Integrating Care for Better Health Charting a Course for Kentucky

Transcription

1 Issue Brief No. 4 September 2012 Integrating Care for Better Health Charting a Course for Kentucky

2 Mission The Foundation for a Healthy Kentucky is a non-profit, philanthropic organization working to address the unmet health care needs of Kentuckians. Our approach centers on developing and influencing health policy, to promote lasting change in the systems by which health care is provided and good health sustained, to: Improve access to care Reduce health risks and disparities Promote health equity The Foundation makes grants, supports research, holds educational forums and convenes communities to engage and develop the capacity of the Commonwealth to improve the health and quality of life of all Kentuckians. History The Foundation was created as a result of a settlement agreement reached after the Commonwealth contested the conversion of assets of Kentucky Blue Cross Blue Shield previously dedicated for charitable purposes, when that entity was acquired by Anthem, Inc. In November 1999, as a result of court-ordered mediation, Anthem, Inc. agreed to place $45 million into an independent charitable foundation that would address the unmet health needs of Kentuckians. In the fall of 2000, a 31-member Community Advisory Committee, whose membership reflected the geographic, gender, racial and ethnic diversity of Kentucky, developed Articles of Incorporation and Bylaws and proposed members of an initial Board of Directors for the Foundation for a Healthy Kentucky. On May 3, 2001, the court approved the Foundation for a Healthy Kentucky to receive the settlement funds. The Board of Directors held its inaugural meeting May 9, Foundation Priorities In 2012, the Foundation launched a new six year strategic plan that narrows our focus in an effort to create deeper and longer lasting changes on the health and health care of Kentuckians. We are pleased to announce the two new priorities that will guide our work in These priorities are: Promoting Responsive Health Policy To make public policy more responsive to the health and health care needs of the people of Kentucky. Investing in Kentucky s Future To improve the health of Kentucky s children by engaging communities to test innovative health strategies. For more information about the Foundation for a Healthy Kentucky, visit our website at: Acknowledgements The Foundation for a Healthy Kentucky would like to thank the members of the Integrated Care Action Team (ICAT) for their commitment, vision, and hard work in continuing to pursue better health, lower health care costs, and improved quality of care for all of Kentucky. We are grateful to everyone who contributed to the research, writing, and editing of this document. Specifically, we d like to thank: Andrea Adams & Joe Smith of the Kentucky Primary Care Association Lora Adams of Bluegrass Regional MHMR Board Carl Boes & Steve Shannon of the Kentucky Association of Regional Programs David Bolt of WellCare of Kentucky Kecia Fulcher & David Ptaszek of Pennyroyal Center Diane Murphy & Julia Richerson of the Family Health Centers, Inc. Donna Penrose Julie Perry of Eastern State Hospital Lisa Rice & Michelle Blevins of the Department for Behavioral Health & Intellectual & Developmental Disabilities Sheila Schuster of Advocacy Action Network; Pamela Vaught & Jeff Drury of Comprehend, Inc. Tina Studts of the University of Kentucky College of Medicine Liz McKune of the Division of Mental Health, Kentucky Department of Corrections»» Karen Martin, Lynne Flynn, & Commissioner Lawrence Kissner of the Department for Medicaid Services, Cabinet for Health & Family Services 2

3 Executive Summary The Foundation s work on integrated care began in Its initiative for Integrating Mental Health and Medical Services built on what was learned in earlier Foundation demonstration projects, and what was then known about foundations working on care integration. In 2012, as the Foundation launches its two initiatives for (Promoting Responsive Health Policy and Investing in Kentucky s Future), integrated care continues to be a priority area for pursuing policy change. In 2009, the Foundation for a Healthy Kentucky brought together key health and health care professionals with a shared commitment to increasing access to care that addresses the whole person, body and mind. We called this group the Integrated Care Action Team (ICAT). A key product of the ICAT was the report, No Wrong Door: Bridging Mental Health and Primary Care Silos in Kentucky. Since the publication of the report in 2010, state and national knowledge and experience with integrated care have grown. With the current report, we revisit some of the key and still-salient issues covered by the original report; update our knowledge based on new research and experience; and reach to a broader audience to expand the conversation and action around integrated care in Kentucky. This Issue Brief represents the Executive Summary of the full report. The idea of integrated care is known by many names and is increasingly a trend in health care in the U.S. and around the world. Integrating care is an important tool in achieving the Triple Aim in the U.S. health care system: improving the individual s experience of care (quality and satisfaction); improving the health of populations; and reducing the cost of health care. Integrated Care: There are several definitions of integrated care, with the core concept being that people can receive services for all of their behavioral and physical health needs in a seamless, coordinated, and systematic manner that addresses the whole person. The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system. 