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Mental Health and Healthcare Reform

Mental Health and Healthcare Reform. On the Banks or in the Mainstream? Harold Alan Pincus, MD Professor and Vice Chair, Department of Psychiatry Co-Director, Irving Institute for Clinical and Translational Research Columbia University Director of Quality and Outcomes Research

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Mental Health and Healthcare Reform

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  1. Mental Health and Healthcare Reform On the Banks or in the Mainstream? Harold Alan Pincus, MD Professor and Vice Chair, Department of Psychiatry Co-Director, Irving Institute for Clinical and Translational Research Columbia University Director of Quality and Outcomes Research New York-Presbyterian Hospital Senior Scientist, RAND Corporation LPHI/CIBHA Conference February3-4, 2011

  2. Agenda • PCASG/CIBHA • Where from? • Where to? • Healthcare Reform • Patient Centered Medical Home (PCMH) • Accountable Care Organizations (ACO) • Pay for Performance (P4P) • Comparative Effectiveness Research • Goals for Today/Tomorrow LPHI/CIBHA Conference February3-4, 2011

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  9. Mental-Health Challenge Emerges As Victims Face Multiple Traumas BATON ROUGE, La. – “…Post-traumatic stress disorder, depression and anxiety are common after major disasters, mental-health experts say, because disasters frighten people and disrupt their lives. But Hurricane Katrina poses special challenges…” “…The hurricane’s upheaval also has exacerbated the symptoms of some people who suffer from developmental disabilities and mental illnesses such as schizophrenia…” LPHI/CIBHA Conference February3-4, 2011

  10. Crossing the Quality Chasm “Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work: Changing systems of care will! LPHI/CIBHA Conference February3-4, 2011

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  12. “Crossing the Quality Chasm” LPHI/CIBHA Conference February3-4, 2011

  13. Six Aims For Improvement • Safe • Effective • Patient-centered • Timely • Efficient • Equitable LPHI/CIBHA Conference February3-4, 2011

  14. Old Rules Care is based on visits. Professional autonomy drives variability. Professionals control care. Information is a record. Decisions are based upon training and experience. New Rules 1. Care is based upon continuous healing relationships. 2. Care is customized to patient needs and values. 3. The patient is the source of control. 4. Knowledge is shared and information flows freely. 5. Decision making is evidence-based. Ten Rules for Achieving the Aims LPHI/CIBHA Conference February3-4, 2011

  15. Old Rules “Do no harm” is an individual clinician responsibility. Secrecy is necessary. The system reacts to needs. Cost reduction is sought. Preference for professional roles over the system. New Rules Safety is a system responsibility. Transparency is necessary. Needs are anticipated. Waste is continuously decreased. Cooperation among clinicians is a priority. Ten Rules for Achieving the Aims LPHI/CIBHA Conference February3-4, 2011

  16. Six Problems in the Quality of M/SU Health Care • Problem 1: Obstacles to patient-centered care • Problem 2: Weak measurement and improvement infrastructure • Problem 3: Poor linkages across MH/SU/GH • Problem 4: Lack of involvement in National Health Information Infrastructure (NHII) • Problem 5: Insufficient workforce capacity for QI • Problem 6: Differently structured marketplace LPHI/CIBHA Conference February3-4, 2011

  17. Crossing the Quality Chasm Consumer Participation Standardize Practice Elements • Clinical assessment • Interventions • IT infrastructure Develop Guidelines • Evidence-based medicine • Shared decision making Measure Performance • For each “6P” level • Across silos Improve Performance • Learn • Reward Strengthen Evidence Base • Evaluate effective strategies • Translate from bench to bedside to community Leadership Support Clinical Perspectives Integrative Processes LPHI/CIBHA Conference February3-4, 2011

