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Proprietary and Confidential. Do not distribute. BH700-092016
Optum Behavioral Health
Proprietary and Confidential. Do not distribute. BH700-092016
Proprietary and Confidential. Do not distribute. BH700-092016
Proprietary and Confidential. Do not distribute. BH700-092016
Commercial Medicaid Medicare
OBH Membership State of RI residents as of August 2016
Product Type Aug16 Mbrs Commercial 141,671 Medicaid 86,875 Medicare 21,671 Total 250,217
Facility Type State Count of Facility Id
Count of Facility
Addresses
Autism/ABA Agency RI 10 13 CMHC Community Mental Hlth Ctr RI 3 17
Freestanding MH IOP RI 1 2 Freestanding SA Day Treatment RI 1 6
Freestanding SA IOP RI 2 3
General Hospital w MH RI 3 5 General Hospital w MH & SA RI 4 21
General Hospital w SA RI 2 2
Methadone Maintenance RI 1 5
Outpatient Detox Center RI 1 4
Psychiatric Hospital RI 1 1
Psychiatric Hospital w SA RI 1 2 Psychiatric Residential Fac RI 5 14
Residential Treat Ctr w MH/SA RI 1 20
SA Rehab Facility RI 3 3
SA Residential Facility RI 4 9
Veterans Admin Facility RI 1 3
Proprietary and Confidential. Do not distribute. BH700-092016
Bubble size = total # commercial admits
Facilities with > 15 admits
White Star = Regional Avg. (N.E.)
Black Star = National Avg.
Data based on 979 Rhode Island Commercial Inpatient Admissions
Source: MH & SUD claims data, August 2015 – July 2016
Proprietary and Confidential. Do not distribute. BH700-092016
Bubble size = total # commercial admits
Facilities with > 15 admits
White Star = Regional Avg. (N.E.)
Black Star = National Avg.
Data represents both MH and SUD admits
Data based on 979 Rhode Island Commercial Inpatient Admissions
Source: MH & SUD claims data, August 2015 – July 2016
Proprietary and Confidential. Do not distribute. BH700-092016
Proprietary and Confidential. Do not distribute. BH700-092016
Focus on recovery and resiliency
We utilize proven “recovery principles” to
improve outcomes
Most programs fail because the underpinnings that
support behavior change are missing
Typical Medical Management Approach
Recovery-centered Approach
• Communication tools focus on consumers’ strengths and what they want to achieve, not how “ill” they are
• We create communities that treat consumers “where they are”
• Transparency of clinical effectiveness for active decision making and tracking goals
• Innovative technology that offers a variety of treatment options
• Focus on symptoms, illness and deficiencies — not personal strengths, desires and life goals
• Program compliancy — not adherent to what’s important to the consumer
• The provider is responsible for clinical progress — not the consumers and their motivated desire to reach their defined goal
• Care is limited to standard mental health services
Our person-centered approach to care is unique and powerful
Proprietary and Confidential. Do not distribute. BH700-092016
MedicalAny action that eliminates a barrier between medical and behavioral services resulting in better outcomes
Behavioral Medical
MBI supports whole person care
Proprietary and Confidential. Do not distribute. BH700-092016
Beh
avio
ral H
ealth
R
isk/
Stat
us
Proprietary and Confidential. Do not distribute. BH700-092016
Accountable Care Organizations
Improve quality
Improve access to care
Reduce avoidable emergency visits
Reduce avoidable admissions
Improve high risk patient care
Community care team
Proprietary and Confidential. Do not distribute. BH700-092016
Architect systems of care, build broad networks, and integrate care management to help create a more effective and efficient provider network
¾ We manage financial risk
¾ We ensure quality measures are met
¾ We manage clinical care
¾ We manage provider networks
Whole-person health
Population-specific interventions
Consumer and provider experience
Recovery
CORE
ELE
MEN
TS
Proprietary and Confidential. Do not distribute. BH700-092016
1) Care management wrapped around individuals with chronic behavioral health conditions, in their Behavioral Health (BH) care settings
2) BH staff integrated into medical practices for screening, brief intervention and referral; currently 12 participating practices
3) Integra and Prospect CharterCARE are the two current Medicaid ACOs; their staff have access to both medical and behavioral information and can coordinate care across the continuum; access occurs through the population health registry
1) Health Homes – integrated case management in CMHO’s and Opiate treatment providers (OTPs)
