1 Preparing for Health Care Reform: Health Homes, Accountable Care Organizations and You Kathleen Reynolds, LMSW ACSW National Council for Community Behavioral Healthcare July 17, 2012
2 The National Council: Serving and Leading Represent 1,802 community organizations that provide safety net mental health and substance abuse treatment services to over six million adults, children and families. National voice for legislation, regulations, policies, and practices that protect and expand access to effective mental health and addictions services.
3 Overview A changing landscape for behavioral health Medicaid expansion and the influx of new consumers New approaches to organizing care Demonstrating value and accountability: Are you ready?
4 ACA Supported Goal: enhanced integration and coordination of primary, acute, behavioral health (mental health and substance use), and long-term services and supports for persons across the lifespan with chronic illness CMS expects that use of the health home service delivery model will result in lowered rates of emergency room use, reduction in hospital admissions and re-admissions, reduction in health care costs, less reliance on long-term care facilities, and improved experience of care and quality of care outcomes for the individual
5 Affordable Care Act Four Key Strategies
6 Coverage Expansion
7 Medicaid Expansion: 2014 Expanded Eligibility for Children and Parents Expanded Eligibility for Childless Adults Benchmark Coverage for Newly Eligible Childless Adults Increased Federal Share and PCP Payments Maintenance of Eligibility Coverage for Former Foster Care Children 133% Federal Poverty Level April 1, 2010 State Plan Option 133% Federal Poverty Level April 1, 2010 State Plan Option Based on Deficit Reduction Act benchmark coverage Limited array of services available FMAP = % in years % of Medicare Reimbursement Eligibility standards maintained until Exchanges open. Compliance tied to receipt of federal matching funds. Does not prevent states from expanding coverage. States may extend coverage, including EPSDT, to former foster children until age 26
8 Benefits for the Newly Eligible Essential benefits include mental health and substance use treatment MH and SUD must be offered at parity with medical/surgical benefits This means Most members of the safety net will have coverage, including mental health and substance use disorders
9 Health Profile of the Newly Eligible 16 million new Medicaid enrollees This group on average is healthier relative to those who are currently enrolled in Medicaid (due to the fact that many of those with the worst health conditions already receive coverage through SSI or other disability pathways) But The newly eligible with the most serious health problems will likely be the first to enroll.
10 General Health Status of Childless Adults at or Below 138% FPL Source: Holahan, et al. The Health Status of New Medicaid Enrollees Under Health Reform. The Urban Institute, August 2010.
11 Chronic Conditions Among Childless Adults at or Below 138% FPL Source: Holahan, et al. The Health Status of New Medicaid Enrollees Under Health Reform. The Urban Institute, August 2010.
12 Co-morbidities in the Adult Population Source: Druss & Walker. Mental disorders and medical comorbidity. The Robert Wood Johnson Foundation Synthesis Project, February 2011.
14 Delivery System Redesign Health Homes (Medical Homes)
15 Medicaid State Option for Healthcare Homes State plan option allowing Medicaid beneficiaries with or at risk of two or more chronic conditions (including mental illness or substance abuse) to designate a health home Community mental health organizations are included as eligible providers Effective Jan. 2011
16 Eligibility for a Health Home To be eligible, individuals must have: Two or more chronic conditions, OR One condition and the risk of developing another, OR At least one serious and persistent mental health condition The chronic conditions listed in statute include a mental health condition, a substance abuse disorder, asthma, diabetes, heart disease, and obesity (as evidenced by a BMI of > 25). States may add other conditions subject to approval by CMS
17 Status of Health Home Statewide Work 6 State Plans have been approved: Missouri (2) Behavioral Health and Primary Care Rhode Island (2) adults and children with SMI New York chronic behavioral and physical health Oregon 3 states have submitted State Plans and await approval: Iowa, North Carolina, Washington 15 States with Planning Grants: Alabama, Arizona, Arkansas, California, District of Columbia, Idaho, Maine, Michigan, Nevada, New Jersey, New Mexico, North Carolina, Washington, West Virginia, and Wisconsin
18 Healthcare Models of the Future Coverage expansions are ONLY sustainable with delivery system reform Collaborative Care Patient Centered Healthcare Homes Accountable Care Organizations Accountability and quality improvement are hallmarks of the new healthcare ecosystem
