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Future Of Health Care Beyond 2020 Series: Interview With Joseph Goldberg, MD

In this interview, Joseph Goldberg, MD, PsychU Bipolar Disorder Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Fatima Sadat, PharmD, Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Goldberg’s perspective on the opportunities and challenges that lie ahead.

Joseph Goldberg, MD, is the PsychU Bipolar Disorder Section Advisor, as well as a Psychiatry Clinical Professor at Icahn School of Medicine, Mount Sinai, in New York City, New York.

Fatima Sadat, PharmD, is a Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

Impairments in psychosocial functioning are demonstrated in 30%–60% of adults with bipolar disorder. The majority of studies investigating the effect of comorbid mental health disorders and age at onset outcomes in bipolar disorder have focused on traditional outcome measures such as mood symptoms, mortality, and treatment response. In “Predictors of Psychosocial Outcome of Bipolar Disorder: Data From The Stanley Foundation Bipolar Network,” published in the International Journal of Bipolar Disorders in December 2019, Francis Bennett et al. investigated the impact of comorbid mental health disorders and age at onset on longitudinal psychosocial outcome in participants with bipolar disorder. Their principal findings are summarized below.

Introduction

Bipolar disorder is a mood disorder characterized by recurrent episodes of mania, hypomania, and depression, separated by periods of euthymia, with psychosocial functioning appearing to remain impaired during euthymia. Psychosocial functioning is an essential component of a person’s quality of life and includes social, psychological, and occupational domains.

A 2001 review concluded that approximately 30%–60% of adults with bipolar disorder had significant impairments in occupational and social functioning during periods of euthymia. The psychosocial dysfunction could be the illness itself or the high prevalence of comorbid mental disorders in bipolar disorder.

Mental health comorbidities in bipolar disorder are more likely to be multiple rather than singular. The World Mental Health Survey reported a 62% lifetime prevalence of three or more comorbidities when strict Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria were applied. Research into the psychosocial effects of multiple comorbidities in bipolar disorder is limited. There is clear evidence of increased rates of both individual and multiple comorbidities in bipolar disorder, even though their impact on daily functioning have not yet been established. Bennett et al. focused on the following comorbidities:

  • Anxiety disorders – High rates of anxiety disorders comorbid with bipolar disorder have been found consistently in both epidemiological and clinical samples, ranging from 46.8% to70%. The presence of a comorbid anxiety disorder in individuals with bipolar disorder is associated with a more severe course of illness, including an increased number of mood episodes, suicide attempts, and hospitalizations, compared with individuals with bipolar disorder alone.
  • Substance use disorder (SUD) – SUD comorbidity is prevalent among the bipolar disorder population, with epidemiological surveys reporting it to be as high as 42.3%.
  • Attention deficit hyperactivity disorder (ADHD) – Its prevalence in bipolar disorder varies widely depending on the age range. Between 10% and 20% of adult patients with bipolar disorder also have ADHD. ADHD comorbidity is also associated with an increased number of mood episodes, higher rates of suicide attempts, and psychosocial dysfunction.

Psychosocial functioning is key to understanding the overall impact that mental health disorders can have on an individual. In the post hoc analysis performed by Bennett et al., data was pulled from the Stanley Foundation Bipolar Network (SFBN) to demonstrate the effect of comorbid mental health disorders and age of onset on psychosocial functioning in participants with bipolar disorder.

Design And Methods

Data pertaining to comorbid mental health disorders and age at onset was collected using items from the Structured Clinical Interview for DSM-IV-Patient (SCID-P) and the Patient Questionnaire (PQ). Age at onset was defined as the age at first hypomanic, manic, or depressive symptoms associated with functional impairment. The Global Assessment of Functioning (GAF) is an instrument that constitutes Axis V of DSM-IV and is extensively used in bipolar disorder research. Following an interview, clinicians rated the participant’s global functioning on a scale of 0–100, recording three scores: best, worst (since the last visit), and current. This study included only the current score so as not to introduce a selection bias.

The total sample study size in the original data was n=648, with 21,993 GAF records. Only participants with complete data were included, leaving a final sample size of n=469, with 12,556 GAF records.

This study utilized mixed-effects modeling (MEM), as it is particularly suited to data sets involving measurements obtained from individual patients that share socioeconomic, demographic, or biomedical characteristics. A key advantage of MEM is that it calculates how much of the variance in the sample is explained by each factor and what residual variance is left. A GAF score for each participant was obtained at baseline, as well as at follow-up, to control for differences in the mean psychosocial function between sites in Europe and the United States.

After the impact of each bipolar disorder subtype, age at onset, and the mental health comorbidities on psychosocial outcomes were determined for each patient, demographic characteristics, such as sex and income, were also assessed as independent explanatory variables additively. Individuals were then grouped according to their respective locations, Europe or the United States, specified as a random effect within the model in order to capture potential sources of unmeasured variation in psychosocial outcomes.

Results

There were greater numbers of participants included in the final analysis from the United States (n=332) than from Europe (n=137). However, a Chi-squared test of independence did not find differences in the distribution of genders between the United States and Europe. In contrast, the distribution of mental health comorbidities, namely anxiety disorders, ADHD, and SUD, all differed significantly between locations and was higher in the United States than in Europe.

A preliminary analysis indicated that the location of the mean of GAF measured at baseline was significantly different between locations and higher in Europe. The location of the mean GAF derived at follow-up was also found to be significantly different between locations.

The relative fits of MEMs were compared using multi-model inference. A model was considered to be a plausible fit to data if the difference in Akaike’s Information Criterion (AIC) between models did not exceed Δ1<2. The model incorporating an interaction between anxiety disorder and ADHD was considered to be the best candidate model from the specific set of models compared. The model incorporating comorbidities was ranked second within the model set, and models that examined interactions between ADHD and SUD and between anxiety disorders and SUD were ranked third and fourth, respectively.

Limitations

The research study here summarized is not without limitations. It has been suggested that the GAF lacks the sensitivity to assess longitudinal change in an individual patient and fails to capture the contributions of each specific dimension of psychosocial functioning to overall dysfunction. A second critical limitation to this study is that it did not control for mood state. The possible impact of mood state on the present findings is twofold: depressive symptoms are strong predictors of poor psychosocial functioning, and the incidence rates of comorbidities are sensitive to mood states when assessed cross-sectionally. A third critical limitation is that the comorbid conditions were characterized by the presence of a lifetime diagnosis; whether patients continued to manifest these difficulties consistently over their lifetime is not known. This limitation would be of particular importance for ADHD, as a substantial group of patients may have the comorbidity in childhood and/or adolescence, but no longer in adulthood.

