health care reform: what is it? why are we doing it? how will it affect psychiatry? wisconsin...
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Health Care Reform:What is it? Why are we doing
it?How will it affect psychiatry?
Wisconsin Psychiatric Association Annual MeetingDecember 2014
Robert N. Golden, MDDean, School of Medicine and Public Health
Vice Chancellor for Medical AffairsRobert Turell Professor in Medical Leadership
Professor of PsychiatryUniversity of Wisconsin-Madison
US Health Care “Brain Trust”
What is Health Care Reform?
• Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily
• Efficiency – Greater percentage of GDP spent on health care with worse outcomes
• Fiscal Sustainability – Health care costs rising faster than real GDP growth
Health Care Reform: Why?
CMS, April 2010
Health Care Reform
• Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily
• Efficiency – Greater percentage of GDP spent on health care with worse outcomes
• Fiscal Sustainability – Health care costs rising faster than real GDP growth
Health Care Reform: Why?
Total Health Expenditures asProportion of GDP – 2009
• Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily
• Efficiency – Greater percentage of GDP spent on health care with worse outcomes
• Fiscal Sustainability – Health care costs rising faster than real GDP growth
Health Care Reform: Why?
Big future deficits projected by Congressional Budget Office are largely a result of growth in health care spending and, to a lesser extent, in Social Security. Projections assume that other forms of spending will shrink as a share of GDP.
Sources: Congressional Budget Office; Center on Budget and Policy Priorities
Growth of Federal Spending
The Wedges of Waste
Berwick, JAMA 2012307(14) 1513-1516
• A transition to outcomes-focused reimbursement
• Operating efficiency will replace
revenue growth as driver of profitability
• Total cost management will supplant fee-for-service incentives in the health system business model
Actualization of the Triple Aim
• Rewards in clinical practice will focus on coordination, chronic disease management, and population health
• Bundled payments and other reimbursement innovations will make specialty care more rare and less profitable
• Information-driven care, not simply information technology adoption, will become a competitive differentiator
Actualization of the Triple Aim
• As of January 1, 2014, all U.S. residents are required to maintain minimum essential coverage unless the individual falls into an exemption
• Individuals are required to maintain essential coverage each month or pay a penalty
• Penalty equals greater of flat dollar amount or percentage of individual’s income:
$95 in 2014 or 1% of taxable income $325 in 2015 or 2% of taxable income $695 in 2016 or 2.5% of taxable income
Individual Coverage Mandate
• Non-grandfathered, individual and small group plans, inside and outside of the new Health Insurance Marketplace, must cover a core package of items and services, known as Essential Health Benefits
Result: These standards help consumers become more confident
when comparingand selecting health plans
Essential Health Benefits
• Ambulatory Care• Emergency Care• Hospitalization• Lab Services• Maternity and Newborn Care• Mental Health and Substance Abuse• Pediatric Services (Oral and Vision)• Prescription Drugs• Rehabilitative and Habilitative
Services• Wellness and Disease Management
Essential Health Benefits
Are We Built for the Job?
• “The effectiveness of ACOs willdepend on the centralization of the administration of medical care, whereas clinical departments in medical schools operate on a decentralized model.”
- Kastor, NEJM, 2/2/2011
Preferred Health Plan Features
Preferred Health Plan Features
Insurance Reform Delivery Reform
IntegratedCare
BetterCoverage
QualityFocus
MorePeople Innovation
MedicaidExpansion
Exchanges
GuaranteedIssue
PreventionBenefits
Cost: MLR,Rate Review,M’Care Adv.
CareTransitions
Dual Eligibles
ACOs,Bundles
PrescriptionDrugs
PreventionFunds
Fraud andAbuse
Transparency,Data Sharing
Value-BasedPayment
CMMI
PricingReforms
FQHCsKids < 26
Don Berwick, GPIN, Boston, MA, Oct. 17, 2012
(Partial) Structure of ACA
Delivery/Payment Reform: Goal
“Improve Medicare beneficiary health outcomes and experience of care by using payment incentives and transparency to encourage higher quality, more efficient professional services.”
