cartesian solutions, inc.™ library/psychiatrists...8/30/16 5 comorbid bh patient general hospital...

8/30/16

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Steps in Transitioning to Sustainable Medical and

Psychiatric Care

Cartesian Solutions, Inc.™ ©

Roger Kathol, M.D.President, Cartesian Solutions, Inc.™

Adjunct Professor, University of Minnesota, Minneapolis, MN([email protected])


Disclosure: Roger Kathol, M.D.

Cartesian Solutions, Inc.™Employment--Direct RelationshipConsulting--Direct RelationshipOwnership--Direct Relationship

Presentation Content1. Describe the health care landscape2. Summarize psychiatry’s approach to integration3. Outline the patient experience related to

segregated BH care--the opportunity4. Suggest models of “value-added” integrated

psychiatric services5. Discuss how to transition from traditional to non-

traditional (integrated) psychiatric services


My Consulting Job--Creating “Vision”

To create a better way to achieve desired total health and system-

based cost outcomes for accountable organizations serving populations of patients by introducing value-added

medical and psychiatric care delivery.


The VisionHealth Setting Care

Provider Network

= Psychiatric Patient

Psychiatrist}

Health Delivery Network


Necessary Contributors to Value-Based Health Care


Delivery of Value-Added Services

Support for Care Delivery

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Setting the Stage--Psychiatric Care--(“Psychiatric” = mental health and substance use disorders)


• System-based “treatment support”• Location & treatment access• Treatments possible• The impact of the treatments possible on

population health and cost• Clinical care

Integration’s Magic Ingredient (if done correctly)

n Ability to identify medical and psychiatric challenges

n Implementation of clinical and non-clinical interventions that improve total health outcomes

n Treat to targetn Assist to target



Traditional Healthcare Infrastructure

2.Fund

Distributors

3.Providers

Patients

1.Purchasers

Health CareOutcome Change

--Vendors--Organizations

--Regulators

Med

Med

Kathol & Gatteau, Healing Body AND Mind, 2007

Body

PublicPrivate BH

BH

PatientMind

2.

3.

*BH = MH + SA

20%

Treatment Support

Clinical Care


Post-ACA Healthcare

3.Providers

Med Home

1.Purchasers

Triple Aim: Better Health Care, Better Outcomes, Lower Cost


--Regulators--BH “Resources”

Med

Med

--adapted from Kathol & Gatteau, Healing Body AND Mind, 2007

Body

PublicPrivate

BH

2.Fund

Distributors

Accountable Care Organization

(Mind?)MindBH

3.2.

2016 ReimbursementMedical Setting Care Psychiatric Setting Care

General Medical Provider Network

Behavioral Provider Network

Behavioral Insurance

Med/Surg Insurance

ACO

Delivery System

Cartesian Solutions, Inc.™ © Cartesian Solutions, Inc.™ ©

Vendored-Out Psychiatric Services in Medical Settings Is Driven by Independent MCO and MBHO Payment

Insurance Leveln Payment Pools --competing on which does not pay

n Contract Benefit Descriptions --segregated medical and BH contract benefitsn Network Providers --disconnected medical and BH network clinicians

n Approval Process --more restrictive processes for BH services

n Case Management Support --CM and UM or medical; UM for BHn Coding and Billing --non-overlapping medical and BH payment procedures

n Claims Processing --independent adjudication rules and pathways

n Data Warehousing & --separate and irreconcilable medical and Actuarial Analysis BH databases and quality analyses

Care Leveln Interaction of Systems --disparate and disjointed with little communication

n Clinical Care --BH segregated with inequitable access even after parity

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Perceived Value of Separate BH System

n Protects BH fundsn Maintains BH autonomyn Retains independent decision

making powern Safeguards privacyn Provides better BH care


Reality of Separate BH System

n Protects funds greater BH losses during housing bubble, state budget shortfalls, sequestration