Overall Findings & Conclusions

This study aimed to investigate the impact of comorbid mental disorders and age at onset on psychosocial functioning in an international sample of participants with bipolar disorder. These factors were entered into MEM with GAF scores as the longitudinal psychosocial outcome measure. The principal finding is that bipolar disorder comorbid with ADHD and anxiety disorder predicted lower GAF scores. Individual comorbidities were explored independently within the final model, with no single comorbidity reaching statistical significance in predicting psychosocial outcomes.

  • The high rate of a comorbid anxiety disorder in bipolar disorder (45.6%) demonstrated in this study is a well-replicated finding. Bipolar disorder and a comorbid anxiety disorder alone did not predict poorer psychosocial function in the Bennett et al. study. One explanation for this finding could be that the diagnostic criteria used did not capture the full spectrum of anxiety states and their effects.
  • The rates of comorbid ADHD and bipolar disorder vary widely according to different age groups. In this current study, comorbid ADHD (13.6%) was less prevalent than either an anxiety disorder (45.6%) or SUD (40.5%).
  • The current study did not find a predictive effect of comorbid SUD on psychosocial dysfunction in bipolar disorder. It may have been an oversimplification to analyze all types of SUD together in this study. Alcohol and cannabis were the most widely abused substances in the SFBN sample; Bennett et al. cite a recent review highlighting the differential impacts of these two SUDs in bipolar disorder.
  • A key similarity between comorbid ADHD and anxiety disorder individually with bipolar disorder is the persistence of symptoms during periods of euthymia. This is likely to hinder psychosocial recovery between mood episodes, leading to a reduced quality of life.

This study by Bennett et al. has demonstrated the negative impact of comorbid anxiety disorder and ADHD on psychosocial functioning in bipolar disorder. Both inpatient and population studies have shown the alarmingly high prevalence of comorbid disorders in bipolar disorder; however, current guidelines offer little help to clinicians when managing these disorders. The findings reported in this study suggest a unique interaction between anxiety disorders and ADHD in bipolar disorder, which will need further research to both replicate and explore this relationship. The resolution of clinical symptoms in bipolar disorder is rarely followed by the recovery of psychosocial functioning. This study has added insights into the role of anxiety disorder and ADHD comorbid disorders in impairing global psychosocial functioning.

As the immediate crisis of the pandemic has now evolved into a chronic state of uncertainty, Dr. Joseph F. Goldberg and Dr. Dri Wang discuss the role of mental providers beyond the surge of the pandemic. Some new challenges relevant to the states’ reopening plans will be discussed.

Joseph Goldberg, MD, currently serves as the Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai and serves on the Board of Directors for the American Society of Clinical Psychopharmacology. Dr. Goldberg has published over 200 peer-reviewed papers on topics related to the treatment and clinical features of bipolar disorder, as well as three books on bipolar disorder and psychopharmacology.

Dri Wang, PharmD, BCPP, is a Senior Medical Science Liaison with Otsuka Pharmaceutical Development & Commercialization.

Joseph Goldberg, MD, is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Dri Wang, PharmD, BCPP, is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

Many individuals incarcerated have a serious mental illness; indeed, there are more mentally ill people in the jail/prison system than in the hospital. Inmates with mental illness remain in jail longer, they are at higher risk of being assaulted, and they present behavioral health management problems that may result in isolation compared with other inmates. Most troubling of all, these individuals are more likely to commit suicide than other inmates. In this webinar, Catherine Judd, MS, PA-C, CAQ-Psy, Darell A. Smith, and Jason Carter, PharmD, discuss the challenges of treating patients with serious mental illness within the criminal justice system, the societal and economic costs of inadequate treatment, and the need for discharge planning that includes sufficient medication and help accessing mental health and other social services.

Featuring:

  • Catherine Judd, MS, PA-C, CAQ-Psy
    Assistant Clinical Professor, University of Texas Southwestern School of Health Professions
  • Darell A. Smith
    President, Greater Dallas Coalition
  • Jason Carter, PharmD
    Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

Catherine Judd, MA, PA-C, CAQ-Psy, is the Assistant Clinical Professor at the University of Texas Southwestern School of Health Professions. Previously, she was a Senior Physician Assistant at Parkland Health and Hospital System and Dallas County Jail Mental Health Program.

Darell A. Smith is President of the Dallas Coalition, a nonprofit that seeks to bring economic, educational, and empowerment wellness to community residents by bridging the gap between service providers and those in need of such services.

Jason Carter, PharmD, is a Medical Science Liaison at Otsuka Pharmaceutical Development & Commercialization, Inc.

 

Catherine Judd, MA, PA-C, CAQ-Ps, and Darell A.Smith are paid consultants to Otsuka Pharmaceutical Development & Commercialization, Inc.

Jason Carter, PharmD, is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc. 

In July 2018, the state of New York became the first to require mental health instruction for all students, grades K-12, as part of the health education curriculum.1 During this webinar, Michael Townsend, MA, LMSW; Amy Molloy, MSW; and Jessica Hull, MS Health Education, will have a roundtable discussion regarding the current state of mental health education and review the successes and challenges of its implementation in the state of New York.

Featuring:

  • Michael Townsend, MA, LMSW
    Deputy Chief Executive Officer at Gateway Counseling Center
  • Amy Molloy, MSW
    Project Director at the School Mental Health Resource and Training Center of the Mental Health Association in New York State, Inc.
  • Jessica Hull, MS Health Education
    Health Teacher at Koda Middle School
  • Bryan Archuleta, PharmD
    Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

Michael Townsend, MA, LMSW, is the Deputy Chief Executive Officer at Gateway Counseling Center, where he assists the Chief Executive Officer (CEO) with managing and directing the organization toward its primary objectives. At Gateway, he serves as a member of the Board of Directors, as well as the Chair of the Audit Committee of the Mental Health Association in New York. He is a parent within the New York school system and also the President of GCC Transportation, LLC, which directs transportation services for those who are disabled or medically frail.

Amy Molloy, MSW, is a non-profit professional with over 20 years’ experience supporting organizations and coalitions involved in improving the health and wellness of families and communities. She is the Project Director, School Mental Health Resource and Training Center of the Mental Health Association in New York State, Inc., as well as the Treasurer of the Board of Directors at the Warren Washington Association for Mental Health in Hudson Falls, NY. She is also a member of the Queensbury Union Free School District Board of Education.

