Succeeding In A World Of Integrated Care: Discussion Panel (Week 1)
Below you will find the Q&A discussion from the Week 1 live session:
“Integration Of Services In Optum’s Pain & Depression Management Program”
Guest presenter: Irvin “Pete” Brock III, M.D., Senior Vice President, Optum
Originally presented: April 7, 2015 at 2:00 p.m.
View the Q&A transcript from weeks 2-4 using the links below:
- Week 2: “Health Home Management”
Guest presenter: Boris Vilgorin, Assistant Vice President, FEGS - Week 3: “Business & Legal Aspects Of Making Medical/Behavioral Integration Work”
Guest presenter: Michael Goldberg, PhD, Director, Child & Family Psychological Services, Inc. - Week 4: “A Medical/Behavioral Integration Model Case Study”
Guest presenters:- Courtney Esparza, Senior Director, Behavioral Solutions, Optum
- Daniel Wilkes, Care Coordination Director, Northwest Primary Care Sellwood
- Helen Kurre, Director, Quality & Medical Practice Integration, Providence Health Plans
Clicking a question below will expand to reveal the answer and discussion during the live session.
What makes you feel that the market is disruptive? What are the factors that are going on right now that are causing this disruption?
George: One of the major aspects of the disruption is that previously developed models for how providers had been paid and the type of services providers were expected to do, especially specialty service models like behavioral health, were pretty consistent for a long time. There might have been changes when the payer system went privately from paying for the full service costs to using managed care, or when Medicaid became a payer instead of block-grants in the public sector, but there was always a consistency about what the service was. The changes in service delivery were driven as much by research in the service delivery area as anywhere. What’s happened that’s been very disruptive is that payers and consumer advocacy have really driven the system. It’s become much more managed, much more competitive, and much more difficult to find a niche in the market than it used to be.
How do independent providers align with health homes or ACOs to realize the benefits from enhanced care coordination and service delivery integration?
George: When you’re talking about aligning with an existing one it’s one thing, and it’s another if you’re part of a group that’s planning to create one. When you’re aligning with an existing one, it becomes a matter of knowing what you do well and what you do cost-effectively. Know yourself well enough to know what you do well within the marketplace and how well you can work within a health home model. Do you have the strength in care coordination? Where do you fit in in the packages that consumers need? How much do you need to be paid to be part of that system? If you’re looking at starting one, that’s a series of questions: what population are you good working with? What can you afford to do? Who are the possible partners you could work with? A lot of systems have looked at federally qualified health centers as excellent places, but even some private practices are interested in becoming health homes. It becomes a matter of sitting down and pursuing in the market a way of working together with someone, defining the population, and seeing whether there is a need for that population for services. There are some ACOs that would love to have a medical or health home for certain populations they serve because those are the high-risk populations that they don’t always do well with. In some states where they have done a pilot for Medicare/Medicaid co-occurring or dual-eligible populations they are looking for people who know how to work with either the elderly or seriously mentally ill and can help provide both services and care coordination.
Is this new system truly saving health care costs on the federal level or is it still too early to tell?
George: The latest federal reports we’ve seen have shown the beginning of the cost-curve going down relative to what was double-digit growth every year, so it’s growing but it’s growing less. Right now, if you were to ask Health and Human Services they would say, “Yes, it’s working”. I think a better way of looking at it would be that if it wasn’t working most of the commercial managed care providers would not be getting involved in it. I’m beginning to see commercial providers looking to develop health homes, not just Medicaid. They are seeing it as a viable alternative that’s both cost-effective and a great way of getting services for people who need a lot of different services. I would say that within the context of what’s going on, it is working. Certainly there are integrative service models that are great examples because they’ve been doing this for so long. They are becoming sought after speakers to explain how they do it. Financially, the first returns are in saying it could work, but there’s a long way to go until most of the systems doing this can say that it is working well, providing clinical outcomes, and also providing cost-effective care.
In regard to personalization of care, what are medical homes doing to assess a patient’s sense of moral or well-being?
George: The medical homes are not only encouraged but expected to (especially if they are being accredited in some way) have tools that actually measure what the consumers desire is for the type of service delivery and treatment plan, and they should have a regular care coordinator to contact and work with. There should be involvement of family or support system as well. If you get someone in a system like this who has chronic illness and complex needs, there should be a support system involved as well so they can keep the individual patient involved and working within the system. Essentially, the simple answer is that the system has to build that into their assessment and treatment planning tools and it should be built in on a regular basis within their progress notes, particularly within the notes of the person responsible for care coordination.
