Overview from the Field: Key Conceptual Models, Definition of

Integrated Behavioral Health, CA IPI and CALMEND Projects

Department of Health Care ServicesBehavioral Health Technical Workgroup

2-24-2010

Barbara Mauer, MSW, CMCMCPP Healthcare Consulting Inc.

Seattle, Washington

Overview from the Field

Part One (Meeting 2/24)1. Healthcare Environment

– Universal Coverage/Parity– Service Delivery Redesign

• Importance of MH/SU conditions

• Patient-centered medical homes

• Care management• The Care Model

2. Integrated Primary Care/MH/SU– Person-centered healthcare homes– Definition of integrated healthcare– Models for clinical care– Four Quadrant model

3. California– Integrated Policy Initiative (IPI) report– CalMEND Learning Collaborative

4. Financing– Paradigms– SPD Plans

Part Two5. Financing and the Waiver

– SPD Plans – Paradigms and Cost Offsets

6. Alignment with the Waiver7. Management Models

– Assumptions– Examples

8. Integration Pilots

Part One

Universal Coverage/Parity: Will Likely Improve MH/SU Access and Available Services

• Mental Health and Substance Use Services must be provided at parity with general healthcare services (no discrimination) – Large Employers (Parity Act)– Medicaid (Parity Act & Reform Legislation)– Health Insurance Exchanges for Individual and Small

Group Policies (Health Reform Legislation)– Medicare: on the way (Medicare Modernization Act of 2003)

• But... the parity regulations may not be the most important component if health reform passes; keep your eye on the Benchmark Benefit Package that ‘s currently in the Senate bill– In Medicaid most/all enrollees may be guaranteed a

benchmark benefit package that at least provides “essential health benefits”

– Mental Health and Substance Use are included in the definition of “essential health benefits”

4

Service Delivery Redesign: MH/SU Conditions are Now on the Health Policy Community’s “Radar Screen”

• 49% of Medicaid beneficiaries with disabilities have a psychiatric illness (this is new information; previous studies that excluded pharmacy claims calculated the rate at 29%)

• Substance use conditions do not show up in this study at the expected levels because it’s based on an analysis of claims and pharmacy scripts

The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic ConditionsCenter for Health Care Strategies, Inc., October 2009

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Service Delivery Redesign: MH/SU Conditions are Now on the Health Policy Community’s “Radar Screen”Morbidity and Mortality in People with Serious Mental Illness • Persons with serious mental illness (SMI) are dying earlier than the

general population (average age of death is 53)• While suicide and injury account for about 30-40% of excess mortality,

60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006)

• OR state study found that those with co-occurring MH/SU disorders were at greatest risk (45.1 years)

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• 45 percent of Americans have one or more chronic conditions.

• Over half of these people receive their care from 3 or more physicians.

• Treating these conditions account for 75% of direct medical care in the U.S.

• PCMH, with care management, is a key strategy

Service Delivery Redesign: Patient-Centered Medical Homes (PCMH)

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• Ongoing Relationship with a PCP• Care Team who collectively take

responsibility for ongoing care• Provides all healthcare or

makes Appropriate Referrals• Care is Coordinated and/or

Integrated • Quality and Safety are hallmarks• Enhanced Access to care is available• Payment appropriately recognizes the Added Value

See the www.pcpcc.net site for more information

Service Delivery Redesign: PCMH Principles

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Service Delivery Redesign: Care Management• Care management is a multidimensional activity with models ranging in level

of intensity and breadth of scope (key components of care management include: patient identification; individual assessment of risks/needs; care planning with patient/family; teaching patient/family about management of disease(s); coaching patient/family; tracking over time; and revising care plan as needed).

• Studies of care management in primary care show convincing evidence of improving quality; however it takes time to realize these quality outcomes (e.g., 12 months is probably not enough time).

• Care management studies in primary care are mixed regarding reductions in hospital use and healthcare costs (two promising studies included emphasis on training of care manager team, care management panel sizes at reasonable levels, close relationships between care managers and PCPs, and interactions with patients in-clinic, at home and by telephone).

• Selecting the right patients for care management is associated with reducing costs and improving quality (e.g., individuals who need end-of-life care need different services).

• Training of care managers is an important factor in the success or failure to reduce costs and improve quality.

• Successful programs have care managers as part of multidisciplinary teams that involve physicians.

• Presence of family caregivers improves success of care management, and use of coaching techniques is a viable approach.

