© 2014 American Psychiatric Association. All Rights Reserved.

Psychiatry and Healthcare Reform

Harsh K. Trivedi, MD, MBAChair, Council on Healthcare Systems and FinancingWPA Annual Meeting 2014

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What is Health Reform?

Health Reform, broadly stated, is a combination of market forces, health policy changes, and statutory and regulatory initiatives shaping public and commercial health insurance markets, coverage, and the organization, delivery and payment for healthcare services.

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What is Driving Health Reform?

• Total healthcare costs• Projected cost trends are unsustainable• Both public and private fiscal resources are limited• There are numerous realities driving costs (e.g. aging

population, technology, etc.)

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“Bending the Cost Curve”

2010 ACA Initiatives to do this

Why Are Individuals with Mental Health/ Substance Use Disorders Relevant?

• MH/SUD conditions are prevalent (especially in populations now eligible for insurance);

• 50% of patients with chronic medical disease have MH/SUD conditions;

• Most MH/SUD conditions are not treated or are undertreated;

• Untreated MH/SUD conditions are associated with higher healthcare costs

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Mental Health/Substance Use Disorder Patients are High Cost

Patients with MH/SUD cost 2-3 times more ($1,000 PMPM compared to $400 PMPM)

Most of the added cost is in facility-based costs (ER and inpatient) for medical care

Milliman Report 2014

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What this Means and Why that Matters

Increased Hospital Stays

$293 BillionIn additional costs incurred by people

with behavioral comorbidities across

commercially-insured, Medicaid,

and Medicare [2012]In both

Increased Emergency Room Visits

$92 BillionAnnual Expenditures on Behavioral Health

Milliman Report 20147

Why Psychiatry Matters to Health Reform

• Psychiatry has an evidence-based value proposition regarding healthcare delivery initiatives.

• Milliman report provides definitive evidence supporting implementation of collaborative care models which favorably impact total healthcare costs.

• Potential health system savings of $26-48 billion annually in general health costs.

• Psychiatry is an integral component of evidenced based care models.

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Health Reform Implications for Individuals with Psychiatric Illnesses/Substance Use Disorders

• Increased access opportunities• Focus on totality of healthcare needs

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What is Vanderbilt’s Response?

© 2014 American Psychiatric Association. All Rights Reserved.

Future Models of Psychiatric Care

Harsh K. Trivedi, MD, MBAChair, Council on Healthcare Systems and FinancingWPA Annual Meeting 2014

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Health Reform Implications for Psychiatrists

• Health reform may not be for everyone, “The implications of health reform for psychiatric practice are quite broad, although they will differentially impact APA members depending on their primary practice settings and choices regarding participation in emerging models of care and payment.

• While the changes wrought by health reform are not fully predictable,

they will, because of the underlying fiscal realities, be widespread and ongoing. It is likely that some aspects of psychiatric practice will remain relatively unchanged, even as reform initiatives change other aspects of practice significantly.” 12

Health Reform Implications for Psychiatrists

• Changed reimbursement methods• Increased reporting requirements via Quality Measures• Increased HIT; e.g. EHR and Patient Registries• Increased access through insurance

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Key Reform Elements that Psychiatrists Need to Understand

• Patient Centeredness Principles• Integrated Care Delivery Initiatives• Changing Physician Reimbursement Methods• Quality of Care/Performance Measures• Health Information Technology (HIT) • Insurance Expansion and Market Reforms• Mental Health Parity as an Insurance Market Reform

Key Policy Directions

• The Triple Aim’s Objectives• Better Population Health• Better Patient Care• Lower Per Capita Cost

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The Current Healthcare Delivery System Problems• Delivery is described as a “cottage industry” in the

United States, • Fragmentation at the national, state, community,

practice levels• No single national entity or guiding set of policies • States divide responsibilities among multiple agencies• Providers often work independently , while care for the

same patients in the same community• Primary care system is on verge of collapse

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Integrated Care: A Health Reform Imperative

The momentum behind the transformation is significant in both public and commercial payor schemes with implications for all subsets of patients who have psychiatric needs

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Five Basic Models of Integrated Care

• Health or Medical Homes• Accountable Care Organizations (ACOs)• Case/Care Management• Collaborative Care Model• Primary Care in Specialty Behavioral Health

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Differentiating Integrated Care Initiatives• Each of the five “models” discussed is about integrating

healthcare delivery;• Each represents something different: a structure, a service

delivery model, or a function; • They may be configured in different ways;• They do vary regarding the levels of evidence which

support their use; • They do vary with regard to incorporation of the four key

elements of reform: access, care coordination, HIT, and payment reform.

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Health or Medical Homes – Defined

The medical home is an approach to the delivery of primary care that is:•Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care. •Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental healthcare needs, including prevention and wellness, acute care, and chronic care.•Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home healthcare, community services and supports.•Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations.•Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health.

PCPCC

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Accountable Care Organization (ACO) Defined

ACO is defined by CMS as groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.

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Care / Case Management Defined

As a healthcare service in which a single person, working alone or in conjunction with a team, coordinates services and augments clinical care for patients with chronic diseases. [The Case Management Society of America]

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Collaborative Care Model Defined• The collaborative care model is an evidence-based

approach for integrating physical and behavioral health services that can be implemented within a primary-care-based Medicaid health home model, among other settings.

• Collaborative care includes: (1) care coordination and care management; (2) regular/proactive monitoring and treatment to target using validated clinical rating scales; and (3) regular, systematic psychiatric caseload reviews and consultation for those who do not show clinical improvement.

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Primary Care in Specialty Behavioral Health Settings DefinedAHRQ defines Behavioral Health and Primary Care Integration as the care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization

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What needs to be different in the future?