1986-2009$ Growth Rate



BH 6.4% 4.2% 4.9%

All Health 7.5% 5.4% 6.2%

Mark TL et al, Health Affairs, 33:1407-15, 2014

Reality of Separate BH System

n BH autonomy perpetuates care fragmentationn Decision making insular; parochial to total

healthn Privacy stigma; poor health outcomesn Better care 75% with BH illness receive no

treatment; 13-25 years shorter survival


What Our Patients and the Health

System Experience

--The Opportunity--Cartesian Solutions, Inc.™ ©

Seventy-five Percent of BH Patients Are Seen in the Medical Setting

Medical Outpatients

Medical Setting

BH Patients Seen in the BH Sector (25%)

Medical Inpatients

Health Complexity

Chronic Medical Illnesses

BH Patients Seen Primarily or Only in the Medical Sector (75%)

95% BH Providers

Mental Health Sector


BH Spending as a Part of the Health Budget in 2014

MH/SUD7%

General Hospitals31%

Physicians20%

Other Professionals2%

Residential Care8%

Prescription Drugs9%

Insurance Administration

8%

Other15%

Total Health Spending--2014$ 3.0 trillion

Insurance Administration

8%

Prescription Drugs25%

Residential Care8.5%

Other BH Professionals 7%

Psychiatrists10%

General HospitalPsychiatry Units

16%

Specialty Hospitals9%

BH Spending--2014$ 211 billion (6.8% of Total Health*)

*does not include BH services provided by non-BH professionals

Cartesian Solutions, Inc.™©

Mark TL et al, Health Affairs, 33:1407-15, 2014

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Is BH the “Bottomless Pit”?

Total Population

Served

% of Pop.

with BH Claims

Total Annual Spend

% BH*Spend

% of Total Medical Claims Incurred by BH

Pop.

Commercial 198.8M 14% 1.0T 6% ($42.9B) 28.7% ($275B)

Medicare/Medicaid 91.8M 9%/20% .67T 7.7%

($46.2B)26.3% ($163B)(17.3%/38.4%)

Total 290.6M 14% 1.7T 6.8% ($91.8B) 27.5% ($444B)

*60% to 75% of psychiatric patients receive no mental health or substance use disorder careMelek, Milliman APA Report, 2014

Cartesian Solutions, Inc.™©

Health and Cost Impact of Comorbidity & Integrated Care


n All Insured $2,920 15%n Arthritis $5,220 6.6% 36% $10,710 94%n Asthma $3,730 5.9% 35% $10,030 169%n Cancer $11,650 4.3% 37% $18,870 62%n Diabetes $5,480 8.9% 30% $12,280 124%n CHF $9,770 1.3% 40% $17,200 76%n Migraine $4,340 8.2% 43% $10,810 149%n COPD $3,840 8.2% 38% $10,980 186%

Cartesian Solutions, Inc.™--consolidated health plan claims data

Illness Prevalence

% with ComorbidBH Condition*

Annual Cost with BH Condition

Annual Cost of Care

% Increase with BHl Condition

Patient Groups

*Approximately 10% receive evidence-based BH condition treatment

Primary Psychiatric Sector CarePrimary BH Patients vs. Total Medical/Surgical Patients

Across 5 Health Systems

1° Psych Total Admissions

Percent of Admissions 3.5% 100%

Annual Admissions 8,256 233,729

Annual Total Days 53,405 903,056

ALOS 6.5 3.9


Cartesian, consolidated data, 2015

A Very Small Piece of the Pie


Claims Expenditures for Patients With and Without BH Condition Service Use

2177

3430 2892

4759 5620

6225

472

1264 2618

1542 1408

1241

1038

2691 983 547

381

$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000

Physical Health Services Only

Any Psych Illness

Psychotic Depression Anxiety Substance Use Disorder

Mental Condition Claims Cost

Pharmacy Claims Cost

Physical Health Claims Cost

7,5758,201

2,649

7,284

– Thomas et al, Psych Serv 56:1394-1401, 2005

7,847

5,732

General Hospital “Medical” Admissions* with BH Comorbidity

Care Delivery Systems

Number of Hospitals

Total Adm/Yr

% BH

Longer BH vs. non-BH ALOS**

Higher BH vs. non-

BH Readmits*

*

Sitter Use***

System 1 >10 135,000+ 26% 1.1 30% $6.0MSystem 2 1 19,000+ 36% 1.2 40% $3.1MSystem 3 4 34,500+ 29% 1.3 70% $.42MSystem 4 5 40,000+ 26% 1.8 30% $2+MSystem 5 1 16,000+ 23% 0.6 45%

