population management of adhd in the era of healthcare...
TRANSCRIPT
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Population Management of ADHD in the Era of Healthcare Redesign
Michael Jellinek, M.D.
March 19, 2017
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Disclosure
• Dr. Jellinek has reported no significant relationships with industry
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Health Care Reform: Drivers
• Extend Coverage (Social Justice and Efficiency)
• Cost (How Fast, How Deep – Cuts or Risk)
• Better Care – Coordination, Outpt. / Home, Palliative
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Recent Cost Data
• NHE grew 5.8% to $3.2 trillion in 2015, or $9,990 per person, and accounted for 17.8% of Gross Domestic Product (GDP).
• Medicare spending grew 4.5% to $646.2 billion in 2015, or 20 percent of total NHE.
• Medicaid spending grew 9.7% to $545.1 billion in 2015, or 17 percent of total NHE.
• Private health insurance spending grew 7.2% to $1,072.1 billion in 2015, or 33 percent of total NHE.
• Out of pocket spending grew 2.6% to $338.1 billion in 2015, or 11 percent of total NHE.
• Prescription drug spending increased 9.0% to $324.6 billion in 2015, slower than the 12.4% growth in 2014.
• The largest shares of total health spending were sponsored by the federal government (28.7 percent) and the households (27.7 percent). The private business share of health spending accounted for 19.9 percent of total health care spending, state and local governments accounted for 17.1 percent, and other private revenues accounted for 6.7 percent.
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The Economic Picture
5
Social Security
Medicare & Medicaid
Federal Spending as a percentage of GDP (CBO Projection)
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Rising health care costs have been squeezing employers and
employees for years
0%
20%
40%
60%
80%
100%
120%
140%
160%
180%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
“The growing costs of health
insurance have absorbed a
large portion of the…
increase in total
compensation”
- Robert D. Reischauer
Former Director of the
Congressional Budget Office
Cumulative Increase in national Health Care Premiums, Wages and Inflation (1999 base)
Health Care Premiums
Workers’ Earnings
Inflation
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Health Care Costs in Context
• In Massachusetts
The Barre, Ma Police
MDC – Trash near the Charles River
Transfer of State Budget Funds from Schools, Towns, DSS, Public Health, Parks
to Medicaid
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Health Care Costs in Context
• Health care costs in developed countries
• Access, technology, rationing, state vs private
poverty, homogeneity of population
• Context of Social Spending
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The Fee for Service Culture
• Volume Driven
• Key to Every Budget and Trustee Meeting
• Key Metrics – Admissions, Procedures, Visits
• Drives Professional Hierarchy, Salary, Cap. $
• Strategic Plan – Grow Surgery, Imaging, Ortho, Oncology (infusions and radiation therapy).
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Fee For Service
• Reimburse for services, face to face, volume
• Little emphasis or reward for quality
• Modest incentives for process measures
• Little focus on outcome, long-term
• No sharing of financial risk
• Silo view of EMR
• Individual incentives
• Limits reimbursement for many Child Psych Services
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Health Care Costs in Context FFS - Readmission
• FFS rewards utilization • Little focus on Multiple admissions, Discharge planning, Emergency room utilization, Medication Adherence • Interventions – No return on investment under FFS • Some readmissions reflect poor quality.
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Lowering Readmissions
• Discharge planning
• 48 hour Discharge Phone Call
• Medication reconciliation (Pharmacist)
• Access to caretaker (especially surgical)
• 7 day follow-up appointment primary care
• Home Care/PT/Heart Failure monitoring
• Care Coordinator
• Behavioral Social Worker
• Palliative Care
• Case Manager/Social supports/Frailty/Medications/
• Food, transportation, co-pays barriers
Why so little concern under FFS? ER overuse, Adherence, MRI?, Ortho surgery?
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Reducing Costs
• Medicare and Medicaid rates reduced
• Global payment (e.g. inpatient)
• Bundles
• Copay and Deductibles
• Penalties –Readmissions, well over half of all hospitals
• Moving risk…FFS risk held by government, insurer or employer
• Population Health Management (PMH) Risk held by Provider
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The Impact of Chronic Disease and Behavioral Conditions-- Massachusetts
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Likely Future
• Global budget payer for costs of care (MH,MRI)
• Focus on quality, outcome, practice guidelines, quality assurance, process improvement, unit cost
• Focus on high risk, high cost, outcome, readmissions, palliative care
• Focus on coordination
• IT facilitation for integration of broad system of care
• Carefully designed incentives, care coordination
• Sub-Populations, Extensive Analytics: Medicare, Commercial, Self-insured, Medicaid and Duals
• Return on Investment (Opportunity for mental health?)