19 Function Access Services Funding Minimal Collaboration Two front doors; consumers go to separate sites and organizations for services Separate and distinct services and treatment plans; two physicians prescribing Separate systems and funding sources, no sharing of resources Governance Separate systems with little of no collaboration; consumer is left to navigate the chasm EBP Data Individual EBP s implemented in each system; Separate systems, often paper based, little if any sharing of data Basic Collaboration from a Distance Basic Collaboration On- Site Close Collaboration/ Partly Integrated THE CONSUMER and STAFF PERSPECTIVE/EXPERIENCE Two front doors; cross system conversations on individual cases with signed releases of information Separate and distinct services with occasional sharing of treatment plans for Q4 consumers Separate funding systems; both may contribute to one project Two governing Boards; line staff work together on individual cases Two providers, some sharing of information but responsibility for care cited in one clinic or the other Separate data sets, some discussion with each other of what data shares Separate reception, but accessible at same site; easier collaboration at time of service Two physicians prescribing with consultation; two treatment plans but routine sharing on individual plans, probably in all quadrants; Separate funding, but sharing of some on-site expenses Two governing Boards with Executive Director collaboration on services for groups of consumers, probably Q4 Some sharing of EBP s around high utilizers (Q4) ; some sharing of knowledge across disciplines Separate data sets; some collaboration on individual cases Same reception; some joint service provided with two providers with some overlap Q1 and Q3 one physician prescribing, with consultation; Q2 & 4 two physicians prescribing some treatment plan integration, but not consistently with all consumers Separate funding with shared on-site expenses, shared staffing costs and infrastructure Two governing Boards that meet together periodically to discuss mutual issues Sharing of EBP s across systems; joint monitoring of health conditions for more quadrants Separate data sets, some collaboration around some individual cases; maybe some aggregate data sharing on population groups Fully Integrated/Merged One reception area where appointments are scheduled; usually one health record, one visit to address all needs; integrated provider model One treatment plan with all consumers, one site for all services; ongoing consultation and involvement in services; one physician prescribing for Q1, 2, 3, and some 4; two physicians for some Q4: one set of lab work Integrated funding, with resources shared across needs; maximization of billing and support staff; potential new flexibility One Board with equal representation from each partner EBP s like PHQ9; IDDT, diabetes management; cardiac care provider across populations in all quadrants Fully integrated, (electronic) health record with information available to all practitioners on need to know basis; data collection from one source
21 Person-Centered Healthcare Homes: A new paradigm Picture a world where everyone has... An Ongoing Relationship with a responsible healthcare provider A Care Team that collectively takes responsibility for ongoing care And where... Quality and Safety are hallmarks Enhanced Access to care is available Payment appropriately recognizes the Added Value What does this look like in practice?
22 What it s not: A residential facility Primary care provider as gatekeeper
23 Defining the Healthcare Home Superb Access to Care Patient Engagement in Care Clinical Information Systems Care Coordination Team Care Patient Feed-back Publicly Available Information Person-Centered Healthcare Home
24 Defining the Healthcare Home Superb Access to Care Everyone has a health home practitioner and team Patients can easily make appointments and select the day and time. Waiting times are short. and telephone consultations are offered. Off-hour service is available.
25 Open Scheduling Same Day Access Model Consumer Engagement Standards 1. Master s Level assessment provided the same day of call or walk in for help (If the consumer calls after 3:00 p.m. they will be asked to come in the next morning unless in crisis or urgent need) 2. Initial diagnosis and assessed service needs determined 3. Level of care and benefit design identified with consumer that includes an estimate of time needed 4. Initial treatment plan developed based on benefit design package 2nd clinical appointment for TREATMENT within 8 days of initial intake 1st medical appointment within 10 days of initial intake 25
26 Defining the Healthcare Home Health Home team has a patient-centered, whole person orientation Care is tailored to the needs of each patient Patients are active participants, with the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventive and follow-up care reminders, access to medical records, assistance with self- care, and counseling. Patient Engagement in Care
27 Defining the Healthcare Home Clinical Information Systems Systems support high-quality care, practice- learning, and quality improvement. based Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments. There is continuous learning and practice improvement.
