Transforming primary care practices in
pursuit of the Triple Aim:
How Great Leadership Can Make or
Break the Deal
Marci Nielsen, PhD, MPH
The Ohio Council of Behavioral Health & Family Services 2014
Annual Conference
National Imperative: “Triple Aim”
Better Patient
Experience
“Triple
Aim”
Lower Per Capita
Health Care Costs
Improved Quality
(better outcomes)
Source : Berwick, Donald M., Thomas W. Nolan, and John Whittington. "The triple aim: care, health, and cost." Health Affairs 27.3
(2008): 759-769.
PCPCC 2014. All Rights Reserved.
Transformation requires…
Consumer
Engagement
Delivery
Reform
Payment
Reform
Benefit
Redesign
ATUL GAWANDE, MD, MPH
Harvard Professor, Surgeon, Writer,
Public Health Researcher
4
Atul Gawande, MD, MPH
• Born: 1965, Brooklyn, NY
• Education: Balliol College
(1989), Stanford University
(1987), Harvard (MD, MPH)
• Additional facts: MacArthur
Fellowship; nomination for
National Book Award for
Nonfiction, New Yorker
author
5
ATUL GAWANDE, MD, MPH
Harvard Professor, Surgeon, Writer,
Public Health Researcher
Chief Executive Officer, PCPCC
6
Coincidence?!
Atul Gawande, MD, MPH
Marci Nielsen, PhD, MPH
• Born: 1965
• Born: 1965
• Education: Balliol
• Education: Briar Cliff
College (1989), Stanford
(1987), George
University (1987),
Washington University
Harvard (MD, MPH)
(1994), Johns Hopkins
(PhD)
• Wrote a speech called
“Cowboys and Pit
• Live in a state with real
crews”
live cowboys and pit
crews
7
Cowboys and pit crews
“We train, hire, and pay
doctors to be cowboys”…
8
Pit crews realities
• Changing this “is the greatest task of your
and my generation of clinician and
scientists”
• Values of humility, discipline (i.e.
standardization), teamwork
9
PCPCC 2014. All Rights Reserved.
Delivery reform:
Growing evidence to support that it
works
Delivery
Reform
PCPCC 2014. All Rights Reserved.
Defining the medical home
The medical home is an approach to primary care that is:
Patient-Centered
Supports patients in
managing decisions and care
plans.
Comprehensive
Whole-person care provided
by a team
Committed to
quality and safety
Maximizes use of health IT,
decision support and other tools
11
Source: www.ahrq.gov
Coordinated
Care is organized across
the ‘medical
neighborhood’
Accessible
Care is delivered with short
waiting times, 24/7 access
and extended in-person
hours.
PCMH at of “Medical Neighborhood”
Health IT
$
Community
Centers
Public
Health
Schools
Home
Health
Patient-Centered
Medical Home
Pharmacy
Hospital
Oral Health
Employers
Faith-Based
Organizations
Mental
Health
$
Health IT
Specialty &
Subspecialty
Skilled
Nursing
Facility
↑ Health care expenditures per person
Requires industry & government solutions
8,000
7,000
Out-of-pocket spending
890
Private spending
6,000
5,000
Public spending
3,092
720
38
4,000
1,350
3,000
449
580
589
246
510
470
360
528
79
571
441
2,000
343
204
542
88
4,005
3,307
2,618
2,726
2,844
2,758
2,716
2,124
1,000
2,446
2,056
0
US
NOR
SWITZ
CAN
FR
GER
SWE
AUS*
UK
ITA
Dollars
13
*Adjusted for Differences in Cost of Living
* 2006
PCPCC 2014. All Rights Reserved.
Source: OECD Health Data 2009 (June 2009), Commonwealth Fund
Health care “waste” = Overuse, Underuse,
Misuse
Frustration with health care costs and
productivity
Iceberg
of Additional
Costs to
Employers
from Poor
Health
70%
30%
Personal Health Costs
Medical Care
Pharmaceutical costs
Workers’ Compensation Costs
Productivity
Costs
Absenteeism
Short-term
Disability Long-term
Disability
Presenteeism
Overtime
Turnover
Temporary Staffing
Administrative Costs
Replacement Training
Off-Site Travel for Care
Customer Dissatisfaction
Variable Product Quality
Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009;
51(4):411-428. and Edington DW, Burton WN. Health and Productivity.
Top 5 conditions in the workplace = Tied to
behavioral/mental health
$400,000
Costs/1000 FTEs
$350,000
$300,000
Presenteeism
Absenteeism
Drug
Medical
$250,000
$200,000
$150,000
$100,000
$50,000
$0
Loeppke, et al., JOEM. 2009;51(4):411-428.