Kathol et al, Chapter 11: CLINICAL INTEGRATION Population Health and Accountable Care, Convurgent Press, 2015


Medical Setting BH Overview in One Hospital System


Hospital Adm/Yr %BH

BHServices/Providers ΔALOS

ConstantObservation

NursesHospital1 33,961 25% yes/0 1.38 $.87MHospital2 16,582 28% no/1 0.95 $.61MHospital3 16,177 32% yes/0 0.95 $.42MHospital4 9,111 28% no/0 0.82 $.17MHospital5 13,927 30% yes/4 1.15 $1.01MHospital6 23,917 24% yes/11 1.15 $1.24MHospital7 11,954 22% no/0 1.03 $.33MHospital8 11,044 24% no/0 1.04 $.47M

Total: 136,670 26% 1.07 $5.23M

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Comorbid BH Patient General Hospital Admissions*

Adult Patients without/with BH Comorbidity

No BH BH Total BH Impact

Percent of Admissions 74% 26% 100%Annual Admissions 100,522 36,148 136,670Annual Total Days (31% BH) 398,810 181,979 580,788ALOS 3.97 5.03 4.2 1.07Cost per Admission $6,716 $7,426 $709Margin per Admission $5,285 $5,012 ($273)Annual Total BH Excess Cost $25.6M


*excludes primary BH admissions and neonates

Benchmark Data on Chronic Illness & BH Comorbidity

(Cost Saving Opportunity)


MDC Illness Category %BH ΔALOS

Δ Total Cost for Admissions

Δ Total Gain/Loss

AMI 34% 1.3 $1,089,346 ($689,946)Arthritis 42% 1.6 $3,688,176* ($2,309,407)Asthma 37% 1.9 $2,336,520* ($2,437,978)Back Pain 41% 1.6 ($412,668) ($1,180,978)CAD 26% 1.3 $1,192,695* ($1,119,291)Cancer 24% 2.2 $5,621,349 ($762,043)CHF 38% 0.9 ($22,393) ($386,457)COPD 48% 1.4 ($668,800) ($167,538)Diabetes 30% 1.6 $1,635,198* ($1,204,304)Pneumonia 40% 2.4 $1,232,453* ($336,095)Renal Failure 39% 1.1 $239,615 ($708,891)Stroke 30% 1.6 $266,105 ($2,309)

*considered targeted opportunities

Models of Value-Added Integrated BH Services

n Medical Settingn Integrated medical and BH case management for complex adults

and childrenn Outpatient, e.g., TEAMCare, Collaborative Care, targeted BH

interventions for focused conditions, medical and BH preventionn Inpatient, e.g., proactive psychiatric consultation, delirium

prevention and treatment, routine “sitter” reviewn Emergency room, e.g., medical and BH services routine in medical

ER (sunset psych ERs)n Post-acute care, e.g., nursing home settings and support with

medical and BH coverage

n BH Setting, e.g., specialty sector services not possible in medical setting


Data on Value from Adult Integrated Case Management1 (CM) Services

n Limited success of medical outpatient programs2

n Necessary components: target high-need, high-cost patients; longitudinal CM assistance; treat to target multidisciplinary (medical and BH) approach

n Outcomesn Fewer hospital and skilled nursing home days; fewer ER visits; higher

home health and hospice costs; equal mortality3,4,5

n Annual savings of ~$1,350-$8,500/patient (12% to 17%)3,4,5

n Implementation cost: economically viable when enough patients are managed6

1. Kathol et al: Physician’s Guide, Chapter 1, Springer, 2016; 2. AHRQ: CM Effectiveness Review, 99, 2013; 3. Basu et al: HSR, 47, 523-43, 2012; 4. De Jonge et al: JAGS, 62, 1825-31, 2014; 5. Edes et al: JAGS, 62: 1954-61, 2014; 6. Basu et al: AIM 163, 580-8, 2015



