The Changing Behavioral Health Care Landscape:
Integration, Innovation, and Financing Models
Friday, May 17, 2013
County of San Bernardino Health Services Auditorium
Friday, July 12, 2013
Koinonia Church, Hanford, CA
Friday, August 16, 2013
San Leandro Marina Community Center
Friday, September 20, 2013
Redding Memorial Veterans Hall
Charles G. Ray
AHP Healthcare Solutions
1
Thank You Sponsors!
• UCLA
Integrated Substance Abuse Programs
• Pacific Southwest Addiction Technology Transfer Center
• California Department of Health Care Services
• County Alcohol and Drug Program Administrators
Association of California
• NIDA Clinical Trials Network – Pacific Region Node and
Western States Node
• Alameda County Behavioral Health Care Services
• County of San Bernardino Department of Behavioral Health
• Kings County Behavioral Health
• Shasta County Health and Human Services Agency
2
AGENDA
• Welcome & Introductions
– Logistics and Orientation
– Objectives
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Overview of Issues and Trends
Understanding Health Care Reform
Optimizing Behavioral Health Revenue
Innovations in Behavioral Health
Marketing Your Value-Add Propositions
3
Key Concepts
• Fear, anxiety and uncertainty are normal reactions to
abnormal events
• These are abnormal times and abnormal events are
unfolding around us with increasing frequency
• The Information Age, the Great Recession, Health Care
Reform, elections, wars, and globalization represent a
lot co-occurring abnormal conditions
• Complexity, volatility and paradigm-shifting ensue
Key Concepts
• This is your field. You worked hard to get here.
• This field was carved from the stone of ignorance and
fear and discrimination
• We’ve won important Civil Rights battles in the form of
the ADA, COBRA, HIPAA, EMTALA, MHPAEA and now
the PPACA
• Our work is not done yet. Far from it!
• More to come for those who can perceive the
opportunities and mobilize their resources despite the
fear and uncertainty.
Key Concepts
• Discontinuity and Disruption (P. Druker)
• Instability (A. Toffler)
• Decay and Irrelevance (G. Hammel)
• Tipping Point (M. Gladwell)
• Strategic Inflection Point (A. Grove)
• Value Migration (A. Slywotzky)
• Disruptive Innovation (C. Christensen)
Issues
 Reducing ED admissions and re-admissions
 Medicaid managed care
 Managed care business operations and infrastructure
 Competition
 Prescription drug abuse
 Financial risk
 Licensure and credentialing
 Compliance with Mental Health Parity & Addiction Equity
Act
 State definitions of Essential Health Benefits
 Preservation of system of care and prevention
Issues
 “Diabesity” epidemic
 Whole health, person-centered care
 Medication assisted treatment
 Integration (vertical)
 Consolidation (horizontal)
 Carve-in
 Retail healthcare
 Health Coaches
 Continued de-institutionalization
 eHealth / mHealth
9
International Comparison of Spending on Health, 1980–2010
Average spending on health
per capita ($US PPP)
Total health expenditures as
percent of GDP
18
$8,000
US
$7,000
16
SWIZ
NETH
$6,000
14
CAN
12
GER
FR
10
AUS
UK
8
JPN
US
NETH
FR
GER
CAN
SWIZ
UK
JPN
AUS
Notes: PPP = purchasing power parity; GDP = gross domestic product.
Source: Commonwealth Fund, based on OECD Health Data 2012.
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
0
1988
$0
1986
2
1984
$1,000
1982
4
1980
$2,000
1980
6
2010
$3,000
2008
$4,000
2006
$5,000
Health Care Costs Concentrated in Sick Few—
Sickest 10 Percent Account for 65 Percent of Expenses
Distribution of health expenditures for the U.S. population,
by magnitude of expenditure, 2009
Annual mean
expenditure
1%
5%
10%
22%
50%
50%
$90,061
$40,682
65%
$26,767
97%
$7,978
Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.
Problem: Causes of Premature Death
in the General Population
Proportional Contribution to Premature Death
Genetic disposition
0%
30%
40%
10% 5%
15%
Social circumstances
Environmental
exposure
Health care
Behavioral patterns
N Engl J Med. 2007 Sep 20;357(12):1221-8.