16
Solutions = Strengthened primary care
Significant
problems
Rising healthcare costs
$2.4 trillion (17% of
GDP)
Gaps/variations in
quality and safety
Poor access to PCPs
Below-average
population health
↑ Aging population
Chronic disease
17
… “Experiments”
underway
• PCMHs
• ACOs
• EHR/HIE investment
• Disease-management
pilots
• Alternative care
settings
• Patient engagement
• Care coordination
pilots
• Health insurance
exchanges
• Top-of-license practice
… Primary care-
centric projects
have proven
results
Across 300+ studies,
better primary care
has proven to increase
quality and curtail
growth of health care
costs
PCPCC 2014. All Rights Reserved.
Primary Care Remains Undervalued
U.S. per-capita health spending,
2012 (under 65 with employersponsored health insurance)
PCPCC 2014. All Rights Reserved.
The reports of our death are greatly
exaggerated.
Methods
Reported outcomes are divided into 6 categories:
Cost Savings
Improved Health
2
Fewer ED / Hospital Visits
Improved Access
Improved Patient/
Clinician Satisfaction
Increased Preventive
Services
PCPCC 2014. All Rights Reserved.
Filter Results by Outcome
Go to the “Outcomes View” for PCPCC’s Primary Care Innovations and
PCMH Map http://www.pcpcc.org/initiatives/evidence
2
PCPCC 2014. All Rights Reserved.
Reported Outcomes: Cost Savings
Program
Outcomes
Date Published
Report Type
Anthem BC ACO
$4.7 Million (in 6 months)
June 2014
Industry Report
BCBS Michigan PCMH
Program
$26.37 PMPM (2009-2010)
$155 million (2008-2009)
July 2013
Peer-Reviewed
Oregon Coordinated Care 18-19% reduction in ED visit spending
Organizations (Medicaid)
Nov 2013,
June 2014
Industry Report
Vermont Blueprint for
Health (Multi-Payer)
Reduced expenditures in 2012 by:
Jan 2014
Industry Report
CareFirst BCBS PCMH
Program (DC, MD, VA)
$267 million avoided costs (20112013)
July 2014
Industry Report
Monarch Healthcare
CMS Pioneer ACO (CA)
5.4% reduction in medical costs in
2012 (Medicare)
Jan 2014
Industry Report
• $386 PMPY commercial (ages 1-17)
• $586 PMPY commercial (ages 18-64)
• $200 PMPY Medicaid (ages 1-17)
• $447 PMPY Medicaid (ages 18-64)
Horizon BCBS of New
$4.5 million savings (ER visits and
July 2014
Industry Report
Jersey PCMH
Source:Program
Primary Carehospitalizations)
Innovations and PCMH Map by Outcomes. PCPCC. Accessed
4% lower total cost of care (all pts)
September 2014. http://www.pcpcc.org/initiatives/evidence
4% lower cost of care (diabetes pts)
Independence BC PCMH
Program (PA)
Total cost savings for high risk groups:
7.9% and 11.2% (2010, 2009)
March 2014
Peer-Reviewed
PCPCC 2014. All Rights Reserved.
Reported Outcomes: Fewer ED/Hospital Visits
Program
Outcomes
Date
Published
Report Type
Aetna PCMH - New
York
35% fewer hospital admissions (WESTMED
Medical Group, year 1)
June 2014
Industry Report
CareFirst BCBS
PCMH Program (DC,
MD, VA)
6.4% fewer hospital admissions
8.1% fewer readmissions (all-cause)
11.1% fewer hospital days
July 2014
Industry Report
BCBS Michigan
PCMH Program
27.5% lower hospital stays
11.8% lower PC-sensitive ER visits (adults)
9.9% lower ER visits (adults)
14.9% lower ER visits (pediatrics)
July 2014
Industry Report
Missouri Health
Homes (Medicaid)
6-8% decrease in ED use
10-13% decrease in hospitalizations
March 2014
Industry Report
New York Health
Homes (Medicaid)
23% decrease in hospital admissions and ER
visits
March 2014
Industry Report
Rhode
Island Primary Care
11.6%
fewer ambulatory-sensitive
visits
Nov 2013,
Source:
Innovations
and PCMH Map byED
Outcomes.
PCPCC.
AccessedPeer-Reviewed,
Chronic
Care
May 2014
Industry Report
September
2014. (2013)
http://www.pcpcc.org/initiatives/evidence
Sustainability
Fewer inpatient hospitalizations among more
Initiative (Multiexperienced participants (2014)
Payer)
PCPCC 2014. All Rights Reserved.