Integrated Case Management

n Illness-focusedn Problem-based (check list)n Occasionally longitudinaln Biomedical clinical

assessment training n Regular handoffsn Illness targeted care plans

n Graduation based on process measurement and completion, e.g., calls made, patients/clients touched

n Complexity-focusedn Relationship-based (dialogue)n Always longitudinaln Multi-domain assessment and

management trainingn Few handoffsn Biopsychosocial and health

system-based care plansn Escalation of care or

graduation based on clinical, functional, cost outcome measurement

Traditional Integrated

Data on Value from Pediatric Integrated Case Management1 (CM) Services

n Necessary components: target children with special health care needs (CSHCN--12% of kids);2longitudinal CM assistance; treat to target multidisciplinary (medical and BH) approach

n Outcomesn Lower odds of functional disabiity,3 school absence,4 barriers

to care,4,5 ER visits,4 personal expense and work loss4

n 70% receive CM; 60% of CM programs considered “adequate”4

1. Kathol et al: Physician’s Guide, Chapter 1, Springer, 2016; 2. Bettell et al: Matern Child Heal J, 12, 1-14, 2008; 3. Litt et al: Acad Peds, 15, 185-90, 2015; 4. Turchi et al: Peds, 124, S428-34, 2009; 5. Wood et al: Matern Child Heal J, 13, 667-76, 2009


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Data on Outpatient Models of IntegratedHealth Services

(Things that work and things that don’t.)n Counseling/behavioral health consultant (BHC)--

improved satisfaction; no long term improvement or cost reduction1

n CCM (TEAMcare) for depression and anxiety compared to usual care or enhanced referraln Statistically better clinical improvement than for up to 2 years

in adults (not adolescents)2; high variability in deployment6n Statistically higher patient satisfaction2

n CCM reduces annual cost ~$450 in 1st 12 months3, ~$900 at 24 months4, and ~$3,350 at 48 months5

1. Bower et al: Cochrane Review, #9, 2011; 2. Archer et al, Cochrane Review, #10, 2012; 3. Green et al: PLOS, 9: e104225, 2014; 4 Katon et al: Diab Care 29,265-270, 2006; 5. Unutzer et al: AJMC 14, 95-100, 2008; 6. Boa et al: Psych Serv, 16, 2015


Services Delivered in Layered Non-Traditional BH Outpatient Care

Integrated Patient-Centric Medical Setting BH Traditional

TIERLEVEL 1

Co-Located BH Therapy Expertise Access

LEVEL 2High Risk

CM/PCP/Psychiatrist/BH Team Co-Manage

Level 3Complex

CM/PCP/Psychiatrist/BH Team Co-Manage

BH Sector TxBH Expertise

Access/Intervention

PopulationServed

Prioritized chronic medical patients w ith BH

Top 5% to 15% of high risk medical patients (40% -60%

w ith BH)

Top 2% to 5% of complex medical patients (60% -80%with BH)

Primary BH patients

Primary TxEasily accessible onsite BH

referral source for CM/PCP/medical specialist

CM/PCP/medical specialist/psychiatrist team

(ready BH access)

CM/PCP/medical specialist/psychiatrist team

(ready BH access)

BH experts w ith PCP access

Care Manager Role

• Prioritized access to & use of designated onsite & tele BH expertise

• Complexity-based Collaborative Care P lan

• Assist in treat-to-target & treatment escalation; measures outcomes

• ICM Caseload ~50-80• ICM Case length ~3-6 months

• Complexity-based Collaborative Care P lan

• Assist in treat-to-target & treatment escalation; measures outcomes

• ICM Caseload ~30-50• ICM Case length ~6-12+

months

• Complexity-based Collaborative Care P lan for high risk BH patients

• ICM Caseload ~40-60• ICM Case length ~3-

12+ months

What’s New

• PCMH team (PC, CM, BH)• Timely BH access• BH expertise that changes

outcomes• Geographic accessibility

• Comprehensive, cross-disciplinary, longitudinal care manager assistance for moderate high risk patients