28 Defining the Healthcare Home Care Coordination The health home team engages in care coordination & management within the team The team also coordinates with other healthcare providers/organizations in the community Systems are in place to prevent errors that occur when multiple physicians are involved. Follow-up and support is provided.
29 Care Coordination The Care Coordination Standard: When I need to see a specialist or get a test, including help for mental health or substance use problems, help me get what I need at your clinic whenever possible and stay involved when I get care in other places. Services are supported by electronic health records, registries, and access to lab, x-ray, medical/surgical specialties and hospital care.
30 Defining the Healthcare Home Team Care Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists). Duplication of tests and procedures is avoided.
31 Defining the Healthcare Home Patients routinely provide feedback doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans. Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. to Patient Feedback Publicly Available Information
32 Substance Use and General Healthcare General Healthcare: Almost 25% of general healthcare patients report they have a comorbid substance use conditions likely related to the physical sequelae that result from untreated substance misuse and dependency (NSDUH, 2005) Substance use conditions often complicate management and treatment of other chronic diseases in primary care such as diabetes, hypertension, asthma and others (PRISM, 2008)
33 Future of Substance Use Disorders and the Health Home Most treatment funding will come from Medicaid and private health insurance New populations medical referrals New billing requirements reporting requirements Emphasis upon outpatient care integrated into Medical Home Emphasis on Evidence Based Practices What is a profitable outpatient model?
34 Substance Use Disorders and the Health Home Emphasis/expansion home health services Will specialty care fill this role? Credentialing of the professionals Role of Block Grant could change Recovery-Oriented services NOT covered in healthcare reform under Medicaid
35 Medication Assisted Treatment/ Recovery Patients have identified a preference for office-based treatment in healthcare settings based on: convenience (combining healthcare and medication management), greater patient-focused orientation and increased role in decisionmaking about treatment, a more supportive environment (including being safer for sobriety) compared with outpatient addiction treatment settings (Korthius, T., Gregg, J. et al., 2010)
36 Payment Models for Healthcare Homes Fee for Service is headed towards extinction Healthcare Home models are beginning with a 3-layer funding design with the goal of the FFS layer shrinking over time: Case Rate Prevention, Early Intervention, Care Management for Chronic Medical Conditions Fee for Service Per Service (Fee for Service) Payments for services provided by Primary Care Providers Bonus Share in Savings from Reduced Total Healthcare Expenditures (bending the curve)
37 New Paradigm Primary Care in Behavioral Health Organizations Funding starting to open up for embedding primary medical care into CBHOs, a critical component of meeting the needs of adults with serious mental illness Clinical Design for Adults with Low to Moderate and Youth with Low to High BH Risk and Complexity Primary Care Clinic with Behavioral Health Clinicians embedded, providing assessment, PCP consultation, care management and direct service Food CBHO Mart Partnership/ Linkage with Specialty CBHO for persons who need their care stepped up to address increased risk and complexity with ability to step back to Primary Care Clinical Design for Adults with Moderate to High BH Risk and Complexity CBHO Food Mart Community Behavioral Healthcare Organization with an embedded Primary Care Medical Clinic with ability to address the full range of primary healthcare needs of persons with moderate to high behavioral health risk and complexity
39 Accountable Care Organizations
40 On Your Mark, Get Set, ACO Accountable Care Organizations bring together healthcare homes, specialty care, and ancillary services
41 Core Principles of an ACO Directed by a coordinated set of providers Provides a full continuum of care to patients and populations Healthcare homes, specialty care, hospital, case management, care coordination, transitions between levels of care and more Financial incentives aligned with clinical goals Cost containment Enhancement of care quality and the patient experience Improvement of overall health status
42 ACOs and the Safety Net Coverage expansions: The massive expansion of coverage in 2014 will require new models to assure access and control costs particularly for serving Medicaid patients, who will make up 14 million of the newly insured Care management: Individuals served by the safety net experience higher rates of serious mental illness, substance use disorders, and poorly controlled multiple chronic conditions Community behavioral health organizations have expertise and experience in caring for these populations, making them valuable partners in an ACO
43 Getting to the ACO Table Are you in conversation with local integrated health systems and at the table of ACO development efforts in order to pitch the importance of MH/SUD services to improving quality and bending the cost curve and building a case for how you can help these organizations succeed in the new world of risk?
