ACOs & Chronic Care Management: Opportunities For ... · 55% of Medicaid enrollees, and 64% of...

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www.openminds.com163 York Street, Gettysburg, Pennsylvania 17325Phone: 717-334-1329 - Email: [email protected]

The 2017 OPEN MINDS Strategy & Innovation Institute Tuesday, June 6, 2017 | 11:45am – 1:00pm

Steve Ramsland, Ed.D., Senior Associate, OPEN MINDS

ACOs & Chronic Care Management: Opportunities For Behavioral Health Organizations In Population Health Management


I. The ACO Landscape

II. Opportunities For Behavioral Health In Population Health & Care Management Models

III. Prospect CharterCare Case Study

IV. Questions & Discussion

Agenda

The ACO Landscape


What Are ACOs?

Groups of health care providers that share mutual responsibility for a population of patients • Improve quality and health outcomes• Reduce health costs and inefficiencies• Reimbursement based on metrics of Quality Care, Patient

Satisfaction, and Reductions in Cost of Care

Population Health Management approach:

• Maintaining and improving people’s health across full continuum of care


ACO Market Trends – 2013 vs. 2016

412

689

2013

2016

Number Of ACOs

12.1%

2016

Percent Of U.S. Insured Population Covered By An ACO

4.4%

2013

11.9

35.1

2013 2016

Lives Covered (Millions)


Of ACOs Are Run By Physician Groups

1.60%

2.30%

3.60%

42.50%

47.30%

Federally Qualified Health Center (FQHC)

Health Plan and Provider Organizations

Hospital System and Physician Group

Hospital System

Physician Group

% of Organizations

Type

of O

rgan

izatio

n

ACO Sponsoring Organizations By Type, 2016


ACOs, By Payer

6.4%11.2%

22.6%

59.8%

MedicaidOnly

Contracts

MultipleContracts

CommercialOnly

Contracts

MedicareOnly

ContractsACO Contract Payer

Accountable Care Organizations By Contract, %, 2016

ACO Contracting Overview, 2016

ACO Contract Payer

Number Of ACOs

Number Of Contracts

Total Beneficiaries

Percent Of Attributed Consumers

Medicare 412 485 14,615,007 41.7%

Medicaid 44 55 3,243,728 9.2%

Commercial 156 229 17,219,745 49.1%

Multiple Contracts

77 - - -

Total 689 769 35,078,480 100%


Largest ACOs By Population, 2016ACO Name Payer Service Area Sponsoring

OrganizationEnrollment

Catalyst Health Network Commercial Texas Physician Group 3,937,000Delaware Valley ACO Medicare/ Commercial New Jersey/

PennsylvaniaHospital System/ Physician Group

1,728,000

Accountable Care Alliance Of Ventura

Medicare California Physician Group 1,500,000

Accountable Care Coalition Of Greater New York

Medicare New York Hospital System 1,500,000

MetroHealth Care Partners ACO

Medicare Ohio Hospital System 1,500,000

Memorial Hermann Accountable Care Organization

Medicare/ Commercial Texas Hospital System 1,134,430

Banner Health Network Medicare/ Commercial Arizona Hospital System 1,077,100

Health Choice Preferred Commercial Utah Hospital System 1,000,000Brown & Toland Physicians Medicare/

CommercialCalifornia Physician Group 766,000

Heritage California ACO Medicare California Physician Group 700,000

Ten Largest ACOs, By Enrollment


Utah Has The Highest Percent Of Their Population Attributed To An ACO – 62.9%

Opportunities For Behavioral Health In Population Health & Care Management Models


History Of Separate Financing & Delivery Of Behavioral Health

Since the time of the HMO Act of 1973, benefits have been separate

In 2001, 80% of health plans had a carve-out their behavioral health benefits– 33% Magellan

– 19% Cigna

– 13% United Behavioral Health

– 11% MHN

– 3% ValueOptions

New model emerging with integration at the individual consumer level


Primary Carve-Outs To Private CMOs, 20161. Arizona2. Colorado (ending)3. Hawaii4. Idaho5. Massachusetts6. Washington (ending)

States With Traditional Primary Medicaid Behavioral Health Carve-Outs Decreasing

Primary Carve-Outs To Public CMOs, 20161. California2. Michigan (at risk of ending)3. North Carolina (ending)4. Pennsylvania5. Utah


Pre-existing condition coverage and parity have driven use of new strategies

Consumers with behavioral disorders

are often ‘super-utilizers’ of health care

resources

Undiagnosed and/or untreated behavioral

health conditions hinder the treatment

of a wide range of medical conditions

Consumers with behavioral disorders

and comorbid chronic medical conditions

have higher average cost than those

consumers without comorbid conditions

Lack of coordination care management results in poorer

outcomes and higher cost per consumer


Consumers With Behavioral Disorders Are Often ‘Super-Utilizers’ Of Health Care Resources

