Start-up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the ACT Program

Deborah Cohen, PhD, Associate Professor

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # G5bOctober 17, 2015

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Understand and define basic terms used in assessing practice expenditures (e.g., start-up expenses, ongoing expenses, effort cost).

• Identify common start-up, ongoing and effort expenses related to initiating and maintaining and integration program.

• Discuss financial and effort expenditures in their own organizations, and identify the sources of these expenses.

References 1. Mclaughlin N, Burke MA, Setlur NP, et al. Timedriven activity-based costing: a driver

for provider engagement in costing activities and redesign initiatives. Neurosrug Focus 2014;37:E3.

2. Grazier KL, Smith JE, Song J, Smiley ML. Integration of depression and primary care: Barriers to adoption. J Prim Care Community Health 2014;5: 67–73.

3. Covell NH, Margolies PJ, Myers RW, et al. Scaling up evidence-based behavioral health care practices in New York State. Psychiatr Serv 2014;65:713–5.

4. Carey TS, Crotty KA, Morrisey JP, et al. Future research needs for evaluating the integration of mental health and substance abuse treatment with primary care. J Psychiatr Pract 2013;19:345–59. 5.

5. Monson SP, Sheldon JC, Ivey LC, et al. Working toward financial sustainability of integrated behavioral health services in a public health care system. Fam Syst health 2012:30:181-6.

Background

• Behavioral health and primary care integration requires investment to implement and sustain

• Financial support for integration is a critical barrier to wide spread and sustainable adoption

• Published information on the level and type of expenses incurred in undertaking the transformation to integrate primary and behavioral health care is limited

• We report start-up and ongoing expenses across a variety of behavioral health and primary care integration interventions

Purpose

To provide credible estimates of the start-up and ongoing effort and incremental practice

expenses for behavioral health and primary care integration interventions

Methods• Practical expenditure data on health care interventions is

sparse in the academic literature

• Expenditures, where reported, typically do not isolate practice expenditures, include start-up expenses, or report expenditures in categories relevant to typical practice activities

• One study - the Prescription for Health program- developed a credible, standardized tool for capturing intervention-related expenditures at the practice level

• We applied this tool, with modest modifications, to the practices in the ACT

Methods

• Setting: Advancing Care Together (ACT) • Sample: 10 of 11 practices participating in ACT• Study design: Comparative case study• Integration Interventions: Specific

interventions and practice characteristics varied across the ACT practices

• Time period for data collection: 2013-2014

Methods – Data collection

• Flowcharts of site specific activities were used to create categories of intervention staff and activities

• This study took an intervention perspective– Each intervention attributed to a sponsoring practice

– Some involved joint efforts of separate BH and PC practices that shared resources to accomplish the intervention

– This study focused on expenses related to the start-up or delivery of the interventions regardless of formal organizational boundaries

Methods – Data Collection• Staff members at each intervention helped with data collection• Staff members received a guidebook and four spreadsheets

– start-up– baseline, and – two for ongoing expenses

• We tailored the data collection instruments to the specific intervention and practice environment within the standardized format

• Data were collected at four points in time: start-up phase, baseline (month), and two times during ongoing intervention (month)

• Practice staff completed data collection tools, and iterated them with our team until they were complete, consistent, and accurate

Methods - Analysis

• Study designed to provide information on type and distribution of expense levels that might be found in “real world” practices seeking to integrate care

• No a priori expectation that expense levels should converge on a mean

• Describe and explore the extent and nature of expenditure variation across different integration efforts and settings

– We present findings at the individual intervention level– As the means of interventions above and below the median (high /

low expense groups)– Overall, sample mean

Analysis

• Start-up– General– Developmental

• Expenses– Ongoing– Incremental– Effort– Direct staff– Administrative staff– Non-staff direct– Overhead

Analysis

• Start-up and ongoing expenses calculated and reported separately

• Start-up expenses were reported in total and the percentage of total that were developmental

• Ongoing expenses were reported as the average of the two sample ongoing months of data collection

• For each expense type, effort and incremental expenditures were calculated and reported

• Incremental overhead expense was estimated by calculating the ratio of new staff to total staff salaries and assigning that portion of non-staff overhead expenses as incremental

Analysis• For each general expense category we calculated

and reported the following expenses:– Total– Staff (direct / indirect)– Non-staff (direct / indirect)

• Start-up expenses reported on a “cash” basis without asset depreciation

• Ongoing expenses are reported on an accrual basis (with depreciation of assets) and on a per patient basis to allow for more standardized comparison

• No adjustments were made for time or inflation

Results

Key practice characteristics

• Whether intervention employed systematic identification of need for BH or relied on clinical discretion

• Number of direct FTE involved

• Whether new staff were hired for the intervention

• Whether the intervention involved substantial capital asset purchase (e.g., IT, physical space investments)

Results – Start-up expenses

• Start-up effort expenses for all practices and five highest/lowest start-up expenses were $44,076, $80,848, and $7,304– Difference in non-staff expenses and /or– Length of start-up

• Start-up incremental expenses for all practices and five highest/lowest start-up expenses were $20,788, $39,956, and $1,621– Difference in non-staff expenses

Results – Start-up expenses

• Incremental start-up expenses where ~50% of total start-up for total and high start-up $ practices, <25% for low $ group

• Developmental start-up expenses represented ~40% of total start-up expenses for total/high/low start-up expense practices– Practices with highest proportion of

developmental expenses (>50%) had longest start-up period

Results – Ongoing Expenses

• Ongoing effort expenses for all practices and five highest/lowest start-up expenses were $44.39, $62.89, and $17.88 per patient– Clinician discretion (high) vs. systemic (low) screening – Scale effects – more patients in systemic – Density of post-screening intervention activity – higher in clinician

discretion interventions • Incremental ongoing expenses for all practices and five

highest/lowest start-up expenses were $4.58, $8.19, and $0.03 per patient – New staff expenses key difference – Only 11%, 13%, and 0.2% of effort costs

Limitations

• Self-reported data• Generalizability• Capturing incremental and

overhead costs

Conclusions: Start-up

• Costs may be daunting or modest• Actual additional costs (incremental)

underestimate practice effort• Knowledge transfer mechanisms – learning

collaboratives, standardized interventions – could lower developmental and thus total start-up costs considerably

Conclusions: Ongoing

• Incremental costs per patient do not likely to overwhelm system

• Effort costs are much more substantial• Payers will need to recognize and support

both to get wide spread adoption• Value based -as opposed to typical

incremental cost based- reimbursement may be best option

Co-authors

• Neal T. Wallace, PhD; lead author and health economist

• Rose Gunn, M.A. • Arne Beck, Ph.D. • Steve Melek, MSA FAAA• Donald Bechtold, MD • Larry A. Green, MD

Wallace NT, Cohen DJ, Gunn R, et al. Start-up and ongoing practice expenses of behavioral health and primary care integration interventions in the Advancing Care Together (ACT) program. J Am Board Fam Med 2015;28:S86 –S97.

Others we’d like to acknowledgePam Wise Romero, PhDMatt Engel, MPHShannon Tyson Poletti, MDMichele StewardGlenn Kotz, MDCandice TalkingtonJulie DeSaireCarol SchlageckCheryl Young, MA, LMFTLori Bryan, PhDLaura Engleman, MPHKatrin Seifert, PsyDCaitlin Barba, MPH

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