• The intensity of the care management needed for success in improving quality and reducing costs is unclear.Bodenheimer T, Berry-Millett R. Care management of patients with complex health care needs Robert Wood Johnson Foundation Research Synthesis Report No. 19. December 2009. www.policysynthesis.org

Service Delivery Redesign: Care Management

Service Delivery Redesign: Overall Model for Improving Primary Care (CALMEND version)

Integrated Care: Patient-Centered Medical Homes become Person-Centered Healthcare Homes

Person-Centered Healthcare Home• Not a clear articulation in the PCMH model of the

role of MH/SU• Change to Person Centered Healthcare Home

signals that MH/SU is a central part of healthcare and that healthcare includes a focus on supporting goals for improved self management

• Use a bi-directional approach to address the integration of primary care services in MH/SU settings as well as the need for MH/SU services in primary care settings

• Build in the care manager/ behavioral health consultant and consulting prescriber functions that have proven effective in the IMPACT model and mirror this model to bring planned primary care into MH/SU settings

PCMH Principles• Ongoing Relationship with a PCP• Care Team who collectively take

responsibility for ongoing care• Provides all healthcare or

makes Appropriate Referrals• Care is Coordinated and/or

Integrated • Quality and Safety are hallmarks• Enhanced Access to care is

available• Payment appropriately recognizes

the added value

Integrated Care: Recent Reports

• World Health Organization– Integrating Mental Health Into Primary Care: A Global Perspective

(Fall 2008)– http://www.who.int/mental_health/resources/mentalhealth_PHC_200

8.pdf• Agency for Healthcare Research and Quality

– Integration of Mental Health/Substance Abuse and Primary Care (Fall 2008)

– http://www.ahrq.gov/clinic/tp/mhsapctp.htm • Hogg Foundation for Mental Health

– Connecting Body and Mind: A Resource Guide to Integrated Health Care in Texas and the United States (Fall 2008)

– http://www.hogg.utexas.edu/programs_RLS15.html

Integrated Care: A Definition

• “It has been defined in many ways, but in essence integrated healthcare is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served… The question is not whether to integrate, but how. Neither primary care nor behavioral health providers are trained to address both issues.”

Hogg Foundation for Mental Health

Integrated Care: The Models for Clinical Care• Co-location

– House BH specialists and primary care providers in same facility, supporting “warm hand-off”

– Does not ensure that providers collaborate in treatment; this may vary greatly across clinics

– Research is somewhat limited—“simply placing a BH specialist in PC is unlikely to improve patients’ outcomes unless care is coordinated and based in evidence-based approaches”

• Primary Care Behavioral Health Model– BH consultant serves as consultant to PCP, focusing on optimizing the PCP’s quality

of BH care for patients– Targets behavioral issues related to medical diagnoses instead of traditional BH

problems like depression and anxiety– Has not yet been systematically evaluated—”although likely beneficial, the

effectiveness of the model is not yet known”

Integrated Care: The Models for Clinical Care

• Collaborative Care– Adaptation of the chronic care model for psychiatric disorders, used stepped

care to treat depression, anxiety disorders, bipolar disorder– Integration of BH care manager and consulting psychiatrist into PC setting, with

registry to track and monitor response to treatment– Numerous studies of clinical and cost effectiveness, with adolescents, adults,

and older adults, with and without co-morbid medical illnesses and from different ethnic groups—”significant research evidence demonstrates that collaborative care improves outcomes for a wide range of patients”

– This is the model the Hogg Foundation has been implementing in a number of Texas PC clinics

Hogg Foundation for Mental Health

The National Council’s Four Quadrant Clinical Integration Model (MH/SU)

Quadrant II

MH/SU PH Outstationed medical nurse

practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP

MH/SU clinician/case manager w/ responsibility for coordination w/ PCP

Specialty outpatient MH/SU treatment including medication-assisted therapy

Residential MH/SU treatment Crisis/ED based MH/SU interventions Detox/sobering Wellness programming Other community supports

Quadrant IV

MH/SU PH Outstationed medical nurse

practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP

Nurse care manager at MH/SU site MH/SU clinician/case manager External care manager Specialty medical/surgical Specialty outpatient MH/SU treatment

including medication-assisted therapy Residential MH/SU treatment Crisis/ED based MH/SU interventions Detox/sobering Medical/surgical inpatient Nursing home/home based care Wellness programming Other community supports

MH

/SU

Ris

k/C

om

ple

xit

y

Quadrant I

MH/SUPH PCP (with standard screening tools

and MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)

PCP-based BHC/care manager (competent in MH/SU)

Specialty prescribing consultation Wellness programming Crisis or ED based MH/SU

interventions Other community supports

Quadrant III

MH/SU PH PCP (with standard screening tools and

MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)

PCP-based BHC/care manager (competent in MH/SU)

Specialty medical/surgical-based BHC/care manager

Specialty prescribing consultation Crisis or ED based MH/SU interventions Medical/surgical inpatient Nursing home/home based care Wellness programming Other community supports

Physical Health Risk/Complexity

Low High

Low

H

igh

Persons with serious MH/SU conditions could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration.