Impact Statement
HEALTH CARE REFORM
12
13
Reform
1. Coverage expansion
2. New models
a) ACOs and integrated delivery systems
b) Health Care (Medical) Homes & Dual Eligibles Initiatives
3. New administrative structure
a) Essential Health Benefits (benchmark plans)
b) Health Insurance Exchanges
4. New risk-based financing mechanisms
Medicaid managed care and capitation
Coverage Expansions
133 – 400% FPL ($88,000 family)
Below 133% FPL ($29,500 family)
Medicaid Expansion To
Childless Adults
State Exchanges
•
•
•
•
•
•
Coverage for essential MH/SA at parity for
benchmark plan
Feds pay 100% for 3 years, then down
90%
Simplified enrollment, express apps: web
too
Integrated data with State exchanges: one
application
Foster kids up to age 26
•
•
•
•
Coverage for essential MH/SA at parity &
prevention @ no co-pays
Helps individuals and small employers
with purchasing health insurance
Assist by voucher to pay premiums or cost
sharing
Develops consumer friendly tools & plain
language on insurance
One application to both exchanges or
Medicaid; can do on the web
California by the Numbers
15
California by the Numbers
16
California
17
California FQHCs
•
•
118 Federally-Qualified Health Centers
Statewide
1,039 FQHC Service Sites
www.statehealthfacts.org
18
Prevalence of Serious Mental Illness Among Adults Ages 18 – 64
by Current Medicaid Status and Eligibility for Medicaid Expansion
or Health Insurance Exchanges: California, US
19
Prevalence of Substance Use Disorders Among Adults Ages 18 –
64 by Current Medicaid Status and Eligibility for Medicaid
Expansion or Health Insurance Exchanges: California, US
20
SUD in CA Medicaid Expansion and
Health Insurance Marketplace
Most common characteristics of persons with SUD
in Medicaid expansion population in California is:
•
•
•
•
Male
18-34 years old
Non-Hispanic White or Hispanic
Less than High School Education
Sources: 2008 – 2010 National Survey on Drug Use and Health (Revised March 2012) 2010
American Community Survey
21
California & ACOs
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•
•
•
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CMS has approved 400+ ACOs nationwide.
Include a range of providers and sizes; about half are
physician-led organizations that serve fewer than 10,000
beneficiaries.
One-fifth include rural health centers, community health
centers, and critical access hospitals, which serve rural
and low-income communities.
Nearly 30 ACOs in CA
Almost half sponsored by physicians and IPAs
(independent practice associations)
22
Sampling of Golden State ACOs
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Brown & Toland Physicians, based in San Francisco;
HealthCare Partners Medical Group, which serves Los Angeles and Orange counties;
Heritage California ACO, which serves southern, central and coastal California;
Monarch HealthCare, based in Orange County;
PrimeCare Medical Network, which serves Riverside and San Bernardino counties;
Sharp HealthCare System, based in San Diego
ApolloMed Accountable Care Organization in Glendale;
Golden Life Healthcare in Sacramento;
John Muir Physician Network in Walnut Creek;
Meridian Holdings in Hawthorne;
North Coast Medical ACO in Oceanside; and
Torrance Memorial Integrated Physicians
UCLA ACO
Cedars Sinai ACO
Hill Physicians/Dignity Health, serving Sacramento
Palo Alto Medical Foundation
Santa Clara County IPA
St. Joseph Health
23
Golden State ACOs
24
Golden State ACOs
25
Golden State ACOs
26
Population Health Management
ACOs must develop a process for identifying patients
who have complex needs (multiple chronic
conditions) or are at high risk of developing such
needs and provide them with wellness and prevention
programs, disease management, and complex case
management, as indicated
ACOs make available or support providers’ use of
electronic prescribing, electronic health records systems,
registries, and self-management tools
PCMH
Principles
Personal physician - each patient has an ongoing relationship with a
personal physician trained to provide first contact, continuous and
comprehensive care.
Physician directed medical practice – the personal physician leads a
team of individuals at the practice level who collectively take
responsibility for the ongoing care of patients.
Whole person orientation – the personal physician is responsible for
providing for all the patient’s health care needs or taking responsibility for
appropriately arranging care with other qualified professionals. This
includes care for all stages of life; acute care; chronic care; preventive
services; and end of life care.
Source: Patient Centered Primary Care Collaborative
PCMH
Principles
Care is coordinated and/or integrated across all elements of the complex
health care system (e.g., subspecialty care, hospitals, home health
agencies, nursing homes) and the patient’s community (e.g., family,
public and private community-based services).
Care is facilitated by registries, information technology, health information
exchange and other means to assure that patients get the indicated care
when and where they need and want it in a culturally and linguistically
appropriate manner.
Source: Patient Centered Primary Care Collaborative
PCMH
Quality and safety are hallmarks of the medical home:
1. Advocacy for patients
2. Evidence-based medicine and clinical decision-support tools guide
decision making
3. Accountability for continuous quality improvement
4. Patients actively participate in decision-making and their feedback is
sought
5. Health IT is utilized appropriately to support care, performance,
education, and communication
6. Practices go through a voluntary recognition process
7. Patients and families participate in quality improvement activities at the
practice level.
Source: Patient Centered Primary Care Collaborative
PCMH
Principles
Enhanced access to care is available through systems such as open scheduling,
expanded hours and new options for communication
Payment appropriately recognizes added value The payment structure should be
based on the following framework:
• reflect the value of care management work and coordination of care
• support adoption and use of health IT and use of monitoring
• support enhanced communication such as secure e-mail and telephone
• allow share in savings from reduced hospitalizations
• It should allow for incentives for achieving quality improvements.