1. 5% of Americans consume half of all health care resources

2. Much of this is due to frequent and preventable use of expensive health care settings

3. This group of consumers is often referred to as “superutilizers” - individuals with multiple illnesses whose care is uncoordinated and fragmented, resulting in high resource use

More than 80% of Medicaid superutilizers have a comorbid mental illness

In 44% of Medicaid super-utilizers, mental illness is in the form of a ‘serious mental illness’

Mental health and addictive disorders were among the ‘top ten’ principal diagnoses for super-utilizers aged 1 to 64 years, regardless of payer


Consumers With Behavioral Disorders & Comorbid Medical Conditions Have Higher Average Costs

1. Mental health and addictive disorder comorbidities increase average health care costs by up to 200%

2. Individuals with these comorbidities often experience gaps in care management, leading to avoidable utilization of expensive health care settings

Asthma&/OrCOPD

CHF CHD Diabetes Hyper-tension

No MH/SUD $8,000 $9,488 $8,788 $9,498 $15,691MH $14,081 $15,257 $15,430 $16,267 $24,693SUD $15,862 $16,058 $15,634 $18,156 $24,281MH and SUD $24,598 $24,927 $24,443 $36,730 $35,840

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

Annu

al P

er C

apita

Hea

lth C

osts


Undiagnosed Behavioral Health Conditions Have Human & Economic Tolls

1. Each year, one in four Americans experience some mental illness

2. The presence of a mental health or addictive disorder comorbidity can increase a person’s chances of hospital admissions by up to 300%

The Impact Of Depression1.Mood disorders like

depression are the third most common cause of hospitalization among non-elderly adults

2.60% of individuals suffering from chronic depression have not received treatment within the last year


Strategies To Optimize Behavioral Health

Use Of Analytics In Identification & Early Intervention Of High-Risk Consumers With Behavioral Conditions

Strategies Focused On Improving Consumer

Access To Care

Strategies For Improving Consumer

Engagement

Improved Coordination Of Care For Consumers

With Behavioral Conditions

Strategies ToEnsure Quality Of Behavioral Health Care

Creating Partnership Models With Behavioral Health Provider Organizations


Identification of High-Risk Consumers To Optimize Population Health Management Strategies

Goal is to identify consumers who are likely to use high levels of resources - to support targeted use of mitigation strategies

Individual-level data that is aggregated for population-level analysis

Requires timely access to integrated data set including physical and behavioral health, pharmacy, social determinants of health, and other factors that impact wellbeing

Supporting consumer care planning and event surveillance –

– Enrollment in specific programs

– Matching referrals of high-risk consumers to provider organizations with special expertise and demonstrated proficiency

– Tracking consumer adherence to recommended treatment plans, emergency department visits, and hospital admissions


1. Consumers with unrecognized/asymptomatic depression had health care expenditures $2,000 to $3,000 per year than those without depression1

2. Patient with symptomatic depression had health care expenditures $5,000 per year higher than those without depression1

3. 59% of Americans with insurance do not get the behavioral health services they need3

4. Strategies to improve access must address three issues: a. Easy access to health care system

b. Ready availability of locations where needed services are provided

c. Matching consumers with a professional they view as trustworthy and easy to communicate with2

Addressing Untreated Behavioral Health Conditions Through Consumer Access Improvement


Improving Consumer Engagement To Drive Health Plan Performance

1. A significant portion (more than 40%) of readmissions have significant consumer engagement-related causes such as lack of support, inability to navigate the health care system, and inability to comprehend and follow instructions1

2. Members' level of engagement with their health plan and the health plan’s provider network is directly related to their disenrollment and satisfaction behavior

3. Complicating factors to engagement specific to the behavioral health are that consumers may not become engaged due to stigma surrounding mental illness, or perceived lack of diversity and cultural competence among professionals4


1. More than 90% of consumers treated for behavioral health conditions have at least one comorbid medical condition, and more than half have four or more.4

2. Lack of coordinated, person-centered care management for individuals with comorbid mental health conditions leads to missed diagnoses, poor follow-up, and gaps in care1

3. HEDIS measures show that more than 47% of commercially-insured individuals, 55% of Medicaid enrollees, and 64% of Medicare enrollees did not receive follow-up care within seven days of discharge from hospitalization due to mental illness2

4. People with psychotic disorders and bipolar disorder are 45 percent and 26 percent less likely, respectively, to have a primary care doctor than those without mental disorders2