Focus: Quadrants I and III

Primary Care and Depression

• Most PCPs do a good job of diagnosing and beginning treatment for depression (studied 1,131 patients in 45 primary care practices across 13 states)

• PCPs do less well following up with treatment over time– Less than half of patients completed a minimal course of medications or psychotherapy– Few patients who don’t respond to initial treatment get adequate changes in treatment or

referrals to specialists– Lowest quality of care among those with the most serious symptoms, including those

with evidence of suicide or substance use• “Our finding of low rates of referral to mental health specialists for complex

patients is typically addressed in collaborative care interventions through stepped care (e.g. , IMPACT) that prioritizes mental health specialist referrals on the basis of need.”

Hepner et al, Ann Int Med, 9/07

Bipolar Disorder in Clinical Populations

649 outpatients receiving treatment for depression

Screened positive* for bipolar disorder

21%

*Using the Mood Disorder Questionnaire (MDQ)Hirschfeld RM, et al. J Am Board Fam Pract. 2005;18:233-239.

Bipolar prevalenceamong 649 depressed patients = 27.9%

MDQ sensitivity = 58%,specificity = 93%; based on SCID for DSM-IV

Patients Treated for Depression in a Family Medicine Clinic

SU Conditions are Relevant for Primary Care

• SU conditions are prevalent in primary care– Tens of millions (McClellan)– 21% + (Willenbring)

• SU conditions add to overall healthcare costs, especially for Medicaid

• SU conditions can cause or exacerbate other chronic health conditions

• SU interventions can reduce healthcare utilization and cost

In Treatment ~2.3 million

“Abuse/Dependence” ~23 million

“Unhealthy Use” ?? million

Little/No Substance Use

Primary Care and SU Services

• Diffusion of screening and brief intervention (SBI) is underway• Motivational interviewing with fidelity should be a consistent

component of SBI• Repeated BI in primary care is a promising practice• Medication-assisted therapies in primary care can be expanded

IMPACT Collaborative Care in Primary Care

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IMPACT: Doubles the Effectiveness of Usual Care for Depression

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care IMPACT

%

Participating Organizations

50 % or greater improvement in depression at 12 months

Unutzer et al., JAMA 2002; Psychiatr Clin N America 2005

Washington State GA-U Project(General Assistance Unemployable)

DSHS | GA-U Clients: Challenges and Opportunities August 2006

GAU Goal: Collaborative Care

GA-UClient

CMHCLevel II

Care

Care Coordinator

Consulting Psychiatrists

CSO (benefits)

Substance Use

TreatmentLevel I Care

PCP

DVR (employment

)Other clinic-based mental

health providers*

* Available in some clinics

6 FQHC systems (26 clinic sites), 10 mental health agencies, the safety net health plan, the RSN and UW

Washington State GA-U Project (First Year Findings)

• Clients with follow up within 4 weeks of initial assessment– Level I: 42% (range across clinics: 32%-64%)

• Clients with Psychiatrist Consultation– Level I: 31% (range across clinics: 20%-83%)

• Level I outcomes 12 weeks after initial assessment– Clients with PHQ-9 score improved at least 50% over 12 weeks = 20% (range

across clinics: 12%-28%)– Clients with GAD-7 score improved at least 50% over 12 weeks = 20% (range

across clinics: 13%-26%)• Quality Improvement effort, with attention to core components/workflow

– High rates of engagement (100%) and 4 week follow-up (93%)– Effective use of in-person and telephone contacts– Psychiatric Consultation at 60%– 63-72 % with substantial (>50 %) clinical improvement

Unutzer. University of Washington

Washington State GA-U Project

• Removing many of the barriers commonly identified (finance, regulation, sharing of information) did not remove the cultural differences, historic lack of trust, or the challenges of implementing evidence-based practices

• While all of the “usual suspect” barriers must be addressed, the most formidable is changing practice in the field– There was significant variation in work processes across PC and MH clinics and in

implementation of the care coordinator role across PC clinics– This created variation in client follow up and use of psychiatric consultation– This reduced ability to provide stepped care and lack of fidelity to the stepped care

model, and negatively impacted outcomes• However, client outcomes were positively impacted by greater fidelity to

the model

The Person-Centered Healthcare Home: Q I and III

• Incorporate the lessons of the IMPACT model, explicitly building into the medical home the care manager/ behavioral health consultant (MH and SU competent) and consulting prescriber functions that have proven effective in the IMPACT model– DIAMOND project in MN—monthly case rate payments for covering

these components in primary care practices, all major payors participating

• All healthcare is local—working out the details of who does what, for what levels of MH/SU services (Intermountain model), has to engage local partnerships—the California IPI Continuum is a guide for these dialogues

http://www.cimh.org/Services/Special-Projects/Primary-Care/Initiative-Feedback.aspx