Source: Patient Centered Primary Care Collaborative
Integration
Patient Value
defined here
(health/cost)
Managing Knowledge (training, process improvement, etc)
Informing & Educating (patient and family education)
Measuring and Monitoring (testing, records, etc)
Assuring Access to Services (continuum of care, hotline, transport)
Prevention
Risk Factors
Screening
Monitoring
Assessment
Diagnosis
History
Testing
Consult
Preparing
Counseling
Interviews
Teaming
Intervening
Orders
Procedures
Counseling
Therapy
Feedback Loops
Source: M. Porter and E. Olmstead Teisberg
Recovery &
Rehab
Fine tuning
Discharge
planning
Monitoring &
Managing
Compliance
Lifestyle
Provider
Margins
made here
Common Collaborative Care Models
1. Coordinated model: behavioral services available at a separate
clinic/location
–Access and convenience is low; patients may not show up for referral/follow
up care
2. Co-located model: behavioral services available at the same medical
center/clinic
–More convenient for patients and providers
3. Integrated: behavioral services are part of the medical treatment
within the clinic
–Creates a “medical home” for the patient with all services under unified
management
–Facilitates closer communication, patient tracking and follow up
Source: Patient Centered Primary Care Collaborative
ACOs and PCMH:
Side-by-Side
ACO
PCMH
 Characterized by sufficient
structure, governance, and
operations
 Assure access and availability
 Focus on primary care and patientcentered care
 Care Management and Navigators
 Clinical Pathways and EHR
 Patient Rights and Responsibilities
 Performance Reporting
 Shared savings
 Personal physician-directed, whole
person orientation
 Care coordination and integration
 Facilitated by access to information
 Care Management and Navigation
 Quality and Safety focus
 Enabled by HIT/EHR
 Practice and financial management
What role do you see yourselves playing?
ACO Payment
Percent of Hospitals' Payment Model
26.8
Shared Savings
52.1
27.2
Shared Savings & Shared
Risk
Global Payment
Partial Capitation
34.3
Health Research & Educational Trust, 2012
35
Medicaid Expansion
36
37
Medicaid Health Homes
• Defined in Section 2703 of the ACA
–to expand traditional and existing medical home models
–to build linkages to community and social supports
–to enhance coordination of medical, behavioral, & longterm care
• New Medicaid State Plan Option effective 1/1/2011
- a comprehensive system of care coordination for
individuals with chronic conditions
• Health Home providers will coordinate all primary, acute,
behavioral health and long term services and supports to
treat the “whole-person”
• Can include dual eligibles
38
Health Homes
•
The chronic conditions listed in statute include






•
mental health condition,
substance abuse disorder
asthma,
diabetes,
heart disease, and
obesity (as evidenced by a BMI of > 25).
States may add other chronic conditions for approval
by CMS
39
Health Homes: Key Features
• Shared services, goals and risk
• Central management
• Community or regional networks
• Multi-disciplinary community health teams
• Dedicated care coordinators
• Integrated primary care/behavioral health services
• High-performing primary care providers
• Population management tools
• Health information technology & data exchange
40
Health Homes: BH Rationale
• People with BH conditions die years earlier by up to 25-35
years
• One million people with behavioral health conditions will
die from heart attack or stroke in the next 5 years.
• Behavioral health conditions are implicated in all major
chronic diseases, and vice versa
• Disabled Medicaid beneficiaries with SMI - 29% to 49%.
• SMIs represented in 3 of the top 5 most prevalent dyads
are in the highest-cost 5% of beneficiaries
State Health Home Activity
As of November 2012
41
Medicaid Expansion
Between 2014 and 2019, a full Medicaid expansion will
provide health insurance coverage to 17 million people with
incomes less than 138 percent of the federal poverty level
(FPL) who were previously uninsured.
About 40 percent of this group – or 6.6 million individuals –
with serious or moderate mental illnesses who are currently
uninsured will obtain health insurance through the Medicaid
expansion by 2019.
42
Essential Health Benefits
Mental Health and Substance Use Disorders treatment are
among what HHS calls Essential Health Benefits (EHB).
States are defining these now.
43
Parity & Equity Applies
The Mental Health Parity & Equity Act (2008) applies to Medicaid Expansion,
all Medicaid Managed Care Plans (expansion or not), and all CHIP.
Highlights
• Fair coinsurance (equal to majority medical co-pay)
• Equitable access in terms of number days/visits allowed, frequency, duration of
treatment
• Provides for in and out of network coverage where same is covered for medical
• Mandates parity in utilization review guidelines and practices
• Ensures access to and equitable coverage for inpatient, outpatient, ED and Rx
formulary
• Disallows “EAP Gatekeeper” and “Fail First” practices in UM
• Mandates fairness in network admission standards and method/setting UCR
rates of reimbursement for providers
44
State Progress
As of 1/4/13
45
Who Benefits from the ACA?