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EMR Patient Portal
Team-Based Care
Practice Redesign w/Lean
Care
Management
Population
Mgmt Tool
High Risk
Chronic Cond
Test &
Referral Tracking
Screening
Protocols
Functioning
Tracking
Financial Analytics
Virginia
Mason
Production
System
(Flow)
Relate to Pediatric Medical Home
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Transition Questions
• Pace of transition
• Extent Living in 2 worlds
• IT, Infrastructure (Need for Capital)
• Who will hold risk (loss/gain) – Third party insurance, Hospitals, Systems, Physicians
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ADHD OUTCOMES
• Children with ADHD healthcare cost $775-1330 more per year and $3000 more per year as adults
• 2 ½ Years less schooling (31% vs. 4% did not finish high school
• 14% Substance use • 30% Nicotine dependence • 24% (vs. 6%) Psychiatric Hospitalizations
How are non medical costs considered?
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Global View of Costs related to ADHD:
• Alcohol Abuse
• Tobacco Use
• Substances
• ? Adherence, chronic diseases
How are societal costs or opportunity costs integrated into decision-making?
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Implications for Child Psychiatry
• Screening of Population (Pediatric Collaboration) • Evaluation (Hierarchy of interventions by severity) • Functional tracking (establishing goals & baseline) • Protocols (Q/A, prevention of secondary issues) • Outcomes (engagement, parent groups, education,
devices) • Value analysis to assess return on investment • Quality Assurance (Fidelity) • Integration into family • Advocacy for Social Supports (e.g. Pre-school, Food)
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References: 1. Telford C, Green C, Logan S, Langley K, Thapar A, Ford T. Estimating the costs of ongoing care for
adolescents with attention – deficit hyperactivity disorder. Soc Psychiatry Psychiatr Epidemiol. On line published June 15, 2012.
2. Wilens T, Martelon M, Joshi G, Bateman C, Fried R, Petty C, Biederman J. Does ADHD Predict Substance-Use Disorders? A 10-year Follow-up Study of Young Adults with ADHD. J Am Acad Child Adolesc Psychiatry. 2011;50(6):543-553.
3. Biederman J, Petty C, Dolan C, Hughes S, Mick E, Monuteaux M, Faraone V. The long-term longitudinal course of oppositional defiant disorder and conduct disorder in ADHD boys:findings from a controlled 10-year prospective longitudinal follow-up study. Psychological Medicine. 2008;38:1027-1036.
4. Biederman J, Petty C, Monuteaux M, Fried R, Byrne D, Mirto T, Spencer T, Wilens, T, Faraone S. Adult Psychiatric Outcomes of Girls with Attention Deficit Hyperactivity Disorder: 11-Year Follow-Up in A Longitudinal Case-Control Study. Am J Psychiatry. April 2010;167:4:409-417.
5. Meyers J, Classi P, Wietecha L, Candrilli S. Economic burden and comorbidities of attention-deficit/hyperactivity disorder among pediatric patients hospitalized in the United States. Child and Adolescent Psychiatry and Mental Health 2010, 4:31.
6. Klein R, Mannuzza S, Olazagasti M, Roizen E, Hutchison J, Lashua E, Castellanos X. Clinical and Functional Outcome of Childhood Attention-Deficit/Hyperactivity Disorder 33 Years Later.
7. Fuchs V, Schaeffer L. If Accountable Care Organizations are the Answer, Who Should Create Them?. JAMA, June 6, 2012;307(21):2261-2262.
8. Blumenthal D. Performance Improvement in Health Care – Seizing the Moment. NEJM;2012;366(21)-p1953-1955.
9. Bradley E., Elkins B., Herrin J. Elbel B. Health and Social Services Expenditures: Associations with Health Outcomes.BMJ Qual Saf 2011;20:826-831.
10. Health Policy Commission; Findings on Select Cost Drivers 2013 Cost Trends Report: All-Payer Claims Database, HPC analysis: Patients with Behavioral Health and Chronic Conditions Have Significantly Higher Medical Expenditures