  18. “6 P” Conceptual Framework • Enhance self-management/participation • Link with community resources • Evaluate preferences and change behaviors Patient/ Consumer • Improve knowledge / skills • Provide decision support • Link to specialty expertise and change behaviors Providers • Establish chronic care model and reorganize practice • Link with improved information systems • Adapt to varying organizational contexts Practice/ Delivery Systems • Enhance monitoring capacity for quality/outliers • Develop provider/system incentives • Link with improved information systems Plans • Educate regarding importance/impact of depression • Develop plan incentives/monitoring capacity • Use quality/value measures in purchasing decisions Purchasers (Public/Private) • Engage community stakeholders; adapt models to local needs • Develop community capacities • Increase demand for quality care enhance policy advocacy Populations and Policies LPHI/CIBHA Conference February3-4, 2011

  19. Don’t Split Mind and Body LPHI/CIBHA Conference February3-4, 2011

  20. Evidence-Based Chronic (Planned) Care Approaches for Treating Depression Are Effective Community Health System Resources and Policies Health Care Organization ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Productive Interactions Patient-Centered Coordinated Timely and Evidence- Efficient Based and Safe Informed, Empowered Patient and Family Prepared, Proactive Practice Team Improved Outcomes LPHI/CIBHA Conference February3-4, 2011

  21. Models of Linkage / Integration Embedded PCP in BHS Co-location of BHS in PCP B P P B Unified Coordination / Collaboration B P B P LPHI/CIBHA Conference February3-4, 2011

  22. Top Ten Issues General Health/Mental Health Relationships • Partnerships • Formalize • Accountability • Referral • Consultation/ Evaluation • Information Flow • Money • Quid Pro Quo • Maintenance • Generalize LPHI/CIBHA Conference February3-4, 2011

  23. PCASG Strategies • Medical Home • Care Management • Communic-Coordin-Integr-ation • Evidence-Based Practices • Training • Technical Assistance • Quality Incentives • Flexibility LPHI/CIBHA Conference February3-4, 2011

  24. “Crossing the Quality Chasm” LPHI/CIBHA Conference February3-4, 2011

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  26. Major Mental Health Policy Questions • How will healthcare reform incorporate mental health? • How should we pay for mental health care? How much? • Who will provide mental health care? • What is the role of the public sector? • Where will new scientific findings/ technologies come from? • Can mental health cross the “quality chasm”? LPHI/CIBHA Conference February3-4, 2011

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  28. Future Policy Initiatives • Healthcare Reform • Patient Centered Medical Homes (PCMH) • Accountable Care Organizations (ACO) • Pay for Performance (P4P) • Center for Medicare/Medicaid Innovation • Health Information Technology • Comparative Effectiveness Research • Concepts/Buckets/Questions • Mental Health Specific Initiatives LPHI/CIBHA Conference February3-4, 2011

  29. Healthcare Reform Innovations • Two Populations • General/Primary Care • Severe/Persistent Behavioral Health Conditions • Two Strategies • Mainstream • Separate Specialty Adaptations LPHI/CIBHA Conference February3-4, 2011

  30. Patient Centered Medical Home and Behavioral Health • Mainstream Strategy (augmentation) • Accreditation • BH one of three conditions • Require BH condition as fourth • Integrate BH care for all three conditions • Payment • Blended FFS and PM/PM • Pricing incremental BH costs • Risk Adjustment • Accessing BH Specialty care LPHI/CIBHA Conference February3-4, 2011

  31. Patient Centered Medical Home • BH Specialty “Health Homes” • In ACA (Sec. 2703) • SAMHSA Demonstration- 50+ Sites • Accessing General Health Care • Buy or Own? • Pricing Issues • Quality Measurement LPHI/CIBHA Conference February3-4, 2011

  32. Accountable Care Organizations • Networks of Hospital, PCPs, VNS, etc. • Bundled Payment • Shared Savings/Accountability for Quality • BH Accountability? • BH Care Management Expertise • Buy or Own? • BH ACOs for SPB populations? • Option 1: Maintain in Mainstream w MBHO Partner • Option 2: BH ACO with Full Accountability • Option 3: BH ACO with Limited Scope LPHI/CIBHA Conference February3-4, 2011