Improved Care Coordination For Consumers With Behavioral Conditions


1. There is a lack of consensus on tools for measuring ‘quality of care’ in behavioral health sector, although efforts to develop a standardized set of quality measures is in process

a. For example, National Quality Forum3 has 55 currently identified measures include 11 addressing depression, 16 addressing medical conditions in psychiatric populations plus 3 about tobacco use, and 9 relating to medications

2. Despite this current lack of consensus, health plans are using a range of quality measures for behavioral health, including measures of symptom level and functional status4

Improving Effectiveness By Improving The Quality of Behavioral Health Care


1. Models for management of behavioral health benefits moving beyond traditional specialty carve-outs

2. The need for ‘integration” of care coordination for consumers with complex needs is driving new designs

3. Integrated care coordination (and integrated service delivery) are not possible without reimbursement realignment – which is resulting in the creation of new gainsharing arrangements

Reshaping Network Design With Partnerships For Gainsharing & Aligned Incentives


ACOs & Complex Consumers


Opportunities for Specialist Organizations Are Many

Behavioral health service system sub-capitation

Specialty care coordination for consumers with behavioral disorders

Specialty ‘center of excellence’ programs for

acute conditions

Behavioral health consultation in office-

based service locations –live or via telehealth

Management of specific acute episodes or chronic conditions via case rate or episodic/bundled payment

Management of short-term inpatient psychiatric and addiction treatment

programs

Psychiatric consultation –live or via telehealth – in

hospital emergency rooms

Behavioral health consultation program for inpatient programs – live

or via telehealth

Hospital diversion programs

Specialty behavioral health ER/crisis stabilization

Hospital readmission prevention programs

Community-based/mobile crisis response

Home-based service delivery Specialty primary care


Business Model Transition For Provider Organizations

Payer Policy = Pay For Cost Or Volume

Payer Policy = Pay For Value

What is paid for is good for the consumer -

- and doing more is the

business model

Giving the consumer (and

their payer) what they want and need is the business model

Good outcome at low cost –

conveniently

A revolution in performance management

required

Prospect CharterCARECase Study

Rebecca Plonsky, LICSW, Vice President of Development for Integrated Behavioral Health-East and Southwest Region, Prospect CharterCARE, LLC

ACOs & Chronic Care Management Opportunities:

The Prospect CharterCARE, LLC Case Study

Rebecca Plonsky, LICSWVice President of Integrated Behavioral Health

June 6, 2017 28

Becoming an ACO

29

Built Continuum of Care

Convened Key Stakeholder

Meetings

Secured Approval from

State & Payer(s

Health Care Transformation

Began

• Expanded continuum of care to meet requirements of ACO

• Enhanced BH and medical integration at all points of care

• Convened series of Executive meetings to discuss launching an ACO model of care

• Formerly submitted application that demonstrated meeting ACO requirements

• Secured Approval and Executed contracts with payers

• Focused efforts on patient retention, population health, and engagement

• Focused on quality and enhanced reporting

• Began to track leading indicators

Our ACO Types

30

Current State in RI:

Medicaid ACO Medicare Next Gen ACO Medicare ACO “like” Commercial ACO “like”

Of Note:

RI Community Mental Health Centers (CMHCs) are eligible to be certified as an ACO for patients with SPMI

Prospect CharterCARE, LLC has deep partnerships with 2 CMHCs and has fully executed MOU’s with each

Future State:

Commercial ACO “like” by Q1 2018 to include BH and medical management

Prospect Population Under Management Growth

3,688 4,786 7,657

29,941 33,546

50,028 64,982

- 10,000 20,000 30,000 40,000 50,000 60,000 70,000

Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17

14-Jul 15-Jan 15-Jul 16-Jan 16-Jul 17-Jan 17-JulBCBSRI MA 3,688 3,986 6,807 7,385 7,823 8,300 8,300Tufts Commercial 800 850 1,056 1,200 1,700 1,700BCBSRI Commercial 14,000 17,023 17,796 18,000United Medicaid Pilot 3,800 3,800 5,600 5,600NHPRI Medicaid Pilot 3,700 3,700 7,300 7,300CIGNA Commercial 2,200 2,200United Commercial 8800United Medicare Advantage 4450Next Gen ACO 7,132 7,132Tufts Medicaid 1,500

