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