• Targeted comprehensive,cross-disciplinary, longitudinal care manager assistance for patients w ith the highest risk

• Improved outcomesfor complex BH patients



Traditional

TIERBH Sector Tx

BH Expertise Access/Intervention

Population Served • Primary BH patients

Primary Tx • BH experts with PCP access

Case Manager Role• Complexity-based Collaborative Care Plan for high risk BH patients

• ICM Caseload ~40-60• ICM Case length ~3-12+ months

What’s New • Improved outcomes for complex BH patients



Integrated Patient-Centric Medical Setting BH

TIER LEVEL 1Co-Located BH Therapy Expertise Access

Population Served • Prioritized chronic medical patients with BH

Primary Tx • Easily accessible onsite BH referral source for CM/PCP/medical specialist

Case Manager Role • Prioritized access to & use of designated onsite & tele BH expertise

What’s New• PCMH team (PC, CM, BH)• Timely BH access• BH expertise that changes outcomes• Geographic accessibility




TIERLEVEL 2

High Risk CM/PCP/Psychiatrist/BH Team Co-Manage

Population Served • Top 5% to 15% of high risk medical patients (40%-60% with BH)

Primary Tx • CM/PCP/medical specialist/psychiatrist team (ready BH access)

Case Manager Role

•Complexity-based Collaborative Care Plan•Assist in treat-to-target & treatment escalation; measures outcomes

• ICM Caseload ~50-80• ICM Case length ~3-6 months

What’s New •Comprehensive, cross-disciplinary, longitudinal care manager assistance for moderate high risk patients




TIERLevel 3

Complex CM/PCP/Psychiatrist/BH Team Co-Manage

Population Served • Top 2% to 5% of complex medical patients (60%-80%with BH)

Primary Tx • CM/PCP/medical specialist/psychiatrist team (ready BH access)

Case Manager Role

•Complexity-based Collaborative Care Plan•Assist in treat-to-target & treatment escalation; measures outcomes

• ICM Caseload ~30-50• ICM Case length ~6-12+ months

What’s New• Targeted comprehensive, cross-disciplinary, longitudinal care manager assistance for patients with the highest risk


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n Referral-based BH consultation--no evidence of health- or cost-related value1

n Non-psychiatric attention to medical ERpsych patients--no impact on outcomes or boarding time2

Data on Inpatient Models of IntegratedHealth Services

(Things that don’t work)

1. Wood et al: JPR, 76, 175-92, 2014; 2. McGrath et al: JEN, 41, 503-9, 2015


n Likely value-added programs (accumulating data)n Standard protocols for common BH conditions in

the medical settingn Alcohol withdrawaln Intervention for violence potentialn ER drug seeking (pain patients)

n Telepsychiatry for various medical venues: rural settings, general hospitals, general hospital ERs, medical clinics


(Things that could work)


n Value-added Inpatient programsn Proactive psychiatric consultation: 1 to 3 day decreased LOS and lower

readmission rates1,2,3

n Inpatient Programs: delirium prevention4

n Psychiatric service (nursing) review of sitter use: reduction from 7,000 hours/month to 5,000 hours/month; halved cost without adverse events5,6

n Psychiatrists in medical ER physician pool: ~25% reduction in psych boarding; hours to days shorter ER stays; lower ambulance cost; 75% fewer psych admissions7

n Complexity Intervention Units (CIUs): better outcomes and shortened LOS in complex high cost comorbid patients8


(Things that work)

1. Desan et al: Psychosom, 52, 513-20, 2011; 2. Tadros et al: NHS Economic Evaluation, 2015; 3. Sledge et al: Psychother Psychosom 84, 208-16, 2015; 4. Hshieh et al: JAMA, 175, 512-20, 2015; 5. Rausch et al: JONA, 2010; 6. Talley et al: APN, 1990; 7. Alameda Model Report, 2015; 8. Honig et al: NTG, 2014