1 Integrated care is a model that engages individuals and care givers in the full range of physical, psychological, social, preventive and therapeutic factors necessary for a healthy life. 2 a team-based approach to health care delivery where mental health and medical services are provided together under one roof, with a unified treatment plan that addresses a person s behavioral, mental and physical health care needs. 3 Types of Integration: Integration can occur by incorporating primary care services into a behavioral health practice or organization, or by incorporating behavioral health services into a primary care practice or organization. Integration models for both pediatric and adult populations exist. For more information on types of integration, see Evolving Models of Behavioral Health Integration in Primary Care, Milbank Memorial Fund, Level of Integration: Coordination: Routine screening; referral relationship; and routine exchange of information. 4 Co-location: Medical and behavioral services in same facility; referral process; enhanced information sharing; and consultation between medical and behavioral providers 5 Integration: Can be in same or separate facilities; single, combined treatment plan for medical and behavioral conditions; multi-disciplinary teambased care; and use of data technology to track patient services.6 Core Elements of Integrated Care: The Integrated Care Resource Center identifies five key system-level elements needed to support a fully integrated system: Aligned financial incentives across physical and behavioral systems; Real-time information sharing across systems to ensure that relevant information is available to all members of a care team; Multidisciplinary care teams that are accountable for coordinating the full range of medical, behavioral, and longterm supports and services, as needed; Competent provider networks; and Mechanisms for assessing and rewarding high-quality care. 7 At the clinical level, integration requires: Comprehensive physical and behavioral health screening; Beneficiary engagement; Shared development of care plans by the beneficiary, caregivers, and all providers; and Care coordination and navigation support. 8 There is solid evidence to support integrated care as a model for addressing the high level of co-occurrence of mental health, substance use, and physical health conditions. Key Players in Integration: Integration brings together physical and mental health professionals who traditionally work separately, for the common purpose of providing high-quality, patient-centered care. Integration depends on many players beyond health providers, including 3

4 communicating and coordinating systems, information, policies, and protocols to make the five core elements of integrated care listed above, possible and sustainable. Policymakers, administrators, advocates, consumers and caregivers, educators, public and private payers, health organization managers, frontline staff, and providers must all work in coordination with a high level of transparency and accountability for integration to fulfill its potential of improved health outcomes, quality and lowered costs. The Need and Opportunity for Integrated Care in Kentucky Research extensively points to the fact that physical and mental health co-exist and interact, and are susceptible to many of the same risk-factors and prevention approaches. In short, integrated care holds the possibility of increasing access to care, reducing stigma, increasing engagement, and improving adherence to care for patients and their caregivers.9 having a major mental health condition is associated with shortened life expectancy and decreased quality of life. Some factors to consider in thinking about integrating behavioral and primary care include: the human toll of fragmented care; the economic cost; access and equity; the implementation of the Affordable Care Act; the growth of Accountable Care Organizations and Health Homes; and health information technology (HIT). 1. Human Toll: Close to one-third of adults with a medical condition also have a mental disorder, and 68% of adults with a mental disorder have a co-existing medical condition. 10 For many, mental health conditions begin and go undetected in childhood, with a significant portion of lifetime cases of mental illness [that] begin by age Further, researchers have found that many visits to primary care offices are related to psychological and social issues for adult and pediatric populations.12 Mental health conditions can both contribute to and result from physical health conditions. 