--> Value = Quality/Cost U.S. Department of Health & Human Services. Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services. Issues Paper [accessed 15 Nov 2012] http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/PhysicianVBP-Plan-Issues-Paper.pdf
Tertiary/Quaternary Care
Secondary Care
Primary Care
Market Segments
Bundles
Population H
ealth
Management
Strategy: Bundled Care & Payment
Diagnostic Services
Procedure
Outpatient Follow-up
$
Diagnostic
Services
Procedure
Outpatient
Follow-up
$
$$
$
$
$
$
$
$
Bundled Care & Payments: Care processes provided and paid for as a bundle; Promotes coordination, quality & efficiency
Fee for Service: Care processes provided and paid for independently; Promotes silos and more services
Delivery System & Payment Reform
• Movement is toward paying for Value– Highest quality care at the lowest
cost
• Increasingly, providers will be assuming financial risk for the care of different sets of populations
• Learn to think about (and manage) populations and episodes of care
Impact on Health Insurers
Macro Impacts on Health Insurance Industry in 2014
• Regulatory approval of premium rate filings – federal and state
• Health insurers required to pay out 80 or 85% of premium dollars as claims
• New premium setting methods: increase premium rates for people under age 40 while lowering rates for people over age 40
• Health reform restricts ability to underwrite Guaranteed issue of policy to any insured No pre-existing condition limitations at time of
application
• Individual states must introduce a Health Insurance Exchange or be subject to Federal Insurance Exchange
New Value Creation
• NCQA and consumers are judging health plans on the delivery of health care services
• Healthcare Effectiveness Data and Information Set (HEDIS) scores become important (104 clinical measures)
• Consumer Awareness of Health Plan Survey (CAHPS) scores become important with consumer purchasing:
Rating of All Health Care Getting Care Quickly Shared Decision Making Rating of Personal Physician Rating of Specialist Seen Most Often
Mechanisms of Acquiring Health Insurance Coverage under the
Affordable Care Act (ACA)
Blumenthal D, Collins SR. N Engl J Med 2014;371:275-281.
Categories of Expanded Health Insurance Coverage under the
Affordable Care Act (ACA)
Blumenthal D, Collins SR. N Engl J Med 2014;371:275-281.
Health Care Reform and Psychiatry:Oil and Water? -or- Salad Dressing?
• Payment streams for psychiatric and substance use care are distinctive and poorly understood
• Scope of the relative sectors - public, commercial, direct state expenditures, self pay - are unique
• Substantial impact of medical and psychiatric co-morbidity on total cost of all medical care
Percentages of U.S. Spending on Mental Health Care, Substance
Abuse Services, and All Health Care That Were Coveredby Various Types of Payers, 2005
Barry CL, Huskamp HA. N Engl J Med 2011;365:973-975.
Medicaid Mental Health
Bending the Medicaid cost curve through financially sustainable medical behavioral integration Steve Melek Milliman July 2012
Public-Private PayerMH 1986-2014
Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment 2004-2014
SAMHSA, 2008
SA ExpendituresPublic–Private 1986-2014
Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment 2004-2014
SAMHSA, 2008
Health Care Reform and Psychiatry
• Payer environment is problematic
• Payment differentials are discriminatory
• The impact of commoditization and stigma on the marginal value of psychiatric services is of particular importance
• There is a larger psychiatric self-pay population
How Psychiatric Practice Differs
Avik Roy: Health Tracking Study Physician Survey
Co-Morbidity and Cost:The Impact of “Psychiatric”
Illnesson “Medical” Illness
Outcomes
Medical Psychiatric Co-Morbidity
Druss BG and Walker ER. Mental Disorders and Medical Comorbidity. Robert Wood Johnson Foundation, Research Synthesis Report No 21, February 2011. www.policysynthesis.org
Depression Rates inMedically Ill Patients
Medical Illness Prevalence %
Cardiac Disease 17-27
Cerebrovascular 14-19
Alzheimer’s 30-50
Parkinson’s 4-75
Epilepsy
Recurrent 20-55
Controlled 3-9
Diabetes
Self Reported 26
Diagnostic Interview 9
Cancer 22-29
HIV/AIDS 5-20
Pain 30-54
Obesity 20-30
General Population 10.3
39After Evans, DL et al Biol Psychiatry 2005; 58: 175-189
80
85
90
95
100
0 100 200 300 400
Time After Discharge for MI (Days)
Surv
ival
Fre
e of
Car
diac
Mor
talit
y, C
umul
ativ
e (%
)
Not Depressed (BDI < 10)
Depressed (BDI ≥ 10)
Frasure-Smith N et al. Psychosom Med. 1999;61:18-20.