Jessica Hull, MS Health Education, holds Professional NYS Certification in Health Education K–12.  She presently is a health teacher at Koda Middle School in Clifton Park, NY, where she designs and implements an 8th-grade skills-based health curriculum based on NYS Standards and Navigate by the Stars. She is also a health teacher at Shenendehowa High School Summer School in Clifton Park, NY, and serves as the Capital Zone Health Representative and Treasurer of the NYS Association for Health, Physical Education, Recreation, and Dance.

Quarantine measures due to the COVID-19 outbreak are sweeping the globe. With widespread mandates in effect to shelter in place, many individuals are largely confined to their homes. All this has resulted in a type of collective isolation on a massive scale. What are the implications for individuals’ psychological well-being during such a time? What can we learn about the effect of quarantine on mental health from past cases when it was mandated?

With little time to tackle these complex questions, Samantha K. Brooks and colleagues, all affiliated with the Department of Psychological Medicine at King’s College, London, performed a review of 24 relevant studies. “The Psychological Impact of Quarantine and How to Reduce It: Rapid Review of the Evidence,” published February 26, 2020, in the Lancet, synthesizes the findings of the collected studies in response to the increasing spread of COVID-19 worldwide. The research team initially identified 3,166 papers from three electronic databases as relating to the psychological effects of quarantining, but when they applied sorting criteria, the selection was narrowed down to 24.

The resulting dataset included studies spanning 10 countries and five historically recent outbreaks: severe acute respiratory syndrome (SARS), Ebola virus disease, influenza A virus subtype H1N1, Middle Eastern respiratory syndrome (MERS), and equine influenza.

An important note is that the authors’ study and resulting recommendations primarily focus on smaller groups of people who have been quarantined in designated facilities, and do not necessarily apply to the large-scale quarantines currently in effect. In addition, there was no evidence found to suggest that social distancing, school closings, or cancellations of large gatherings had similar effects on mental health. Cultural differences were also unaccounted for. Nevertheless, their findings offer insight on the possible psychological implications of current global quarantine measures.

Purpose of the Review

According to Brooks et al., “Given the developing situation with coronavirus, policy makers urgently need evidence synthesis to produce guidance for the public.” Part of that guidance must be informed by an understanding of the negative psychological effects of quarantining.

Findings

The authors’ review of the studies showed that the negative psychological effects of quarantining include the following:

  • Acute stress disorder
  • Post-traumatic stress (PTSD) symptoms
  • Depression
  • Anger and confusion
  • Emotional exhaustion
  • Detachment and avoidance behaviors
  • Irritability
  • Insomnia
  • Suicidal ideation

Significantly, some of these effects were found to sometimes last months or even years following a period of quarantine.

The most common stressors include:

  • Quarantine duration: Significantly more severe results were found if the quarantine lasted for more than 10 days.
  • Fear of infection: This included fear of contracting a disease or virus as well as the fear of contaminating others.
  • Frustration and boredom: Both of them could be exacerbated by having socializing largely limited to virtual communication.
  • Inadequate supplies: An insufficient store of supplies was associated with feelings of anxiety and fear four to six months after the quarantine period ended.
  • Inadequate information: A lack of clear guidelines or a rationale for the quarantine was associated with PTSD symptoms.

Groups Most Negatively Impacted

Health Care Workers

Those most negatively affected in most studies reviewed by the authors were quarantined health care workers, who experienced a host of short- and long-term psychological effects. Many reported increased alcohol abuse or dependency, as well as avoidance behaviors. Many experienced stigma from colleagues, family members, and the general public, as they were assumed to be contagious and hence dangerous. In a few cases, fearful employers did not permit these workers to return to work even after the quarantine period had ended. Health care workers additionally reported higher levels of PTSD symptoms, lost income, anger, annoyance, fear, frustration, guilt, feelings of helplessness, loneliness, nervousness, sadness, and worry.

Individuals with a History of Mental Illness

Only one study that the authors reviewed accounted for a history of psychological illness in their assessment of quarantine effects. This study revealed an association between an identified history of anxiety and increased levels of anxiety and anger reported four to six months after a period of quarantine.

Mitigating of Negative Psychological Outcomes

The authors of this article foresaw the coming need for quarantine on a worldwide scale, but at the time of writing, they may not have known just how widespread it would be. That, combined with a limited amount of research and that research being mostly confined to studies of small groups of people in quarantine facilities, may not yield the most helpful or relevant recommendations. That said, the following recommendations resulted from their review:

  • Keep the quarantine period as brief and defined as possible.
    • By not adopting an overly cautious approach, health officials could minimize negative psychological effects.
    • Indefinite periods of quarantine may be more psychologically damaging than a period with a definite end.
  • Give the public as much information, including a rationale for the quarantine, as possible.
    • If people don’t understand why they are being quarantined, stigmatization of those quarantined can result. Having access to information can curb unnecessary fears, worries, and irrational conclusions.
  • Provide adequate supplies.
    • Rapid access to supplies (food, water, medicine, other household necessities) for households reduces short- and long-term anxiety.
  • Reduce boredom and improve communication.
    • In order to mitigate effects of isolation, health officials should provide practical techniques for coping and stress management.
    • Keeping quarantined individuals socially engaged is critical for curbing anxiety and distress. Encourage them to stay socially active through remote communication methods, social media, support groups, and hotlines, if needed.
    • Provide supplies necessary for social engagement where needed: phones, power cords, and WiFi access.

Additionally, the authors concluded the following:

  • Quarantined health care workers merit extra attention due to higher rates of reported negative psychological effects, and additional organizational and managerial support is needed for these workers.
  • Appealing to people’s altruism is preferable to compulsion when implementing a quarantine. If individuals feel that they are helping their loved ones and the community at large by quarantining, feelings of anger and confusion can be mitigated.

Conclusion

The authors of this rapid review studied cases of small groups of people quarantining in designated facilities, and not whole communities and regions of people self-quarantining in their homes or practicing social distancing. Therefore, the psychological effects that the authors’ review found cannot necessarily be inferred to be the same or similar when forecasting the results of the current COVID-19 pandemic as it affects the United States; one exception may be those small groups quarantined in facilities (or on cruise ships, as has occurred in several cases). Nonetheless, it appears reasonable to conclude that there will be negative psychological effects resulting from any type of quarantine or isolation, and the effects found through the authors’ study are helpful indicators of symptoms to be aware of and alleviate where possible.

This summary was developed independently from the authors.

Authors declared the following conflicts: no conflicts of interest.