13 A 2010 study found that persons with serious mental illness died, on average, 4.2 year 14 earlier than a comparable group of people without serious mental illness Economic Cost: In addition to human costs, there are clear economic and clinical efficiency arguments for providing integrated care. Strohsal has identified three ways care integration has economic benefits, by: a. Improving care effectiveness; b. Increasing productivity of medical providers; c. Decreasing costs by addressing psychosocial aspects. Actuarial analysis of the health care and employer costs of treating persons with mental and physical health co-morbidities identified higher medical costs for individuals with co-morbidities. Researchers also point to the fact that having a behavioral health professional on staff can better serve the needs of patients with mental health needs while freeing up the medical provider to attend to other patients, thereby making better use of time and resources and leading to more revenuegenerating activity and clinical efficiencies, whereby primary care physicians can cut the time it takes them to attend to behavioral health concerns. 16 One study found that visits with a behavioral health component took pediatricians 2 to 2.5 times the length of a medical-only visit Access and Equity: Several childhood, stress-related, and socioeconomic factors are associated with increased likelihood of developing physical and/or behavioral health conditions (including substance use). Some of the key risk factors include poverty, isolation, and negative neighborhood characteristics, and these factors are particularly prevalent among certain racial and ethnic groups, as well as rural populations. 18 This unequal distribution of risk factors raises concerns about health inequity with certain groups of people carrying a disproportionate burden of physical and mental illness and the related quality of life consequences. Exacerbating these disparities in the prevalence of physical and mental health illnesses are well-known inequities in access to both primary care and mental health services often compounded when such services are only offered separately within a community. 4. The Affordable Care Act and Integrated Care: While uncertainties remain regarding the continued roll-out of the Affordable Care Act, the law contains several provisions that can facilitate the integration of behavioral and primary care, including: Increased coverage of substance use prevention, early interventions, and treatment; Mental health and substance use coverage parity; Preventive care, without cost-sharing, including screening for mental health and substance use, by primary care providers; Expanded Medicaid mental health mandated benefits; Support and funding for Accountable Care Organizations (ACOs) that can include integration of behavioral and physical health in their structure; Funding to develop community health teams to support the development of patient-centered health homes incorporating interdisciplinary care teams, including mental health and behavioral providers; The creation of state Health Insurance Exchanges and an essential benefits package intended to assure that all persons have access to comprehensive health care, including preventive and wellness services, chronic care management, mental health services, and substance use disorder services; Overall, greater opportunity for continuity and coordination of care as more people gain access to health coverage. 4

5 5. Accountable Care Organizations and Health Homes: The health care reform law includes funding and incentives for the expansion of Accountable Care Organizations (ACOs) - service delivery models intended to improve care coordination, use evidence-based practices, and change payment incentives to improve quality and health outcomes while decreasing health care costs. Health homes are a specific patient-centered model supported in the ACA through funding mechanisms and through the development of health homes for Medicaid enrollees with chronic health conditions, including mental health and substance use conditions. 19 Both ACOs and health homes provide evolving opportunities to better integrate behavioral and physical care across the continuum of care. Providers in Kentucky will need to assess their readiness for and develop the skills necessary to participate in these new models. 6. Health Information Technology: Central to integrated care is the ability to communicate and share information effectively between medical and behavioral health providers, and between providers and consumers. Health Information Technology (HIT), such as electronic health records, is key to better communication and coordination between providers. Particularly in rural Kentucky, the use of HIT, such as telemedicine, can have a significant impact on access and quality of care. There is solid evidence to support integrated care as a model for addressing the high level of co-occurrence of mental health, substance use, and physical health conditions. Lessons Learned There are as many approaches to integrated care across the states as there are definitions of integrated care. Some efforts taken by other states include: Funding: In California, a 1% tax on millionaires funds training and technical assistance for integration 20. Training and Education: California, Maine, and Texas developed training resources (in writing and in person) on billing and payment for integrated services21. Policy: Maine made integrated care a core element of its patient-centered medical home pilot, and is incorporating integration into ACOs and other payment reform initiatives22. Colorado passed House Bill 1242 in 2011, which directed the state s Medicaid agency to review identified barriers to integrating care and propose policy-level solutions. Administrative/Regulatory: California renewed an 1115 Medicaid Waiver for local counties to finance integrated care, at their discretion23. California, Maine, and Tennessee opened Health and Behavior Assessment codes to allow behavioral health providers to bill for non-psychiatric diagnoses. 