MHPA Annual Meeting November 13, 2015 Linda Rosenberg, The National Council of Behavioral Health

Beyond Physical Health: Addressing Underlying Mental Health Issues

11/23/2015

We really needed this!

• Medicaid most vital health care safety net program, covering more than 72 million Americans

• Spent more than $450 billion last year, responsible for oldest, sickest, most complex and costly patients

• Platform for innovation and care improvement for people with mental illnesses and soon – addictions

Prevalence

• 25% of adults experience mental illness each year • 50% develop a mental illness during their lifetime • 27% a substance abuse disorder • 1 in 8 ED visits due to Behavioral Health Disorders • ¼ of adult stays in U.S. hospitals involve

Behavioral Health Disorders • 47% with SMI used the ED • 20.4% with SMI are hospitalized

Low-Income General PCPatients Population*

At Least One Psychiatric Dx 51% 28%Mood Disorder 33% 16%Anxiety Disorder 36% 11%Alcohol Abuse 17% 7%Eating Disorder 10% 7%

- 35% of low-income patients with a psychiatric diagnosissaw their PCP in the past 3 months

- 90% of patients preferred integrated care- Based on findings authors argue for system change

PREVALENCE OF PSYCHIATRIC DISORDERS

Disorder

Source: Mauksch LB, et. Al. Mental Illness, Functional Impairment, and Patient Preferences for CollaborativeCare in an Uninsured, Primary Care Population. The Journal of Family Practice , 50(1):41-47, 2001.

PsychiatricIN LOW-INCOME PRIMARY CARE PATIENTS

“Of course you feel great. These things are loaded with antidepressants.”

Primary Care

Access • 2/3 of primary care

reports poor access to specialty mental health for their patients.

• With insurance, average wait 25 days to see specialist.

“We couldn’t get a psychiatrist, but perhaps you’d like to talk about your skin. Dr. Perry here is a dermatologist.”

Addictions Little change in 50 years

The Irrationality of Alcoholics Anonymou

*Beacon health options

Life Expectancy

40

45

50

55

60

65

70

75

80

No Mental Disorder Any Mental DisorderGeneral Population

Any Mental DisorderPublic Sector

9

• BH→PC RESPECT – MacArthur Initiative

Cluster randomized controlled trial 60% response to treatment and 37%

remission at 6 months, compared to 47% and 27% in usual care practices

• BH→PC IMPACT Study

Randomized clinical trial of collaborative care intervention for elderly patients

Significant improvements in symptoms and functionality at 6 and 12 months, and 2 years

• BH→PC DIAMOND Initiative

Adapted IMPACT program for general population setting and studied outcomes

64% response to treatment and 44% remission at 6 months; 72% response and 52% remission at 12 months

• PC→BH P-CARE - NIMH-funded Trial

Medical case management for individuals with serious mental illnesses

Fewer medical ER visits, improved cardio risk factors

• PC→BH Diabetes Care Coordination - AHRQ Health Care Innovation

Nursing and mental health care coordination to clients with SMI to manage their diabetes

Clients with ideal blood sugar levels increased from 32% to 43%. Mean health risk status improved.

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The Research

Economics

Effective integration of medical and behavioral care could save $26 billion - $48 billion annually in general health care costs. Economic Impact of Integrated Medical-Behavioral Healthcare, Milliman

Report, April 2014

The ACA • Expansion and Insurance Reform – 49.1 “technical fix” • Contain cost and improve quality Reduce hospitalizations and unnecessary treatments Integrate care Focus on “high user” populations

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• Dual Eligible • Accountable Care

Organizations • Medical/Health Homes • State Medicaid Waivers -

DSRIPS

13

Socially vulnerable patients (income, language, race/ethnicity, health disparities)

Clinically vulnerable

patients

(complex, difficult healthcare needs)

Comprehensive Care Single care plans

Real time information sharing Aligned financial incentives

Multidisciplinary teams Care management connects the dots

Current Reality Half Full or Half Empty?

2006…2009…present

• Behavioral Health Integration grantees – 186 • FQHC Integration awardees - 450

Policy and Practice

Integration

Collaborative Care • Primary Care Provider • Patient + • Behavioral Health Care

Manager • Psychiatric Consultant

Psychiatric Consultation

in primary care

Jurgen Unutzer, University of Washington - IMPACT

Camden, New Jersey, one per cent of patients account for third of city’s medical costs.