The research was funded by the National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response at King’s College, London, in partnership with Public Health England, and in collaboration with the University of East Anglia and Newcastle University.

“Ninety meetings in 90 days”: This is one mantra repeated to and by many individuals early in recovery from substance use disorder (SUD). Regular attendance at peer-run meetings offered by organizations like Narcotics Anonymous provides structure and social support to individuals deeply in need of both. But amid pandemic, such meetings are suspended. On top of that, social distancing can create isolation, triggering boredom, which in turn can invite relapse. Moreover, many people face economic hardship and uncertainty as the shutdown of normal life continues indefinitely.

“This situation is likely to increase stress, anxiety, and trauma,” writes Dr. Roueen Rafeyan, a board-certified psychiatrist who is chief medical officer of Gateway Foundation, which offers addiction treatment1; additionally, he is affiliated with Northwestern Memorial Hospital and Saint Anthony Hospital. “Using is a way of coping,” he says.2 While COVID-19 and methods to avoid contagion are top of mind right now, “this is not a time to ignore the vulnerability of those with the disease of addiction,” Rafeyan writes. “Approximately 130 people die of an overdose every day in the United States.”1

Another sobering statistic: More than 20 million people in the United States have a substance use disorder.3 Rafeyan predicts that substance use is likely to increase as a result of COVID-19 and the precautions it demands, with those with a dual diagnosis at higher risk of relapse.2 This article will explore the factors that make those in recovery especially vulnerable to the novel coronavirus infection and the effects of social isolation, as well as provide resources for providers and those they treat.

Vulnerabilities

Having an active SUD increases the risk for catching COVID-19 and experiencing more-severe symptoms: smoking marijuana, vaping, and smoking crack cocaine compromise lung function; sharing paraphernalia is an obvious vector for contagion. Individuals who use opioids, whether legal or illicit, and those who use methamphetamine may have suffered ill effects on their respiratory and pulmonary health. “The research community should thus be alert to associations between COVID-19 case severity/mortality and substance use, smoking or vaping history, and smoking- or vaping-related lung disease,” writes Dr. Nora Volkow, director of the National Institute of Drug Abuse.4

Additionally, those who use drugs or alcohol sometimes have weaker immune systems and infections such as hepatitis C or HIV/AIDS. Among individuals with an active SUD there is also a very high rate of cigarette smoking, which also affects the lungs.5 Those with severe SUDs sometimes spend time in various institutional settings—emergency departments, jails, homeless shelters—where their risk of contracting COVID-19 is dramatically increased.6

Finally, stigma may confer additional risk. “If hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19,” Volkow writes.4

Making (Positive) Adjustments

One recent trend is virtual happy hours, in which people who are following recommendations to stay home can nevertheless socialize and drink together, although separated by distance. Such online gatherings can be tempting to those who are lonely, who find the pandemic’s upending of the usual day-to-day troubling, and who crave relief. This sort of adjustment to the pandemic is clearly unhealthy for those struggling with alcohol use disorder—or, indeed, any substance use disorder.

Substance Use Treatment Facilities: How Affected

 Residential addiction centers face a quandary: How to keep accepting and treating patients without increasing the chances that they—and staff plus the staff’s families—will be exposed to the novel coronavirus. Outpatient services can be delivered via telehealth—and widely are—but residential facilities do not have the luxury of shutting down that avenue of contagion.

Cutting off admissions would limit exposure to infection to those already in residence. But that is not the ideal answer, says Dr. Roueen Rafeyan, a psychiatrist and chief medical officer of Gateway Foundation, which offers a network of addiction treatment facilities. “People are in crisis. If I don’t admit someone, they might overdose and die,” he says.2

In response, facilities have been rigorously screening patients, staff, and new admissions for signs of infection. This limits the risk of contagion, as do deep cleaning and disinfecting of facilities. Meticulous attention to hand-washing protocols is critical.6 Visits are temporarily suspended at Gateway facilities, writes Rafeyan, and any patient with a fever is tested immediately.1

Whatever their substance of choice, those with an addiction can make some positive adjustments now that may strengthen their chances at recovery. Individuals should keep a close eye on symptoms, says Rafeyan, and reach out if use occurs or increases.2 Online meetings are one source of support. (See the end of the article for a list of resources for individuals who wish to attend an online or phone meeting.)

Individuals should continue to take medicine as prescribed. Sticking to a regular routine or adopting one can help create structure for those who lack it. Exercise, a walk outside, or just stretching or meditating at home: all are salubrious—as is practicing mindfulness to stay in the moment and assuage stress.

“Checking reality and taking note of what’s OK can prevent anxiety from taking over,” says Rafeyan. “We should remind ourselves that eventually this will come to an end. It’s important for all of us to keep that light at the end of the tunnel in sight.”2

Resources for Online and Phone Support

AA-Alcoholics Anonymous: http://aa-intergroup.org/directory.php

Cocaine Anonymous Online: https://ca.org/

In the Rooms: https://www.intherooms.com/home/

LifeRing: https://www.lifering.org/online-meetings

Moderation Management: http://www.moderation.org/

Narcotics Anonymous: https://www.na.org/

Recovery Dharma: https://recoverydharma.online/

SAMHSA: Substance Abuse and Mental Health Services Administration: https://www.samhsa.gov/find-help/national-helpline

SMART Recovery: https://www.smartrecovery.org/

Women for Sobriety: https://wfsonline.org/

 

Resources for Care Providers

American Psychiatric Association (APA): Coronavirus Resources page is at: https://www.psychiatry.org/psychiatrists/covid-19-coronavirus

American Society of Addiction Medicine (ASAM) offers resources across a variety of topics at https://www.asam.org/Quality-Science/covid-19-coronavirus:

SAMHSA Coronavirus Resources: https://www.samhsa.gov/coronavirus

SAMHSA: Considerations for the Care and Treatment of Mental and Substance Use Disorders in the COVID-19 Epidemic: March 20, 2020: https://www.samhsa.gov/sites/default/files/considerations-care-treatment-mental-substance-use-disorders-covid19.pdf

In this interview, Dr. Gaurava Agarwal discusses the balancing act we all face to perform at our highest level, both personally and professionally, while avoiding the obstacle of burnout. He provides his insights and expertise into burnout among health care professionals during the coronavirus crisis and how this may change the field moving forward. Listen in and learn from one of the leading experts on preventing burnout by establishing and maintaining wellness with a special focus on the behavioral health care profession.