24 Maine, Tennessee, and Texas allow same-day billing under Medicaid (in Texas, federally-qualified health centers (FQHC) are not allowed to bill for same day but do receive the enhanced FQHC rate) 25. Texas opened Health and Behavioral Assessment codes to allow behavioral health providers to bill for primary care diagnoses. 26 Tennessee has statewide integrated care through its managed care program, TennCare. Pennsylvania s Medicaid program established a two-year pilot project to address the physical and behavioral health needs of severely mentally ill beneficiaries. Kentucky s Experience In April 2012, the Foundation for a Healthy Kentucky, in partnership with the Kentucky State Department for Behavioral Health and Intellectual and Developmental Disabilities (DBHIDD), the Kentucky Association for Regional Programs (KARP), and the Kentucky Primary Care Association (KyPCA), launched a web-based survey to gauge current integrated care efforts in the state. In collaboration with the Center for Community Health and Evaluation (CCHE), the Foundation developed a survey for primary care and behavioral health providers. The survey was open for a total of 7 weeks and received 52 responses, from 40 organizations. Most respondents identified themselves as administrators of their organizations, with 60 percent of those who took the survey working at an organization primarily providing primary care services and 38 percent working at an organization primarily providing behavioral health services. Fortyfour percent of those who participated worked at federally qualified health centers, while 23 percent worked at community mental health centers. 68 percent of respondents stated that they have initiated internal efforts to integrate primary care and behavioral health services by: Providing care that includes a behavioral health provider; Co-location of services; Providers addressing some basic primary care/ behavioral issues; Referral systems; Behavioral health or primary care screening; Changes in how services are delivered; Provider training; and Providing primary care/behavioral health information and resources to patients. 5

6 Among primary care providers, anxiety disorders, mood disorders (including depression), and Attention Deficit Disorder/ Attention Deficit Hyperactivity Disorder (ADD/ADHD) were identified as the most common behavioral health conditions encountered. Substance use and abuse was identified by 52 percent of respondents. Among behavioral health provider organizations, diabetes, hypertension, and obesity were the three physical health conditions most identified in their patient population. Most respondents identified significant barriers to integration, including: Limited funding and reimbursement for integrated care services (73% of primary care, and 92% of behavioral health) Difficulty finding appropriate staff (47% of primary care, and 50% of behavioral health) Clinic space restrictions (43% of primary care, 33% of behavioral health) Licensure barriers (50% of behavioral health but just 7% of primary care) Other barriers included: difficulty incorporating services into clinic flow; difficulty finding appropriate partners; and administrative challenges with scheduling, billing, medical records, and others. The survey also asked respondents about current efforts and interest in the patientcentered medical home (PCMH) model. Most participants (82 percent) expressed interest in pursuing a PCMH status, while only 3 percent currently meet federal guidelines for PCMH status. About one-third of respondents were not sure if their organization met the PCMH status, so additional education and information about this model and what is necessary to meet PCMH guidelines may be warranted. Of those interested in pursuing PCMH status, about 70 percent plan on doing so within the next two years. Achieving integrated care throughout the state in a sustainable way will require systemic changes in the way we understand, deliver, and incentivize health care. While key components of integrated care have been identified, the context in which individuals live needs to be taken into consideration. Recent changes to the state Medicaid program through the transition to Medicaid managed care also present new opportunities and challenges to implementing integrated care. The Cabinet for Health and Family Services believes that combining management of all the major components of Medicaid services physical health, behavioral health, pharmacy and dental care within the MCOs [managed care organizations] is a critical factor in integrating care across these service components. 