2) Care Transformation Collaborative (CTC)-RI’s Integrated Behavioral Health initiative
3) Medicaid “Accountable Entities”(AE) can share savings in Total Cost of Care, which includes medical, pharmacy, and behavioral costs
Proprietary and Confidential. Do not distribute. BH700-092016
Proprietary and Confidential. Do not distribute. BH700-092016
•
•
• Peer-directed Programs
• Substance use programs
• Mental health program
• Internal peer coaching
19 peer locations nationwide with 426 members served in Q1 2016
Network Strategy Key Performance Indicator Report, July 2016, D. Adler
Proprietary and Confidential. Do not distribute. BH700-092016
Wisconsin Peer Bridger program1 Texas Whole-Health Peer Coaches2
Rhode Island Recovery Coach program3 RI PRAISE program4
1. Results within 6 months after enrollment in peer support programs in Wisconsin compared to 6 months prior to enrollment; among 130 participants enrolled from 12/9/2009 to 12/31/11 with continuous eligibility for 6 months pre- and post-referral and at least one behavioral health claim during that period; Internal UBH Report, R.Cate, 2013.. 2. Results within six months after enrollment in whole-health peer support program in San Antonio, Texas, compared to six months prior to enrollment, among a sample of 25 participants 60 years of age or older with continuous eligibility for six months pre- and post-referral, at least two hospitalizations in the prior year, and diagnosed with both a mental health issue and a general heal th issue; enrolled in the program between 06/1/2010 and 09/30/2011; Ashenden, 2011. 3. Engagement rate among 502 member referrals to the Rhode Island Recovery Coach program made from August 1, 2014 to July 31, 2016; Rosales, 2016.. 4. Increase in ROI based on results within 12 months after enrollment in the RI PRAISE program compared to 12 months prior to enrollment; claims data from 1/1/2013 to 12/31/15.; Bruce ,2/2016.
Proprietary and Confidential. Do not distribute. BH700-092016
Significant rise in utilization of 18- to 25-year-olds driven by several converging factors
1. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602. 2. In 2012, the rate of substance dependence or abuse among adults aged 18 to 25 was 18.9%, adults aged 26 and older was 7.0%. Source: Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings (HHS Publication No. SMA 13-4795, NSDUH Series H-46). 3. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013). Treatment Episode Data Set (TEDS): 2001-2011.
Affordable Care Act
Federal Mental Health Parity
Risk of Onset for
SMI & SUD
Higher Rates of
SUD
Increase in Overall
Opioid Treatment
Variance in Clinical
Approach
Unprepared Provider System
18- to 25-year-olds became newly eligible on parents’ employer- sponsored plans
Benefit changes eliminated substance abuse treatment limits and network restrictions
Age of onset for most MH and SUD disorders is in the second and third decade of life1
2X substance use disorder rates compared to adults 26 and older2
346% increase in all treatment admissions from 2001 to 20113
MH and SUD treatment covers wide range of philosophical and evidence-based approaches
Historically low demand and lack of coverage hindered advancement in clinical innovation
Proprietary and Confidential. Do not distribute. BH700-092016
*Appleby, Julie, (2016, September 12), Study: Health Spending Related To Opioid Treatment Rose More Than 1,300 Percent. Retrieved from Kaiser Health News (http://khn.org/news/study-health-spending-related-to-opioid-treatment-rose-more-than-1300-percent/)
Proprietary and Confidential. Do not distribute. BH700-092016
increase from 2002 to 20134 4X increase from
2010 to 20135 3X Heroin-related deaths are rising
Americans have a substance use disorder with
prescription pain killers
1.9M 586K 12% of all Substance Use Disorders
are Opioid Use Disorders1
It is estimated that 23% of individuals who use heroin develop an opioid addiction2
Drug addiction is now the leading cause of accidental death driven by Opioid Use Disorders3 #1
Americans have a substance use
disorder with heroin
1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2. National Institute on Drug Abuse. (2014). Drug Facts: Heroin. Bethesda, MD: National Institute on Drug Abuse.3,4. Centers for Disease Control and Prevention, Today’s Heroin Epidemic, July 7, 2015. 5. Hedegaard H, Chen L, Warner M, Drug-poisoning Deaths Involving Heroin: United States, 2000–2013, National Center for Health Statistics Data Brief No. 190, March 2015.
