Mental Health and Healthcare Reform

LPHI/CIBHA Conference February3-4, 2011 1

Mental Health and Healthcare Reform

On the Banks or in the Mainstream?

Harold Alan Pincus, MDHarold Alan Pincus, MDProfessor and Vice Chair, Department of PsychiatryProfessor and Vice Chair, Department of Psychiatry

Co-Director, Irving Institute for Clinical and Translational ResearchCo-Director, Irving Institute for Clinical and Translational ResearchColumbia UniversityColumbia University

Director of Quality and Outcomes ResearchDirector of Quality and Outcomes ResearchNew York-Presbyterian HospitalNew York-Presbyterian Hospital

Senior Scientist, RAND CorporationSenior Scientist, RAND Corporation

AgendaAgenda

• PCASG/CIBHAPCASG/CIBHA– Where from?Where from?– Where to?Where to?

• Healthcare ReformHealthcare Reform– Patient Centered Medical Home (PCMH)Patient Centered Medical Home (PCMH)– Accountable Care Organizations (ACO)Accountable Care Organizations (ACO)– Pay for Performance (P4P)Pay for Performance (P4P)– Comparative Effectiveness ResearchComparative Effectiveness Research

• Goals for Today/TomorrowGoals for Today/TomorrowLPHI/CIBHA Conference

February3-4, 2011 2








Mental-Health Challenge Emerges As Victims Face Multiple Traumas

BATON ROUGE, La. –

“…Post-traumatic stress disorder, depression and anxiety are common after major disasters, mental-health experts say, because disasters frighten people and disrupt their

lives. But Hurricane Katrina poses special challenges…”

“…The hurricane’s upheaval also has exacerbated the symptoms of some people who suffer from developmental disabilities and mental illnesses such as schizophrenia…”


Crossing the Quality ChasmCrossing the Quality Chasm

““Quality problems occur typically Quality problems occur typically not because of failure of goodwill, not because of failure of goodwill, knowledge, effort or resources knowledge, effort or resources devoted to health care, but devoted to health care, but because of fundamental because of fundamental shortcomings in the ways care is shortcomings in the ways care is organized”organized”

The American health care The American health care delivery system is in need of delivery system is in need of fundamental change. The current fundamental change. The current care systems cannot do the job. care systems cannot do the job. Trying harderTrying harder will not work: will not work:Changing systems of care will!Changing systems of care will!



““Crossing the Quality Chasm”Crossing the Quality Chasm”

Six Aims For ImprovementSix Aims For Improvement

• SafeSafe

• EffectiveEffective

• Patient-centeredPatient-centered

• TimelyTimely

• EfficientEfficient

• EquitableEquitable

13LPHI/CIBHA Conference

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LPHI/CIBHA Conference February3-4, 2011

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Ten Rules for Achieving the AimsTen Rules for Achieving the Aims

Old Rules Old Rules 1.1. Care is based on visits.Care is based on visits.

2.2. Professional autonomy Professional autonomy drives variability. drives variability.

3.3. Professionals control Professionals control care. care.

4.4. Information is a record.Information is a record.

5.5. Decisions are based Decisions are based upon training and upon training and experience.experience.

New RulesNew Rules1. Care is based upon 1. Care is based upon

continuous healing continuous healing relationships.relationships.

2. Care is customized to 2. Care is customized to patient needs and patient needs and values.values.

3. The patient is the source 3. The patient is the source of control.of control.

4. Knowledge is shared 4. Knowledge is shared and information flows and information flows freely.freely.

5. Decision making is 5. Decision making is evidence-based.evidence-based.


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Ten Rules for Achieving the AimsTen Rules for Achieving the Aims

Old Rules Old Rules 6.6. ““Do no harm” is an Do no harm” is an

individual clinician individual clinician responsibility. responsibility.

7.7. Secrecy is necessary.Secrecy is necessary.

8.8. The system reacts to The system reacts to needs. needs.

9.9. Cost reduction is Cost reduction is sought. sought.

10.10. Preference for Preference for professional roles over professional roles over the system.the system.

New RulesNew Rules6.6. Safety is a system Safety is a system

responsibility.responsibility.

