F404 1 Promoting Whole Person Care through Value Based Purchasing and Community Reinvestment Dr. Keith Brown Chief Medical Officer Community Health Plan of Washington The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated. ~ Plato 2 Objectives • Share CHPW’s perspective on opportunities and benefits for whole person, integrated care. – What’s the data and what does it tell us? • Share CHPW’s approach to supporting high value, integrated care through customized capacity development and innovative payment models.
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Promoting Whole Person Carethrough Value Based Purchasingand Community Reinvestment
Dr. Keith BrownChief Medical Officer
Community Health Plan of Washington
The greatest mistake in the treatment of diseases isthat there are physicians for the body and
physicians for the soul, although the two cannotbe separated.
~ Plato
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Objectives
• Share CHPW’s perspective on opportunitiesand benefits for whole person, integratedcare.– What’s the data and what does it tell us?
• Share CHPW’s approach to supporting highvalue, integrated care through customizedcapacity development and innovativepayment models.
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Opportunities and Benefits OfWhole Person Integrated Care
Prevalence ofBehavioral Health Conditions and Primary Care
• Prevalence estimates for psychiatric disorders of individualsseen in primary care range from 26 to 60 percent. *
• An estimated 20 percent of children in pediatric primary carehave a clinically significant psychosocial problem/condition.
• An estimated 60 percent to 70 percent of physician visits are bypatients with no medical illness.
* Source: Studies of patient populations based on the PRIME-MD
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Behavioral Health PrevalenceSerious Mental Illness 4.1 % US adultsAny Mental Health disorder: 18.6% US adults• (13.4% receive treatment)Substance Abuse: 8% of Americans age 12 and older
About 13% of 95 million ER visits in the United States in 2007were due to a mental health and/or substance abuse problem.Most common mental health diagnoses in ED:• Mood disorder (42.7%)• Anxiety disorders (26.1%)• Alcohol-related problems (22.9%• Other drug disorders (17.6%).
Source: AHRQ-HCUP Statistical Brief July 2010)
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Behavioral Health Prevalence-Comorbidity
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• 9 Million people in US have both a Mental Health andSubstance Use Disorder
• Only 7% receive treatment for both issues
• Substance Abuse patients: 45% have a comorbid MentalHealth disorder
• Mental Health consumers:
• Overall 18.5 % have active Substance Use Disorder• Young adults 55%• Personality disorder 34%• Behavioral Health inpatient: 28%
Prevalence of Behavioral HealthDisorders – CHPW Members
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Medicaid• 13% Serious Mental Illness• 29% Behavioral Health Condition• 13% Substance Use Disorder
Medicare• 32% Serious Mental Illness• 56% Behavioral Health Condition• 20% Substance Use Disorder
Chronic Conditions and Depression
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Adherence and Antidepressant Medications
Premature Discontinuation Rates:• 29% to 42% stop medication at 4 weeks• 63% to 76% stops medications at 6 months• Study of 147 patients: Only 19% took
antidepressants medication for the recommended6-month period
Source: Hunot, V.M., et al (2007) A Cohort Study of Adherence to Antidepressants in Primary Care: TheInfluence of Antidepressant Concerns and Treatment Preferences. Primary Care Companion J ClinPsychiatry. 9:91-99.
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• 80% of children; 70% of adolescents receive at least ayearly PCP visit
• Only 23% of pediatricians and family physiciansroutinely screen their patients for MH disorders
• When pediatricians rely on clinical judgment, 40-80% of children with developmental or MH problemsare missed
Missed Opportunities for Kids
Consequences of Poor Integration
• People with SMI die, on average, 8-25 yearsearlier than the general population
• 60% of premature deaths: due to cardiovascularand pulmonary disease, obesity, and smoking .
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Benefits of Integrated Care:The Value Proposition
• Promote a holistic approach• Reduce fragmentation• Gain operational efficiencies• Create flexibility in service delivery• Focus on quality, outcomes, with less duplication of services
Blending Cultures in Integration
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PhysicianNurses
BehavioralHealth
ConsultantPatient
Four Quadrant Model of Integration
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SAMHSA Levels of Collaboration/Integration
Coordinated
Level 1: Minimal Collaboration
Level 2: Basic Collaboration at a Distance
Co-Located
Level 3: Basic Collaboration Onsite
Level 4: Close Collaboration Onsite with SomeSystem Integration
Integrated
Level 5: Close Collaboration Approaching anIntegrated Practice
Level 6: Full Collaboration in aTransformed/Merged Integrated Practice
Implementing Integrated Physical andBehavioral Care
– BH professionals become part of total health team– Makes medical possible in BH; BH possible in medical– Sustainable payment for value-added integrated services
(bidirectional--true parity)– Challenge--requires change from status quo
• Improved care– Increased availability of/access to care– Condition/disease management
• Improved health– Health condition– Quality of Life
• Improved patient satisfaction• Improved cost management and cost savings
– Reduced preventable hospitalizations and ED utilization
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How can a Health Plansupport
Whole Person care?
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We are a local, Washington-based Health Plan with long-established ties to communitiesthroughout the State and well-equipped to facilitate and coordinate with local resourceson behalf of our members.
As a not-for-profit company, we make decisions that are motivated by the best interestsof our members, providers and communities within the State of Washington. We aregoverned by community organizations (Community Health Centers) that are in turngoverned by individuals that receive care within those organizations.
The health of our members is our primary concern. Our programs are designed toproactively identify and address the behavioral, social, and medical needs of our membersand to recognize the whole person’s needs.
