mortality in People with Serious Mental Illness?

88% of the deaths and 83% of premature years of life lost in persons with serious mental illness are due to “natural causes”

– Cardiovascular disease– Diabetes– Respiratory diseases– Infectious diseases

5

-60

-50

-40

-30

-20

-10

0

10

79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95

Dec

line

(%)

Noncardiovascular Disease

Coronary Heart Disease (CHD)

Stroke

Morbidity and Mortality Weekly Report. 1999; 48(30):649-656.

Change in US General Population Age-Adjusted Mortality (1979-1995)

Year

6

Mortality Risk From all causes and cardiovascular disease increased in patients with schizophrenia between 1970-2003

70-74 75-79 80-84 85-89 90-94 95-99 00-030

0.5

1

1.5

2

2.5

3

1970-1974

1975-1979

1980-1984

1985-1989

1990-1994

1995-1999

2000-2003

0

0.5

1

1.5

2

2.5

Test for time trends of excess relative risks for SMRs were statistically significant (P<0.001) for all causes of mortality due to cardiovascular disease.

Men Women

Ösby U et al. BMJ. 2000;321:483-484, and unpublished data courtesy of Urban Osby.

All causes Cardiovascular Disease

7

Maine Study Results Comparison of health disorders between SMI & Non-SMI groups

59.4

33.930 28.6 28.4

22.8 21.7

16.5

11.5 11.1

6.3 5.9

0

20

40

60

80

% M

embe

rs

SMI (N=9224)

Non-SMI(N=7352)

8

Comparison Metabolic syndrome prevalence in fasting CATIE & matched NHANES III subjects

Males

CATIE NHANES p

N=509 N=509

Females

CATIE NHANES p

N=180 N=180

Metabolic Syndrome Prevalence

36.0% 19.7% .0001 51.6% 25.1% .0001

Waist Circumference Criterion 35.5% 24.8% .0001 76.3% 57.0% .0001

Triglyceride Criterion 50.7% 32.1% .0001 42.3% 19.6% .0001

HDL Criterion 48.9% 31.9% .0001 63.3% 36.3% .0001

BP Criterion 47.2% 31.1% .0001 46.9% 26.8% .0001

Glucose Criterion 14.1% 14.2% .9635 21.7% 11.2% .0075

Meyer et al., Presented at APA annual meeting, May 21-26, 2005. McEvoy JP et al. Schizophr Res. 2005;80:19-32.

9

The CATIE Study

At baseline investigators found that:

88.0% of subjects who had dyslipidemia

62.4% of subjects who had hypertension

30.2% of subjects who had diabetes

were NOT receiving treatment.

10

Causes of Excess Mortality

Smoking

Obesity

Inactivity

Polypharmacy

Under-diagnosis of medical conditions

Inadequate medical

treatment

11

Per Member Per Month Costs

Private Sector Medicare Medicaid$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

No Mental DisorderAny Mental Disorder

Melek et. al, Milliman, Inc., 2013

12

MH/SU costs in NY state’s Medicaid program

MH Disorder SU Disorder No MH/SU Disorder

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

$22,000

$24,000

$26,000

$28,000

$30,000

Behavioral Health costsPhysical Helath costsPhysical Health costs

13

Recovery for persons with serious mental illness (SMI)

CMHC Mission

14

CMHC Problem

Early death from physical illness prevents recovery from SMI

17

Big Trends

Increased coverage Increased demand Focus of high utilizers Increased desire for integration by payers Shrinking psychiatric workforce

18

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

ACA insurance reforms and coverage expansions provide new coverage many people need and want BH services