Dr. Agarwal is Assistant Professor for the Departments of Psychiatry and Behavioral Sciences and the Department of Medical Education at Northwestern Memorial Hospital. He also serves as the Director of Physician Well-Being for the Northwestern Medical Group. Dr. Agarwal earned his medical degree at Baylor College of Medicine in Houston, TX; he has lectured extensively at the regional, national, and international levels; and he has expertise across clinical trials and original research domains. Dr. Agarwal has numerous scientific publications to his name.

Rachel Self, PhD, is a Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

 

 

Dr. Agarwal is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Rachel Self, PhD, is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

In a conversation with pharmacist Dr. Megan Ehret, Dr. Samantha Sweeney gathers insights on how pharmacists can best prepare for medication shortages amid natural disasters and pandemics. Dr. Ehret addresses the rapidly changing challenges pharmacists are facing every day and how they can make proactive plans—without losing sight of the main goal: providing quality care for patients.

Megan Ehret, PharmD, MS, BCPP, is the Pharmacist Corner Section Advisor for PsychU. Dr. Ehret is an Associate Professor in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy.

Samantha Sweeney, PharmD, MBA, is a Senior CNS Medical Science Liaison for PsychU. Dr. Sweeney’s areas of expertise include psychiatry and general pharmacy practice.

Anxiety, fear, and trauma can be rampant during times of natural disaster. Kimberly Lonergan, RN, MSN, interviews Tony Amberg to hear his perspectives on nurses’ role during a pandemic, including issues of self-care while caring for others.

Alan “Tony” Amberg, MS, MSN, APRN, PMHNP-BC, is the Nurses Corner Section Advisor for PsychU. Mr. Amberg is a Psychiatric Consult Liaison Psychiatric Nurse Practitioner at Northwestern Memorial Hospital in Chicago, IL. He is also an Emeritus Board Member and Former President of the Illinois Chapter of the American Psychiatric Nurses Association (APNA).

Kimberly Lonergan, RN, MSN, is a Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc. Ms. Lonergan covers North Texas, and her areas of expertise include critical care management, trauma medicine, and gastroenterology.

Speakers are paid consultants of Otsuka Pharmaceutical Development & Commercialization, Inc.

Dr. Mehdi Qalbani discusses his experience providing telepsychiatry in the Information Age. Topics include regulatory concerns, practice guidelines, and web-side manner when working remotely.

Mehdi Qalbani, MD, MSPH, is the Co-Founder of Integrated Behavioral Health, LLC. Dr. Qalbani received his medical degree from the Tulane University School of Medicine and completed his residency in psychiatry at the University of Illinois at Chicago.

Chip Meyer, PhD, is a Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc. Dr. Meyer received his PhD in Experimental Psychology from the University of Kentucky.

Medhi Qalbani is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Chip Meyer is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

The coronavirus can significantly affect mental health for everyone, but especially for those with mental illness. Both the anxiety of contracting the disease as well as the increase in loneliness and isolation can worsen and trigger symptoms.

Acknowledging, recognizing and acting on mental distress in these uncertain times is key to lessening the impact.

What Are The Mental Health Implications? 

Acknowledging, recognizing and acting on mental distress in these uncertain times is key to lessening the impact.

A working knowledge of different mental health implications can help us understand and address the mental health risks of this global health pandemic. Here are the potential symptoms to watch out for.

Anxiety 
Anxiety related to the coronavirus is to be expected. A survey of Chinese citizens published in February found that 42.6% of respondents experienced anxiety related to the coronavirus outbreak.

A poll by the Kaiser Family Foundation found that the key worries related to the coronavirus pandemic were:

  • You or someone in your family will get sick
  • Your investments, such as retirement or college savings, will be negatively impacted
  • You will lose income due to a workplace closure or reduced hours
  • You will not be able to afford testing or treatment if you need it
  • ​You will put yourself at risk of exposure to the virus because you can’t afford to stay home and miss work

Obsessions 
In a situation like this one, it is easy to become obsessive about disease prevention, especially for those with OCD who already experience contamination obsessions— “unwanted, intrusive worry that one is dirty and in need of washing, cleaning or sterilizing.”

Loneliness 
Social distancing is considered critical to slowing the spread of the coronavirus. However, it can understandably lead to loneliness. Numerous studies have shown the adverse mental health and physical impacts of loneliness, including the potential to trigger a depressive episode.

Traumatic Stress 
Individuals who have been quarantined may also experience traumatic stress.

What Can I Do?

With the awareness of these mental health risks, we can work towards coping with this challenging situation and reduce the potential impact on our mental health. Here is a list of coping strategies to help get you through these uncertain times.

Be Mindful Of Your News Consumption 

The news can be helpful by encouraging precautions and prevention, but compulsively and obsessively reading and watching about the outbreak can be detrimental to mental health. Here are a few suggestions that may help you follow the news while protecting your mental health.

Limit your sources
Rely on only one or two reliable sources of news as misinformation and bad reporting are rampant. The CDC is a great resource for updates and precautions. You can also select a news medium that allows you to avoid potentially triggering content. For example, when reading from an article on your phone or computer, you can scroll past disturbing photos and quickly reach the information you are interested in.

Practice acceptance
Accept that the news coverage will not answer all your questions or address all your worries. Accept uncertainty. Trust that officials around the globe and the medical community are trying their best to address the situation.

Limit consumption
Establish a reasonable rate of consumption, which may be checking for updates one or two times a day. Consume only what you need to know, what’s most relevant to you and particularly what is happening or anticipated in your own community.

Distinguish between global and local
The virus will not necessarily take the same course in the U.S. as it has in other countries. It’s important to think critically about the information provided and not jump to conclusions.

Ask someone for help
If you feel you need separation from the news, have a friend or loved one filter the news for you, and give you updates based on a reasonable assessment of what’s relevant to you. This will allow you to reduce direct news consumption.

Make a Health Disruption Plan
Education can be critical to alleviating stress and anxiety. Speak to your health care advisor about coronavirus precautions specific to your health needs, including a health disruption plan.

Learn about coronavirus preventative and precautionary measures from reliable sources such as the CDC. Make a plan for your household needs —a shopping list, a pharmacy list. It may also help to develop an emergency plan, especially for elderly members of the family.

Stay Connected
Stay connected with friends and family by Skype, Facetime, email, messenger and text, especially those who may be isolated. Be ready to listen to their concerns and share yours. Learn effective listening skills to help your friends and loved ones.

Reflective listening is an excellent communication technique, where you listen to what a person is saying and repeat it back to them. You may help validate their concerns, and show them you understand their concerns, which can help put them at ease. Talking to another person about worries and fears can help, and just knowing that others share them can validate your own fears and worries.

