RWJ Depression in Primary CareRWJ Depression in Primary Care

State Medicaid Strategies for Integrated CareHealth Plan Experience

Marshall R. Thomas M.D.V.P. of Medical Services/CMO

Colorado AccessVice Chair Department of Psychiatry

UCH/UCHSC

2

Colorado Colorado AccessAccess• Non-profit Medicaid/Medicare Health Plan

– Product Lines• Access Health Plan• Access Behavioral Care • Access CHP+• Access Advantage

– Medicaid/Medicare Duals

• Mental Health Co-morbidities– 40% of adult Medicaid recipient

• Depression, anxiety, SA (15% each)– High cost to the medical plan

• Bipolar, schizophrenia (5% each)– High cost to BH, Medical/Pharmacy

– 1/3 seen by MH specialists– Overall increase costs 2.3 fold

3

Depression and Depression and Primary Care InitiativePrimary Care Initiative

• MacArthur Grant– Dissemination of Three Component Model (TCM)– Remission in severe depression

• TCM- 58.8%• Usual Care- 0%

– Lessons learned• PCPs appreciated the help

– Practice patterns difficult to change• Providers referred patients they wanted help with; not

the patients who qualified for the studies– Help with medical and psychiatric co-morbidities

• Patients liked the care managers

4

How Are Medicaid Populations and How Are Medicaid Populations and Providers Different?Providers Different?

• Incentive Misalignment– As in commercial world

• Medicaid Populations– Higher prevalence of mental health issues– Higher rates of poverty and other psychosocial stressors– Diverse

• Pregnant moms and babies, TANF moms and kids, and Disabled• Culturally and ethnically diverse

– Hispanic, African-American, Asian-Pacific, Eastern European....– Harder to reach– ? Multiple co-morbidities– ? More likely to be helped by care management

• Medicaid Providers– Diverse

• FQHCs, University (resident) clinics, and private FM and Pediatric practices– Too much work, too few resources– Mission driven; philosophically dedicated to underserved; – ? More economically and technologically challenged– Decision-making mosaic

5

Robert Wood Johnson Foundation: Robert Wood Johnson Foundation: Depression in Primary CareDepression in Primary Care

• RWJ: Linking Clinical and System Strategies– Develop an economically sustainable model for implementing

depression care management• Build into already prioritized disease management programs• 50% rates of depression in asthma/COPD, CHF, diabetes, and

high Kronick scores (90 percentile).• Depression associated with 2-4 fold increase in costs• Initial target of diabetes, CHF etc with co-morbid depression.• Diabetes depression pilot

– 10.6/14 diagnostic categories– 26.5 diagnoses– 66% mental health diagnoses– 75% narcotic use

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The Current System is The Current System is Not WorkingNot Working

• Usual care for complex Medicaid patients– Ineffective, inefficient, costly, and frustrating for all involved

• “System overload”– Multiple medical comorbidities, psychosocial issue, psychiatric and

substance use disorders

• Multiple providers– Inadequate communication/coordination

– Lack of a “medical home”

– Lack of communication between PH and mental health providers

• Polypharmacy– Use of expensive and addictive meds

– Ineffective doses and strategies

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Patient-focused Intensive Patient-focused Intensive Care Management ProgramCare Management Program

• Focus on top 2-3 % of population– Risk stratification– High Kronick/Health Risk Assessment

• Integrated general medical/behavioral health focus– Medical, behavioral, psychosocial domains– Basic needs

• Food, shelter, transportation, benefits– Patient engagement/self-management goals– Mental health/cognitive barriers to engagement– Coordination of care among providers– Poly-pharmacy and medication adherence issues– Help navigating the medical and social service systems

• Care management team– Nurses, social workers and resource coordinators

• Consumer navigators and family resource coordinators

• Home-grown care management software

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Enrollee DemographicsEnrollee Demographics

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PHQ-9 TrendsPHQ-9 Trends

PHQ-9 Scores over Time

0

2

4

6

8

10

12

14

16

18

20

Baseli

ne

3 m

th6

mth

9 m

th

12 m

th

15 m

th

18 m

th

21 m

th

Time Period

PH

Q-9

To

tal

Sco

re Bipolar

Schizophrenia

Anxiety

Psychosis

Dysthymia

Substance Abuse

MDD Only

PHQ-9 Symptoms over Time

0

1

2

3

4

5

6

7

Baselin

e

3 m

th6

mth

9 m

th

12 m

th

15 m

th

18 m

th

21 m

th

Time Period

PH

Q-9

To

tal

Sm

ypto

ms

Bipolar

Schizophrenia

Anxiety

Psychosis

Dysthymia

Substance Abuse

MDD Only

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ER and Office Visit TrendsER and Office Visit Trends

ER Visits per 1000

220.3

181.3

163.0

0.0

50.0

100.0

150.0

200.0

250.0

12 mths pre 12 mths post 24 mths post

Time Period

ER

Vis

its

per

100

0

Office Visits per 1000

211.8

547.7

358.2

0.0

100.0

200.0

300.0

400.0

500.0

600.0

12 mths pre 12 mths post 24 mths post

Time Period

Off

ice

Vis

its

per

100

0

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Admit and Days/1,000 TrendsAdmit and Days/1,000 Trends

Admits per 1000

49.7

40.337.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

12 mths pre 12 mths post 24 mths post

Time Period

Ad

mit

s p

er 1

000

Days per 1000

232.5 228.6

205.4

100.0

120.0

140.0

160.0

180.0

200.0

220.0

240.0

12 mths pre 12 mths post 24 mths post

Time Period

Inp

atie

nt

Day

s p

er 1

000

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Medical Cost TrendsMedical Cost Trends

• Savings of $170 per enrollee per month

• 12.9% reduction in costs in high-cost, high risk patients

• $2040/year per patient

• 370 patients x $2040 = $754,800 annual medical cost savings

• Need Comparative Cohort analysis

Net Pay PMPM Trends

$837 $807

$650

$480$558

$497

$1,317 $1,364

$1,147

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

12 mths pre 12 mths post 24 mths post

Time Period

Do

llar

s S

pen

t P

er M

emb

er P

er

Mo

nth

Net Pay Med PMPM Net Pay Rx PMPM Net Pay Med and Rx PMPM

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Colorado Access’ Depression Colorado Access’ Depression Integration Initiative (RE-AIM)Integration Initiative (RE-AIM)

• Reach– Directly reaches a relatively small but important subset of Medicaid patients– Directly reaches all health plan care management staff– Indirectly reaches many more providers and patients

• Efficacy– Appears good (see proceeding data)

• Adoption– High within the health plan staff

• Implementation– Challenged to obtain model fidelity across staff– Competing demands– Decision support tools

• Maintenance– High- depression and MH co-morbidity screening/monitoring part of all ICM assessments – New initiatives

• FQHC clinic-based depression and diabetes CM • Bipolar (and SMI) CM• Enhanced MH screening for perinatal moms• AFFIRM- SED kids and families

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Ingredients for SuccessIngredients for Success

• Support of senior management

• Effective clinical leadership

• Clear focus that supports both clinical and business priorities

• Sphere of influence versus sphere of concern

• Credible data to support start-up, implementation, and ongoing evaluation

• Titrate degree to which innovation requires organizational change

• Plan for program sustainability from the start; create a specific infrastructure with resources and expertise devoted to diffusion

• Close relationship between the disseminating infrastructure and the adopting organization.

• Perceived ability of the innovation to reduce external threats

Bradley, et al., Commonwealth Foundation Fund: Issues Brief, 7/04