46
Community-Based Strategy for
Improving Care of High-Cost Patients
Regulatory relief,
technical assistance
Community governance
Seed funding
High-cost patients with
multiple chronic
conditions
Payment reform
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•
•
•
•
•
•
•
Medical home care management fee
Accountable Care Organizations
Bundled payment for acute episodes
Partial capitation
Shared savings and shared risks
Gain-sharing
Value-based purchasing
Public–private payer harmonization
Health information
technology
Primary care
•
•
•
•
•
•
Medical homes
Primary care practice teams
System of off-hours care
Transitions in care
Reduced readmissions
Care coordination
•
•
•
•
•
•
Electronic health records
Electronic prescribing
Meaningful use
Support for self-care
Mobile health applications
Computerized decision support
Synergistic Strategy: Cumulative Savings, 2013–2023
Payment reforms to accelerate delivery system innovation ($1,333 billion)
• Pay for value: provider payment incentives to improve care
• Strengthen patient-centered primary care and support care teams
• Bundle hospital payments to focus on total cost and outcomes
• Align payment incentives across public and private payers
Policies to expand and encourage high-value choices ($189 billion)
• Offer new Medicare Essential plan with integrated benefits through Medicare, offering positive incentives for use
of high-value care and care systems
• Provide positive incentives to seek care from patient-centered medical homes, care teams, and accountable care
networks (Medicare, Medicaid, private plans)
• Enhance clinical information to inform choice
System-wide actions to improve how health care markets function ($481 billion)
• Simplify and unify administrative policies and procedures
• Reform malpractice policy and link to payment*
• Target total public and private payment (combined) to grow at rate no greater than GDP
per capita**
Source: Commonwealth Fund Notes: SGR = sustainable growth rate formula; GDP = gross domestic product.
* Malpractice policy savings included with provider payment policies.
** Target policy was not scored.
CONSOLIDATION &
INTEGRATION
49
M&A Activity 2012
• In 2012, dealmakers committed $143.3 billion to finance
the year’s activity in the health care merger, acquisition
and takeover market.
• In terms of the number of health care deals announced,
2012 was one of the busiest in the past decade, with 1,063
deals, up 5.9% compared with 2011’s 1,004.
Source: Irving Levin Associates, January 2013
Deals in 2012
Sector
2012
2011
% Change 2012 Value
2011 Value
% Change
Behavioral Care
17
13
30.8%
$1,006,650,000
$304,488,600
230.6%
Home Health & Hospice
35
29
20.7%
$5,718,950,000
$289,992,000
1872.1%
Hospitals
94
92
2.2%
$1,886,217,010
$8,280,060,000
-77.2%
Labs, MRI & Dialysis
45
29
55.2%
$2,213,817,500
$6,002,543,000
-63.1%
Long-Term Care
188
172
9.3%
$9,180,208,579
$16,413,994,935
-44.1%
Managed Care
27
20
35.0%
$18,815,500,000
$7,906,000,000
138.0%
Physician Medical Groups 68
108
-37.0%
$4,411,539,350
$466,534,545
845.6%
Rehabilitation
18
14
28.6%
$750,243,000
$1,337,796,000
-43.9%
Other
121
86
40.7%
$12,033,703,400
$40,722,978,000
-70.4%
Services subtotal
613
563
8.9%
$56,016,828,839
$81,724,387,080
-31.5%
Source: Irving Levin Associates, January 2013
Behavioral Health
• This sector will see a lot more activity in the future, now
that mental health issues have gained national attention
and addiction has lost much of its stigma
• Health care M&A activity will stay strong through 2013 as
the sector looks forward to welcoming many more insured
patients once the Affordable Care Act fully takes effect on
January 1, 2014
Behavioral Health
• M&A activity in behavioral health has surged because in
such a fragmented service sector, there is substantial
untapped opportunity for consolidators to create critical
mass and competitive advantages
• With acquisition demand across the spectrum of
behavioral health and social services greater than supply,
valuations have climbed.
Behavioral Health
Behavioral Health
Value of Behavioral Health
Source: Wyatt Matas, 2013
Value of Behavioral Health
49% of Medicaid Beneficiaries with disabilities have a
psychiatric illness. Top 3 behavioral dyads:
1. Psychiatric/Cardiovascular
2. Psychiatric/Central Nervous System
3. Psychiatric/ Pulmonary
Creating Value
Many providers will play a vital role in achieving value-based
care milestones required by the ACA. Within these markets
especially, value-based care requires:
1. Aligned leadership,
2. Strategies, and
3. Operations to align for the realization, building, or
maintenance of consistent growth
Source: Wyatt Matas, 2013
Innovation
Innovation will be driven by Knowledge Networks and
Markets (KNMs), largely made possible by health
information technology to support decision-making for
governments, systems, providers, and patients.
–Faster adoption of innovation. With key provisions and penalties in
the ACA implemented in 2014, providers will scale to test and
adopt innovative care models and population health approaches
in 2013.
–Creative strategic alliances and alliance networks: bundled
payments, ACOs and the lack of infrastructure to coordinate care
across silos require providers to build formal strategic partnership
alliances across healthcare: provider-to-provider, provider-to-vendor,
and provider-to-payer relationships will accelerate in 2013.
Behavioral Health Value
• The market now understands the cost impact of patients
with behavioral and physical health co-morbidities, leading
payers to search, test, and develop new care models to
address both behavioral and physical health.
• While integrating behavioral health and physical medicine,
redefinitions of case management promotes need for
cross-trained health workers, placing greater emphasis on
social and life circumstances.