Reported Outcomes: Improved Access
Program
Outcomes
Date
Published
Report Type
BCBS Michigan PCMH
Program
21.3% lower ER visits (pediatrics) due to
appropriate/timely PC
July 2014
Industry
Report
Maryland Multi-Payer
PCMH Program
Statistically significant improvement in
patient access to care (based on survey
data)
Feb 2014
Peer-Reviewed
New York Health
Homes (Medicaid)
14% increase in primary care visits
March 2014
Industry
Report
Oregon Coordinated
Care Organizations
18% increase in outpatient PC visits
36% increase in PCMH enrollment
Nov 2013
Industry
Report
• Increased phone encounters (from 2.7 to
July 2013
Peer-Reviewed
28.8/100 patients/quarter)
• Increased use of personal health records
(3% to 13% enrolled pts)
• Increased electronic messaging to
providers (.01%
to 2.3%Map
pts/qtr)
Source: Primary Care Innovations
and PCMH
by Outcomes. PCPCC. Accessed
•
Increased
same
day
appts
(p<.01)
September 2014. http://www.pcpcc.org/initiatives/evidence
• Increase in patients seen within 7 days of
desired appointment date (85% to 90%,
p<.01)
VA Patient Aligned
Care Team (National)
PCPCC 2014. All Rights Reserved.
Reported Outcomes: Improved Health
Program
Outcomes
Date
Published
Report Type
Anthem BC ACO (CA)
Increase in meeting quality measures:
• 7.5% LDL (diabetes)
• 3.8% in cholesterol management for heart
disease patients
June 2014
Industry Report
CareFirst PCMH
Program (DC, MD, VA)
• 3.7% higher quality scores for panels
receiving incentives
• 9.3% higher quality scores for PCMH panels
(2011-2012)
June 2013
Industry Report
Horizon BCBS NJ
PCMH Program
• 14% higher rate in improved diabetes
control
• 12% higher rate in cholesterol management
July 2014
Industry Report
South Central
Pennsylvania Alliance
Improved blood pressure control from 67% in
2010 to 79% in 2013 (East Berlin Family
Medicine practice)
June 2014
Industry Report
Fresno PCMH Initiative 50% increase in diabetes patients with
Feb 2014
Industry Report
Source: Primary Care
Innovations
and
PCMH
Map
bypilot
Outcomes. PCPCC. Accessed
(CA-AFP)
controlled
blood
sugar
after
1-yr
September 2014. http://www.pcpcc.org/initiatives/evidence
Primary Care
Outperformed non-PCMH practices on BD
June 2014
Peer-Reviewed
Information Project
control in hypertension/ diabetes patients,
(NY Medicaid)
and smoking cessation intervention
measures
PCPCC 2014. All Rights Reserved.
Reported Outcomes: Improved Patient/Clinician
Satisfaction
Program
Outcomes
Date Published
Report Type
BCBS Michigan PCMH
Program
3.5% - 5.2% higher adult quality
composite score (2009-2010)
July 2013
Peer-Reviewed
Fresno PCMH Initiative
(CA-AFP)
Overall improvement in patient
satisfaction
Feb 2014
Industry Report
MGM Resorts Direct
Care Health Plan
88% satisfaction rating among
members (2013)
Jan 2014
Industry Report
Rhode Island Chronic
Care Sustainability
Initiative (Multi-Payer)
Practices increased their positive
patient experience ratings for:
• access to care
• communication with care team
• office staff responsiveness
• shared decision-making
• self-management support
May 2014
Industry Report
VA Patient-Aligned
• Lower staff burnout in PCMH
June 2014
Peer-Reviewed
Care
Team Primary
(National)
practices (2.29
vs. 2.80,
Source:
Care Innovations
and PCMH
Mapp=.02)
by Outcomes. PCPCC. Accessed
• Higher patient satisfaction
September 2014. http://www.pcpcc.org/initiatives/evidence
scores in PCMH practices (9.33
vs. 7.53, p<.001)
PCPCC 2014. All Rights Reserved.
Reported Outcomes: Increased Preventive Services
Program
Outcomes
Date
Published
Report Type
Aetna PCMH – New
York
Physicians met or exceeded 9/10 targeted goals:
cancer screenings, diabetes & heart disease
management & screening, (WESTMED Medical
Group, year 1)
June 2014
Industry
Report
Horizon BCBS NJ
PCMH Program
8% higher rate in breast cancer screenings
6% higher rate in colorectal screenings
July 2014
Industry
Report
Husky Health PCMH
(CT Medicaid)
Children seen in PCMH 10% more likely to receive
recommended EPSDT screenings
July 2014
Industry
Report
MGM Resorts Direct
Care Health Plan
95% participation in annual physicals led to
increase in preventive screening rates and
diagnosed conditions (2012)
Jan 2014
Industry
Report
Oregon Coordinated
Care Organizations
(Medicaid)
58% increase in children screened for risk of
developmental, behavioral, and social delays
(2011)
June 2014
Industry
Report
South Central
Tobacco cessation counseling improved from 36%
June 2014
Source: Primary in
Care
Innovations
Outcomes. PCPCC. Accessed
Pennsylvania
2010
to 86% inand
2013PCMH
(East Map
BerlinbyFamily
September 2014.Medicine
http://www.pcpcc.org/initiatives/evidence
Alliance
practice)
Vermont Blueprint
for Health (MultiPayer)
• Increased screenings for breast and cervical
cancer (adult commercial & Medicaid).
