"Integration Can Work! Demonstrating Cost Effectiveness and Marketing It in the Real World"

1. Session # G2b Friday, October 11, 2013 "Integration Can Work! Demonstrating Cost Effectiveness and Marketing It in the Real World" Natasha Gouge, PhD Psychologist, MSMG Pediatrics, Kingsport TN Jodi Polaha, PhD Associate Professor, Department of Psychology, East Tennessee State University Collaborative Family Healthcare Association 15th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives • Learn a method of assessing cost effectiveness of behavioral health integration within a primary care clinic • Obtain results from a study assessing cost effectiveness of behavioral health integration within a primary care clinic • Identify strategies for disseminating and marketing cost effectiveness results to administrators and third party payers • Discuss applications of this case study to a wide array of clinics and styles of integration

4. Learning Assessment Audience Question & Answer

5. Overview • Rationale • Study aim • Methods • Results • Marketing • Q & A

6. Rationale • A barrier cited by PC administrators in integrating BH is financial risk • Fee-for-service billing mechanisms remain complex and there is little empirical guidance on cost-effective models • indirect benefits of hiring a Behavioral Health Consultant have been demonstrated in large health care industry but not in small, stand-alone practices • evaluate the cost effectiveness of an integrated care model in a pediatric private practice clinic Study Aim

7. Method • Procedure • BHC is available one full day per week • Case consultation • Warm hand-offs • Follow-up referrals • Located near nurse pods

8. Method • Overall comparison BHC vs non-BHC days • Total # of patients seen • Time spent by staff and providers in DPC • Billing codes/levels used • Reimbursement received • Prorate revenue generated on BHC days for possible cost offset

9. Method • Additional output • Concerns raised • % of concerns addressed • Utilization of BHC services • Insurance providers • % of reimbursement rates

10. Hypotheses • More patients seen on BHC days • More revenue generated on BHC days • Incorporation of BHC is cost effective

11. 669 complete appointments • 277 Non-BHC Day • 392 BHC Day • 63 BHC-patient contacts • 59% Medicaid • 49% Commercial • 1% Self Pay • Data was obtained for 92% of all visits • 8% accounted for participation refusal • 30% of data used for inter rater reliability • score of 96%

12. Visits & BHC Contacts

13. Concerns

14. Concerns

15. Top Concerns Presented Medical Behavioral BHC used

16. BHC averages 6 pts/day • 7-57 minute appts • Average appt = 27 minutes • Primarily complicated psychiatric referrals Medical Behavioral BHC used

17. Visits by Clinic Day Hypothesis 1: 115 more pts on BHC days; 42% increase in volume

18. Time Savings BHP Day in General • Patients • Increase in direct care • Off-site earlier • 5 minutes less of wait times • Providers • Save 3 minutes per patient • @ 15 pts = 45 extra available minutes • @ 20 pts = 60 extra available minutes BHP Contacts • Patients • 22 additional min of direct care • Onsite 10 minutes longer • 10 minutes less in non-care • 4 minutes less in waiting room • Providers • Save 5-50 minutes per BHP patient • Highest savings from complicated well visits and psychiatric visits

19. Hypothesis 2: Reimbursement: Visit Type/Day Calculations

20. Hypothesis 3: • Yearly stipend $10,000 • @ 1 day a week for 52 weeks • $193/day • Current data shows additional revenue generated on BHC days = $1,120 • $927 average daily profit • $48, 204 annually

21. Discussion points • All hypotheses confirmed • 42% increase in patient volume across all visit types • Increase in revenue generated because of more pts seen, and time saved • Increase revenue generated is more than adequate to cover current BHC costs • Differences remain statistically significant even when controlling for pre-scheduled BHC appts

22. Consider… • Areas to get at maximum cost effectiveness • Increase BHC coverage • Increase BHC on WCC and Psych appts • Remember Acute and Psychiatric visits have the highest reimbursement ratio • Use BHP strategically before/after drs and primary/secondary to NPs • Increase compliance with co-pays • Continue monitoring data

23. Using the Data Jodi Polaha, Ph.D. Associate Professor, Psychology ETSU

24. Rationale • Further growth of integrated care movement. • Create jobs for graduates of ETSU’s doctoral program. • Build needed workforce in rural Appalachia.

25. Taking the Data on the Road

26. Taking the Data on the Road

27. Interested in nuanced aspects to data. Caused reflection on practice habits. Underscored utility of student BHC Led credence to “gut feeling” Resulted in efforts to make job offer/increase student hours on site Mountain View Pediatrics

28. Mountain States Medial Group Pediatrics • Providers trained in integrated care • Providers rally administration • Resulted in a full-time hire

29. Mountain States Medial Group Pediatrics In the world of pediatrics, revenue is ALWAYS  going to come down to one key thing:  numbers.  I don't care what anyone says.  Numbers are what makes money in peds.  So if you can offer a service that increases your numbers, you can't go wrong.  That this type of service makes us more productive and gets much needed services to our patients makes hiring a BHP a no-brainer to me.  I've been begging for something like this for years. It’s all about numbers. Time savings make a huge impact in peds.  You try to ask a mom to only give you their top two concerns and schedule a future appointment for the rest, and she will be looking for another pediatrician.  We get new patients all the time because they feel like their current provider isn't giving them enough time and attention.  That is what every concerned parent wants when they walk in the door:  time and attention.  And we give it, because it is important and it hurts your practice if you don't, but quite frankly it costs us a great deal of money and productivity because we can't get reimbursed for that.

30. Mountain States Medial Group Pediatrics I love that this model doesn't include psychiatric billing, and the cost savings is still demonstrated.  I think billing for the service would actually deter patients from using it.  If there is a way to maximize the time savings piece and do other things for our wealthier self-pay patients like cash for service appts, flat fees for groups, or camps in the summer, I think that is actually the best way to go here.  Parents get frustrated when they get a bill because you charged for cleaning out their child's ear in the office and come in pitching a fit, so the more of this type of service that can be offered without relying on direct billing the better probably.  Marketing this as a free service that we offer our patients will ultimately get us more patients, which gets us more money.  Plain and simple, really.

31. ETSU Pediatrics (Residency Program) • Agreed with utility (service/training) and value for patients • Unconvinced BHC could “save time” given precepting model. • Wondered about BHC impact on “quality of life” for residents/ preceptors, impact medical errors/fatigue etc.

32. Cost savings would not be realized due to strength in setting agenda. Still: “After (considering data) I propose we consider having one of your doctoral candidates—isn’t that the level of learner in her study?—come to our clinic a couple of half-days/month. ETSU Family Medicine (Residency)

33. BlueCare (Third Party Payer) • Estimate #s patients served who might need services if you had more to offer. Children vs. Adults? • List high risk populations (chronic pain, pregnant moms, opioid users). • Add as outcome “closing HEDIS gaps in care”. • Add as outcome “reduction of acute care and ED with projection of $$ saved”

34. Marketing the Data • Audience X Data match • Implications for future research • Thoughts about Dissemination

35. Dissemination

36. Q & A