Factors Contributing to Growth
• National expenditures on mental health and substance
abuse treatment are expected to reach $239 billion in
2014, up from $121 billion in 2003, representing a
compound annual growth rate of nearly 7%.
• The demand for behavioral health services has increased
in recent years due to earlier and more accurate diagnosis
of mental health conditions and the de-stigmatization of
seeking treatment.
Other Factors
• Influx of returning veterans from Iraq and
Afghanistan
• Mental Health Parity and Addiction Equity Act
• Affordable Care Act
• Essential Health Benefits
• Medicaid Expansion
• Diverse Payer Mix
• Niche markets and segments
Vision, Goals, Objectives
BUILDING NEW BUSINESS &
NEW REVENUE STREAMS
63
Marketing Basics
1.
Is there a market for what you have to sell? What specifically is
that market?
2.
What particular product(s) are in highest demand?
3.
What level of competition exists in each space?
4.
What regulations and other constraints act on those products and
markets? How?
5.
What does it cost to produce your product or service?
6.
What price is acceptable to each market?
7.
Are the margins sufficient to become successful and maintain
viability?
8.
Is it possible to innovate your product making it more effective, less
complex and more convenient for the consumer at a lower cost?
64
Market Data Analysis
What does market profile data tell you about:
a. Competition among payers?
b. Competition between key providers?
c. Availability of continuum of services?
d. Gaps in services, populations served, or holes in
service areas?
e. Opportunities to innovate?
f. Opportunities to provide payers with a real
solution to a real problem?
g. Opportunities to partner?
Soft Market Research
 Visit and scour payer websites
 Read their provider newsletters
 Ask the Insurance Commissioner/Department for any
and all information specific to a particular payer
 Identify their Board members
 Call and speak with Provider Relations
 Talk to your agent/broker
 Download and study provider manuals, practice
guidelines, provider network directories, and
applications
What Constitutes Market Research for
Behavioral Health Providers?
•
•
•
•
•
•
•
•
•
Population/Census Data
Prevalence and Epidemiological Data
Competitive Analysis
Health Insurance Market Research
Analysis of Medicaid Market
Due Diligence into Potential Partners
Laws, Rules and Regulations
Reimbursement
Other?
PRODUCT & SERVICE-LINE
INNOVATION
5 Reasons to Innovate Now
1. Advent of health care reforms
2. Cycle of breakthrough in research and brain science
3. Prevalence of psychiatric and substance use disorders
and incidence of trauma among Veterans and children
4. Explosion of diabetes, asthma, autism, and obesity
5. Availability of consumer and provider-friendly
technologies
R&D
Skills
and
Abilities
Market
Structure
Ancillary
Markets
Customer
Needs &
Market
Demands
Access to
Technology
Access to
Capital
What
Drives
Innovation?
Elements of
Disruptive Innovation
 Technology simplifies what had previously been
complicated and cumbersome
 Lower-cost financial model
 Value Network is economically coherent (mutually
reinforcing)
Source: Clayton Christensen
Why Innovate?
Innovation for sake of novelty
Innovation for sake of change
Innovation to gain strategic
advantage over competition
Conditions
 Is the political, legislative and regulatory environment
stimulating change in the market (YES!)
 Is government supporting the diffusion of innovations
(YES!)
 Has the economy performed at a level that is
impacting consumer behavior and pricing? (YES!)
 Are social and cultural dimensions of the market
supportive of new approaches? (YES!)
 Is technology supporting innovations? (YES!)
Innovation Framework
Research – better understanding the market, unmet demand,
customers and their preferences, pricing and profit models, the cuttingedge of science and technology, and value networks across partners
and supply chain.
 Review existing product-line and previous attempts at innovations
 Survey payers, customers, partners, line-staff and leadership team
 Analyze customer pain points
 Assign Innovation Instigators across the ranks
 Conduct key informant interviews
 Conduct environmental scan and literature review
 Conduct market research and competitive intelligence
 Review financials and other business intelligence
Innovation Framework
Development – identifying a more effective and efficient way to
promote and manage disruptive innovations, pilot programs,
demonstrate viability and bring new products to market
Product Development and Innovation Process
 Learning to ask disruptive questions
 Looking for natural product bundling opportunities
 Observing how customers interact with services today to detect
opportunities for improvement
 Investigating and experimenting with new ways of doing things
 Networking and associating with people, technologies, and ideas
from diverse backgrounds
Innovation Framework
Identifying:
 Gaps, voids and opportunities
 Market compatibility
 Quality and compliance standards
 Key performance indicators, forecasts and projections
 Potential issues and risks
 Early-stage business operating and/or financial models and
their implications
Innovation Framework
Critiquing the proposal
 Is the proposal overly optimistic or too cautious?
 Is quality assured?
 Were there contrary opinions on the Team?
 Are there credible alternatives to the proposed solution?
 Is there sufficient data to support the decision? Valid sources?
 Is there an assumption of success with the pilot based on past
performance elsewhere? Where?
 Is planning overconfident? Is the worst case awful enough?