Social connectedness is critically important to warding off loneliness and resulting depression. There are many online peer support communities to turn to, including those for mental illness caregivers such as ForLikeMinds, and for people living with mental illness such as: 7 Cups, Emotions Anonymous, Support Groups Central, Therapy Tribe, Support Groups, 18percent and PsychCentral.

Take Care Of Yourself

It’s essential to make your health a priority during this time. The critical self-care activities are sleep, physical exercise and a healthy diet. Find ways to address forms of stress, such as journaling, going for walks or calling a loved one. Maintaining a sense of normality and routine can also reduce stress.

It can be especially helpful to practice mindfulness and try not think of the future or worst-case scenarios. There are many online references, including Kindle books on Amazon, YouTube guided meditation and yoga videos, and apps such as Headspace.

Find Things To Do/Distractions

Activities that distract you from current events can be helpful. Here are a few ideas:

  • Household chores, such as spring cleaning, will give you a sense of purpose and accomplishment when completed.
  • Free online university courses and courses through cousera, such as Yale University’s most popular class ever: The Science of Well-Being. They offer a great learning opportunity.
  • Movies are moving from theaters to online. Netflix is also a good option.
  • TV programming has expanded during the crisis, particularly through streaming services like Netflix. You can also currently stream the Met Opera for free. The NFL and NBA are also offering complementary access to online streaming platforms.
  • ​Virtual parishes, which the Pope and other faith leaders are offering, can help maintain religious connections.

Help Others 

The helper principle shows that helping others is also a benefit to the helper. In hard-hit Europe and other impacted communities, people are helping those self-isolating by shopping or running errands for them. Canada has developed a movement called “caremongering.”

Mutual aid communities are developing across the U.S and online organizers have put together an exhaustive list of resources. There area few different kinds of organizing. Some focus on “local efforts to build networks that can respond at the neighborhood or community level,” while others “build networks to serve more at-risk groups, like the immunosuppressed or -compromised, incarcerated folks, and workers who will be out of jobs.” This document enables people who need help to ask for it and this one enables people who can provide help to offer it.

In these uncertain and unprecedented times, it is natural to experience stress and anxiety. However, an awareness of these stressors better positions us to address them. And there are many tools and coping strategies available to combat the strains on our mental health.

We are creative creatures. We are also social creatures. So, we are finding ways to remain socially connected while physically disconnecting. Perhaps we will also emerge from this crisis with a better appreciation and respect for our fellow humans and citizens.

Reliable Resources:

  • NAMI COVID-19 (Coronavirus) Information and Resources
  • Find Your Local NAMI
  • American Psychiatric Association
  • American Psychological Association: Pandemics, Anxiety and Depression Association of America(ADAA)
  • Psychology Today Therapist Directory
  • Centers for Disease Control(CDC)
  • World Health Organization(WHO)
  • SAMSA Disaster Distress Help 800-985-5990
  • NAMI Helpline 800-950-6264
  • NAMI Crisis Text Line: Text HOME to 741741
  • National Suicide Prevention Lifeline 800-273-8255

Provided with permission from National Alliance on Mental Illness (NAMI) a PsychU Supporter. To learn more about NAMI, please visit their website at www.nami.org.  

Katherine Ponte is a mental health advocate, writer and entrepreneur. She is the founder of ForLikeMinds, the first online peer-based support community dedicated to people living with or supporting someone with mental illness and Peersights, a mental illness recovery coaching service for caregivers and their loved ones. She is also the creator of the Psych Ward Greeting Cards program in which she personally shares her recovery experiences and distributes donated greeting cards to patients in psychiatric units. She is in recovery from severe bipolar I disorder with psychosis. She is also on the board of NAMI New York City. 

Today’s podcast will focus on COVID-19’s impact on the work of a peer specialist in mental health care. It will discuss how the role of a peer specialist has changed because of the pandemic and how he is working to support colleagues and clients at this time. Our speaker will share his thoughts on how to best take care of oneself as a peer specialist, as well as explore wellness strategies and tools that could help with mitigating the mental health impacts of the COVID-19 pandemic.

Dwayne Mayes is the Patient & Caregiver Section Advisor for PsychU and a Program Director of the Recovery Network & Peer Training Program at the Mental Health Association of Westchester. He is also a former board member of the International Association of Peer Specialists. Mr. Mayes received a BA in sociology from Hunter College, CUNY.

Speaker is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Mr. Paul Gionfriddo, President and CEO of Mental Health America (MHA), and Dr. Dennis Pabis, Senior Medical Science Liaison with Otsuka Pharmaceutical Development & Commercialization, Inc., discuss the effects of the COVID-19 pandemic on the efforts of advocacy organizations, including MHA. They discuss how MHA is addressing the unique challenges COVID-19 poses to those affected by trauma-related symptoms. They also share their thoughts on legislation regarding telehealth rules, as well as resources that MHA has available for patients and caregivers.

Paul Gionfriddo is the President and CEO of MHA and a PsychU Stigma Section Advisor. He has worked in a variety of health and mental health–related positions during a career spanning over 30 years. He has served on many local, state, and national nonprofit boards for organizations serving individuals living with mental illness, substance use disorders, and developmental disabilities.

Dr. Dennis Pabis, PharmD, is a Senior Medical Science Liaison for PsychU. His areas of expertise are psychiatry, schizophrenia, neurology, pain medicine, migraines, medical affairs, and clinical pharmacy. Dr. Pabis attended the University of the Sciences in Philadelphia and University of Texas at Austin.

Paul Gionfriddo is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Dennis Pabis is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

Telemedicine in the Treatment of Substance Use Disorder: Clinical and Payer Implications

PsychU interviewed Deborah Adler, senior associate at OPEN MINDS, for her take on the clinical and payer implications of the research described in “Telemedicine in the Treatment of Substance Use Disorder.” The conversation has been edited for clarity and brevity.

Can you give us a little recent history about substance use disorder and its treatment costs?

Over the last 10 years, there has been increasingly greater utilization of addiction treatment services and greater costs, the result of a perfect storm:

  1. The passage of the Affordable Care Act (2010) resulted in surge of individuals age 19 to 26 having coverage.
  2. At the same time, there was the rising use of opioids—the opioid epidemic.
  3. Residential programs for addiction treatment in destination locales—Florida, California, Hawaii—started popping up, and they were expensive. Individuals would stay typically 28 days, then go back to their home communities.