• Increased adolescent well-care visits
Jan 2014
Industry
Report
Industry
Report
PCPCC 2014. All Rights Reserved.
Reported Outcomes: Behavioral Health
Program
Georgia PCMH
University
Outcomes
•
•
Depression screening rate in elderly
increased from 11% to 56% (use PQH-2
every visit)
6% improved rate of tobacco cessation
counseling
•
•
•
•
Lower ED use
Lower hospitalization rates
Lower staff burnout
Higher scores of patient satisfaction
Missouri Medicaid
Health Home
•
•
•
6-8% decrease in ED use
10-13% decrease in hospital admissions
Cost savings of $52 PMPM
New York Medicaid
Health Home
•
VA Patient-Aligned
Care Teams
(Integrated BH, 1 fulltime BH coordinator
at each facility)
Date
Published
Report Type
2013
Industry Report
June 2014
Peer-Reviewed
March 2014
Industry Report
23% decrease in hospital admissions and ER
March 2014 Industry Report
visits
• 14% increase in primary care visits
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed
RhodeSeptember
Island
• http://www.pcpcc.org/initiatives/evidence
Practices met every targeted patient health
May 2014
Industry Report
2014.
Chronic Care
outcome and show improvement over time
Sustainability
(e.g., weight management, diabetes, high
Initiative (Multiblood pressure, tobacco cessation)
PCPCC 2014. All Rights Reserved.
Payer)
Reported Outcomes: Oral Health
Program
Outcomes
Date Published Report Type
North Carolina
Pediatric and
General Dentist
(opinion survey)
Awareness of AAPD referral guidelines found
to significantly lower relative risk of
recommending that physicians wait to refer
children without varnish.
2014
PeerReviewed
Connecticut Health
Enhancement
Program (State
Employees)
Enrollees receive cost-sharing reductions if
commit to two free dental cleanings per year
(among others). Program results:
• 22.9% fewer monthly ED visits
• 75% increase in PC visits
• 70% reduction in medical trend growth rate
Jan 2013
Industry
Report
Institute for Family
Health PCMH
Program (Manhattan
& Hudson Valley –
NY Medicaid)
4 of these program sites offer dental
May 2013
services. Program results:
• Reduced mean annual A1c levels (from
10.7% to 8.3%)
• Increased access to psychosocial,
diabetes education, and primary care
Source: Care Coordination
Among
Pediatricians
services
(diabetes
patients)and Dentists. BMC Oral Health.
http://www.medscape.com/viewarticle/825528_4
• Increased patient outreach services,
diabetes education support, and HbA1c
monitoring & testing.
PeerReviewed
PCPCC 2014. All Rights Reserved.
VISIT THE PCMH MAP AT
WWW.PCPCC.ORG/INITIATIVES
Payment Reforms:
Necessary to sustain the model (and
the progress made)
Payment
Reform
PCPCC 2014. All Rights Reserved.
Emerging Payment Reform Trends
Bundled
payments
Fee-ForService
Volume-based
reimbursement
Global
budget
contracts
ACOs
Value-based
reimbursement
PCPCC 2014. All Rights Reserved.
2013 Greenway Medical Technologies, Inc
PCMH and Accountable Care:
Joining Forces
Accountable Care
Medical
Neighborhood
PCMH
PCMH
Hospitals
Care Coordinators
Care Managers
Behavioral health
Specialists
Public &
Community Health
PCMH
PCMH
Health IT Infrastructure
36
PCMH
Trajectory to Value-Based Purchasing
It is a journey, not a fixed model of care
Primary Care
Capacity:
Patient
Centered
Medical
Home
Operational
Care
Coordination:
Embedded RN
Coordinator
and Health Plan
Care
Coordination $
Value/
Outcome
Measurement:
Reporting of
Quality,
Utilization and
Patient
Satisfaction
Measures
HIT
Infrastructure:
EHRs and
Connectivity
37
Source: THINC - Taconic Health Information Network and Community
Value-Based
Purchasing:
Reimbursement
Tied to
Performance on
Value
Supportive Base
for ACOs, PCMH
Networks,
Bundled
Payments,
Global
Capitation
ACO Growth Since 2011
http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/
PCPCC 2014. All Rights Reserved.