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Focus: Quadrants II and IV

Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts 1998-2000

0

5

10

15

20

25

30

35

40

25-34 35-44 45-54 55-64

Rat

es p

er 1

00,0

00

DMH

MA

3.5 RR

4.9RR 2.2RR1.5RR

Comparison of Metabolic Syndrome and Individual Criterion Prevalence in Fasting SMI Subjects and

Matched General Population Subjects

Males

SMI Gen.Pop.

N=509 N=509

Females

SMI Gen.Pop.

N=180 N=180

Metabolic Syndrome Prevalence

36.0% 19.7% 51.6% 25.1%

Waist Circumference Criterion 35.5% 24.8% 76.3% 57.0%

Triglyceride Criterion 50.7% 32.1% 42.3% 19.6%

HDL Criterion 48.9% 31.9% 63.3% 36.3%

BP Criterion 47.2% 31.1% 46.9% 26.8%

Glucose Criterion 14.1% 14.2% 21.7% 11.2%

CATIE source for SMI dataNHANESIII source for general population dataMeyer et al., Presented at APA annual meeting, May 21-26, 2005. McEvoy JP et al. Schizophr Res. 2005;(August 29).

CATIE Study

• At CATIE baseline:– 88% of subjects who had dyslipidemia– 62.4% of subjects who had hypertension– 30.2% of subjects who had diabetesWERE NOT RECEIVING TREATMENT FOR THESE CONDITIONS

CATIE Study

Bi-directional Primary Care/MH/SU Services

• Many individuals served in specialty MH/SU have no PCP• Health evaluation and linkage to healthcare can improve MH/SU status• On-site services are stronger than referral to services• Housing First settings can wrap-around MH, SU and primary care by mobile

teams • Person-centered healthcare homes can be developed through partnerships

between MH/SU providers and primary care providers• Care management is a part of MH/SU specialty treatment and the

healthcare home

The Person-Centered Healthcare Home : Partnership

• Assure regular screening and registry tracking/outcome measurement for all MH /SU consumers

• Locate medical NPs/PCPs in MH/SU settings—provide routine primary care services in the MH/SU setting via staff out-stationed under the auspices of a full scope person-centered healthcare home MH/SU organization hiring a nurse practitioner directly, without the backup of a skilled PCP and a full scope healthcare home cannot be described as providing a healthcare home, and is not a recommended pathway

• Identify a primary care supervising physician within the full scope healthcare home to provide consultation on complex health issues

• Assign nurse care managers to support individuals with elevated levels of glucose, lipids, blood pressure, and/or chronic medical conditions

• Use evidence-based preventive care practices, adapting these practices for use in the MH/SU system (immunizations, cancer screening, etc.)

• Create wellness programs that use peer counselors

California: The Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (IPI)

Vision: Overall health and wellness is embraced as a shared community responsibility

• To achieve individual and population health and wellness (physical, mental, social/emotional/ developmental and spiritual health), healthcare services for the whole person (physical, mental and substance use healthcare) must be:– seamlessly integrated– planned for and provided through collaboration at every level of

the healthcare system, as well as coordinated with the supportive capacities within each community

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California: IPI Principles (Additional Handout)

• Ten principles introduce the expectation that planning and implementation ensure that:– Each individual has a person-centered healthcare home, which provides mental

health (MH) and substance use (SU) services in the primary care setting or primary care services in the MH/SU setting.

– Each community has established a Collaborative Care Mental Health/Substance Use Continuum (the IPI Continuum). The IPI Continuum is a framework for service development that identifies population need across MH/SU levels of risk/complexity/acuity and assigns provider responsibilities within any given community for delivering those services. The community dialogue to establish the Continuum should result in mechanisms for stepped MH/SU healthcare back and forth across the Continuum, mechanisms to address the range of physical health risk/complexity/acuity needs of the population, and collaborative links between the integrated healthcare system and other systems, community services and resources.

– Measurement is aligned to support the IPI Continuum, Quality Improvement and fidelity implementation of proven models as well as evaluation of emerging models, with accountability, transparency and measures matched to the levels of the Continuum.