The Hot Spotters Lower medical costs by giving the neediest better care…care that addresses housing, jobs, jails and prisons

Dr. Jeffrey Brenner

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Inside medical homes/hospital systems/ACOs: addressing prevention & early intervention, behaviors & disorders

Specialty Care… Specialty organization— delivering whole-health care to

population with complex psychiatric and addiction conditions (collaborating, co-locating or opening ambulatory health)

Harriet Hall Dale Klatzker Tim Swinford

“Organizations that have made progress in integrating behavioral and primary care have either funded the initiatives themselves or relied on grants.” The Commonwealth Fund

Fearless but not reckless in the Face of Change

Leaders…

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Positioning for Risk (aka Value Based Purchasing)

• Hospitals as Health Systems/insurance companies/ACOs • Insurance Co. as providers • Primary care anytime, anywhere • Rethinking size and scope of specialty BHOs

Geography is not Destiny Colleagues do Compete

Talk a different language with unfamiliar colleagues

23

Harvard Business Review: Cross-cultural Communication

Partnerships

DON’T

Talk about your need first

Expect to get something

Limit assistance to a project

Make it about this deal

Push a specific position

Withhold information

Let them take their lumps

DO Ask about their needs first

Give something

Assist wherever you can

Make it about the next 10

Pursue common interest

Reveal anything helpful

Take one for the team

Principles…

Wide

(revenue in millions) YTD YTD YTD Annual

nces (in Millions)

2013

2014

2015

Accounts Receivable Balan 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2

-

2013 2014 2015 Budget 5.6 6.4 7.1 25.3

Costs and Outcomes

Michael Porter and Timothy Lee - measure costs and outcomes for every patient

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Technology

Clinical and Fiscal: • Engage Patients • Coordinate Care • Analytics • Extend/Replace Staff

Non-Profits on a Journey

Value Based Payment (Retail)

Agent of Government

Charitable Organization

The Hope of Trickle Down…

Operating Cash

13

6

8

24

28

14

7

> 1 Y E A R

1 0 - 1 2 M O

7 - 9 M O

4 - 6 M O

2 - 3 M O

< 1 M O

0

0 5 10 15 20 25 30

NEW ENGLAND NFP SURVEY CASH ON HAND 2014 % of Agencies

In 2014, Third Sector New England partnered with foundations and other to conduct a broad survey of their members. 877 leaders (primarily executive directors) and 330 board members of nonprofit organizations responded.

The Future…the view from the beltway

• 24/7 • One Stop Shopping • Early Identification/Intervention • Care Transitions • Care Coordination for Whole Health • Evidence Based Practices • Peer Support • Standardized Reporting • Pay for Performance

Mental Health and Substance Use Legislation in the 114th Congress

Over 30 bills introduced so far in the 114th Congress

Rep. Tim Murphy bill Helping Families in Mental Health

Crisis Act (H.R. 2646) Sens. Murphy/Cassidy bill

Mental Health Reform Act (S. 1945) HELP Committee bill (Murray-Alexander) Mental Health Awareness and Improvement

Act (S. 1893) Cornyn bill

Mental Health and Safe Communities Act (S. 2002)

Addictions

• Comprehensive Addiction Treatment Act (S.524/H.R.953)

• Treatment and Recovery Act (S.1410)

• Supporting Positive Outcomes After Release Act (S.1409)

• Safe Prescribing of Controlled Substances Act (S.1392)

*White Middle Aged American with no more than a high school education*

FQHCs July 25, Sylvia Burwell, secretary of HHS, announced $100 million in grants to Federally Qualified Health Centers for treatment for substance use disorders

Certified Community Behavioral Health Clinics

Behavioral Health is Out of the Closet

“Reinventing American Health Care” -Ezekiel J. Emanuel

6 Megatrends in Health Care: The Long-Term Impact of the ACA

http://www.newrepublic.com/article/116838/six-healthcare-megatrends-caused-obamacare

• VIP care for the chronically and mentally ill (2020) • Emergence of digital medicine and closure of hospitals

(2020) • End of health care inflation (2020) • End of employer-sponsored health insurance (2025) • End of insurance companies as we know them

(effective 2025) • Transformation of medical education (2025)

The Future…What an ACA architect is saying