27 In the current arrangement between the State and the MCOs, MCOs are required to provide the full array of covered services included in Kentucky Medicaid s state plan and regulations,[and] each MCO is responsible for establishing its own services delivery procedures, including a formulary, utilization management procedures, and payment rates and methodologies, among many other procedures specific billing and service delivery requirements are governed by the contracts between the MCOs and their provider networks 28 It is important to note that integration is moving forward within different contexts depending on health coverage source. The private insurance and the public insurance systems have different rules, different networks, and different reimbursement rates. As individuals and families transition from one coverage type to another, we will need to assure the seamlessness and coordination of these systems to avoid individuals falling through the cracks or having separate and unequal systems. Integrated care has many definitions, and as one provider put it, it is highly userdependent. How it is implemented, where it is implemented, and who is leading and working the daily implementation, make all the difference. While economic and clinical efficiency evidence exist to support the shift to integrated care, we must keep in mind the human impact and the qualityof-life value of adopting a whole person approach as we transform how individuals are viewed by and interact with the health care system. Making Integrated Care Sustainable in the Commonwealth: Focus on Solutions State experiences, in Kentucky and beyond, have consistently identified a long list of existing barriers to both implementation and sustainability of integrated care. At the same time, we continue to see improved health outcomes with integrated care and to learn of the positive impact of integrated care models on providers, patients, and their caregivers. Some movement has been achieved on the integrated care front, but much work remains to be done in order to make it sustainable. Specifically, questions have prevailed about the ability to do same-day billing for physical and behavioral health at the same location. The Cabinet for Health and Family Services states that there is no general prohibition of this billing practice in Kentucky s fee-for-services billing rules, although this varies by provider type providers billing all-inclusive rates would not be paid for both types of service on the same day...[e]ach MCO may establish its own payment rules related to this question. 29 Further, questions have been raised in Kentucky, and other states, about the ability of providers to bill for mental health consultation using the Health and Behavior Assessment codes. The Cabinet for Health and Family Services states that they do not tie diagnosis to payment for mental health consultation through the primary care center or physician (psychiatrist) reimbursement programs [i]n Community Mental Health Centers, behavioral health assessments are only paid if the assessment results in a treatment plan with on-going services MCOs may establish their own payment rules 30 Providers have expressed concern about the linkage between assessment, diagnosis, and services for 6

7 reimbursement, as screening is a key element of integrated care. As MCOs may establish their own rules, consistency across the Commonwealth is not guaranteed. Kentucky s ICAT identified in 2010 the use of peer support specialists to assist in navigation and support as a priority area of interest. Prior efforts to incorporate peer support in the Medicaid State Plan have been unsuccessful. Currently, the Cabinet for Health and Family Services has indicates that [s]everal of the MCOs have expressed interest in peer support as an effective and cost-saving evidence-based practice. 31 Allowing for peer support specialists would require amending the MCO contracts. In terms of telemedicine and telepsychiatry reimbursement, non-psychiatrist physician care at Community Mental Health Centers, behavioral assessment codes, and sameday billing, MCOs may establish their own rules and methodologies as long as they provide the full array of covered services included in Kentucky s Medicaid state plan and regulations and they comply with their contracts. Again, this provides opportunities as well as concern over statewide consistency. One area of previous concern where Kentucky has made tremendous progress is the incorporation of behavioral health providers into Electronic Medical Records (EMRs) and Health Information Technology (HIT). Specifically, the Cabinet for Health and Family Services states that as a result of the SAMHSA grant Kentucky is currently piloting two sites on development of the interface to include transmission and acceptance of Behavioral Health provider services CHFS has been developing a common consent form in conjunction with the Community Mental Health Centers for members to authorize the use of their data with EMR. The modified consent form is close to sign off. 32 Once these efforts are completed, Kentucky will be including behavioral health services in EMR and HIT. 33 Whether we look at Kentucky, Colorado, Pennsylvania or another state, the list of priorities that rise to the top includes addressing reimbursement in both private and public insurance, workforce readiness, regulatory and administrative roadblocks, information sharing and technology, and, above all, committed leadership. We also know that despite the barriers and challenges that exist, there are isolated examples of successful integration of behavioral and primary care health services across the country, and in Kentucky. These organizations have managed to create environments where integrated care thrives and serves the needs of the individual patients, and the community as a whole, despite the obstacles. Kentucky s current transition to Medicaid managed care makes the future of integrated care in the Commonwealth unclear. To the extent that each MCO may establish its own payment rules and