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California: IPI Continuum

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California: CalMEND—Joint Project of DHCS and DMH• State agencies working together to use the Care Model and use the IHI

Breakthrough Series Learning Collaborative model to make major rapid changes that produce significant breakthrough results and sustained use of these changes

• Pilot Collaborative will bring together mental health and primary care practitioners: Orange County, San Diego County, San Mateo County and Santa Clara County

• CalMEND Primary Care and Mental Health Integration Change Package developed over the last year includes change concepts that operationalize the Care Model and integrated care– Health Care Organization– Delivery System Design– Decision Support– Clinical Information system– Community

California: CalMEND—Joint Project of DHCS and DMHCARE MODEL

ELEMENT CHANGE CONCEPT TESTABLE IDEA EXAMPLE

o Use non-licensed staff to coordinate care and services

for clients

Medical assistants and peer supporters

o Case conferences for joint care planning and coordination of planned interventions

Develop cross-consultation between clients, MH and PC providers to improve communication

o Link psychiatrists in MH with PC physicians for consultation and training

o Develop methods to identify primary care clients requiring MH and mental health clients requiring PC

PC uses screens for level of MH need: PHQH providers screen for physical conditions (e.g. metabolic syndrome)

MD and PC providers screen for alcohol/drug use

o Assist practitioners to triage referrals received to ensure that the most urgent referrals are seen first

"Fast Track" automatic referrals for: brief psychotherapy group (CBT, DBT, problem solving therapy, etc.); in place for depression anxiety, unexplained physical disorder, borderline personality disorder

Psychiatric consultation, cross-referral and crisis MH access protocols for primary care providers

o Standardize information that should accompany a client referral, such as the results of diagnostic tests

Establish criteria for shared registry; include data at time of referral

o Allow MH to schedule PCP visit and allow PCP to schedule visits with MH

Establish and implement shared guidelines or protocols

o Create a shared formulary Driven by DHCS drug list o Adopt/adapt shared care plan Create document for shared care plan

to be reviewed and signed by PCP, MHP, and client as part of joint session

o Organize patient care teams with defined roles that address the integrated mental health/primary care plans

DELIVERY SYSTEM DESIGN

Develop team-driven care

o Include peer workforce in teams to enhance client

Financing: Paradigms• How will funds in other systems be integrated to support clinical integration?• We need a new paradigm—none of the old models (Carve-in or Carve-out)

work for implementing bidirectional integrated care for the whole population• Lessons from the “field”:

– Medical Home Pilots— case rate in addition to FFS, to cover prevention, care management of chronic medical conditions (why not build the BHC in PC role into the case rate?)

– MN—financing the DIAMOND case rate (for BH in PC) out of the healthcare side (rather than the mental health side) believing that cost and quality improvements will be there

– WA General Assistance project—explicit stepped care model that finances both Level 1 (primary care) and Level 2 (specialty) MH/SU benefits; dedicated financing for Levels 1 and 2; neither draw on dedicated mental health funding

– Washtenaw Co, MI—global budget for Medicaid population; local consolidation of medical and behavioral health funding streams

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Financing: Paradigms• Assuming that parity will be embedded as a requirement for most health plans

in the final healthcare reform legislation and a broader behavioral health benefit will be available for most people with coverage, and …

• Drawing on the California Integration Policy Initiative framework of Mild, Moderate, Serious and Severe Levels of Care, and …

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Current Healthcare

FundingCurrent MH/SU Funding

General Healthcare System Funds MH/SU Services for Mild &

Moderate Levels of Care (mostly in Primary Care Settings)

Specialty MH/SU System Funds MH/SU Services for Serious & Severe

Levels of Care (mostly in Specialty Care Settings)

Untangling the MH/SU Funding

For example, the SPD plans should have a MH/SU benefit for primary care-based brief services

Financing: SPD Plans• Ensure that the MH/SU community and consumers know about the

consumer protections proposed in the California Healthcare Foundation 2005 report: Performance Standards for Medi-Cal Managed Care Organizations Serving People with Disabilities and Chronic Conditions

http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSPDs.aspx

• Consider overall recommendations for SPD Plans– Capitation rates that cover adequate (e.g., Medicare) reimbursement

rates for primary care FFS– Capitation rates that include funding for a PMPM case rate payment

to medical homes for care management activities– Capitation rates that include funding for a PMPM case rate for brief

MH/SU services provided in primary care (e.g., behavioral health consultant/care manager and consulting psychiatrist )