How ACOs today differ from 1990’s
“Managed Care/Cost Organizations”
Accountable Care
40
Capitated Managed Care
First and foremost, providers
“Gateway” to system through
primary care
Mix of Fee-For-Service (FFS)
with shared saving; shared
savings and shared risk; or
partial capitation
Payment also linked to
quality targets
First and foremost, insurers
“Gatekeeping” that limited
provider choice
Full capitation where
providers carried vast
majority of risk
Rarely included payment
linked to quality
Frakt, AB and Mayes, R (2012) Health Affairs
Benefit Redesign:
Need employer and health plan
engagement
Benefit
Redesign
PCPCC 2014. All Rights Reserved.
The importance of benefit design
Wise Investments in Employee Health Are Cost-Effective
Reduction in
Medical
Costs
Reduction
in HealthRelated
Absences
Benefit
Cost
Reduction in
On-the-Job
Productivity
Losses
Employers are increasingly adopting cost-effective – or value-based
benefits design strategies
Source: Larry Pheifer and Dave Eitrheim, MD (2011)
42
PCPCC 2014. All Rights Reserved.
Typical US employer healthcare cost
distribution
2%
18%
9%
Healthcare cost
Primary care
Inpatient
Outpatient
38%
33%
Pharmacy
Emergency
dept.
• By improving care quality with a PCMH, primary care costs will increase
• However, implementation of PCMH has been shown to result in lower
hospitalization rates – and will likely lead to lower health care costs.
PCPCC 2014. All Rights Reserved.
Public Engagement:
Patients, Families & Caregivers, and
Consumers must drive demand for
the model
Public
Engagement
PCPCC 2014. All Rights Reserved.
Authentic Patient Engagement and
Activation
IOM (2002); modified from Dahlgren and Whitehead (1991)
45
Patient activation is developmental & predicts
health behaviors
Research consistently finds that those who are more activated are:
Engaged in more preventive behaviors
Engaged in more healthy behaviors
Engaged in more disease specific self-management behaviors
Engaged in more health information seeking behaviors
Source: J.Hibbard, University of Oregon
A
Multidimensional
Framework For
Patient And
Family
Engagement
Carman K L et al.
Health Aff 2013;32:223-231
©2013 by Project HOPE
Back to the: “Triple Aim”
Better Patient
Experience
“Triple
Aim”
Lower Per Capita
Health Care Costs
Improved Quality
(better outcomes)
Source : Berwick, Donald M., Thomas W. Nolan, and John Whittington. "The triple aim: care, health, and cost." Health Affairs 27.3
(2008): 759-769.
PCPCC 2014. All Rights Reserved.
Lower Per Capita Costs?
Manage high-risk, high need populations
• Risk stratification and diligent
monitoring for all patients
• Right care, right place, right time with
the right primary care team
• Track care plans and medication
adherence
• Care coordination across continuum of
care
• Patient engagement and activation
PCPCC 2014. All Rights Reserved.
Working with patients based on their
needs
Outreach/screening
Low Risk, Low Cost
Number
of
Enrollees
Care Management:
Medium Cost, Manageable Risk
The “Boundary” is Flexible
Case Management:
High Risk, High Cost
Risk or Care Gaps or Costs/Charges per Member
Source: Sidarov, J (2013) Population Health Management & the Medical Neighborhood, PCPCC Monthly
National Briefing, September
Better Patient Experience of Care?
Improved Access to Care & Compassionate Care
51
• 24/7 access to care team (phone
or e-consults with nurses, etc.)
• Open scheduling & alternatives to
traditional face-to-face visits,
including telemedicine, group
visits, e-consults
• Culture of compassion and
personal relationship with patient
• Communication, communication,
communication!
PCPCC 2014. All Rights Reserved.
Improved Population Health Outcomes?
Care is coordinated and data shared
electronically
• Data shared across providers and
institutions available at point of care
and referrals are tracked
• Patients engaged through electronic
records, portals, mobile apps, email
• Focus on whole person and
recognition of behavioral health
needs
PCPCC 2014. All Rights Reserved.
Terminology preferred by patients and
consumers
Amanda Holt (2014). Communicating health care concepts: Finding language to help consumers
understand the PCMH. Masters Thesis.
PCPCC 2014. All Rights Reserved.
Connecting the dots: Care
coordinators/diverse care teams
•
•
•
•
Care coordinators
Patient navigators
Health coaches
Behavioral
health/mental
health
• Community
supports and social
workers
• Pharmacists
PCPCC 2014. All Rights Reserved.