7.7. Transparency is Transparency is necessary. necessary.

8.8. Needs are anticipated.Needs are anticipated.

9.9. Waste is continuously Waste is continuously decreased.decreased.

10.10. Cooperation among Cooperation among clinicians is a priority.clinicians is a priority.


Six Problems in the Quality of Six Problems in the Quality of M/SU Health CareM/SU Health Care

• Problem 1: Obstacles to patient-centered careProblem 1: Obstacles to patient-centered care• Problem 2: Weak measurement and Problem 2: Weak measurement and

improvement infrastructureimprovement infrastructure• Problem 3: Poor linkages across MH/SU/GHProblem 3: Poor linkages across MH/SU/GH• Problem 4: Lack of involvement in National Problem 4: Lack of involvement in National

Health Information Infrastructure (NHII)Health Information Infrastructure (NHII)• Problem 5: Insufficient workforce capacity for QIProblem 5: Insufficient workforce capacity for QI• Problem 6: Differently structured marketplaceProblem 6: Differently structured marketplace


Crossing the Quality Chasm

Standardize Practice Elements– Clinical assessment– Interventions– IT infrastructure

Develop Guidelines– Evidence-based medicine– Shared decision making

Measure Performance– For each “6P” level– Across silos

Improve Performance– Learn– Reward

Strengthen Evidence Base– Evaluate effective strategies– Translate from bench to

bedside to community

Consumer ParticipationConsumer Participation

Leadership Leadership SupportSupport

Clinical Clinical PerspectivesPerspectives

Integrative ProcessesIntegrative Processes


““6 P” Conceptual Framework6 P” Conceptual FrameworkPatient/Consumer

Practice/Delivery Systems

Purchasers (Public/Private)

• Enhance self-management/participation• Link with community resources• Evaluate preferences and change behaviors

• Improve knowledge / skills• Provide decision support• Link to specialty expertise and change behaviors

• Establish chronic care model and reorganize practice• Link with improved information systems• Adapt to varying organizational contexts

• Enhance monitoring capacity for quality/outliers• Develop provider/system incentives• Link with improved information systems

• Educate regarding importance/impact of depression • Develop plan incentives/monitoring capacity• Use quality/value measures in purchasing decisions

Populations and Policies

• Engage community stakeholders; adapt models to local needs• Develop community capacities• Increase demand for quality care enhance policy advocacy

Providers

Plans


Don’t Split Mind and BodyDon’t Split Mind and Body


Evidence-Based Chronic (Planned) Care Approaches Evidence-Based Chronic (Planned) Care Approaches for Treating Depression for Treating Depression

Are EffectiveAre Effective

Prepared, ProactivePractice Team

Informed, Empowered Patient and Family

Productive InteractionsPatient-Centered Coordinated

Timely and Evidence- Efficient Based and Safe

Improved Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health SystemCommunity

Health Care OrganizationResources and Policies


Models of Linkage / Models of Linkage / IntegrationIntegration

Embedded PCP in BHSEmbedded PCP in BHS Co-location of BHS in PCPCo-location of BHS in PCP

BP

UnifiedUnified Coordination / Collaboration Coordination / Collaboration

B

PB

B PP


Top Ten IssuesTop Ten Issues General Health/Mental Health General Health/Mental Health

RelationshipsRelationships

1.1. PartnershipsPartnerships2.2. FormalizeFormalize3.3. AccountabilityAccountability4.4. ReferralReferral5.5. Consultation/ EvaluationConsultation/ Evaluation6.6. Information FlowInformation Flow7.7. MoneyMoney8.8. Quid Pro QuoQuid Pro Quo9.9. MaintenanceMaintenance10.10. GeneralizeGeneralize


PCASG StrategiesPCASG Strategies

• Medical HomeMedical Home• Care ManagementCare Management• Communic-Coordin-Integr-ationCommunic-Coordin-Integr-ation• Evidence-Based PracticesEvidence-Based Practices• TrainingTraining• Technical AssistanceTechnical Assistance• Quality IncentivesQuality Incentives• FlexibilityFlexibility


““Crossing the Quality Chasm”Crossing the Quality Chasm”


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Major Mental Health Policy Questions

• How will healthcare reform incorporate mental health?