Innovation Framework
Prototype and Pilot
 Develop the product/service in its entirety, ready to test
Execution – planning and deploying new products with adequate
resources and management, reporting progress, remaining accountable,
capturing lessons-learned, and knowing when and how to say “No”
Develop proof of concept model and parameters
 Decide whether to pilot prototype internally, to outsource it, or to spin it off under its own brand
 Implement the strategy, develop and test the
product/service
 Manage expectations, people and outcomes
Innovation Framework
Evaluation – measuring the impact of the new product
and the success of the implementation team
 Actual costs, revenues, and profits
 Return-on-Investment
 Customer, Employee and Payer Satisfaction
 Customer Experience
 Quality
 Outcomes
 Market demand
Opportunities for Innovation

Multiple Chronic Conditions (MCC)







Clinical Pathways
Care Coordination
Health Informatics
Health & Wellness
Prescription Drug Monitoring Programs and Pain
Mgmt.
Population Mgmt.
New market structures: Accountable Care
Organizations (ACO), Patient-Centered Medical
Home and Health Home Models (PCMH) – Focus
on Primary Care Integration
TELE-HEALTH
Tele-Health
Two types of Tele-Health
1. Live interaction
2. Store and Forward
82
Quick Facts about Tele-Health in CA
AB 415 replaces the terminology of “telemedicine” with “telehealth” in
California law.
• Under the old law’s terminology, telemedicine was defined as the practice
of medicine via live video connections between patients and providers in
separate locations, or via “data communications.” Telehealth is broader.
• AB 415 was an update to the Telemedicine Act of 1996. It allows for the
provision of a broader range of telehealth services, expansion of
teleheatlh providers to include all licensed healthcare professionals, and
the expansion of telehealth care settings.
•
AB 415 does not mandate the use or reimbursement of any telehealth
services by public or private payers. Covered services, and the locations
of their delivery, are still negotiated in contracts between health plans and
providers, and in public insurance programs such as Medi-Cal, the state’s
Medicaid program. Nor does AB 415 change the scope of practice of any
licensed health professional, or change interstate licensure laws.
83
Quick Facts about Tele-Health in CA
AB 415 removes limits on the physical locations where telehealth
delivered services may be provided.
• Under the old State law, Medi-Cal restricted delivery and receipt of
telemedicine services to four specific licensed facilities: hospitals,
clinics, doctors’ offices, and skilled nursing facilities.
• AB 415 clears up the confusion on location by explicitly removing limits
on the settings for telehealth. This will allow for services delivered via
telehealth to be covered, regardless of where it takes place.
• However, locations for telehealth are still subject to policies and
contracts enacted by Medi-Cal and private payers.
84
Quick Facts about Tele-Health in CA
AB 415 expands the definition of health care provider, to include all health care professionals licensed by the
State of California. Under the old law, only these health professionals could provide services via telehealth:
•
Physicians
•
Surgeons
•
Podiatrists
•
Clinical psychologists
AB 415 expands this list to include all professionals licensed under the state’s healing arts statute, which also
include:
•
Pharmacists
•
Nurse practitioners
•
Physician assistants
•
Registered nurses
•
Dental hygienists
•
Physical therapists
•
Occupational therapists
•
Marriage, family and child counselors
•
Dentists
•
Optometrists (in limited scope)
•
Speech and language pathologists
•
Audiologists
•
Licensed vocational nurses
•
Psychologists
•
Osteopaths
•
Naturopaths
85
Quick Facts about Tele-Health in CA
Additional Resources
CCHP
Established in 2008 by the California HealthCare Foundation, the Center for Connected
Health Policy (CCHP) is a non-profit planning and strategy organization working to remove
policy barriers that prevent the integration of telehealth technologies into California’s health
care system. CCHP conducts objective policy analysis and research, develops non-partisan
policy recommendations, and manages innovative telehealth demonstration projects.
www.connectedhealthca.org
CTEC
CTEC is one of the country’s leading resources for telehealth education, expertise, and
implementation guidance. A federally designated Telehealth Resource Center, CTEC is the
go-to source for unbiased information, serving healthcare providers, health systems, clinics
and government agencies. Working to make telehealth services widely available, CTEC
creates systems that make people healthier, increase access to care, improve patient
outcomes, drive down healthcare costs, and sustain a reduced-carbon economy. For more
information on CTEC, please visit www.cteconline.org
Medi-Cal Telemedicine Guidelines
http://files.medi-cal.ca.gov/pubsdoco/DocFrame.asp?wURL=publications%2Fmastersmtp%2Fpart2%2Fmednetele_m01o03.doc
86
Funding Tele-Health
FCC Healthcare Connect Fund
CTN Will Begin Enrollment in April 2013
As California’s authorized FCC broadband consortia for healthcare, the
California Tele-Health Network (CTN) has priority access to the
Healthcare Connect fund for California health care providers and will
begin enrolling providers in the program as soon as April, 2013. In
addition, for most CTN members the 35% match requirement will be
reduced by half. The FCC award funds will pick up the remaining cost of
infrastructure development.