Part Two

Financing: SPD Plans

• Ensure that the MH/SU community and consumers know about the consumer protections proposed in the California Healthcare Foundation 2005 report: Performance Standards for Medi-Cal Managed Care Organizations Serving People with Disabilities and Chronic Conditions

http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSPDs.aspx

• Consider overall recommendations for SPD Plans– Capitation rates that cover adequate (e.g., Medicare) reimbursement

rates for primary care FFS– Capitation rates that include funding for a PMPM case rate payment

to medical homes for care management activities– Capitation rates that include funding for a PMPM case rate for brief

MH/SU services provided in primary care (e.g., behavioral health consultant/care manager and consulting psychiatrist )

Financing: Paradigms• Assuming that parity will be embedded as a requirement for most health plans

in the final healthcare reform legislation and a broader behavioral health benefit will be available for most people with coverage, and …

• Drawing on the California Integration Policy Initiative framework of Mild, Moderate, Serious and Severe Levels of Care, and …

46

Current Healthcare

FundingCurrent MH/SU Funding

General Healthcare System Funds MH/SU Services for Mild &

Moderate Levels of Care (mostly in Primary Care Settings)

Specialty MH/SU System Funds MH/SU Services for Serious & Severe

Levels of Care (mostly in Specialty Care Settings)

Untangling the MH/SU Funding

For example, the SPD plans should have a MH/SU benefit for primary care-based brief services

IMPACT Lowers Total Health Care Costs

$7,949

$7,471

$6,800

$7,200

$7,600

$8,000

$8,400

$8,800

Study UsualCare

StudyIMPACT

Post StudyIMPACT

$ / year

Grypma, et al; General Hospital Psychiatry, 2006

Washington State Studies of SU and Healthcare Costs• Medicaid medical expenses prior to specialty SU treatment and over a five-year follow

up were compared to Medicaid expenses for the untreated population. • For the Supplemental Security Income (SSI) population, Washington studied the

Medicaid cost differences for those who received treatment and those who did not. – Average monthly medical costs were $414 per month higher for those not receiving

treatment, and with the cost of the treatment added in, there was still a net cost offset of $252 per month or $3,024 per year.

– The net cost offset rose to $363 per month for those who completed treatment. – Providing treatment for stimulant (methamphetamine) addiction resulted in higher net cost

savings ($296 per month) than treatment for other substances. For SSI recipients with opiate-addiction, cost offsets rose to $899 per month for those who remain in methadone treatment for at least one year.

• In the SSI population, average monthly Emergency Department (ED) costs were lower for those treated—the number of visits per year was 19% lower and the average cost per visit was 29% lower, almost offsetting the average monthly cost of treatment. – For frequent ED users (12 or more visits/year) there was a 17% reduction in average visits

for those who entered, but didn’t complete SU treatment and a 48% reduction for those who did complete treatment.

Kaiser Permanente Northern California Studies• The setting was an internally operated outpatient and day treatment SU program in

which primary care was added• Kaiser tracked a subgroup of patients with Substance Abuse-Related Medical

Conditions (SAMCs) which included: depression, injury and poisonings/overdoses, anxiety and nervous disorders, hypertension, asthma, psychoses, acid-peptic disorders, ischemic heart disease, pneumonia, chronic obstructive pulmonary disease, cirrhosis, hepatitis C, disease of the pancreas, alcoholic gastritis, toxic effects of alcohol, alcoholic neuropathy, alcoholic cardiomyopathy, excess blood alcohol level, and prenatal alcohol and drug dependence– Many of these are among the most costly conditions to the health plan

• Focusing on the SAMC subgroup, they found that SAMC integrated care patients had significantly higher abstinence rates than SAMC independent care patients

• SAMC integrated care patients demonstrated a significant decrease in inpatient rates while average medical costs (excluding addiction treatment) decreased from $470.39 PMPM to $226.86 PMPM.

Align with 1115 Concept PaperPopulation Focus

Key Objectives• Bring the majority of

Duals and ABD(SPD) now in FFS into Managed Care

• Bring the CCS Youth into Managed Care

• Bring the Rest of TANF into Managed Care

• Expand the Medi-Cal “box” by bringing more Indigent/ Uninsured into Managed CareNote: Most of the costs are in the FFS Dual & FFS ABD boxes

50

1,846,000; 26%

(Managed Care)

Medi-Medi (FFS) 977,000; 14%

Medi-Medi & Medi-ABD (Mg Care) 434,000; 6%

Medi-Cal ABD (FFS) 379,000; 5%

Medi-Cal - Other

3,399,000; 48%

Medi-Cal Other

(Fee for Service)

Align with 1115 Concept PaperFour Area of Fragmentation

• FFS population: no integration of primary, acute, SU, MH, social & long-term care; mix of services paid and administered by different systems

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• Managed Care population: fragmentation between health, MH and SU