  33. Quality Measurement • “You can’t improve what you don’t measure” • Develop quality metrics (indicators) - Structure - Process - Outcomes • Across silos of MH/SU/GH • At each “P” level • Multiple activities/No stewardship LPHI/CIBHA Conference February3-4, 2011

  34. Improve Performance • Guideline Dissemination • Provider Training/Education/CME • Certification/Accreditation/Licensure • Provider Reminder Systems/Decision Support • Patient Education/Reminders • Quality Measurement • Quality Improvement- PDSA/Six Sigma/IHI • Public Reporting • Financial Incentives/P4P LPHI/CIBHA Conference February3-4, 2011

  35. P4P in Behavioral Health • Early study by Bremer, Pincus, et al • 23 programs identified • 11 targeting primary care providers • 10 focused on depression • Movement to go beyond “black box” of visit to specific PHQ measures • Longitudinal implementation of structure, process, outcomes measurement e.g. Minnesota DIAMOND project LPHI/CIBHA Conference February3-4, 2011

  36. Pay for Performance • Stewardship for BH Field • Measure Development • Risk Adjustment • “Market Basket” Problem • Multi Payer • Joint Accountability • Process-Outcomes Link LPHI/CIBHA Conference February3-4, 2011

  37. Comparative Effectiveness Research Issues for Behavioral Health and Wellness • CER Definitions • CER Questions: • Who, What, Where, When, Why LPHI/CIBHA Conference February3-4, 2011

  38. Why Now? “Only a limited amount of evidence is available about which treatments work best for which patients…” - Peter Orszag LPHI/CIBHA Conference February3-4, 2011

  39. Uncertainty, CER and Health Reform In situations where the right thing to do is well established, physicians from high- and low-cost cities make the same decisions. But in cases where the science is more unclear, some physicians pursue the maximum possible amount of testing and procedures; some pursue the minimum. And what kind of doctor they are depends on where they came from. In case after uncertain case, more was not necessarily better. Dr. Atul Gawande LPHI/CIBHA Conference February3-4, 2011

  40. BOGSAT Model LPHI/CIBHA Conference February3-4, 2011

  41. Economic Model LPHI/CIBHA Conference February3-4, 2011

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  43. Evidence-Based Practices • specific interventions • medications, psychotherapies, team-based, etc. • appropriateness/fidelity measurement • training, supervision • Measurement-Based Care (MBC) • clinical measures (e.g. HA1c, PHQ-9) • systematic, consistent, longitudinal • action-oriented • Best Practices/Context • accessibility • therapeutic alliance • patient centeredness • cultural competence LPHI/CIBHA Conference February3-4, 2011

  44. Institute of Medicine Report Definition of Comparative Effectiveness Research (CER) • “The generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist patients, clinicians, purchasers, policy makers, and the public to make informed decisions that will improve health care at both the individual and population levels.” LPHI/CIBHA Conference February3-4, 2011

  45. Federal Coordinating Council Report Definition of CER • “CER is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in ‘real world’ settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances…” LPHI/CIBHA Conference February3-4, 2011

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  47. CER Questions • Who • What • Where • When • How • Why LPHI/CIBHA Conference February3-4, 2011

  48. Who • Identifying and characterizing participants • Diagnoses (within/beyond DSM) • Co-morbidity (MH, SUD and GMC) • Gender, Age, Ethnicity • Severity/Functioning • Preferences/Expectations LPHI/CIBHA Conference February3-4, 2011

  49. What • Medications • Other Somatic Treatments • Psychotherapies • Other Psychosocial Interventions • ACT, Supported Employment, etc. • Combinations/”Cocktails”/Algorithms • Systems/Policy/Economic Interventions LPHI/CIBHA Conference February3-4, 2011

  50. Where • Academic Settings • Primary Care Clinics • Mental Health Clinics • Community Hospitals • LTC, Home Care, Clubhouses, Other • Private Practice • Multiple Clinical Disciplines LPHI/CIBHA Conference February3-4, 2011

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