87
BEHAVIORAL MEDICINE
Issues of BH in Primary Care
The importance of primary care integration
–PCPs deliver half of BH care
–PCPs prescribe 70% of psychotropic drugs
–PCPs have limited BH training; widespread under
diagnosis
–Up to 70% of primary care visits stem from psychosocial
issues
Problems faced by PCPs
–PCPs have limited time to treat psychosocial issues
–BH care inaccessible to PCPs
–Many referrals do not result in visits/services
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
Behavioral Medicine Targets
 Adolescent Health
 Aging
 Arthritis
 Asthma
 Cancer
 Cardiovascular Disease
(heart disease,
hypertension, stroke),
 Children's Health
 Chronic Pain
 Cystic Fibrosis
 Depression
 Diabetes
 Eating Disorders
 HIV/AIDS
 Obesity
 Pulmonary Disease
 Substance Use Disorders
including Smoking
Cessation
 Women's Health
Behavioral Medicine
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
Get the Big Picture
How Many Opportunities for Innovation Might There Be?
SUD Outpatient
Psychiatric
Outpatient
Outpatient MH
Counseling
Psychiatric
Inpatient
Residential
Emergency
Department
Pediatrics, Childhood
Trauma, SED
ID/DD, Autism
Heart Disease Cardiology
Diabetes and
Obesity
SBIRT
Health Home, Health
Neighborhood, PCMH, ACO,
CCO
Intensive Case Mgmt,
Care Coordination,
ACT
COPD, Asthma,
Tobacco Use
Disease Mgmt
Prescription Drug Mgmt., Drug-Seeking,
Narcotic Medication Abuse (pain meds,
sleep meds, anxiety meds), Pharmacy
Consult/Education
Behavioral Medicine
0%
0%
0%
0%
n’
ts
ee
m
Is
to
no
be
ts
om
ve
ry
et
...
hi
Re
ng
qu
w
ire
e
sm
ca
n.
o
..
r
Is
e
so
ex
m
pe
et
rti
hi
se
ng
.. .
Is
w
so
e
m
ar
et
e
hi
alr
ng
.. .
w
ea
re
to
ta
l..
0%
Do
es
A. Doesn’t seem to be very
important
B. Is not something we can
afford to wade into this year
C. Requires more expertise
than we have available
D. Is something we are
already engaging in quite
well
E. Is something we are totally
committed to doing as soon
as feasible but we need
additional resources
95
New Mind-Set
“We don’t serve the indigent. We treat people.”
“What were once our “consumers” have become our patients. Consumers
consume. Patients are treated by healthcare professionals.”
“Our facilities should be as dignified and comfortable as any business that
hosts and serves people.”
“We are a vital and integral facet of the healthcare delivery system.”
“The people we serve are not “non-compliant” and they don’t “drop-out”.
They don’t have “dirty” UAs. They have a chronic disease that is highly
treatable.”
“We do everything we can to partner with or recruit MDs and NPs”
“We provide sub-acute inpatient treatment services”
Getting into Action
MARKETING PLANS
97
Fundamentals of Market
Positioning
•
•
•
•
•
•
Market Research
Customer Value Proposition
Channels, Alliances and Partnerships
Product Development
Pricing
Our job is to find the gaps that exist in
Brand Message
the system of care and in the market.
Who would pay for what given the
opportunity?
Marketing Action Plan
•
•
•
•
•
•
•
•
Market segment traits and features
Promotion mix to reach segment(s)
Detailed approach and methods
Timeline, milestones, tasks
Key performance indicators
Organizational chart and supervision
Resource needs
Budget
Business Models and
Customer Value Propositions
Answers the Essential Question:
“Why should I buy from you
instead of buying what your competitor has to offer?”
CVP is NOT
1. Your services
2. A list of benefits
and features
3. Your Mission
4. Your tagline
5. A headline
What is a Customer Value
Proposition?
Customer Value Propositions (CVP) address customers’
perceived value and attempt to position services such
that the value returned to the customer is greater
than perceived cost.
However, as in the case of brand truth, there is true
value to keep in mind. If you promise an experience of
value and fail to deliver…
101
Patient CVP
What are their needs?
• Effective treatment for their behavioral health
issues
• Support for/from their families and community
• Safe environment
• Convenience
• Lack (or reduction) of stigma
• Re-entry plan (for residential programs)
• Post-treatment support
• Financial issues addressed
Referral Source CVP
What are their needs?
• Effective treatment
• Access and convenience of easy referral process
• Treatment options and in-network status
• Communication and collaboration
• Confidence
• Timely reporting and reliable follow-up
• Lack of resistance and/or negative feedback from
clients
• Gratitude
• Reciprocal referrals
Payor CVP
What are their needs?