The vision of CHPW is to provide services and supports that impact the health and well-being of our members, both directly and through our valued partnerships withcommunity-based providers. We meet this challenge by identifying and addressing needsthat impact the health of our members both within the clinical setting and beyond.
20 Community Health Centerswith more than 130 clinics
More than 2,500Primary Care Providers
More than 14,000Contracted Specialists
Behavioral Health Networkstate wide
More than 100 hospitals
Provide coverage and services inall 39 counties
One of the first MCOs to provideIntegrated Managed Care
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Whole PersonSystem of Care
)SavingsInvestment in OurCommunity
$ Community Reinvestments
HomelessResources
Housing RespiteServices
Ci)Youth Treatment Services
Harm Reduction Center
Clinic Expansion
Bi-Directional Integrated Care
Integrated Regional team focused on care coordination and transitionsfor individuals with complex behavioral health and physical health conditions.
Example of Activities:• Daily monitoring of members with BH diagnoses in the ED to offer members
connections to inpatient diversion resources and/or follow-up care, including medical.• Cross-system care coordination plan development for members that frequent the ED
and are not engaged in services.
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Flexibility
Key Principalsof Integration
Integrated CareCoordination
• No single model• Collaborative Care/Mental Health Integration Program
(MHIP) and Primary Care Behavioral Health (PCBH)• Bree Collaborative Recommendations• Four Quadrant Model• SAMHSA Levels of Integration
• Person-centered, Recovery oriented• Communication/Information Sharing• Team-based approach to care• Population-based• Measurement-based care
• Improved access to medical and behavioral health information• Single care management plan• Single point of coordination
• Cross system vehicle for systemimprovement planning
Behavioral Health PlanningCouncil
• MCO/BH-ASO collaboration to align clinicalprocesses and standardsClinical Alignment Group
• Including claims payment and denials,grievances, ED visits
Reporting and Monitoring“Early Warning System”
Indicators
Metrics showing statistically significant improvement for adult Medicaid beneficiariesresiding in the FIMC region, relative to the balance of state:• Adults' Access to Preventive/Ambulatory Health Services• Cervical Cancer Screening• Chlamydia Screening in Women• Comprehensive Diabetes Care - Hemoglobin A1c Testing• Antidepressant Medication Management - Continuation Phase Treatment• Follow-up after ED Visit for AOD Dependence-Within 7 Days• Follow-up after ED Visit for AOD Dependence-Within 30 Days• Percent Homeless - Narrow Definition• Percent Homeless - Broad Definition
Source: DSHS Services and Enterprise Support Administration, Research and Data Analysis Division August 7, 2017
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How can VBP supportintegrated, whole
person care?
Value-based Purchasing
• “Can Integrated Care Save American HealthCare?”(Washington Post January 18, 2013)
Health Care Payment-Learning Action Network:National and State Framework for VBP
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CHPW’s Approach to VBPEngagement of providers in design of models.
• Supplemental Payments to support infrastructureand operational capacity; incentives for reporting
• Pay for Performance: Rewards and Penalties• Alternative Payment Methodologies with upside
gainsharing and downside risk• Introduction of quality gate and ladder utilization
How MCOs work in partnership withproviders in VBP arrangements
• Define plan value and organizational culture• Data provision, analytics and quality improvement
support• Financial Support for targeted investments• Care management and coordination support• Utilization and disease management• Consultation and training based on capacity assessment• Facilitate partnerships across network participants to
ensure collaboration• Partner with other plans to ensure administrative
simplification
Capacity elements needed for VBP
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Can a health plan provide theright kind of payment and theright kind of support andcapacity development to allowfor a provider to deliver adifferent kind of care?
Yes.
Sample VBP Method with PsychiatricHospitals
• Case rate for each admission• LOS less than 48 hours = no payment• Bonus potential related to reduction in
30- day readmission rate• Bonus Potential related to attendance
at 7-day follow up appointment
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Yakima Neighborhood Health Services
Our mission is to provide accessible, affordable, quality health care, provide learning opportunitiesfor students of health professions, end homelessness and improve quality of life in our communities.
Needs and Challenges in Yakima County
4,400 square miles with limited public transportation
Highest % of uninsured in state (23% in 2015)
32% of County’s children live below 100% poverty
64% of employment is farm labor (low wages) – per capita income is 35%less than state average
Low educational levels (Granger) have less than 9th grade completionrates (32%)
Health challenges of county and our patients worse than state and US:
Obesity (“8th fattest city in the US”)
Diabetes (Yakima County in the “worse” category at 175 per thousand)
STD rate is 42% worse than the state
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Yakima County remains the highest Uninsured County –in spite of our high Medicaid enrollment
1975-YNHS founded
1980 – Maternal Child Health Contract1981 – WIC Contract
1992 – YNHS secures Yakima County designation as Medically Underserved Area / YNHS becomes FQHC-Lookalike
1994 – Yakima Federal Savings & Loan funds 11,000 square foot expansion of 8th Street Campus
1996 – Dental Clinic opens at 8th Street Campus
2000 – YNHS earns first Joint Commission accreditation
2001 – National Recognition comes with “Models that Work” nomination
2002 – Yakima campus adds 10,000 square ft with donation of the “Richey House”
2004 – First onsite pharmacy opens
2007 – Major expansion of Sunnyside site – adding dental services
2007 – Transitional and Permanent Supportive Housing
2010 – Medical respite program opens
2005 – Notice of Award – BPHC Health Care for the Homeless
2011 – First CHC in WA State awarded PCMH Level 3 recognition
2013 – ACA Award to expand Sunnyside Site, includes first Vision Center
2015 – Granger Medical site and Mobile unit begins2016 – Granger Dental opens