44 Initial Approved ACOs for Medicare -1.Allina Hospitals & Clinics Minnesota and Western Wisconsin 2. Atrius Health Services Eastern and Central Massachusetts 3. Banner Health Network Phoenix, Arizona Metropolitan Area (Maricopa and Pinal Counties) 4. Bellin-Thedacare Healthcare Partners Northeast Wisconsin 5. Beth Israel Deaconess Physician Eastern Massachusetts 6. Bronx Accountable Healthcare Network (BAHN) New York City (the Bronx) and lower Westchester County, NY 7. Brown & Toland Physicians San Francisco Bay Area, CA 8. Dartmouth-Hitchcock ACO New Hampshire and Eastern Vermont 9. Eastern Maine Healthcare System Central, Eastern, and Northern Maine 10. Fairview Health Systems Minneapolis, MN Metropolitan Area 11. Franciscan Health System Indianapolis and Central Indiana 12. Genesys PHO Southeastern Michigan 13. Healthcare Partners Medical Group Los Angeles and Orange Counties, CA 14. Healthcare Partners of Nevada Clark and Nye Counties, NV 15. Heritage California ACO Southern, Central, and Costal California 16. JSA Medical Group, a division of HealthCare Partners Orlando, Tampa Bay, and surrounding South Florida 17. Michigan Pioneer ACO Southeastern Michigan 18. Monarch Healthcare Orange County, CA 19. Mount Auburn Cambridge Independent Practice Association (MACIPA) Eastern Massachusetts 20. North Texas Specialty Physicians Tarrant, Johnson and Parker counties in North Texas 21. OSF Healthcare System Central Illinois 22. Park Nicollet Health Services Minneapolis, MN Metropolitan Area 23. Partners Healthcare Eastern Massachusetts 24. Physician Health Partners Denver, CO Metropolitan Area4 25. Presbyterian Healthcare Services -Central New Mexico Pioneer Accountable Care Organization Central New Mexico 26. Primecare Medical Network Southern California (San Bernardino and Riverside Counties) 27. Renaissance Medical Management Company Southeastern Pennsylvania 28. Seton Health Alliance Central Texas (11 county area including Austin) 29. Sharp Healthcare System San Diego County 30. Steward Health Care System Eastern Massachusetts 31. TriHealth, Inc. Northwest Central Iowa 32. University of Michigan Southeastern Michigan
45 Health IT at the Heart of the ACO Framework Builds patient-centric systems of care Improves quality and cost Coordinates care across participating providers Uses IT, data, and reimbursement to optimize results Builds payer partnerships and accepts accountability for the total cost of care Assesses and manages population health risk Reimbursed based on savings and quality value
46 Healthcare Reform Context Under an ACO model, the value of healthcare services will depend on our ability to: 1.Be accessible (fast access to all needed services) 2.Be efficient (provide high-quality services at lowest possible cost) 3.Connect with other providers (via electronic information exchange) 4.Focus on episodic care needs 5.Produce outcomes
47 State Role in Reform Implementation States are responsible for many elements of reform Health Insurance Exchange planning and implementation Medicaid enrollment simplification Grants and demonstration projects Responsibility for changes rests with governors, state government agencies, and state legislatures (in cases where changes to state law are necessary) It will be crucial to establish strong relationships with elected officials at the state and federal levels
48 Partnering with Health Homes and Accountable Care Organizations National Council report acos_and_health_homes Webinar with Dale Jarvis & Laurie Alexander recordings_presentations Live Blogchat -webchat/
49 BYour Opinion Matters! log with us at
50 Questions? Kathleen Reynolds LMSW ACSW