Depression and 1-Year Post-Myocardial Infarction(MI) Cardiac Mortality
N = 896Odds Ratio = 3.4 (1.8-6.7)
P < .001
Copyright © 2012 American Medical Association. All rights reserved.
From: The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors
JAMA. 2013;():-. doi:10.1001/jama.2013.13805
Number of Years Lived With Disability by Age for 20 Broad Groups of Diseases and Injuries in the United States in 2010 for Both Sexes
Combined
Copyright © 2012 American Medical Association. All rights reserved.
From: The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors
Top 20 Causes of Years Lost to Disability in the United States
JAMA. 2013;():-. doi:10.1001/jama.2013.13805
Cost of Physical & Mental Illness
Medicaid Medical Admission Risk Stratified by
Psychiatric/Substance Use and None
Source: Steve Daviss, MD
Models of MedicalPsychiatric Integration
Integrating Medical & Psychiatric Care
– Institute of Medicine• Health care for general,
mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body
Improving the Quality of Health Care for Mental Health and Substance-Use Conditions: Institute of Medicine 2006
Core Principles ofEffective Collaborative Care
Patient-Centered Care Teams
• Team-based care: effective collaboration between PCPs and Behavioral Health Providers.
• Nurses, social workers, psychologists, psychiatrists, licensed counselors, pharmacists, and medical assistants can all play an important role.
Population-Based Care
• Behavioral health patients tracked in a registry: no one ‘falls through the cracks.’ Population-based screening
Measurement-Based Treatment to Target
• Measurable treatment goals clearly defined and tracked for each patient
• Treatments are actively changed until the clinical goals are achieved
Evidence-Based Care
• Treatments used are ‘evidence-based’
AIMS Center 2011 From Lori Raney MD
IMPACT Study
• Multi-site randomized controlled trial
• Assessed effects of collaborative care compared to usual care in 1,801 depressed primary care patients >60 years old
• Patients with depression were identified using the Scl-20 and followed-up with PHQ-9
Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life
depression. Am J Manag Care. 2008 Feb;14(2):95-100.
IMPACT Study Design
Intervention (n = 906 )• Access to depression care
manager who provided:• Education• Behavioral Activation• Support of self-care• Problem solving
treatment• Screening and follow up
Usual Care ( n = 895 )• Encouraged to follow up
with PCP for treatment.• Eligible to receive all
treatments:AntidepressantsSupportive counselingSelf-or physician-referral
to mental health specialist
Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life
depression.Am J Manag Care. 2008 Feb;14(2):95-100.
Clinical Results
• At 12 months:– 45% of intervention
patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants
• Compared to UC, intervention pts had: – rates dep tx– rates of
satisfaction– functional
impairment– quality of life
Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life
depression.Am J Manag Care. 2008 Feb;14(2):95-100.
IMPACT Study
Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life
depression.Am J Manag Care. 2008 Feb;14(2):95-100.
Psychiatry and the U.S. MentalHealth Workforce: 1972
Total MH workforce =40,000From: DHHS CMHS 2004, chap 18
Source: Ben Druss MD
Psychiatry and the U.S. MentalHealth Workforce: 2006
Total n for MH workforce =549,000From: DHHS MH United States 2010 CMHS 2011
Source: Ben Druss MD
Barriers and Next Steps
• Psychiatrists are more disconnected from existing payer systems and appear to be less likely to be in large groups or employed
• Delivery systems should apply the insights from research in medically co-morbid illness and models of care in planning for their future
• Training and education for all physicians both currently in practice and in training will be needed
Guiding Principles for Reform:The Triple Aim
• Improving the patient experience of care (including quality and satisfaction)
• Improving the health of populations
• Reducing the per capita cost of health careThe Long Term Costs of Health Care –Public and Private are Unsustainable