Transcript Case Study #2: Using IT to Enhance Data Exchange with

RWJ Depression in Primary Care
State Medicaid Strategies for Integrated Care
Health Plan Experience
Marshall R. Thomas M.D.
V.P. of Medical Services/CMO
Colorado Access
Vice Chair Department of Psychiatry
UCH/UCHSC
Colorado Access
• Non-profit Medicaid/Medicare Health Plan
– Product Lines
• Access Health Plan
• Access Behavioral Care
• Access CHP+
• Access Advantage
– Medicaid/Medicare Duals
• Mental Health Co-morbidities
– 40% of adult Medicaid recipient
• Depression, anxiety, SA (15% each)
– High cost to the medical plan
• Bipolar, schizophrenia (5% each)
– High cost to BH, Medical/Pharmacy
– 1/3 seen by MH specialists
– Overall increase costs 2.3 fold
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Depression and
Primary Care Initiative
• MacArthur Grant
– Dissemination of Three Component Model (TCM)
– Remission in severe depression
• TCM- 58.8%
• Usual Care- 0%
– Lessons learned
• PCPs appreciated the help
– Practice patterns difficult to change
• Providers referred patients they wanted help with;
not the patients who qualified for the studies
– Help with medical and psychiatric comorbidities
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• Patients liked the care managers
How Are Medicaid Populations and
Providers Different?
• Incentive Misalignment
– As in commercial world
• Medicaid Populations
– Higher prevalence of mental health issues
– Higher rates of poverty and other psychosocial stressors
– Diverse
• Pregnant moms and babies, TANF moms and kids, and Disabled
• Culturally and ethnically diverse
– Hispanic, African-American, Asian-Pacific, Eastern European....
– Harder to reach
– ? Multiple co-morbidities
– ? More likely to be helped by care management
• Medicaid Providers
– Diverse
• FQHCs, University (resident) clinics, and private FM and Pediatric practices
– Too much work, too few resources
– Mission driven; philosophically dedicated to underserved;
– ? More economically and technologically challenged
– Decision-making mosaic
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Robert Wood Johnson Foundation:
Depression in Primary Care
• RWJ: Linking Clinical and System Strategies
– Develop an economically sustainable model for implementing
depression care management
• Build into already prioritized disease management programs
• 50% rates of depression in asthma/COPD, CHF, diabetes, and
high Kronick scores (90 percentile).
• Depression associated with 2-4 fold increase in costs
• Initial target of diabetes, CHF etc with co-morbid depression.
• Diabetes depression pilot
– 10.6/14 diagnostic categories
– 26.5 diagnoses
– 66% mental health diagnoses
– 75% narcotic use
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The Current System is
Not Working
• Usual care for complex Medicaid patients
– Ineffective, inefficient, costly, and frustrating for all involved
• “System overload”
– Multiple medical comorbidities, psychosocial issue, psychiatric and
substance use disorders
• Multiple providers
– Inadequate communication/coordination
– Lack of a “medical home”
– Lack of communication between PH and mental health providers
• Polypharmacy
– Use of expensive and addictive meds
– Ineffective doses and strategies
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Patient-focused Intensive
Care Management Program
• Focus on top 2-3 % of population
– Risk stratification
– High Kronick/Health Risk Assessment
• Integrated general medical/behavioral health focus
– Medical, behavioral, psychosocial domains
– Basic needs
• Food, shelter, transportation, benefits
– Patient engagement/self-management goals
– Mental health/cognitive barriers to engagement
– Coordination of care among providers
– Poly-pharmacy and medication adherence issues
– Help navigating the medical and social service systems
• Care management team
– Nurses, social workers and resource coordinators
• Consumer navigators and family resource coordinators
• Home-grown care management software
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Enrollee Demographics
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PHQ-9 Trends
PHQ-9 Symptoms over Time
PHQ-9 Scores over Time
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20
18
12
10
8
6
4
Bipolar
Schizophrenia
Anxiety
Psychosis
Dysthymia
Substance Abuse
MDD Only
5
4
3
2
1
2
0
Time Period
m
th
21
m
th
18
m
th
15
m
th
12
m
th
9
m
th
6
m
th
3
e
Ba
se
lin
m
th
21
m
th
18
m
th
15
m
th
12
m
th
9
m
th
6
m
th
3
e
0
Ba
se
lin
PHQ-9 Total Score
Bipolar
Schizophrenia
Anxiety
Psychosis
Dysthymia
Substance Abuse
MDD Only
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PHQ-9 Total Smyptoms
6
16
Time Period
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ER and Office Visit Trends
Office Visits per 1000
ER Visits per 1000
600.0
250.0
547.7
220.3
500.0
181.3
163.0
150.0
100.0
50.0
Office Visits per 1000
ER Visits per 1000
200.0
400.0
358.2
300.0
200.0
211.8
100.0
0.0
0.0
12 mths pre
12 mths post
Time Period
24 mths post
12 mths pre
12 mths post
24 mths post
Time Period
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Admit and Days/1,000 Trends
Days per 1000
Admits per 1000
60.0
240.0
232.5
49.7
40.3
40.0
37.4
30.0
20.0
10.0
Inpatient Days per 1000
Admits per 1000
50.0
228.6
220.0
205.4
200.0
180.0
160.0
140.0
120.0
0.0
100.0
12 mths pre
12 mths post
Time Period
24 mths post
12 mths pre
12 mths post
24 mths post
Time Period
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Medical Cost Trends
• Savings of $170 per
enrollee per month
• $2040/year per patient
• 370 patients x $2040 =
$754,800 annual medical
cost savings
• Need Comparative Cohort
analysis
Dollars Spent Per Member Per
Month
• 12.9% reduction in costs in
high-cost, high risk
patients
Net Pay PMPM Trends
$1,600
$1,400
$1,317
$1,364
$1,200
$1,147
$1,000
$837
$800
$600
$480
$400
$807
$558
$650
$497
12 mths post
24 mths post
$200
$0
12 mths pre
Time Period
Net Pay Med PMPM
Net Pay Rx PMPM
Net Pay Med and Rx PMPM
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Colorado Access’ Depression
Integration Initiative (RE-AIM)
• Reach
– Directly reaches a relatively small but important subset of Medicaid patients
– Directly reaches all health plan care management staff
– Indirectly reaches many more providers and patients
• Efficacy
– Appears good (see proceeding data)
• Adoption
– High within the health plan staff
• Implementation
– Challenged to obtain model fidelity across staff
– Competing demands
– Decision support tools
• Maintenance
– High- depression and MH co-morbidity screening/monitoring part of all ICM assessments
– New initiatives
• FQHC clinic-based depression and diabetes CM
• Bipolar (and SMI) CM
• Enhanced MH screening for perinatal moms
• AFFIRM- SED kids and families
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Ingredients for Success
• Support of senior management
• Effective clinical leadership
• Clear focus that supports both clinical and business priorities
• Sphere of influence versus sphere of concern
• Credible data to support start-up, implementation, and ongoing
evaluation
• Titrate degree to which innovation requires organizational change
• Plan for program sustainability from the start; create a specific
infrastructure with resources and expertise devoted to diffusion
• Close relationship between the disseminating infrastructure and
the adopting organization.
• Perceived ability of the innovation to reduce external threats
Bradley, et al., Commonwealth Foundation Fund: Issues Brief, 7/04
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