capg.2015.daviss - acos and behavioral health integration

6/13/15

Steve Daviss MD - m3information.com 1

Steve Daviss, MD, DFAPA Chief Medical Informa:on Officer, M3 Informa:on, LLC President & Co-‐Founder, FUSE Health Strategies, LLC Clinical Assistant Professor, University of Maryland

Behavioral Health Integration in ACOs

June 13, 2015

CAPG Annual Healthcare Conference

@hitshrink

•  Introduc:on •  Learning objec:ves •  Integra:on -‐ Parity •  Quality standards •  Accredita:on standards •  Tx models: Specialty care vs

Collabora:ve care •  Screening •  Measuring & Managing •  Challenges •  Case studies •  Take home (Pearls)

Ag

end

a

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Steve Daviss MD [email protected]

@HITshrink

m3clinician.com

Slides @ http://fhs.io/capg15

Co

ntact

Contract Administration Price Guide

Central Asia Partnership Group

Curb Agajanian Performance Group

Chronic Active Plasmacytic Gastritis

Car Allocation Policy Group

Child and Adolescent Psychopathology Group

Compression Annealed Pyrolytic Graphite

Center for Advanced Power Generation

?

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Other Hats I Wear • Chair, APA Committee on Mental Health IT

•  Former Department Chair, U of Md

• URAC Health Standards Committee

• HIE Policy Board, Md Health Care Commission

• Clinical Advisory Committee, CRISP

•  Shrink Rap blog -- My Three Shrinks podcast

•  Book: Shrink Rap: Three Psychiatrists Explain Their Work

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Learning Objectives

1.  List 3 reasons to integrate behavioral health 2.  Describe the ACO accredita:on standards for

behavioral health for URAC & NCQA 3.  Explain the 3 elements of the collabora:ve

care model 4.  List 4 risks of not addressing mul:dimensional

behavioral health

Mental Health Parity and Addic:on Equity Act

MHPEA Integration - Parity

•  financial limita:ons •  quan:ta:ve treatment limits •  nonquanta:ve treatment limits (NQTLs)

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Source: WSJ 1/16/2014

Slide: Courtesy of Jurgen Unutzer MD

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Source: Cartesian Solutions, consolidated health claims data

Increased costs of chronic medical condi:ons when mental illness co-‐exists

Dol

lars

Slide courtesy of Wayne Katon MD

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Slide courtesy of Ben Druss MD

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2008: Chronic condi:ons and comorbid psychological disorders

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


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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

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1 S

ourc

e: H

illto

p In

stitu

te, 2

012

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None +MH +SU +MH+SU

HIV R

elat

ive

Ris

k 15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1


None +MH +SU +MH+SU

Epilepsy

Rel

ativ

e R

isk

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

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None +MH +SU +MH+SU

Diabetes R

elat

ive

Ris

k 15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1


None +MH +SU +MH+SU

Cellulitis Septicemia

Rel

ativ

e R

isk

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

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

None +MH +SU +MH+SU

COPD Asthma Pneumonia NOS Bronchitis

Rel

ativ

e R

isk

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

15 14 13 12 11 10 9 8 7 6

5 4 3 2 1

-- Maryland Medicaid Adults, 2011

Association of Anxiety Disorders and Depression With Incident Heart Failure Garfield et al, Psychosomatic Medicine 2014 76:128

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Effect of Collaborative Care for Depression on Risk of Cardiovascular Events: Data From the IMPACT Randomized Controlled Trial Stewart, Perkins, & Callahan, Psychosomatic Med 2014 76:129

Why bother integra:ng behavioral health?

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Qu

ality stand

ards

NQF Measures

Qu

ality stand

ards

NQF Measures

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Qu

ality stand

ards

NQF Measures

Accred

itation

stand

ards

Clinical Integra:on

•  Structure & Opera:ons •  Health Informa:on Technology

•  Clinical Management

•  Popula:on Health •  Care Coordina:on •  Performance Measurement & Repor:ng

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Accred

itation

stand

ards

Clinical Integra:on

•  OPS 6: “The organiza:on establishes documented management prac:ces, policies and procedures that clearly define transparent organiza:onal rela:ons between clinically integrated providers including… behavioral health providers and services considered contributors to program specific quality and performance measures for the CLIN’s target popula:on…”

v.1.0

Accred

itation

stand

ards

Clinical Integra:on

•  OPS 9: “The ability to direct consumers to urgent and emergent medical and behavioral health services during and aler business hours of opera:on; and…”

v.1.0

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Accred

itation

stand

ards

Accountable Care

•  Structure and Opera:ons •  Risk Contrac:ng •  Performance Improvement Program

•  Consumer Centeredness

•  Care Coordina:on •  Performance Improvement Program

Accred

itation

stand

ards

Accountable Care

•  AC 29: “Assessment for mental health and substance use disorders.”

