BEHAVIORAL HEALTH INTEGRATION: CREATING EQUITY IN HEALTH CARE

PETER CURRIE, PH.D

INLAND EMPIRE HEALTH PLAN

•Non-profit public health plan, serving low-income families and individuals in San Bernardino and Riverside Counties.

•Today IEHP serves 1,100,000 members in government-sponsored programs

• With Health Care Reform and the ACA, IEHP is projected to grow to well over 1,300,000 members by 2016.

Carve Out Of Behavioral Health: Unintended Consequences – Separate is not Equal

Lessons about segregation apply to health care too Health Plans and PCPs did not have responsibility Separate funding streams for behavioral health created silos Medicaid benefits created “excluded diagnoses”

E.g.: Autism and other Developmental Disabilities County Mental Health programs were limited to provide

services to only those with severe mental health conditions – “Specialty Mental Health”

Substance Abuse was further segregated from Mental Health at the State level and in most Counties until recently “Drug Medi Cal”

Riverside County Mortality Report Provided Courtesy of RCDMH

“206 Adverse incidents reported January 2007 – May 2010 145 Deaths US average Life Expectancy: 77.7 years RCDMH Average age at death: 41.8 years 36 years less than the general population

Natural Causes: 46.8 years Unnatural/unexpected Causes: 38.8 years Deaths in older adults may be under-reported”

Why IEHP Integrated BH: Creating the business case for Integration

Physical Health and Behavioral Health (BH) care were Separate and Disconnected

Outpatient Mental Health Services Under Utilized & Substance Abuse Treatment was Nil

IEHP had no influence over the BH Network Coordination of Care – PCPs describe referring into the

“Black Hole” High Cost of BH Administrative Services: 50% of BH dollars reached the MBHO’s Providers (2009) Context – 95% of Tax Payer Dollars paid to IEHP reach IEHP Medical Providers

The BH Integration Plan

Fully Integrated BH Program – “In House” Streamline the coordination of physical and mental

health benefits Redirect MBHO Admin/Profit (50%)to fund Expanded

BH Services Directly Contracted BH Network – Identify and

Support Best Practices Eliminate Reliance on out-of-area Vendors (MBHOs)

for all BH Expertise including NCQA Compliance

The Launch – Feb 1, 2010

One phone # access at IEHP for physical & mental health BH Call Center: Triage & referral by BH Care Managers

who live in the IE and reflect our Member’s ethnic and cultural diversity

Higher than average rate of pay for the initial evaluation: Incentivize prompt Access Payment triggered by Coordination of Care TX Report

with PCP – eliminating the “Black Hole” Added Intensive Outpatient Programs (IOP) Direct Partnership with County Mental Health

BH Integration Results

Increased access to BH services – Cost Neutral to Plan Improved coordination of physical & behavioral healthcare Medical Cost-Offsets for high-risk/high-cost populations Infusing BH expertise within IEHP for crisis calls Met 100% of the NCQA BH requirements in 2012 Audit IEHP’s BH network - Private Sector, FQHCs, County Mental

Health & CBOs – Growing Capacity and Best Practices in IE

BH Integration Exposes Huge Gap in Medi Cal Mental Health Services “Specialty Mental Health” under Medi Cal was

designed to serve Severely Mentally Ill Everyone else in Medi Cal with mental health needs

was served in Primary Care without access to mental health providers

IEHP BH Care Managers helped to illuminate the gap in Mental Health Care and the resulting Medical Costs

Case examples were articulated in a letter to DHCS that all the California Medicaid Health Plan CMOs signed on to - Using Health Plan leverage to address the Gap in Care

On January 1, 2014 California finally got the Expanded Mental Health benefit for Medi Cal

Member Response to Expanded Medicaid MH Benefit

July-Sept 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-June 2014 July-Sept 2014 Oct-Dec 2014Total Presented Calls 2,281 1,949 11,535 11,683 15,054 16,552

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Behavioral Health Quarterly Call Volume Report Period: July 2012 - December 2014

PCP Referrals Increase in Response to Expanded MH Benefit

July-Sept 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-June 2014 July-Sept 2014 Oct-Dec 2014Fax 5 4 198 519 394 368Web 6 11 740 2057 2756 3219Total 11 15 938 2576 3150 3587

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PCP Referrals Via Web & Fax Report Period: July 2012 - December 2014

Using BH Integration as Platform for Population Health Initiatives: IEHP Implements Wrap Around Program

Pre TeleCare Post TeleCare

36

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Dual Eligible SMI Psych Admits Reduced by 61% for Participating Members

For each Member information was collected six (6) months prior to TeleCare enrollment up May 29, 2013

* Video courtesy of Youtube.com

Psychiatric Wrap Around Services Bring Down ED Costs by 74%

Pre Telecare Post Telecare

0.87

0.23

ED Visits PMPM Cost

Visits Months Reflected ED Visits PMPM Pre Telecare Post Telecare Pre Telecare Post Telecare Pre Telecare Post Telecare

89 29 102 125 0.87 0.23

Average ED Cost per Visit is $510 ($110 for the professional component and $400 for the facility) - [Information Provided by IEHP's Provider Contracting Department]

25% Return on Investment (ROI) for IEHP

Pre TeleCare Post TeleCare

$4,131

$3,084

Cost Per Member Per Month - Combined

For each Member information was collected six (6) months prior to TeleCare enrollment up May 29, 2013

Pressure on Health Plans to Integrate Behavioral Health

Download of BH Benefits into the Health Plans January 1, 2014 Medicaid Expansion of Mental Health April 1, 2014 Dual Eligible Pilot September 15, 2014 EPSDT Benefit for Autism

State Direction & Lessons from IEHP’s recent CMS Audit Expectation that Health Plans have a Care Plan for

members that includes BH provider Treatment Plans Expectation that BH providers participate in

Interdisciplinary Care Teams

Integration In California: Agenda for 2015

The Impact of the ACA on California From Silos to Accountable Organizations New Benefits require changes in responsibility Expect movement from “Carve-Out” to “Carve-In” Funding

Health Home Array to add Behavioral Health Homes Promoting Innovation County by County Piloting new BH Integration Models in Primary Care New Behavioral Health Home Models for SMI Population

served by County Mental Health and Innovative Wrap Around Programs (e.g. Telecare)

Lessons Learned: Integration of BH Key to achieving the Triple Aim

Integration of Behavioral & Physical Health Care at the Health Plan enables Population Health Care Separate is not Equal: Whole Person Care does not happen in a Segregated System of Care

Parity is not Enough: Parity is a mandate, Integration is the Work to be done

Coordination of Care in not Sufficient: just a stepping stone toward integration

Health Plans Need to develop direct relationships with BH Providers in private practice, County BH programs and Community Based Organizations

Direct Relationships are best Health Plans must bring BH expertise “In House” to ensure Quality BH Care

In a well integrated Model of Care, Open Access to BH Services pays for itself in Medical Cost Offsets

Achieving the Triple Aim

by Integrating the Social and Behavioral Determinants of Health into Health Care

Payment and Delivery Systems