• Evidence based practices that produce better
outcomes at lower cost
• Access to adequate specialty provider network
coverage
• Positive patient experience and member
satisfaction ratings to meet performance incentives
• Low risk and low exposure to fraud, waste,
malpractice
• Shared interest in making best use of finite
resources, particularly for chronic conditions
Differentiators
• Populations Served
• Continuum
• Quality
• Access (location, after-hours, weekends)
• Health and QoL Outcomes
• Alumni Program
• Outreach
• Privacy and Security
• Education, Job Training, Transportation, Child
Care
Communicating your Customer
Value Proposition
• Your organization's name
• Your graphic identity and slogan
• Your signage
• Your web site
• The names of your services/programs
• Your collateral materials (e.g., brochures, staff bios)
• Letters and telephone calls
• Talking points for your staff and stakeholders
• Ads, videos, blogs, social media…
Exercise
Customer Value Proposition
Customer Segment
Patient and/or family
Payor – private insurer
and/or managed care
organization
Employer
Referral Source – health
care/medical/MH and/or
hospital
Referral Source – CJ
Referral Source – EAP
and/or Case Mgr
Referral Source Interventionist
State/County agency
Job to be Done
Pain (avoid)
Gain (deliver)
Exercise
Customer Value Proposition
Key Question
Our intended customer is…
They will find us (where)…
What we do together in exchange
is…
They chose us because…
Your Answer
Exercise
Customer Value Proposition
Key Question
Answer
Compared to the Next Best Alternative, we…
Quality
Access
Price
Outcomes
Quality of Life
Other
How do you know?
Resonates with?
Who cares?
Business Model Canvass
Customer
Relationships
Key Activities
Key
Partnerships
Value
Proposition
Key
Resources
Cost Structures
Customer
Segments
Channels
Revenue Opportunities
110
Opportunity: Assessment
•
•
•
•
•
Assess Board, leadership team and staffing
Evaluate market share and contracts, partnerships and alliances
Assess finances, reserves and revenue cycle
Evaluate IT Infrastructure (practice management, billing, EHR)
Develop new business processes, quality programs and other
performance measures
Build:
 Managed Care Competencies
 Contemporary Brand
Challenges
•
•
•
•
•
•
•
Board comprehension and support for reforms
Performance measures
Staff credentials
Reserves
IT
Business partners, shared services and networks
Marketing action plans
Challenges
•
•
•
•
•
•
Strategic plans (6 months and older)
Leverage negotiating contracts and understanding of
terms and conditions
Revenue cycle management
Outcomes and Quality measures in new markets
Managed care competencies
Facilities and brand image
Assessing the Market
•
•
•
•
ACOs and CCOs
Self-Insured Plans (ERISA)
Traditional Indemnity (fully-insured)
Managed Care Plans
–MBHOs (carve-out)
–HMOs (network-centric, referral-based)
–PPOs (wider network, medical necessity standards)
–POS (combines HMO and PPO with coinsurance differentials)
Challenges
•
•
•
•
Relationship to Insurance Commissioner
Familiarity with association of health plans and
underwriters, HR and benefits associations
“Getting In” - commercial marketing and
contracting
Reaching veterans
Assessing the Environment
•
Federal, State and county budgets
•
State laws and regulations
•
Scope of service and scope of practice
•
Waivers and State Plan Amendments
•
Health Insurance Exchange
•
Reimbursement reforms and other funding
opportunities
•
Mergers and Acquisitions, joint ventures in local
health care sector
Challenges
•
•
•
•
•
Defining scope of service and scope of practice
Definition of Essential Health Benefits
Question of Medicaid Expansion
Reimbursement reforms and financial risk
M&A due diligence and alignment of vision, mission,
cultures and values
Challenges
•
•
•
•
•
Time
Expertise
Capital required to develop effective, manageable
plans
Competing priorities
Tension between “the way we’ve always done it” and
the paradigm shift
Market Planning
•
•
•
•
•
•
•
Define and Segment the Market
Identify New Prospects
Identify Emerging Needs
Product Development / Innovation
Develop Unique Selling Proposition (USP) and
Customer Value Proposition
Packaging (promotional materials), Promotion and
Placement (billboards, media spots, press)
Competitive Analysis and Intelligence
Challenges
•
•
•
•
Managed approach to plan execution
Meaningful differentiation
Habit of being too under-resourced to promote business
interests
Treatment philosophy versus business strategy
Next Steps: Strategy
• Become a Learning Organization…Now
– Reforms and regulations
– Markets and trends
• Think Innovation
– Simpler, enabled, less costly
– Adds value
• Lead
– Champion the strategy
• Hold Everyone Accountable for Results
– Do what matter most
Next Steps: Strategy
• Build from your Core and Craft a Value Proposition
– Focus on patient experience and quality
– Show “value creation” capabilities
• Assure Infrastructure is Ready
– IT, staff, workflow, and Evidence-Based Practices
• Build Alliances
– Networks and new business relationships (MH, hospitals, ACOs,
FQHCs and primary care)
• Make your Presence Known
– Assert evidence that you must be a partner
Challenge: Remember…
•
•
•
•
•
Your vision, your mission and your customers
Your commitment to your field, your employees and
their families
The needs of your communities
Your Board’s understanding and participation
Your bottom-line, sustainability and viability
Angela Halvorson
ahalvorson@ahpnet.com
217-553-2633
Thank You!
Questions