•  CORE (P-‐CP 1): “Communica:on to delegated contractors regarding changes impac:ng compliance, including parity of health care services such as mental health and/or substance use disorder parity (MHPAE), as applicable; and Performance of a thorough review of state and federal laws and regula:ons related to Parity of health care services such as mental health and/or substance use disorder parity, including the MHPAEA, as applicable; and (Mandatory)…”

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PCMH 2014 Standards and Guidelines Accred

itation

stand

ards


itation

stand

ards

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itation

stand

ards


itation

stand

ards

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N=551 depressed pts 60+ yrs > randomized

2013 National 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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•  84% had 1+ contract with MH/SU in total cost of care •  66% of all ACOs w/commercial contracts said largest contract had MH/SU included

•  37% of ACOs had no formal rela5onship w/BH grps •  42% included BH grps in their org •  22% contracted with outside orgs

•  ACOs w/only medical groups sig less likely to include BH providers (22%, p<.001) vs ACOs with IDNs, hospitals, or FQHCs (49-‐53%)

Interviewed 16 ACOs in depth •  7/16 had SU providers •  14/16 had MH providers

•  14/16 screen for depression •  12/16 screen for substance use

“Generally, ACOs reported that they referred pa3ents who screened posi3ve” though most provided some BH services.

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14% complete integra3on

More likely… •  comprehensive chronic care mgmt program •  FQHC

3 models of integra3on •  consul:ng •  co-‐loca:on •  embedded

Mo3va3ons for Integra3on

minimal when

possible

quality measures

only strong

- + Contextual

Paym

ent -!

+

Contextual - access - population

Payment -‐ contrast -‐ quality measure

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Screenin

g

Mul:dimensional •  M3 •  MINI

Mood disorders •  BDI •  PHQ-‐9 •  MDQ •  M3

Anxiety disorders •  GAD-‐7 •  M3 •  PCL

Substance use disorders •  AUDIT, AUDIT-‐C •  NIDA •  DAST •  M3

Issues •  paper vs computer

•  office vs remote

•  simple vs comprehensive

•  reimbursable

•  screening vs monitoring

•  single disease vs multidimensional

•  EHR integration

•  work"ow integration

•  cost

•  reports

•  data "exibility

•  population health

•  state, fed, MU requirements

Tools

Bipolar disorder iden:fied in 22% of depression-‐posi:ve screens in postpartum women

Bipolar 22%

Unipolar 78%

Source: Wisner 2014 JAMA

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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 sensi:vity & 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

2

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Risks of not addressing mul:dimensional behavioral health: misdx – mistx -‐ cost -‐ safety

m3clinician.com

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whatsmym3.com

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10

M3 Clinician Report

•  measured care

•  monitor trend

•  fit in workflow

•  patient engagement

•  aids communication

•  team-based care

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“…none of the screens posed a significant time burden on patients. In the one study that conducted an implementation evaluation, both patients 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 fifteen studies were methodologically rigorous enough to warrant Level I ratings.”

“The likelihood ratios for the detection of PTSD, both positive and negative, for the M-3 indicated that the M-3 performed better than the GAD-7 at identifying probable cases of PTSD.”

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Learning Objectives

1.  List 3 reasons to integrate behavioral health 2.  Describe the ACO accredita:on standards for

behavioral health for URAC & NCQA 3.  Explain the 3 elements of the collabora:ve

care model 4.  List 4 risks of not addressing mul:dimensional

behavioral health

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Take-h

om

e

1.  Combine data, analyze comorbidity

2.  Measure mul:ple common dimensions (at least depression, bipolar, anxiety, substance)

3.  Track progress 4.  Behavioral care manager

5.  Collabora:ve care psychiatric consultant

6.  Measure impact (quality, u:liza:on)

Behavioral Health Integra:on in ACOs

Steve Daviss MD

@HITshrink

m3informa:on.com

Slides @ http://fhs.io/capg15

steve@m3informa:on.com

•  integra:on.samhsa.gov •  aims.uw.edu

capg.2015.daviss - acos and behavioral health integration

Healthcare

steve daviss md

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maryland medicaid adults

apa committee