Comprehensive Medication Management
Gaps in clinical goals are
determined, drug therapy
problems identified, and
therapeutic
recommendations made
Patient Family
& Caregiver
Clinical Pharmacist/
Pharmacotherapy Manager
Optimal therapeutic
recommendations are
based on the
experience/needs of the
patient
Appropriate, Effective,
Safe and Adherent
Medication Use!
Patient understands her
medications
and participates in a care plan
to
improve health
Physicians/
Providers - PCMH
Clinical goals of therapy are
determined and medication
recommendations are considered
Technology needed but interoperability is required
“Top Ten List” of health IT-based
population health management tools:
• Electronic Health Records (EHRs)
• Patient registries
• Health information exchange
• Risk stratification
• Automated outreach
• Referral tracking
• Patient portals
• Telehealth / telemedicine
• Remote patient monitoring
• Advanced population analytics
PCPCC 2014. All Rights Reserved.
BEHAVIORAL HEALTH
– INTEGRAL TO THE MEDICAL HOME
57
Six Reasons Why Behavioral Health
Should be Part of the PCMH
1. High prevalence of behavioral health
problems in primary care
2. High burden of behavioral health in primary
care
3. High cost of unmet behavioral health needs
4. Lower cost when behavioral health needs
are met
5. Better health outcomes
6. Improved satisfaction
58
1. Prevalence
As physical health worsens, the odds of having mental illness increase.
59
Barnett et al, Lancet 2012
Primary Care is the ‘De Facto’
Mental Health System
National Comorbidity Survey Replication
Provision of Behavioral Health Care: Setting of Service
General Medical
56%
No
41%
Treatment Receiving
59%
Care
MH
Professional
44%
Pie of all behavioral health needs.
60
Adapted from Katon, Rundell, Unützer, Academy of PSM Integrated Behavioral Health 2014
Wang P et al. Arch Gen Psychiatry, 2005: 62
2. Unmet Behavioral Health Needs
• 67% with a behavioral health disorder do not get behavioral
health treatment1
• 30-50% of referrals to behavioral health from primary care
don’t make first appt2,3
• Two-thirds of primary care physicians reported not being able
to access outpatient behavioral health for their patients4 due
to:
•Shortages of mental health care providers
•Health plan barriers
•Lack of coverage or inadequate coverage
1. Kessler et al., NEJM. 2005;352:51523.
2. Fisher & Ransom, Arch Intern Med.
1997;6:324-333.
3. Hoge et al., JAMA. 2006;95:10231032.
4. Cunningham, Health Affairs. 2009;
3:w490-w501.
5. Mitchell et al. Lancet, 2009;
374:609-619.
6. Schulberg et al. Arch Gen Psych.
1996; 53:913-919
• Depression goes undetected in >50% of primary care
patients5
61
62
1. McGinnis JM et al. JAMA 1993;270:2207-12.
2. Mokdad AH, et al. JAMA 2004;291:1230-1245
Behavioral Health Conditions Among
Highest Morbidity
63
US Burden of Disease Collaborators, JAMA 2013; 310.
2. Unmet Behavioral Health Needs
21%
Behavioral health conditions account for the largest
proportion of years of productive life lost (YPLL).
64
Martin et al., Lancet. 2007; 370:859-877
3. High
Cost of Unmet BH Needs
• Individuals with behavioral health and substance use
conditions cost 2-3 times as much as those without1
• BH disorders account for half as many disability days as
“all” physical conditions2
• Annual medical expenses--chronic medical & behavioral
health conditions combined cost 46% more than those
with only a chronic medical condition3
• Top five conditions driving overall health cost4
1. Depression
2. Obesity
3. Arthritis
4. Back/Neck Pain
1. Milliman report to the APA, August 2013 available here.
2. Merikangas et al., Arch Gen Psychiatry. 2007;64:1180-1188
5. Anxiety
3. Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS.
4. Loeppke et al., J Occup Environ Med. 2009;51:411-428.
65
3. High Cost of Unmet BH Needs
•
Annual healthcare costs much greater for diabetes and heart disease patients with
depression1
$8,000
$7,000
$6,000
$5,000
$4,000
No Depression
$3,000
Depression
$2,000
$1,000
$0
Heart Condition
66
High Blood
Pressure
Asthma
Diabetes
•
Untreated mental disorders in chronic illness are projected to cost commercial and
Medicare purchasers between $130 and $350 billion annually2
•
Approximately 217 million days of work are lost annually to related mental illness and
substance use disorders (costing employers $17 billion/year)2
1. Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS.