How does Optum define enhanced care coordination? Does enhanced care included face-to-face contact with the participant?
Pete: In this particular example, the enhanced care coordination is what the care advocates do with our UHC counterparts. For example, when we’ve identified a member with a pain issue we want to make sure that the pain issue is dealt with. We would be reaching out directly to the primary care provider with the correct release of information or we might be working with our colleagues on the UHC side who are also managing the pain indirectly (through authorizations and following the quality of care) to either address services that the member needs (consult to a chiropractor, referral to prescriber for medication assessment). It could take on different forms with whatever program or model that you’re working with.
Are you looking for groups of providers to give services for these programs? Do you envision sole proprietors of mental health services as fitting in with your needs and if so, how?
Pete: Right now the program is not taking open referrals – we’re not actively looking for large practices because of the scope. We are currently looking to demonstrate that there are improved outcomes by co-management. What I do see is that if we can demonstrate and answer those questions effectively (that outcomes improve for both depression and pain, that functional impairment is reduced, and if costs are reduced for both) I think that we would be looking for any large practice that would be willing to partner, use our data and our program but have it directed specifically to a large practice.
Is there trauma screening/trauma informed care to identify if a certain percentage have not had a 15% increase? Many patients with pain and depression have a lot of trauma yet meet PTSD criteria, so using somatic interventions can sometimes be helpful with that sub-group. This is based on our understanding of the 43% have improved 15% or more concept.
Pete: That is not involved in this program but it is a great point, if folks are familiar with the adverse childhood experience study that showed significant improvement in outpatient primary care utilization by just asking a few questions about trauma. I don’t believe this is one of the modules, but I can take this back as a suggestion because that is a great idea.
As a sole proprietor of mental health services, if I see people identified in your care coordination system, can I expect to receive phone calls from your coordinators for either oversight or to make new referrals? I’m wondering how I would fit with your program?
Pete: I would hope that if a sole practitioner was seeing a member within this program that our team would have identified that as going on versus maybe not knowing. I would hope that we could get release of information to be able to share that with the provider. Sometimes that’s a stickler because patients don’t want to release information to their current provider. The other thing about this is that if you have a member in some program, we need to make sure you get engaged, but also we need to use the wellness assessment since it’s such a critical tool – not only in regards to participation in the program but in this context of value and demonstrating value. The best thing a solo practitioner can do is objectify their value. There are tools out there right now but they are not used systematically across the behavioral service system. That would be the first step – demonstrating your value in an objective fashion. Then there are two options – you can contact someone within the program, or you can talk to your patient about their participation in the program and ask for contact through them and how you can be more active.
If an ACO is responsible for behavioral health care, why do you think so many have not built formal relationships with behavioral health providers?
George: I worked with one statewide system that was moving to ACO models within their public payer system, and was using a very different model- almost carving out their behavioral health. Some of that has to do with understanding the economics of behavioral health and whether the people organizing the ACOs understand those economics well enough to embed that into their system versus the comfort of carving out. So that’s one. Number two is that we, as behavioral health providers, have to be able to go and engage them and show them we know how to manage that population for quality and cost-effectiveness.
Pete: I would agree with your comments. ACOs, saying their frightened is probably too strong a word, but probably do not know how. That’s where the strength and opportunity comes from behavioral. Most of us are deeply invested in metrics, so not only can we demonstrate our value on the behavioral side but also to their bottom line. If we believe that there is significant co-morbidity in disease and pathology, then to the extent that you can use your expertise to help them manage, measure, and track their costs, and in particular, if you can demonstrate that there is a cost offset and improved quality you will have made a number of new friends. I think it has to start with us, because I think some just struggle with how to get that conversation started.
Could either of you talk more about the risk of behavioral health becoming primary care? And what does that mean exactly?
George: When I made that statement, what I really meant was that primary care is becoming the full coordination for the whole person and there is such a big element of that that involves behavioral health. Dr. Brock, your case study is a perfect example. I’d be challenged to identify a chronic health condition that does not include some element of behavioral health in it. We are really part of primary care and our future, from the standpoint of how the Accountable Care Act is designed, how payer systems (public and private) are designing how they are incentivizing us as providers, what they are really saying is you need to be part of the solution. Part of the solution is integration. In a sense, the more we think of ourselves as separate or apart (and there is a role for some separate services) the less we are going to be part of the solution for health care quality of service and service delivery.
We are a mental health provider that has recently added FQCHs, what is your advice for contracting with the various organizations to provide integrated services?