3,688 4,786 7,657 29,941 33,546 50,028 64,982

Our ACO Population Health Approach

32

Addiction Medicine

• Medication Assisted Treatment Case Rates

– Allowed treatment flexibility based on acuity of symptoms

• Enhancing connectivity between primary care and Addiction Medicine Services

Serious and Persistent Mental Illness

• Partner and Coordinated Care for Patients In Integrated Health Homes

• Engage patients who are not affiliated with CMHC

• Focus on patients who decline care management

Geri Psychiatric

• Nursing Home Initiative with 24/7 Access Line

• Exceptional medical team has been nationally recognized for providing exceptional medical and bh treatment for highly complex patients

Long Term Behavioral Health Care

• Built best practice programming focused on recovery and community Integration

• Programming also included Peer Recovery Services and AA

• Improved Effective and Successful Discharge Planning to the community

Introduction to CharterCARE Health Partners Integrated Continuum of Care- Outpatient

1. Addiction Services Center on the Roger Williams Medical Center Campus

Multi-disciplinary team including: (Peer Specialist Q2 2017) Offer same day appointments for co-occurring disorders and/or co morbid conditions Short and Long term counseling Suboxone treatment from induction phase to maintenance Early Recovery Groups Partial Hospital Program (PHP) and an Intensive Outpatient Program (IOP)

2. Outpatient Programs on the Our Lady of Fatima Hospital Campus

MH and Dual Diagnosis IOP and PHP General Outpatient Counseling opened in February 2017

3. St Joe’s Health Center

LICSW fully integrated within primary care team Warm hand offs, brief interventions Evidence based routing screenings PHQ 2/9, Gad 2/7 SBIRT go live in Q2 2017

33

CharterCARE Health Partners Integrated Continuum of Care-Inpatient

We offer comprehensive individual and group interventions including early recovery and building effective coping skills for varying levels of needs across our 110 Inpatient Beds.

Our compliment of beds focus on meeting the demands of our patient community

1. Our Lady of Fatima Hospital (71 Beds)

2 South – Long Term Behavioral Health Unit: 20 beds 2 Center – Adult General Psych: 30 beds 3 South – Geri/Psych: 21 beds

2. Roger Williams Medical Center (39 Beds)

West 4 – Geri/Psych: 12 beds West 3 – Dual Diagnosis: 12 beds Center 1 – Detox: 15 beds

34

Key Elements in Advancing Our ACO and Integration

Rhode Island has made significant strides to move toward integrated care across the delivery system through the following:

Strong statewide commitment across providers

Payer Accountability and Partnership

Behavioral Health State wide Work Groups focused on Integrated Health Homes

Care Transformation Collaborative (CTC)/ Patient Centered Medical Home

Prospect CharterCARE’s Strategic Goals to Strengthen Integration include:

A member centric, holistic, “whole person” approach with a focus on recovery and integrated care

Member access to broad networks of specialized care

Coordination & collaboration of care through multi-disciplinary behavioral health and medical teams with ease of access

Promotion of high quality, innovative payment structures, & evidence based best practices that are outcome driven

Ensure rate adequacy via actuarial soundness35

Key Elements in Advancing ACOs and Integration cont.

Member signs Release of information

Share Information

MeasureOutcomes

Case Consultation

• Routine Bi-Directional Communication

• Share treatment plan, medication dosing, & goals• 80% of Medicaid

members have co morbid medical & BH Issues

• Implement Standardized Outcome measures: HEDIS, total cost of care, & quality of life measures

36

COORDINATEDKey Element:

Communication

CO-LOCATEDKey Element:

Physical Proximity

INTEGRATEDKey Element:

Practice Change

LEVEL 1:Minimal Collaboration

LEVEL 2:Basic Collaboration at a

Distance

LEVEL 3:Basic Collaboration

Onsite

LEVEL 4:Close Collaboration Onsite with Some System Integration

LEVEL 5:Close Collaboration

Approaching an Integrated Practice

LEVEL 6:Full Collaboration in

a Transformed/Merged Integrated

Practice

Heath B, Wise Romero P, and Reynolds K from SAMHSA-HRSA (2013) proposed a Standard Framework for 6 Levels of Integrated Healthcare.

Key Components:

RI CTC July 14 Survey Results from at least 14 Practice Sites: Screening for BH Problems

What it Tells Us…

Practices are very good at screening for depression and smoking Not systematically screening for anxiety, overall substance use, pain, or

domestic violence

3

Of patients with serious mental illness like schizophrenia or bipolar disease:

About 1/3 of the practices believe they manage the physical health of these patients less well than they manage the physical health of other patients

Where We’re Going in CY 2017 & Beyond• Across our ACO continuum of we have adopted a coordinated regional care model (CRC)

which is built on the foundation of the Collaborative Care Model (CCM).• CCM an evidence-based practice endorsed by SAMHSA and the American Psychological

Association. • It is proven to have positive outcomes for patients with depression, anxiety, PTSD,

diabetes, heart disease, and cancer. Advance practice sites use screening and brief interventions (like SBIRT) for SUD.