• Medi-Medi fragmentation

• CCS (Youth) fragmentation

Medi-Medi (FFS) 977,000; 14%

Medi-Medi & Medi-ABD (Mg Care) 434,000; 6%

(Managed Care)

3,399,000; 48%

Medi-Medi & Medi-ABD (Mg Care) 434,000; 6%

Medi-Cal - Other (Fee for Service)

1,846,000; 26%

Medi-Medi (FFS) 977,000; 14%

Medi-Cal ABD (FFS) 379,000; 5%

Medi-Cal Other

Align with 1115 Concept PaperOrganized Delivery Systems of Care Key Objectives

• Rely on existing Managed Care Plans “provided such plans can meet the needs of the population and achieve the State’s performance standards”

• Bring in new Managed Care plans “as necessary and appropriate the meet diverse geographic and population needs”

• Translation: If you’re in a county with high Mg Care penetration, start coordinating and/or partnering; If you’re in a county with little or no Mg Care, join the planning process to make it happen ASAP

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The MH/SU systems have an important contribution to make to this process!

Medi-Cal - Other Medi-Cal Other

(Managed Care) (Fee for Service)

3,399,000; 48% 1,846,000; 26%

Organized Delivery Systems of Care

Medi-Medi (FFS) 977,000; 14%

Medi-Cal ABD (FFS) 379,000; 5%

Medi-Medi & Medi-ABD (Mg Care) 434,000; 6%

Payment Reform Models Link to the Ability to Demonstrate Outcomes and Manage Costs• New funding mechanisms will be

utilized to fund services that manage total healthcare expenditures

• Many PCMHs will be funded with a 3-layer model—now being piloted

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Case Rate

Fee for Service/PPS

Bonus

Prevention, Early Intervention, Care Management for Chronic Medical Conditions

Per Service PaymentProspective Payment System (PPS)

Settlement (FQHC model) to cover shortfalls

Share in Savings from Reduced Total Healthcare Expenditures (bending the curve)

• Payment for inpatient care will bundle hospital and physician services that only pay for part of Potentially Avoidable Complications (PACs)

• Bundled payments may include all costs in the 30 days post an inpatient stay, including any return to the hospital

Management Models to Consider• Acknowledging that all healthcare is local, we have identified

three models of integration that build on existing designs in the California Counties– Single County Organized Health System Model (8 counties)– County Organized Health System + Private Health Plan Model (9

counties)– Small County Collaboration Model (31 counties)

• All three models are organized aroundthe idea that each county would havean integrated design for the four Priority Populations (at a minimum)identified in the Waiver ConceptPaper, bringing current MediCal FFS populations into managed care and expanding coverage for indigent uninsured

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Management Model Assumptions• Each Model assumes that:

– Structures are put in place to support and ensure that the clinical activities mirror the healthcare reform goals of Improving Quality and managing Total Healthcare Expenditures

– Substance use, mental health and primary care services will be clinically integrated and the financial and management structure will support clinical integration, versus hinder it (e.g., pay for same day services, etc.)

– Services will be provided through an “Organized Delivery System of Care” (managed care) that operates within a quality improvement and performance measurement structure using the IPI Continuum as the framework for developing a collaborative delivery system that includes all levels of care

– The Management Structure will seamlessly manage both Medicaid and non-Medicaid funds and services

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Single County Organized Health System Model

• 8 Counties - Yolo, Monterey, Santa Cruz, Santa Barbara, San Luis Obispo, Orange, Merced, and San Mateo

• Current components could support an integration effort involving the County Mental Health Department, Alcohol & Drug Program, Medically Indigent Service Program (MISP) and Public Entity Medi-Cal Managed Care Plan (PEMMCP)

• Could serve as an organized system of care for the priority populations (at a minimum) to address their healthcare, mental health and substance use needs in an integrated manner

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MISP

Mental Health

Alcohol & Drug

PEMMCP

Delivery System- Hospitals- Primary Care Clinics/FQHCs- Medical Specialists- Mental Health Providers- Substance Use Providers- etc.