Some employers experienced double-digit percentage increases in substance use disorder treatment costs from 2007 to 2011.

How did payers respond to this increase in spending?

With huge jumps in expenditures, particularly out-of-network expenditures, payers implemented tactical steps to rein in costs. They took note of the fact that, in many cases, individuals were receiving care that was not consistent with evidence-based practices. So they tried to increase access to evidence-based programs, such as those that use medication-assisted treatment (MAT).

In short, payers started looking for three things in addiction treatment programs:

  1. Use of medications that have been proven efficacious in treating opioid use disorder and alcohol use disorder.
  2. Access to psychosocial support.
  3. Access to peer coaches (also known as recovery coaches) who have lived experience in battling addiction and can help those in recovery navigate the health care system and offer support.

Additionally, addiction treatment should ideally occur close to one’s home community versus an out-of-state program, so that individuals are supported in recovery in their home environments. Therefore, many payers focused on expanding access to community-based, outpatient MAT programs. And for good reason: The relapse rate is much higher for out-of-state programs versus local, evidence-based programs.

Access has been a nagging issue, given the widespread shortage in psychiatrists. Can telemedicine address that problem?

Yes, access has been a huge challenge in the behavioral health and addiction spaces because of workforce shortages in psychiatrists and others with prescriptive authority. To increase access, payers have introduced telemedicine as allowed by state law. It is very complicated because every state’s regulatory requirements must be followed. For example, in Ohio an individual must have a face-to-face visit first before moving into services delivered via telemedicine. Many medications for opioid use disorder are controlled substances, and often state regulations do not allow for the delivery of controlled substances through telehealth.

So telemedicine is used as a part of a comprehensive treatment package that includes in-person visits?

Yes, a hybrid model—in-person visits married with telemedicine sessions—is a very desirable approach. While not yet the predominant approach, it gives the patient the option to have face-to-face and virtual treatment and may therefore reduce no-show appointments and enhance engagement. Medications and the lab tests that are typical in addiction treatment take place in person; counseling, by care professionals as well as by peer coaches, takes place by virtue of telemedicine.

This is outpatient care that we have been talking about. How does telemedicine figure in higher-level care for substance use disorders?

In intensive outpatient programs, individuals typically spend at least three hours a day, three days a week getting treatment. We are beginning to see some use of telehealth services in the form of cognitive behavioral therapy delivered through electronic means.

My sense is that payers are waiting and watching to see if telemedicine’s use in intensive outpatient program is effective.

Is it used inpatient?

Yes, telemedicine is used inpatient as well, though not so much for substance use disorder treatment as for mental health care more broadly. To tackle the workforce shortage of psychiatrists, many inpatient programs are using telehealth. In fact, I understand inpatient programs are having challenges in recruiting psychiatric attendings as many psychiatrists turn to working in virtual settings, given that virtual medicine gives them greater flexibility and a better work/life balance.

What do you think we’ll see in a year? In five years?

Right now, there is low utilization of telemedicine services, despite the fact that these services are covered as part of the standard medical and behavioral health benefit. There’s a lack of awareness on the consumer’s part that telemedicine is an option.

So I think a year-plus from now, we’ll see growing awareness and adoption of telehealth; over the next five years, more remote monitoring and case management, particularly in the addictions space. More and more substance abuse treatment programs will incorporate telemedicine as one modality among several.

Some 21 million people in the United States have a substance use disorder (SUD) related to their use of alcohol, opioids, or other drugs. From 1999 to 2016, the rate of fatal opioid overdoses nearly quadrupled. Joining these sad statistics is a third: Fewer than 20% of people with SUD receive treatment. One significant factor for that is a shortage of providers, a shortage that is particularly acute in rural areas.

The use of telemedicine for mental health treatment has increased tremendously in recent years, and research has shown it to be at least as effective as in-person care. So there is widespread hope that telemedicine might prove helpful in alleviating the shortage of SUD providers and thereby expand SUD treatment in the face of pressing need.

But what is the current state of telemedicine for SUD treatment? How is it used and by whom? Those are the questions a group of researchers, primarily from Harvard Medical School, set out to answer. In a paper entitled “How Is Telemedicine Being Used in Opioid and Other Substance Abuse Treatment?” Haiden Huskamp and colleagues looked at deidentified data covering 2010–2017 for privately insured individuals and Medicare Advantage enrollees. It included physician, hospital, and pharmacy charges.

The paper’s aim is to describe who is using telemedicine services for substance disorder treatment, detail the particulars of that care (e.g., synchronous vs. asynchronous, alone vs. in conjunction with in-person care), and compare that use to how telemental health is used.

Methods

The study population consisted of 1,914,821 individuals age 12 or older who received a SUD diagnosis during the study period. The unit of measure was the person-year; for this study, the number of person-years was 2,550,047. To identify telemedicine visits, they looked for Healthcare Common Procedure Coding System (HCPCS) codes specifying a telemedicine encounter. Additionally, they used procedural codes to identify telemedicine services such as ED consultations or pharmacologic management that occurred via telehealth technology. Modifiers attached to the codes signified whether the telemedicine encounter was synchronous—occurring live in real time—or asynchronous.

The study’s authors also gathered data about nontelemedicine SUD treatment, including inpatient, partial hospitalization, ambulatory visits, and use of buprenorphine and other SUD-specific medications. They identified individuals whose SUD was moderate or severe, their specific type of SUD (e.g., opioid use disorder, alcohol use disorder, other), and their mental health diagnoses, if any.

Steep Rise in Use, but Still Little Used

Over the course of the study period, 2010 to 2017, the number of telemedicine visits for substance disorder treatment increased dramatically, from 0.62 visits per 1,000 people diagnosed with SUD to 3.05 visits. At the same time, such visits accounted for only 1.4% of telemedicine visits for any health condition and just 0.1% of all SUD encounters. During the same time period, the number of telemedicine visits for mental health treatment grew even more dramatically, from 0.91 visits per 1,000 people diagnosed with a mental illness to 16.59 visits. Visits for mental health treatment accounted for 34.5% of all telemedicine visits.

A significant majority of telemedicine visits for substance use disorder treatment, 81.3%, occurred in outpatient settings, with 41.7% being for new-patient intake, 32.9% for established patients, and 14.5% for psychotherapy. Nearly all were synchronous. Some 61.2% of individuals who used telemedicine for SUD treatment were men, and slightly more than half (54.8%) were under age 40.

