Integrating Prevention & Treatment of Substance Use Disorders with Primary Care Webinar – June 19, 2013 Patrick Gaut

1. Integrating Prevention & Treatment of Substance Use Disorders with Primary Care Webinar – June 19, 2013 Patrick Gauthier AHP Healthcare Solutions

2. Problem • Fragmentation • Marginalization • Discrimination • High Costs • Poor Quality and Outcomes • High Morbidity and Mortality • High Societal Costs • Multiple Chronic Conditions

3. International Comparison of Spending on Health, 1980–2010 Average spending on healthper capita ($US PPP) Total health expenditures aspercent of GDP Notes: PPP = purchasing power parity; GDP = gross domestic product. Source: Commonwealth Fund, based on OECD Health Data 2012.

4. Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 65 Percent of Expenses 1% 5% 22% $90,061 10% 50% $40,682 65% 50% $26,767 97% $7,978 Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009 Annual mean expenditure Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

5. Causes of Premature Death N Engl J Med. 2007 Sep 20;357(12):1221-8.

6. Solution Applying the Chronic Care Model in Integrated Practice • Developing an Informed, Activated Patient • Using Information Technology • Developing a Prepared, Proactive Practice Teams • Re-Organizing HealthcareSystem to Include SUD Treatment, Prevention, Health and Wellness

7. Integrating SUD with MH and Primary Care • Pre-Reform = special pilot programs and grant-funded initiatives • Post-Reform = Chronic Care Model, Triple Aim, Accountable Care Organizations, Patient-Centered Medical Homes, and Health Homes • Integration via Consolidation • De-Institutionalization and focus on community-based care • Primary Care locus and “medicalization” • Reimbursement reforms and shared risk

8. Accountable Care Organizations There are over 400 recognized ACOs today. More than 30 in California Dartmouth Institute

9. Primary Care Medical Homes

10. Primary Care Medical Home

11. Integration: Behavioral Medicine “the field concerned with the development of behavioral science knowledge and techniques relevant to the understanding of physical health and illness and the application of this knowledge and techniques to prevention, diagnosis, treatment, and rehabilitation” Yale Conference on Behavioral Medicine

12. Support for Integrated Models • One study showed that medical costs of patients with chronic diseases reduced by 20% if these patients received behavioral health interventions, but increased by 17% to 27% if they were treated in traditional office settings • Another study of non-diabetic patients showed that lifestyle (behavioral) changes reduced the incidence of diabetes by 58% compared to patients who received the placebo therapy • One analysis of 91 studies showed that medical utilization decreased by an average of 15.7% over baseline following behavioral intervention, compared with an increase of 12.3% without behavioral intervention, and thus yielded an overall 28% cost return

13. Behavioral Medicine Targets

14. Key Strategies Lifestyle Changes Improve nutrition, increase physical activity, stop smoking, use medications appropriately, practice safer sex, prevent and reduce alcohol and drug abuse.Training Coping, relaxation, self-monitoring, stress management, time management, pain management, problem-solving, communication skills, time management, priority-setting.Social Support Group education, caretaker support and training, health counseling, community-based sports events

15. Key Strategies • Integrating behavioral medicine strategies into primary care and managed care; • Increasing public awareness of behavioral interventions; • Including effective behavioral interventions in development of clinical practice guidelines; • Increasing use of information technology for behavioral interventions; • Improving integration of research and practice

16. Why is this Important? • Approximately one in four Americans has MCC, including one in 15 children. • Among Americans aged 65 years and older, as many as three out of four persons have MCC. In addition, approximately two out of three Medicare beneficiaries have MCC. • People with MCC are also at increased risk for mortality and poorer day-to-day functioning. • MCC are associated with substantial health care costs in the United States. Approximately 66 percent of the total health care spending is associated with care for the over one in four Americans with MCC.

17. Objectives

18. Objectives

19. Elements of Integrated Care • Integrated Services • Integrated Teams • Cross-functional Screenings/Assessments • Integrated Treatment Planning Tools • Cross-trained Practitioners • Stage-wise Treatment • Motivational Interventions • Cognitive-Behavioral Treatment • Integrated Medication Management • Integrated Billing • Integrated Outcomes and Quality

20. Other Settings • Community Mental Health Centers • Federally-Qualified Health Centers • Emergency Departments • Critical Access Hospitals (25 and fewer beds) • Rural Health Centers • Primary Care Clinics/Community Health Centers • Public Health • Correctional Facilities

21. Setting

22. Implementation Considerations • Networking and Affiliation • Business Model and Marketing Material • Agreements • Revenue Share/financial model • Reimbursement reforms • Billing for Case Management/Care Coordination

23. Implementation Considerations • Knowledge barriers • Stigma and cultural differences • Privacy laws • Willingness to collaborate and partner • Access to capital • Structure and governance • Health IT infrastructure compatibility

24. Evidence-Based Practices • Integrate EBP into policies and procedures • Assess training needs • Share tools and expertise across boundaries • Monitor and evaluate regularly • Ensure services are culturally competent

25. The System of Care: Goals & Objectives GOAL 1: Improve the Coordination of Behavioral Health Services with Primary Care and Supportive Services and Maximize the Use of Available Resources to Effectively Address Behavioral Healthcare Needs by Reducing Fragmentation and Ensuring a Full Spectrum of Care Source: Taking Integration to the Next Level: The Role of New Service Delivery Models in Behavioral Health. 2012 - Cornerstones for Behavioral Healthcare Resource Series. Joel E. Miller, Senior Director of Policy and Healthcare Reform National Association of State Mental Health Program Directors (NASMHPD)

26. Objectives • Accelerate the necessary linkages between physical health care and behavioral health services to promote and achieve recovery for people with mental illnesses and/or substance abuse who also have chronic physical diseases. • Provide content expertise in the development and implementation of behavioral health aspects of service delivery system reforms such as medical homes, health homes and accountable care organizations, and related payment initiatives such as bundling and capitation.

