Transcript Slide 1

“Healthcare Reform”
Preparing for the Change
Mental Health Association of New York State
October 26, 2011
Ps & Qs
“To mind one's P's
and Q's; to be
attentive to the
main chance.”
The Dictionary of the Vulgar Tongue
Francis Grose, 1785 ed.
Ps & Qs
1.
2.
3.
4.
5.
Pillars
People
Players & Plans
Promotion
Questions
Healthcare Reform
Why Now?
1. Pillars
of
Healthcare
Pillars
of Healthcare
Cost --Contain costs
 Quality -- focused on outcomes
 Access -- timely, right service
at the right time
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Cost
Spending on mental illness grew faster than for
heart disease, cancer, trauma-linked disorders &
asthma
 Americans seeking treatment for mental health
conditions almost doubled, from 19M to 36M
 Treatment cost for mental disorders rose from $35B
to nearly $58B between 1996 and 2006
 Antidepressant use among U.S residents almost
doubled from 1996 to 2005.
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AHRQ data
(HHS Agency for Healthcare Research and Quality-August 2009.
August 6, 2009 — Anne Ziegler (Fierce Health)
Cost of Health &
Mental Health
Among the most expensive 1% of Medicaid
beneficiaries (acute care only)
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Almost 83% have three or more chronic
conditions
Over 60% have five or more chronic
conditions
And most of them are in unmanaged fee-for-service
Source: Kronick RG, Bella M, Gilmer TP, Somers SA, “The Faces of
Medicaid II: Recognizing the Care Needs of People with Multiple
Chronic Conditions.” Center for Health Care Strategies, Inc.
October 2007
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Quality
Purchasers (employers or government) seek
value for health care expenditure &
managed care companies to deliver:
 Member satisfaction
 Positive clinical outcomes and recovery
 Timely access to needed services
 Controlling the rate of cost increases
 Targeting scare health care dollars to the
High Risk/High Cost/High Need members.
Access
Timely
 Culturally responsive
 Right service, right time, right
LOS, right reason

Quality
20 Years:
Research to Practice
18 Months:
Technology Change
(Data)
Cost, Quality & Access
Practice Models:
what types of interventions work
— and for whom
“ …knowing which treatments work won’t matter
unless we know how to target the interventions to
the people who will benefit most….In the absence of
such knowledge we risk treatment decisions guided
by accessibility to resources rather than patient
needs.”
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Psychological scientists Varda Shoham, Ph.D., and Thomas R. Insel, M.D.
Perspectives on Psychological Science.
Source: Association for Psychological Science
http://psychcentral.com/news/2011/09/14/mental-health-care-reform-urged-by-topscientists/29412.html
Healthcare Reform
Why Now?
2. People
Incidence of
Mental Illness &
Medical Conditions
 1 in 4 Americans has a diagnosable mental disorder
 6% of Americans have a serious mental illness, e.g.
Bi-polar disorder or schizophrenia
 50 million children and adults in this country are
diagnosed every year with mental illness
 People with diabetes, heart disease, asthma &
cancer are at greater risk of becoming depressed.
http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-healthcare_b_862051.html
The Case for
Health Homes
If you are depressed & have asthma, diabetes, heart
disease or cancer your are:
 2X as likely to develop cardiovascular disease and
stroke,
 4X more likely to die within six months of a heart
attack
 3X more likely to be non-compliant with your
treatment.
http://www.huffingtonpost.com/lloyd-i-sederer-md/mental-health-care_b_862051.html
Healthcare Reform
Why Now?
3. Players & Plans
Who Are They
 DOB & DOH
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OMH & OASAS
Managed Care Companies
Providers
Counties
Peers/Recipients
All are advocates
Managing State Medicaid Costs
The Economist-April 2011
In challenging economic times States move
more aggressively to manage costs. States
have 3 ways to manage costs
Restrict eligibility, which is prohibited under the
federal health care reform initiative
 Cut benefits-vision, dental, pharmacy, etc.
 Cut provider payments
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Addressing
System
Stressors
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Managed Care
Health Homes
ACOs
Service Limits
Regulatory Reform
Future of Medicaid
The Economist-October 2012
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CA & NY are moving the elderly and
disabled into a managed care system
Second step in Managed Care - integrate
the dual eligibles into MC
Dual eligibles account for 40% of
Medicaid’s cost and just 15% of the
population.
Future of Medicaid
The Economist-October 2012
 If the managed care system works as
designed, doctors (health care
professionals) can monitor all aspects of
care, in contrast to the fragmented fee for
service system.
 If states do not draft their contracts
properly or fail to be vigilant in monitoring
patient’s health, their experiment in
managed care could be a disaster.
Why States Use
Managed Care
To limit the financial exposure of the state
 Design and manage systems of care
 To bring together health care financing and health
care service delivery into one operating system
 Manages data for quality monitoring, to track &
trend utilization, etc.
 Use of clinical outcome measures and use of
standardized measures to track progress

Health Homes & ACOs
NCCBH -http://www.thenationalcouncil.org/galleries/defaultfile/ACOs%20and%20Health%20Homes%20Exec%20Summary.pdf
 Health Homes & ACOs are responsible for
providing the full range of healthcare services
needed by the populations they serve
 Goals are to improve quality, patient
experience, & reduce costs
 MH/SU providers are urged to prepare for
participation in the larger healthcare field
 Ensure IT readiness of providers
ACOs
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Final Federal Regulations published Oct 20
Decreased quality measures from 65 to33
Re: ACO regulations,
"But fundamentally, most health systems continue
to struggle with the fact that their present
operations are oriented toward billing per service,
and not taking on risk and responsibility for
quality."
Dan Mendelson, CEO
Washington-based consulting firm Avalere Health
Oct 20, 2011
Quality
Outcomes
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Life improvements, e.g. community
tenure, education, jobs, housing,
etc.
Services in least restrictive settings
Decreased use of ER & avoidable
inpatient and residential stays
Customer satisfaction with personal
goal achievement
Healthcare Reform
Why Now?
4. Promotion
Components of
Managed Care
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Benefits designed by the purchaser, e.g.
the state in Medicaid or the insurance
company with approval by the employer
group
Networks are built for Access & to:
 Meet geo-access requirements
 Provide timely access to ambulatory
services, e.g. medication management
 Provide the “right” level of care to
support recovery & build on strengths
Services
not Programs
Services
 Individual Therapy
 Group Therapy
 Medication Therapy
 Detox
 Case Management
 Care Coordination
 Peer Support
Interventions
 Assessment
 Treatment Planning
 Discharge Planning
 Medication
Therapy/Education/Mon
itoring
 Verbal Therapies
 Assistance with ADLs
 Safety Planning
Services & Interventions vary by:
frequency, duration & location of care--in other words, the program
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Members & Money
in Managed Care
Members: Who is in
 Adults
 Adults with SMI
 Children
 Dual Eligibles
Money: What is in
 Medicaid
 Grant Dollars
 Other State & Local
Money
Who gets served
Preserve the base
funding
Less about the Models: Carve In or Carve Out
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Opportunities
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People
Pillars: Cost, Quality & Access
Players & Plans
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Services not Programs
Evidence based practices
Measurable outcomes
Care coordination
Recovery
Follow the Money not the Model
What MHA knows….
Questions
Ann Boughtin
615-498-4398
[email protected]
www.boughtinandorndoff.com