• How should we pay for mental health care? How much?

• Who will provide mental health care?• What is the role of the public sector?• Where will new scientific findings/

technologies come from?• Can mental health cross the “quality

chasm”?LPHI/CIBHA Conference

February3-4, 2011


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??


Future Policy InitiativesFuture Policy Initiatives• Healthcare ReformHealthcare Reform

– Patient Centered Medical Homes (PCMH)Patient Centered Medical Homes (PCMH)– Accountable Care Organizations (ACO)Accountable Care Organizations (ACO)– Pay for Performance (P4P)Pay for Performance (P4P)– Center for Medicare/Medicaid InnovationCenter for Medicare/Medicaid Innovation

• Health Information TechnologyHealth Information Technology• Comparative Effectiveness ResearchComparative Effectiveness Research

– Concepts/Buckets/QuestionsConcepts/Buckets/Questions

• Mental Health Specific InitiativesMental Health Specific Initiatives

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Healthcare Reform InnovationsHealthcare Reform Innovations

• Two PopulationsTwo Populations– General/Primary Care General/Primary Care – Severe/Persistent Behavioral Health Severe/Persistent Behavioral Health

ConditionsConditions

• Two StrategiesTwo Strategies– MainstreamMainstream– Separate Specialty AdaptationsSeparate Specialty Adaptations


Patient Centered Medical Home Patient Centered Medical Home and Behavioral Healthand Behavioral Health

• Mainstream Strategy (augmentation)Mainstream Strategy (augmentation)– AccreditationAccreditation

• BH one of three conditionsBH one of three conditions• Require BH condition as fourth Require BH condition as fourth • Integrate BH care for all three conditionsIntegrate BH care for all three conditions

– PaymentPayment• Blended FFS and PM/PMBlended FFS and PM/PM• Pricing incremental BH costsPricing incremental BH costs• Risk AdjustmentRisk Adjustment

– Accessing BH Specialty careAccessing BH Specialty care


Patient Centered Medical HomePatient Centered Medical Home

• BH Specialty “Health Homes”BH Specialty “Health Homes”– In ACA (Sec. 2703)In ACA (Sec. 2703)– SAMHSA Demonstration- 50+ SitesSAMHSA Demonstration- 50+ Sites– Accessing General Health CareAccessing General Health Care

• Buy or Own?Buy or Own?

– Pricing IssuesPricing Issues– Quality MeasurementQuality Measurement


Accountable Care OrganizationsAccountable Care Organizations• Networks of Hospital, PCPs, VNS, etc.Networks of Hospital, PCPs, VNS, etc.• Bundled PaymentBundled Payment• Shared Savings/Accountability for QualityShared Savings/Accountability for Quality• BH Accountability?BH Accountability?• BH Care Management ExpertiseBH Care Management Expertise

– Buy or Own?Buy or Own?• BH ACOs for SPB populations?BH ACOs for SPB populations?

– Option 1: Maintain in Mainstream w MBHO Option 1: Maintain in Mainstream w MBHO PartnerPartner

– Option 2: BH ACO with Full AccountabilityOption 2: BH ACO with Full Accountability– Option 3: BH ACO with Limited Scope Option 3: BH ACO with Limited Scope



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Quality MeasurementQuality Measurement

• ““You can’t improve what you don’t measure”You can’t improve what you don’t measure”• Develop quality metrics (indicators)Develop quality metrics (indicators)

- Structure- Structure

- Process- Process

- Outcomes- Outcomes• Across silos of MH/SU/GHAcross silos of MH/SU/GH• At each “P” levelAt each “P” level• Multiple activities/No stewardshipMultiple activities/No stewardship


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Improve PerformanceImprove Performance