Transition Step Options--The Challenge--

Health Outcomes Cost Outcomes1. Do

Nothing• Poor BH access• Retarded medical illness

improvement due to untreated BH comorbidity

• Unfavorable BH finances• Comorbid medical patients: 1 day

longer ALOS, >$6M for sitters, ~30% higher 30-day readmissions; ~$22M+ in extra service delivery costs

2. Buy Traditional

BH

• é BH access• Small impact on medical

sector outcomes

• More unfavorable BH finances• Similar cost outcomes to above since

value-added BH not possible in medical setting

3. Build BH into Medical

• BH access in medical setting• Medical/BH provider

communication; patient satisfaction

• é inpatient and outpatient care coordination and medical and BH outcomes

• Better payment for BH services frommedical benefits

• Gap closure on ALOS, sitter use, 30-day readmissions, cost/net margin for general medical patients with BH comorbidity


BH Future State--Steps to Creating the Vision--

Future State1. Start System-level BH Service Line

2. In-source BH into Medical Delivery System3A. Initiate Integrated Medical Payer Contracts

3B. Layered BH Care in Outpatient Medical Settings3C. Value-added ER & Inpatient Psychiatric Services

3D. Institute Integrated Case Management


ReferralMedical Practice

Behavioral Practice

Medical Practice

BH Behavioral Practice

Med

Medical & Behavioral Practice

Model 1: “Cross-Referral”

Model 2: “Bidirectional”

Model 3 “Integrated”

Patient sorting

(75% of BH Patients)


Specialty BH Setting(10% of BH Patients)


Manderscheid & Kathol, AIM:160, 61-65, 2014


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The Transition to Non-Traditional BH Care and Care Support

3.Med/BH

Med Home

1.Purchasers

Health CareOutcome Change


--Regulators

Med/BH

Body

PublicPrivate

BH

2.Fund

Distributors

Accountable Care Organization

Mind2. contracting for BH services as part of medical benefits; 3. BH clinicians part of medical provider network; Patients--integrated medical and BH services


Desired Post-ACA Infrastructure

3.Providers

Med Home

1.Purchasers

Triple Aim: Better Health Care, Better Outcome, Lower Cost


--Regulators

Med/BH

Med/BH

--adapted from Kathol & Gatteau, Healing Body AND Mind, 2007

Body/Mind

PublicPrivate

2.Fund

Distributors

Health Delivery Networks

Vision--2025 GoalHealth Setting Care

Provider Network

Health Delivery Network

}Cartesian Solutions, Inc.™ ©

Basic Requirements of a Value-Added System

n Network and Practice Location: single network of co-located BH and physical health specialists

n Service Delivery: collaborative physical and BH services in unified settings (med & psych)

n Payment: common and consistent physical & BH reimbursement procedures from one payment pool, e.g. same codes, etc.

n Documentation: single health record


Indicators of a Financially Integrated System

n One patient identifier and payment pool for all health services, including psychiatric

n Uniform set of reimbursement rules n One contact list of all network providersn No “medical setting” practice restrictionsn One health notes record (EHR)


Prioritized Transition to Sustainable Integrated Care


Medical & Psychiatric Practice

Model 3 “Integrated” Specialty BH Setting(10% of BH Patients)


1. Educate health systems, medical and BH clinicians, and administrators about value-added integration

2. Create insourced medical payment procedures for SMI patients

3. Consolidate medical and BH provider networks and payment procedures (sunset MBHOs)

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Prioritized Transition to Sustainable Integrated Care


Medical & Psychiatric Practice

Model 3 “Integrated” Specialty BH Setting(10% of BH Patients)


4. Initiate stepwise integration of value-added medical/BH inpatient, outpatient, and post acute care services, including integrated case management for complex patients

5. Iteratively update strategy Thank you!Cartesian Solutions, Inc.™ ©

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