2. Hertz RP, et al. Pfizer Outcomes Research. Publication No P0002981. Pfizer; 2002.
4. Lower cost when BH is treated
• Medical use decreased 15.7% for those receiving behavioral health
treatment while controls who did not get behavioral health medical use
increased 12.3%1
• Depression treatment in primary care for those with diabetes resulted
in $896 lower total health care cost over 24 months2
• Depression treatment in primary care $3,300 lower total health care
cost over 48 months3
• This resulted in a return of $6.50 for every $1 spent
• Multi-condition collaborative care for depression and diabetes saved
$594 per patient over 24 mos.4
1. Chiles et al., Clinical Psychology. 1999;6:204–220.
2. Katon et al., Diabetes Care. 2006;29:265-270.
3. Unützer et al., American Journal of Managed Care 2008;14:95-100.
4. Katon et al. Arch Gen Psych, 2012:69:506-514
67
4. Lower cost when BH is treated
IMPACT Collaborative Care for Depression Reduces Costs
Cost Category
4-year
costs
in $
IMPACT program cost
Intervention
group cost
in $
Usual care
group cost in
$
Difference in
$
522
0
522
Outpatient mental health costs
661
558
767
-210
Pharmacy costs
7,284
6,942
7,636
-694
Other outpatient costs
14,306
14,160
14,456
-296
Inpatient medical costs
8,452
7,179
9,757
-2578
Inpatient mental health /
substance abuse costs
114
61
169
-108
Total health care cost
31,082
29,422
32,785
-$3363
68
$avings
Unützer et al., American Journal of Managed Care 2008;14:95-100
5. Improved mental health outcomes
• Over 75 trials in collaborative care in
nearly 2 decades have proven
significant benefit for depression and
anxiety disorders1
• Interventions work in a wide variety of
settings in a wide variety of mental
health conditions2
Improved Outcomes2
69
1.
2.
Archer et al, Cochrane Syst Data Rev, 2012: 10.
Woltman et al, AJP, 2012: 169:790-784
5. Improved physical health outcomes
• When treated in harmony with mental health, chronic
physical health improves significantly1
Improved Diabetes1
Improved BP1
Improved Cholesterol1
Overall quality of life and physical health improve consistently2
Physical health
Quality of life
70
1.
2.
Katon et al, NEJM, 2010:363:2611-2620
Woltman et al, AJP, 2012: 169:790-784
6. Improved patient satisfaction
• After 12 months of care, multi-condition collaborative care
improved patient satisfaction in depression AND diabetes
care1 Diabetes care
Depression care
Patient testimonial on integrated care:
"...the staff at Marillac Clinic actually cared about what I had to say- they were
there to help when I needed it - not just medical help, but counseling - and the
medications needed to get well. They helped me learn how to care for myself I understood how to accept myself from the kindness in their eyes.”
Past patient of Marillac Clinic, Grand Junction, Colorado
71
1.
Katon et al, NEJM, 2010:363:2611-2620
6. Improved provider satisfaction
• Primary care physicians like integrated care for a variety of
reasons1
Behavioral health specialists are also
satisfied with working in integrated settings2
photo courtesy: http://www.teamcarehealth.org/
72
1.
2.
Gallo et al, Ann Fam Med, 2004:2: 305-309
Levine et al., Gen Hosp Psych. 2005; 27:383-391
Integration: An Evolving Relationship
Consultative Model
• Psychiatrist/psychologist/social worker
(behavioral /mental health expert) sees patients
in consultation in behavioral health setting
Co-located Model
• Behavioral/mental health expert sees patients in
primary care setting
Collaborative (or Embedded) Model
• Behavioral/mental health expert provides
caseload consultation about primary care
patients; works closely with primary care team
73
Source: http://uwaims.org
PCPCC 2014. All Rights Reserved.
Four Quadrant Clinical Integration Model
74
Source: Mauer BJ (2004). Behavioral Health / Primary Care Integration: The Four Quadrant
Model and Evidence-Based Practices. National Council for Community Behavioral Health.
PCPCC 2014. All Rights Reserved.
www.mcpphealthcare.com
Fully Integrated Primary Care: The System
75 Source: Center for Integrated Primary Care, UMass Medical School
Most And Least Common Behavioral Health Care Providers And Services In
Sixteen Accountable Care Organizations (ACOs) Whose Leaders Were Interviewed
Provider
Most common (more than 7 sites)
or service
Least common (7 sites or fewer)
Providers
Psychiatric providers (including
psychiatrists, psychiatry residents,
pediatric or adolescent psychiatrists,
and advanced-practice nurses)
Psychologists
Social workers, counselors, or
psychotherapists
Substance abuse treatment providers
(including rehabilitation specialists,
licensed addiction counselors, and
other substance abuse counselors)
Case managers
Health coaches
Psychiatric care coordinators or managers
Other behavioral health paraprofessionals
Inpatient
services
Inpatient psychiatric care
Partial inpatient care
Detoxification facilities
Outpatient
services
Psychotherapy
Psychiatry
Substance abuse treatment
Case management
Health coaching
Behavioral health care coordination
Screening
Depression screening
Substance abuse screening
Other behavioral health screening
(such as severe mental illness)
Lewis et al (2014) Few ACOs Pursue Innovative Models That Integrate Care For Mental Illness And Substance
Abuse With Primary Care. Health Affairs
Where Integration is Happening
Source: AHRQ, The Academy Integration Map. Accessed September 2014.
http://integrationacademy.ahrq.gov/ahrq_map
7
PCPCC 2014. All Rights Reserved.