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

19

So, what to do…

There is NO one magic bullet

Integration of behavioral health and primary care

Team care with everyone working at the top of their training

Population health management

Health care delivery based on deep partnerships

20

4 Strategies

1. Coordination of care

– EHR, CyberAccess, PROACT, and Missouri Health

Connection

– Care management – CMHC & FQHC as Health Homes

2. Co-Location/Integration of primary and behavioral healthcare –

CMHC/FQHC partnering and Health Homes

3. Medical disease management including for persons with mental

illness

4. BH interventions for medical risks

– Obesity/activity

– Smoking

– Screening for prevention and treatment

21

CMHC Health Home Performance Progress

LDL, A1C, and Blood Pressure

Outcomes | LDL Levels

CMHCs PCHHS100.0

105.0

110.0

115.0

120.0

125.0

130.0

135.0

130.3 130.3

115.0

121.5

111.5

117.2

Baseline Year 1 Year 2

10% ↓ in LDL level 30% ↓ in cardiovascular

disease

Outcomes | A1C Levels

CMHCs PCHHS7.50%

8.00%

8.50%

9.00%

9.50%

10.00%

10.50%

10.01%

9.81%

8.96%

9.20%

8.58%

9.07%

Baseline Year 1 Year 2

1 point drop in A1c

21% ↓ in diabetes-related deaths

14% ↓ in heart attack 31% ↓ in microvascular

complications

Outcomes | Hypertension and Cardio

Good Cholesterol for Clients w/ CVD(<100 mg/dL)

Normal Blood Pressure for Clients w/ HTN

(<140/90 mmHg)

0%

10%

20%

30%

40%

50%

60%

70%

21%24%

37%41%

49%

55%55%

62%

55%

65%

Feb'12Baseline

Feb'1312 Months

June'1318 Months

Jan'142 Years

June'142.5 Years

34% 41%

Outcomes | Diabetes

Good Cholesterol(<100 mg/dL)

Normal Blood Pressure(<140/90 mmHg)

Normal Blood Sugar(A1c <8.0%)

0%

10%

20%

30%

40%

50%

60%

70%

22%

27%

18%

38%

46%42%

47%

59%

53%50%

67%

57%59%

69%

64%

Feb'12Baseline

Feb'1312 Months

June'1318 Months

Jan'142 Years

June'142.5 Years

37% 42% 46%

Outcomes | Metabolic Syndrome Screening

Metabolic Syndrome Screening (All HCH Enrollees)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12%

46%

61%

80% 80%

86%

Feb'12Baseline

Feb'1312 Months

June'1318 Months

Jan'142 Years

June'142.5 Years

March '153 Years

74%

Outcomes | Reducing Hospitalization

CMHCs PCHHS0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

35.9

27.5

30.4

23.5

28.3

22.6

18.5

12.6

Baseline Year 1 Year 2 Year 3

% of patients with at least 1 hospitalization(non-duals, 9+ attestations)

CMHC Hospital Days Per 1000 Member Month

Pre4 Pre3 Pre2 Pre1 Post1 Post2 Post30

50

100

150

200

250

300

350

<18 18-64 65+ Total

CMHC ER Visits Per 1000 Member Month

(attestation method)

30

Initial Estimated Cost Savings After 18 Months

PC Health Homes

– 23,354 persons total served (includes Dual Eligibles)– Cost decreased by $30.79 PMPM– Total cost reduction $7.4 M

CMHC Health Homes

– 20,031 persons total served (includes Dual Eligibles)– Cost decreased by $76.33 PMPM– Total cost reduction $15.7 M

What Makes it Possible?

A Relationship of basic trust between:

– Department of Mental Health

– MO HealthNet (Medicaid)

– State Budget Office

– MO Coalition of CMHCs

– MO Primary Care Association Transparent use of data instead of

anecdotes to explore and discuss issues

Willingness of all partners to tolerate and share risk

Principled negotiation and Motivational Interviewing

Partnership Principles

DO

Ask about their needs first

Give something

Assist wherever you can

Make it about the next 10

Pursue common interest

Reveal anything helpful

Take one for the team

DON’T

Talk about your need first

Expect to get something

Limit assistance to a project

Make it about this deal

Push a specific position

Withhold information

Let them take their lumps

Character– Talk Straight– Demonstrate Respect– Create Transparency– Right Wrongs– Show Loyalty

Competence– Deliver Results– Get Better– Confront Reality– Clarify Expectations– Practice Accountability

Character & Competence– Listen First– Keep Commitments– Extend Trust

S.M.R. Covey, The Speed of Trust

Behaviors that Promote Trust

Resources

NASMHPD Technical Reportshttp://www.nasmhpd.org/publications/NASMHPDPublications.aspx

Healthcare Home Source documents pagehttp://dmh.mo.gov/mentalillness/introcmhchch.html

Missouri CMHC Healthcare Homeshttp://dmh.mo.gov/mentalillness/mohealthhomes.html