• Guideline DisseminationGuideline Dissemination• Provider Training/Education/CMEProvider Training/Education/CME• Certification/Accreditation/LicensureCertification/Accreditation/Licensure• Provider Reminder Systems/Decision SupportProvider Reminder Systems/Decision Support• Patient Education/RemindersPatient Education/Reminders• Quality MeasurementQuality Measurement• Quality Improvement- PDSA/Six Sigma/IHIQuality Improvement- PDSA/Six Sigma/IHI• Public ReportingPublic Reporting• Financial Incentives/P4PFinancial Incentives/P4P


P4P in Behavioral HealthP4P in Behavioral Health• Early study by Bremer, Pincus, et alEarly study by Bremer, Pincus, et al• 23 programs identified23 programs identified• 11 targeting primary care providers11 targeting primary care providers• 10 focused on depression10 focused on depression• Movement to go beyond “black box” of visit Movement to go beyond “black box” of visit

to specific PHQ measuresto specific PHQ measures• Longitudinal implementation of structure, Longitudinal implementation of structure,

process, outcomes measurement e.g. process, outcomes measurement e.g. Minnesota DIAMOND projectMinnesota DIAMOND project

Pay for PerformancePay for Performance

• Stewardship for BH FieldStewardship for BH Field

• Measure DevelopmentMeasure Development

• Risk AdjustmentRisk Adjustment

• ““Market Basket” ProblemMarket Basket” Problem

• Multi PayerMulti Payer

• Joint AccountabilityJoint Accountability

• Process-Outcomes LinkProcess-Outcomes Link



Comparative Effectiveness Research

Issues for Behavioral Health and Wellness

• CER Definitions

• CER Questions: – Who, What, Where, When, Why

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Why Now?

“Only a limited amount of evidence is available about which treatments work

best for which patients…”

- Peter Orszag

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Uncertainty, CER and Health Reform

In situations where the right thing to do is well established, physicians from high- and low-cost cities make the same

decisions. But in cases where the science is more unclear, some physicians pursue the maximum possible

amount of testing and procedures; some pursue the minimum. And what kind of doctor they are depends on

where they came from. In case after uncertain case, more was not necessarily better.

Dr. Atul Gawande

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BOGSAT ModelBOGSAT Model


Economic ModelEconomic Model



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• Evidence-Based PracticesEvidence-Based Practices– specific interventionsspecific interventions– medications, psychotherapies, team-based, etc.medications, psychotherapies, team-based, etc.– appropriateness/fidelity measurementappropriateness/fidelity measurement– training, supervisiontraining, supervision

• Measurement-Based Care (MBC)Measurement-Based Care (MBC)– clinical measures (e.g. HA1c, PHQ-9)clinical measures (e.g. HA1c, PHQ-9)– systematic, consistent, longitudinalsystematic, consistent, longitudinal– action-orientedaction-oriented

• Best Practices/ContextBest Practices/Context– accessibilityaccessibility– therapeutic alliancetherapeutic alliance– patient centerednesspatient centeredness– cultural competencecultural competence


Institute of Medicine Report Definition of Comparative

Effectiveness Research (CER)

• “The generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist patients, clinicians, purchasers, policy makers, and the public to make informed decisions that will improve health care at both the individual and population levels.”

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Federal Coordinating Council Report Definition of CER

• “CER is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in ‘real world’ settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances…”

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CER QuestionsCER Questions

• WhoWho

• WhatWhat

• WhereWhere

• WhenWhen

• HowHow

• WhyWhy

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WhoWho

• Identifying and characterizing participantsIdentifying and characterizing participants

• Diagnoses (within/beyond DSM)Diagnoses (within/beyond DSM)

• Co-morbidity (MH, SUD and GMC)Co-morbidity (MH, SUD and GMC)

• Gender, Age, EthnicityGender, Age, Ethnicity

• Severity/FunctioningSeverity/Functioning

• Preferences/ExpectationsPreferences/Expectations

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WhatWhat

• MedicationsMedications

• Other Somatic TreatmentsOther Somatic Treatments

• Psychotherapies Psychotherapies

• Other Psychosocial InterventionsOther Psychosocial Interventions– ACT, Supported Employment, etc.ACT, Supported Employment, etc.