Single County Organized Health System Model

• These counties could create an integrated clinical design based on person-centered healthcare home principles

• And develop one of the following financial and management designs

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MISP

Mental Health

Alcohol & Drug

PEMMCP

A Single, Integrated, Healthcare, Mental Health and Substance Use Managed Care Entity serving Medi-Cal and Indigent, Uninsured

Residents

MISPBehavioral Health (MH

& SU)

Alcohol & Drug

PEMMCP MOU MOU

Option A: “Virtually” integrated Managed Care Entity via MOUs

MISPMental Health

PEMMCP MOUMOUMOU

Option B: “Virtually” integrated Managed Care Entity via MOUs

All of the Models...Would be built around an integrated clinical design based on person-centered healthcare home principles combined with one of the financial and management designs and a shared savings pool across medical, MH and SU

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A Single, Integrated, Healthcare, Mental Health and Substance Use Managed Care Entity serving Medi-Cal and Indigent, Uninsured

Residents

MISPBehavioral Health (MH

& SU)

Alcohol & Drug

PEMMCP MOU MOU

Option A: “Virtually” integrated Managed Care Entity via MOUs

MISPMental Health

PEMMCP MOUMOUMOU

Option B: “Virtually” integrated Managed Care Entity via MOUs

Current Healthcare

FundingCurrent

BH Funding

General Healthcare System Funds BH Services for Mild & Moderate Levels of Care (mostly in Primary

Care Settings)

Specialty BH System Funds BH Services for Serious & Severe Levels

of Care (mostly in Specialty Care Settings)

Untangling the Behavioral Health FundingCase Rate

Fee for Service/PPS

Bonus

Prevention, Early Intervention, Care Management for Chronic Medical Conditions

Per Service PaymentProspective Payment System (PPS)

Settlement (FQHC model) to cover shortfalls

Share in Savings from Reduced Total Healthcare Expenditures (bending the curve)

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California 1115 Waiver Pilot for MH/SU Integration with Healthcare

Pilot Project Abstract Date: Geographic Service Area (e.g., county, region): Cascade County Target Populations to be Served (check all that apply): Seniors and Persons with Disabilities X Dual-eligible beneficiaries Adults with severe mental illness and/or substance use disorders X Children and Families not currently enrolled in organized delivery systems Children with special healthcare needs Type of Project (check all that apply): Clinical integration X Management integration Management integration via MOUs X Financing integration Goals this Project will Address (check all that apply): Strengthen safety net, including DSH hospitals Reduce number of uninsured individuals X Increase FFP X Promote efficient use of state and local funds X Improve health care quality and outcomes X Promote home and community-based care

Integration Pilots

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Project Description: Cascade County proposes the following components: Inclusion of the SPD population in the County Health Plan, and expansion of the coverage initiative to

include 75% of indigent uninsured clients served for >1 year by the MH and/or SU system (approximately 2500 individuals). Adoption of a long range plan for types of MH/SU services, sites of service and payment models, to be implemented by MOUs among the three managing entities.

Contracting with CHCs and private practice clinics in Cascade County to develop the patient-centered medical home (PCMH) model for enrollees in the County Health Plan, with a PMPM case rate for care management in addition to regular FFS claims. The case rate will be calculated to include primary care-based MH and SU interventions and implemented through partnerships with community-based MH and SU providers.

Redesign of Cascade County primary care clinics to the PCMH model, including primary care-based MH and SU interventions implemented through partnership with county and/or community based MH and SU providers. While building this integration model, we will use data to identify individuals in Quadrant IV, with multiple, co-morbid conditions, for a focused care management initiative.

Initiation of basic health screening in all MH and SU programs, connection to and coordination with PCMHs. As a second phase, incorporation of basic primary care services into higher volume MH and SU services

sites. Project Partners (Names of Organizations) Service Providers: Cascade County Mental Health Services, Cascade County Substance Use Services, subcontracted service providers for MH/SU services, Cascade County Health System (Hospital and Clinics), CHCs and private practice clinics located in Cascade County Management Entities: Cascade County Mental Health Services, Cascade County Substance Use Services, Cascade County Health Plan/Coverage Initiative Payor Sources: Medicaid capitation payments to the Health Plan, Medicaid general fund match (SU), local general fund CPE (current level of health, MH, and SU financing), FFP, MHSA

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California 1115 Waiver Pilot for MH/SU Integration with Healthcare

Pilot Project Matrix This matrix summarizes the potential California pilots that would advance MH/SU integration with healthcare in support of the Waiver Goals. The notation in the matrix shows the geographic service area the pilot. The attached pilot abstracts provide detail regarding each of the pilots.

Target Populations

Waiver Goals

Seniors and Persons with Disabilities

Dual-eligible beneficiaries

Adults with severe mental illness and/or substance use disorders

Children and Families not currently enrolled in organized delivery systems

Children with special healthcare needs

Strengthen safety net, including DSH hospitals

Reduce number of uninsured individuals

Cascade County

Increase FFP

Cascade County Cascade County

Promote efficient use of state and local funds

Cascade County Cascade County

Improve health care quality and outcomes

Cascade County Cascade County

Promote home and community-based care

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Contact Information:Barbara J. Mauer, MSW CMCbarbara@mcpp.net 206-613-3339