Behavioral Health at the PCPCC
– Behavioral Health Special Interest Group
– PCPCC’s Behavioral Health Advisory Team
•
•
•
•
•
•
Alexander Blount, EdD, University of Massachusetts
Parinda Khatri, PhD, Cherokee Health Systems
Benjamin Miller, PsyD, University of Colorado
George Patrin, MD, Serendipity Alliance
CJ Peek, PhD, University of Minnesota
David Pollack, MD, Oregon Health & Science University
– Erik Vanderlip, MD, University of Oklahoma
78
*Originally adapted from PCPCC’s Behavioral Health Task Force Slide Deck.
Last updated September 2014.
PCPCC 2014. All Rights Reserved.
Transformation Lessons
Learned
• A strong foundation is needed for successful redesign.
– Broad organizational support, previous experience with teams, financial stability,
focus & commitment with few distractions
• The process of transformation can be a long and difficult
journey.
– Ambitious & challenging and requires time, dynamic & time intensive with ebbs
and flows, requires deep changes in structures and systems, tensions & tradeoffs should be expected
• The approaches to transformation vary.
– Increased use of team-based care, expanded patient access & improved
coordination, data-driven measurement & feedback, formal or informal learning
collaboratives
Source: McNellis RJ, Genevro J, Meyers DS (2013) Lessons learned from the study of primary care transformation. Annals of Family Medicine
79
PCPCC 2014. All Rights Reserved.
Transformation
Lessons Learned
• Visionary leadership and a supportive culture ease the way
for change.
– Communication with staff & patients, cultural attributes
(collaboration, respect, accountability), alignment of incentives &
rewards, mission based focus
• Contextual factors are inextricably linked to outcome.
– National, state, & local policies, dynamics of the health system or
related systems, influence of the community & other stakeholders,
financial incentives, staff dynamics & characteristics, approach to
transformation
Source: McNellis RJ, Genevro J, Meyers DS (2013) Lessons learned from the study of primary care transformation.
Annals of Family Medicine
PCPCC 2014. All Rights Reserved.
About PCPCC – or “the Collaborative”
Our Mission
• Dedicated to advancing an effective and efficient health system built on a
strong foundation of primary care and the patient-centered medical home.
Activities
• Strengthening public policy that advances and builds support for primary
care and the medical home
• Disseminate results and outcomes from medical home initiatives and their
impact on outcomes, quality and costs
• Convene health care experts and patients to promote learning, awareness,
and innovation of primary care and the medical home
81
PCPCC 2014. All Rights Reserved.
History of PCPCC
National not-for-profit coalition founded in 2007 to:
• Facilitate achievements toward the Triple Aim: better
health, better care experience, and health care cost
control
• Create a more effective and efficient model of
healthcare delivery, grounded in primary care
Acts as conveners to bring together thought leaders and
stakeholders to address challenges, opportunities, and
barriers to health system transformation
• Contributed to developing PCMH language for health
reform proposals
• Published dozens of reports
PCPCC 2014. All Rights Reserved.
Membership
Since 2007, PCPCC membership has grown to represent
more than 1,300 organizations providing care to 50 million
Americans, including:
•
•
•
•
•
•
•
Provider associations
Large employers
Health plans
Providers & health systems
Pharmaceutical firms
Policymakers
Patient advocacy groups
PCPCC 2014. All Rights Reserved.
Role of the Collaborative
– Challenge the status quo and drive
the marketplace
– Disseminate timely information and
evidence
– Provide networking & educational
opportunities
84
PCPCC 2014. All Rights Reserved.
PCPCC Annual Fall Conference
• Patient-Centered Primary Care: At the Heart
of Value and Quality
– November 12 – 14th in Washington, DC
• Inaugural Awards Dinner
– November 12th, 6:00 – 8:00PM
– PCPCC Awardees:
• Debra L. Ness, MA
• Ted Wymyslo, MD
• Southeast Texas Medical Associates
PCPCC 2014. All Rights Reserved.
Everyone doing their part…
Everything is Awesome!
Contact:
Marci@pcpcc.org
www.pcpcc.org
87