• Combinations/”Cocktails”/AlgorithmsCombinations/”Cocktails”/Algorithms

• Systems/Policy/Economic InterventionsSystems/Policy/Economic Interventions

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WhereWhere

• Academic SettingsAcademic Settings

• Primary Care ClinicsPrimary Care Clinics

• Mental Health ClinicsMental Health Clinics

• Community HospitalsCommunity Hospitals

• LTC, Home Care, Clubhouses, OtherLTC, Home Care, Clubhouses, Other

• Private PracticePrivate Practice

• Multiple Clinical DisciplinesMultiple Clinical Disciplines

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WhenWhen

• AssessmentAssessment

• Acute/Short-termAcute/Short-term

• IntermediateIntermediate

• Long-termLong-term

• Longitudinal/Chronic Care ManagementLongitudinal/Chronic Care Management

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WhyWhy

It’s the patient, stupidIt’s the patient, stupid

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HCR and U.S. Alphabet Soup HCR and U.S. Alphabet Soup

• CERCER• ONCHITONCHIT• CMSCMS• AHRQAHRQ• DM/EAPDM/EAP• EHREHR• PQRIPQRI• RHIORHIO• NICENICE• PCORIPCORI

• ACAACA• ACOACO• PCMHPCMH• CMICMI• NQFNQF• NCQA/HEDISNCQA/HEDIS• JCAHO/TJCJCAHO/TJC• ACGMEACGME• LCMELCME• T1/T2/T3…..T/12T1/T2/T3…..T/12

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You are the mammals!You are the mammals!


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57LPHI/CIBHA Conference

February3-4, 2011

CIBHA AgendaCIBHA AgendaFebruary 3-4, 2001February 3-4, 2001

• What did we do?What did we do?

• What did we learn?What did we learn?– ClinicalClinical– Systems/EconomicsSystems/Economics– CollaborationsCollaborations– WorkforceWorkforce

• What’s coming?What’s coming?– And what do we need to do?And what do we need to do?



Top Ten IssuesTop Ten Issues General Health/Mental Health General Health/Mental Health

RelationshipsRelationships

1.1. PartnershipsPartnerships2.2. FormalizeFormalize3.3. AccountabilityAccountability4.4. ReferralReferral5.5. Consultation/ EvaluationConsultation/ Evaluation6.6. Information FlowInformation Flow7.7. MoneyMoney8.8. Quid Pro QuoQuid Pro Quo9.9. MaintenanceMaintenance10.10. GeneralizeGeneralize

CIBHA Lessons LearnedCIBHA Lessons Learned

1.1. Systematic data (removes myths)Systematic data (removes myths)2.2. K.I.S.S.K.I.S.S.3.3. Relationships are keyRelationships are key

– Formal and informal connectionsFormal and informal connections

4.4. Communication is essential Communication is essential – In all directions (360 degrees)In all directions (360 degrees)

5.5. Culture/Environment makes a differenceCulture/Environment makes a difference6.6. Tools usher in behavior (e.g.,PHQ-9)Tools usher in behavior (e.g.,PHQ-9)7.7. Relentless follow-up gets results (longitudinality)Relentless follow-up gets results (longitudinality)8.8. Training for competence and reinforcementTraining for competence and reinforcement9.9. Quality improvement is your friendQuality improvement is your friend10.10. Flexibility in roles, time, structure, workflowFlexibility in roles, time, structure, workflow


CIBHA ChallengesCIBHA Challenges

1.1. Economics/Incentives/Sustainability Economics/Incentives/Sustainability 2.2. TechnologyTechnology3.3. Substance Use DisordersSubstance Use Disorders4.4. AccountabilityAccountability

– 6 Ps/Local-State-National6 Ps/Local-State-National5.5. MeasurementMeasurement

– S/P/O-Quality/Costs-Clinical/PolicyS/P/O-Quality/Costs-Clinical/Policy6.6. Prediction- who should get what?Prediction- who should get what?7.7. Information/CommunicationInformation/Communication8.8. WorkforceWorkforce

– Amount/Competencies/Training/ConsistencyAmount/Competencies/Training/Consistency9.9. Stigma/Language/CultureStigma/Language/Culture10.10. LeadershipLeadership


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Mental Health and Healthcare Reform