Pete: It’s a great opportunity but you have to know your metrics, unit cost, and what your cost model is. Also then, knowing what their drivers of spend are. When you know those things you can develop the business case for engagement. If you know that a certain medical condition is at a high-prevalence or high-cost and there is a behavioral health component to that, you can make your business case that through a different form of relationship there is a return on this for me as a behaviorist and a return for the medical side. It’s those business cases where you analyze the risk and opportunities and demonstrate a return on the change, that’s how you get movement.
George: I agree with Dr. Brock. There are going to be two different ways of looking at the relationship/partnership with an FQHC. First, they have service needs that you can meet and help them be more cost-effective within their current environment, even without new contracts or agreements. The same could be true of them for you. Looking at both cost-efficiencies and service improvements that can be made is one piece. The second will be how can we even sell this model and what would this model be? is it defined by certain populations or overall integrated cost-efficiency for everyone? Are we going to be moving towards a medical home model or a health home model or are we just going to be a general integrated system? Some of this has to do with who else is doing integrated or care coordination in the marketplace and what the needs that aren’t being met are. Look internally what you can do for each other, and then secondarily at how you can grow your integrated business and so forth.
How do principles of patient-centered care factor into care integration? For example, what if the patient fails to see or acknowledge the need to treat both pain and depression?
Pete: I think there’s no one answer for this, it depends on the person and the reasons. The modules are designed to use a cognitive based approach. Instead of waxing from the white jacket, it’s really meant to educate the patient and evaluate where the person is on their stage of activation and their readiness for change. As we all know from treating patients with SA disorders, sometimes people just aren’t ready to hear or participate. At some point you have to continue to motivate and educate members, and sometimes it doesn’t work on the first time and they need to come back after digesting the information. It’s an understanding that people come into these programs and our office at different levels, part of the art of what we do is helping to move people along that continuum.
George: Motivation interviewing is part of your model.
Could you comment on strategies for behavioral health providers to engage primary care providers who have been traditionally been resistant to integrated approaches?
Pete: My approach is that data speaks volumes, and of course this is easier said than done when you’re a small group. We have had the same struggle ourselves working with our colleagues on the medical side when we feel there is an opportunity. One suggestion is having lunch with a provider and asking them what their paying points are. When you’re presenting and looking at data it can’t be ignored.
George: As a historical perspective, back in the old days when it was a check-off box that you had to contact the primary care providers since most behavioral health providers were independent, the primary care provider may have ignored the copy of the evaluation or the phone calls. However, I find that now, most primary care providers are eager to get assistance because they find that their practices have complex needs. They are looking for partnerships to help them with more difficult systems. It’s not just the data, they are aware that they need to get more efficient and effective at what they do. The more complex the presenting groups of patients are for them, the more likely they are to want to collaborate. Some of it is outreach, some data, some have the data and are just looking for someone to work with them from the perspective they are facing, basically meeting them half way on practice issues.
Will UBH be looking at incentivizing coordinated care in the integrated service delivery model so that private practice mental health providers can be reimbursed for speaking to medical providers about care?
Pete: I can’t speak for the company, however, from the business model perspective we want to incentivize value because value ends up being good for everyone (better patient outcomes, lower care cost). I think part of the issue is how do you communicate and engage with a managed care company? In my personal experience, when I was in private practice I thought I was doing pretty good care but I was paid the same as everyone else and I was making calls to primary care doctors, I was using metrics to measure outcomes. I definitely think the tide is changing, in part because of the Affordable Care Act. The other part is small groups or single practitioners are going to be the ones who struggle the most. To get managed care companies to pay attention there has to be something on the table; there have to be dollars that are meaningful. There are administrative issues – if you’re going to incentivize it will require administrative handling. It’s difficult for individual providers, but definitely for large groups, in particular if you can keep people out of the hospital and in their community, I know that we’d be very interested in developing business models because it’s better for everyone. So yes. The answer is yes. When it happens I can’t tell you. We’re beginning – we now have a program called ACE (Achievements in Clinical Excellence) where we use data (facility inpatient data – performance, length of stay, readmissions, care cost, individual attending). In those facilities that have good value and are efficient, we work with them to ensure that we can steer members into their facilities because we want members to go where the best care is available. If you apply that model it would apply to an outpatient setting. In large practices if you can demonstrate either through wellness assessments or other outcomes measures that you kept people in their communities versus the endless cycle of admission/readmission, I know we would be very excited to work around some incentivized agreement – we call it pay-for-performance.