procedures, it remains to be seen what each MCO will do in terms of developing policies and procedures that facilitate and sustain integration in a meaningful way. This also means that each MCO may have somewhat different rules for what is reimbursed and what is not. We have identified the obstacles and challenges, and have identified some solutions. Much work remains: To select the tools and channels through which we can address barriers and implement solutions successfully. To set in place policies and system-level changes that provide the framework for how health care is carried out. The policies we develop and implement reflect our society s values and create a road for achieving our shared goals and vision of a healthier, safer, and thriving Kentucky. Next Steps Some specific options for seeking clarification and uniting key stakeholders to tackle identified barriers include: a. A bill similar to Colorado s HB 1242 that provides leadership, guidance, and financial support to explore ways to overcome current barriers; b. Creation of a government-sponsored, state-level task force to address integrated care implementation, expansion, and sustainability through identifying solutions to barriers and challenges, and developing recommendations with specific action steps; c. An integrated care pilot project with appropriate process and outcome evaluation components to provide data on the financial and health benefits of integrated care to Kentuckians. 7

8 1 World Health Organization, Integrated Health Services What and Why?, available online at service_delivery_techbrief1.pdf Visited June 26, The Colorado Health Foundation, The Colorado Blueprint for. 3 Collaborative Family Health Care Association, Integrated Primary Care, Inc., and Patient Centered Primary Care Collaborative, What is Integrated Care? 4 Blount, A., Integrated Primary Care: Organizing the Evidence, Families, Systems, and Health, 21(2), pages , Blount, A., Integrated Primary Care: Organizing the Evidence, Families, Systems, and Health, 21(2), pages , Blount, A., Integrated Primary Care: Organizing the Evidence, Families, Systems, and Health, 21(2), pages , Allison Hamblin, James Verdier, and Melanie Au, State Options for Integrating Physical and Behavioral Health Care, Technical Assistance Brief, Integrated Care Resource Center, October Allison Hamblin, James Verdier, and Melanie Au, State Options for Integrating Physical and Behavioral Health Care, Technical Assistance Brief, Integrated Care Resource Center, October Butler, Ph.D., M.B.A. Mary, et al, Integration of Mental Health/ Substance Abuse and Primary Care, Evidence Report/Technology Assessment, Number 173, Agengy for Healthcare Research and Quality, U.S. Department of Health and Human Services, October Available online at evidence/pdf/mhsapc/mhsapc.pdf, visited on July 16, Goodell, et al, Mental disorders and medical comorbidity, The Synthesis Project, Robert Wood Johnson Foundation, February National Institute of Mental Health, Treatment of Children with Mental Illness, available online at health/publications/treatment-of-children-with-mental-illnessfact-sheet/index.shtml/index.shtml, visited on July 5, Gatchel and Oordt, 2003, as cited in Pelican Monson, et al, Working Toward Financial Sustainability of Integrated Behavioral Health Services in a Public Health Care System, Families, Systems, & Health, Vol. 30, No 2, , June Colton and Manderscheid, Congruencies in Increased Mortality Rates, Years of Potential Life Lost, and Causes of Death Among Public Mental Health Clients in Eight States, Preventing Chronic Disease, Vol. 3, No 2, April Piatt, et al, An Examination of Premature Mortality Among Decedents With Serious Mental Illness and Those in the General Population, Psychiatric Services, Vol. 61, No 7, July Cummings et al, 2009, as cited in in Pelican Monson, et al, Working Toward Financial Sustainability of Integrated Behavioral Health Services in a Public Health Care System, Families, Systems, & Health, Vol. 30, No 2, , June Meadows, T., Valleley, R., Haack, M. K., Thorson, R., & Evans, J. (2011). Physician costs in providing behavioral health in primary care. Clinical Pediatrics, 50(5), Goodell, et al, Mental disorders and medical comorbidity, The Synthesis Project, Robert Wood Johnson Foundation, February Alexander, Laurie, Partnering with Health Homes and Accountable Care Organizations: Considerations for Mental Health and Substance Use Providers, The National Council for Community Behavioral Healthcare, January The Colorado Health Foundation, The Colorado Blueprint for 20 The Colorado Health Foundation, The Colorado Blueprint for 21 The Colorado Health Foundation, The Colorado Blueprint for 22 The Colorado Health Foundation, The Colorado Blueprint for 23 The Colorado Health Foundation, The Colorado Blueprint for 24 The Colorado Health Foundation, The Colorado Blueprint for 25 The Colorado Health Foundation, The Colorado Blueprint for 26 Correspondence from Commissioner Lawrence Kissner to the 27 Correspondence from Commissioner Lawrence Kissner to the 28 Correspondence from Commissioner Lawrence Kissner to the 29 Correspondence from Commissioner Lawrence Kissner to the 30 Correspondence from Commissioner Lawrence Kissner to the 31 Correspondence from Commissioner Lawrence Kissner to the 32 Correspondence from Commissioner Lawrence Kissner to the Foundation for a Healthy Kentucky, August 15, Issue Brief No. 4, September 2012