27. Objectives • Accelerate the necessary linkages between behavioral healthcare services and the array of supportive services (supported housing, employment, transportation, education and training, etc.) • Develop and implement effective behavioral health promotion, wellness and prevention activities. • Provide content expertise on the development of and inclusion of behavioral health quality measures in specifications for electronic health records, in the development of health information exchanges, and in public and private sector initiatives to improve the quality of behavioral healthcare.

28. Objectives • Provide leadership to health providers, federal and state policymakers and officials, national medical societies, including primary care organizations, to ensure the adequacy of providers in the behavioral health workforce to deliver quality behavioral health care services. • Empower consumers to maximize control of their recovery through new and emerging ways to design, apply and organize existing treatments and by finding new platforms and avenues to deliver new treatments. • Provide content expertise on benefits and scope and requirements for behavioral health services – in partnership with state insurance authorities – that are offered in public and private health insurance plans operating in the state.

29. Objectives • Actively ensure the outreach and enrollment of individuals with mental and substance use disorders so they may receive and maintain health coverage based on their eligibility and are able to easily access care.

30. Conducting Your Environmental scan Source: Mady Chalk, TRI

31. Accountability • Environment: • Major focus on medical home in primary care setting • Pressure to implement EHRs • Field still struggling with hand-offs and transitions between levels of care/agencies • Co-morbidity (MH/SA and MED/SA) issues are still befuddling payers and providers

32. Patient/Family Role • Environment: • Focus on patient centered care • Increase pressure on offering choice of provider • New eligibles—different age/socio-economic group—maybe more vocal about their treatment and treatment options

33. Performance Expectations • Environment • Implementing National Quality Forum (NQF) Standards of Care • Decreasing drop-outs/increasing engagement, retention, and continuing care • Increasing use of medications as part of comprehensive treatment • Continuous monitoring during treatment and use of data to adapt treatment services during treatment

34. SUD Role in Health Care • Environment: • Increase access to treatment through FQHCs • SBIRT is both an NQF Standard and consider important to provide in healthcare settings • Medi-Cal authorities’ decision-making process about changes in benefits, providers, services and reimbursement • Pressures by health plans to have credentialed practitioners deliver services • Linking health and specialty care is considered critical

35. Access • Environment: • Access is still a premium to payers • Still defined in fairly traditional terms • Medi-Cal, payers, managed care organizations and the Department of Insurance will be tracking access for newly eligible patients more closely • Assumes new coverage = new or different utilization patterns and services

36. Value/Cost • Environment: • Identification of services/practices that add value • Proof or evidence to support purchasing decisions • Payers more likely to define value in terms of savings or offsets—not necessarily on improved health outcomes • Will have to show value to the customer who will have some “skin” in the game (deductibles, co-pays)

37. Integration • Environment: • Developing standards for integrated care • Providers are further along than payers • Assumption that carve-ins will get you closer to integration • Reimbursement rules don’t necessarily encourage integration at the practice level • Still focusing on differences versus similarities • Public payer silos continue to thwart integration

38. Workforce • Environment: • Payers equate a credentialed workforce with quality although a significant portion of workforce is not credentialed • All over the map regarding a definition of competency (versus credentialed) • Good supervision is diverted by productivity expectations and reimbursement • Recovery support providers have momentum and creating formal networks to compete for dollars

39. Role of Technology in Delivery • Environment: • Technology is moving faster than practice • There are simple uses of technology to enhance access (texting reminders) • Investment in technology in the provider community is spotty

40. Treatment Interventions • Environment: • Interventions should produce value and we have evidence of what works • Pressures exist to keep buying the “same old” • Payers don’t yet fully embrace newer interventions – this is an “educated sale” • We aren’t good at the “elevator speech” in describing interventions

41. Reimbursement • Environment: • Continued focus by payers on purchasing units of services, some initial discussion re: purchasing episodes of care versus widgets • Providing integrated treatment made difficult by outdated reimbursement rules that preclude billing two services on same day from same address • Pay for performance strategies not widely used yet in SUD • Different payers/different rates/same services

42. Next Steps • Conduct Local Market Research • Conduct Your Own Environmental Scan • Develop Business Model/Integration Model • Begin Networking with Primary Care/Settings • Prepare Internally: • Board on board • Staff trained and ready to meet requirements • Infrastructure assessed and deployed (staffing, EBPs, Tools, IT, etc.) • Ready for new reimbursement, quality and outcomes models, methods and measures

43. Thank You – Questions? Contact: Patrick Gauthier Director AHP Healthcare Solutions pgauthier@ahphealth.com