Proprietary and Confidential. Do not distribute. BH700-092016
There seems to be a direct correlation between overdose deaths rising and the increase in opioids being prescribed
1 Centers for Disease Control and Prevention. (2014). Opioid Painkiller Prescribing, Where You Live Makes a Difference. Atlanta, GA: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vitalsigns/opioid-prescribing/. 2 Hedegaard MD MSPH, Chen MS PhD, Warner PhD. Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013. National Center for Health Statistics Data Brief. 2015:190:1-8. 3Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.
Proprietary and Confidential. Do not distribute. BH700-092016
56% increase due to misuse/abuse of pharmaceuticals
21% increase due to illicit drug use
46% increase due to adverse reactions
Reasons for drug-related emergency visits2
Drug-related emergency room visits have soared over the last decade
increase in U.S. ER costs1
from 2004 to 2011
423%
Consequences of opioid abuse in young adults3
1. Meier B, Marsh B, The Soaring Cost of the Opioid Economy. NY Times, Sunday Review, June 22, 2013. 2. Rates reflect increases in illicit drug use and misuse/abuse of pharmaceuticals from 2004 to 2011, and increases in adverse reactions from 2005 to 2011, as reported in: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013). Treatment Episode Data Set (TEDS): 2001-2011. State Admissions to Substance Abuse Treatment Services. BHSIS Series S-68, HHS Publication No. (SMA) 14-4832. 3. National Institute on Drug Abuse/Substance Abuse and Mental Health Services Administration: The Blending Initiative. Buprenorphine Treatment for Young Adults: Fact Sheet. Retrieved from http://www.drugabuse.gov/sites/default/files/ files/BupTx_YngAdlts_Factsheet.pdf
2X Emergency room visits have more than doubled
Proprietary and Confidential. Do not distribute. BH700-092016
• Expand the recruitment of Medication-Assisted Therapy (MAT) providers
• Partnered with the State of RI to implement Opiate Treatment Health Home Programs.
• Enhance our use of age-specific peer support groups and recovery coaches
• Implementing SUDS HelpLine
• Expand “immediate access” provider network
• Promote local community-based care
• Incentive providers to improve member outcomes (e.g., bundled payment)
Substance use strategy
Proprietary and Confidential. Do not distribute. BH700-092016
Small % of financial risk Large % of financial risk Moderate % of financial risk
Low Accountability Maximum Accountability Moderate Accountability
P4P/Shared Savings Contracts with Qualified Facilities and Outpatient Providers
(national footprint across all payor types)
ACOs, medical-behavioral integration in health homes
Capitation + Performance-
Based Contracting
Capitation Shared Risk
Bundled and
Episodic Payments
Shared Savings
Performance- Based
Contracting
Fee-for- Service
• SUDS Medication Assistance Therapy (MAT) Providers
• DRGs • COE Bundle Payments
“The payment approach best aligned with value is bundled payment ... Well-designed bundled payments encourage teamwork and high-value care.”
− Michael E. Porter, PhD Harvard Business School Harvard Business Review, Oct 2013
Proprietary and Confidential. Do not distribute. BH700-092016