• The collaborative care model can include a care manager, a medical assistant, a psychiatric consultant (typically by phone or video link), and an LICSW, psychologist, or RN. It is led by a PCP.

In a CCM an impact study, findings indicate that for every $1 spent, $6 was saved.

ACO CRC Opportunities in 2017 support:– Tracking member progress over time– Provider effectiveness– Meeting agreed upon performance targets– Informing population management strategies

38

• We Have Strengthened our Core Competencies and Mission– Broadened and provided better clinical care and outcomes– Increased patient engagement in their treatment and recovery– Committed to reducing total cost of care– Strengthened our network and deepened critical partnerships across the state and

have received recognition

• Made Meaningful and Smart Investments– Integrating behavioral and physical healthcare across our primary care network,

convene meetings with CMHCs to coordinate care, hired revenue generating clinicians and prescribers

– Revamped physical space– Optimized EHR platform and reporting to flag at risk patients and to track and trend

leading indicators

• Received Approval from payers for Case Rates and to accept further risk– Pilot programs focused on highly specialized care for high-risk populations

• Serious and Persistent Mental Illness (SPMI)• Addiction Medicine• Depression in Primary Care

39

Our Experience as an Accountable Care Organization to Date

Partnering with Insurers4 Levers of Our ACO Success

40

Robust Continuum of Care

Commitment to Quality

Willingness to Accept Financial Downside Risk

Develop Strong Partnership with

Insurers and State Leaders

Lever 1: Robust Continuum of Care

Our Strong Network is Critical

Demonstrated our organization has a full compendium of services; committed to Coordinated Regional Care Model

Demonstrated deep partnerships with community providers through contracts; (preferably not MOUs or affiliation agreements)

Committed to PCMH advancement and integration

Started small, Deploy onsite clinicians in primary care

Ensured our providers are paid within fair market value

Moved prescribers to wRVUs to demonstrate productivity

Offered Telehealth 41

Lever 2: Commitment to Quality

Improve both patient and provider outcomes

Committed to full adoption of standardized and validated outcomes Demonstrated an interest in implementing an insurance driven outcome tool e.g. On Track GAD 2 and 7 PHQ 2 and 9 SBIRT Moved the needle on HEDIS measures e.g. MH After Care Follow Up

Committed to training and innovation Launched a monthly joint operating committee Convened Grand Rounds focused on Integrated Care Launched Integrated Behavioral Health Internship program Partnered with Colleges Shared best practices

Committed to provider and patient satisfaction 42

Lever 3: Willingness to Accept Financial Downside Risk

1. Committed to winning together or losing together

2. Proposed a 1 year pilot on a specialty population

3. Conveyed willingness to accept varying degrees of risk which may include: Accepting 5-10% of downside risk Quality Withholds Joint participation in shared savings

4. When accepting risk, we asked for full delegation

43

Lever 4: Develop Strong Partnerships with Insurers and State Leaders

44

• ACO BH CEO• Senior BH Leader

• Insurer Chief Medical Officer

• Senior BH Leader• Senior Contract

Administrator

• Community Partners e.g. CMHCs

• ACO Vice President

• State Director (May include multiple departments)• BH Chief Medical Officer• Senior State Contract Administrator

• Governor and/or Senator

Health System Transformation is Possible

Member Centric

Approach

Network Adequacy(PCP &

Pediatric)EMR/

Shared Medical Records

Care Managementfor Complex

Needs

MaximizeTreatment Adherence

CrisisIntervention

Community Support

Preventative Care

Health Education

AfterCare Follow

Up

Quality & Outcome

Real Time Data &

Analytics

InnovativePayment

Structures

Holistic, Whole Person Approach

45

Our Lessons Learned to Date

46

Transformation is possible but we cannot move faster than the systems will allow

We were able to clearly answer the question to insurers, “What is in it for me?”

We had to be flexible and nimble when establishing terms of ACO; Heard what the insurers were asking and modified our position as

needed Optimized our EHR

Leveraged our IPA comprised of 500 Specialists and PCPs to further medical integration

Learned over time, we needed to be conservative with ramp up time lines

Questions & Discussion

47

Table Talk Discussion Questions

1. How do you begin to work through current constraints to partner with or become an ACO?

2. What are the 3 most significant challenges for your organization to advance integrated medical care and behavioral health?

3. What are 3 successful innovations that have been implemented over the past 12 months to promote integrated care across your delivery system?

48

www.openminds.com 163 York Street, Gettysburg, Pennsylvania 17325 717-334-1329 [email protected]

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