The authors compared characteristics of those who used telemedicine for SUD treatment versus those who did not use such services for SUD treatment. The former group were more likely to have a moderate or severe diagnosis for SUD, to have opioid use disorder, and to have a severe mental illness.

Telemedicine Supplements Traditional Care

The researchers found that telemedicine SUD treatment is almost exclusively used in tandem with in-person care; 99% of those who had at least one telemedicine visit for substance use disorder treatment also had at least one in-person visit for treatment. They also found that those who received telemedicine SUD treatment receive a greater intensity of care compared with those who did not, with telemedicine SUD treatment users having more in-person medical visits for SUD treatment on average (10 vs. 4), a greater use of higher-intensity care (64.1% had inpatient stay for SUD treatment vs. 26.1%), and more medication use tied to their SUD treatment (23.2% had any type of SUD medication vs. 6.7%).

A similar pattern played out when the researchers looked at individuals with opioid use disorder (OUD). Those who used telemedicine as part of their SUD treatment had higher rates of inpatient stays, intermediate care, and medication use compared with those who did not.

Family practice physicians or internists led nearly half of sessions (45.6%), and psychiatrists led almost a third (29.2%).

Limitations and Conclusion

The authors identify several limitations of their analysis. They used data for individuals who were either privately insured or enrolled in Medicare Advantage. Hence, the study’s findings may not be generalizable to individuals insured by Medicaid or other public insurance. Second, they caution that SUD is sometimes undercoded in claims data; hence, they may have underestimated the proportion of those with SUD in their analysis.

Compared with telemental health, telemedicine SUD treatment is much less commonly used, but the researchers conclude that it has the potential to alleviate the huge need for effective SUD care.

This summary has been developed independently of the authors.

Drs. Rachel Self, Carolyn Tyler, and Heather Davidson provide an understanding of the immune system and neuroinflammation and their impact on mood disorders. Topics covered in part two of this PsychU series include inflammatory response in the brain, potential causes of inflammation and potential anti-inflammatory treatment approaches.

Rachel Self, PhD, is a Senior Medical Science Liaison for the OPDC Field Medical Affairs team. Dr. Self earned her PhD in Behavioral Neuroscience and Psychopharmacology at the University of Kentucky.

Carolyn Tyler, PhD, is a Senior Medical Science Liaison for the OPDC Field Medical Affairs team. Dr. Tyler earned her PhD in Neuroscience at the University of Rochester School of Medicine and Dentistry.

Heather Davidson, PhD, is a Medical Science Liaison for the OPDC Field Medical Affairs team. Dr. Davidson earned her PhD in Physiology and Neuroscience at the Medical University of South Carolina.

Speakers are paid employees of Otsuka Pharmaceutical Development & Commercialization, Inc.

The Affordable Care Act (ACA) OF 2010 was the largest expansion of health services in the United States in more than 50 years. Twenty million adults obtained health insurance under the ACA, either through expanded access to private insurance, subsidies, or expanded access to Medicaid. One goal of the ACA was to expand primary care and other services to reduce unnecessary health care costs, such as those incurred by unnecessary emergency department (ED) services. Frequent ED users are more likely to have serious health conditions and comorbidities. ACA care coordination requirements were established to with the intent to lower costs.

This study examines frequent users of EDs before and after the implementation of the ACA to better understand that policy and fiscal implications of expanded coverage. The study was focused on populations in California. The researchers of this study were from the University of California–San Francisco and the San Francisco-based Public Policy Institute of California. The study was concerned with whether frequent ED use would increase because of demands of populations who were previously not insured or be lowered because of better access to routine health services.

As a result of ACA implementation, roughly 2.7 million people in California were eligible for Medicaid in California. This was a higher proportion than expected. There was concern that frequent ED use would escalate because populations would not have to spend out-of-pocket funds. The study found that the probability of being a frequent ED user decreased in Medicaid and uninsured populations after the researchers controlled for mental health and substance abuse.

How the Study Was Designed

Data was studied from all licensed hospitals, collected by the California Office of Statewide Health Planning and Development. Data of the pre-ACA period of years 2012 and 2013 were compared to the post-ACA period of 2014 and 2015. Frequent users were defined as people who experienced four or more ED visits in one year. The study was limited to adults age 18 to 64. Elderly and Medicare patients were excluded from the study, because these groups were less affected by the ACA. A comprehensive diagnostic history was also formulated for patients using discharge abstract data. Patients were also segmented into exclusive insurance categories and patients with multiple insurance types were assigned to a single category based on the type of insurance billed for the majority of visits. The study examined 13.7 million patients who had at least one visit to the ED in a given year, resulting in 24.5 million visits.

Use Increased

Follow-up data indicated that the total number of ED users increased by 7.7%, or 511,284 individuals, as a result of ACA expansion. Post-ACA patient populations had a higher proportion of behavioral health demands such as substance use or mental health conditions, as well as chronic medical conditions. The proportion of ED patients who were frequent users increased from 7.0% to 8.5% in the study period. Patients covered by Medicaid increased from 21.5% to 37.6%. Uninsured patients declined from 26.9% to 13.2%.

The primary insurance coverage source was the largest factor of change. Frequent ED users covered by Medicaid increased from 44.6% to 67.6%. Uninsured frequent users declined from 29.0% to 8.3%. According to the researchers’ analysis, the odds of a Medicaid patient being a frequent user dropped by 12%, the odds for the uninsured decreased 50%. Females were more likely to be frequent users than males. Non-Hispanic blacks had higher odds than non-Hispanic whites for frequent ED use. Asians were less likely to be frequent ED users than the general population.

Substance use (non-alcohol related) and mental health conditions were correlated with more frequent ED use. This was observed across all insurance types. When these conditions were accounted for, the odds of Medicaid-covered patients being frequent ED users were significantly lower than the odds for those not covered by Medicaid.

Limitations of the Study

There were concerns about how California data could be generalized to the rest of the country. California operates the largest Medicaid program in the United States. Missing patient identifiers prevented the linkage of patients to all ED visits. It was not possible to track privately insured patients alternating between low- and high-deductible plans, the later designed to incentivize lower ED use. The study examined patient behavior only in the first two years of the ACA, when the program was still immature.

Implications for Medical and Behavioral Health Services

Individuals with high-level needs may be better served with increased opportunities for Medicaid coverage. That, however, would have a significant impact on Medicaid managed care plans and also for state budgets. This study indicates that behavioral health conditions, such as mental illness and substance use, significantly influence frequent ED use. Improved access and better care coordination between mental health and medical services are essential goals and should be considered by payers, government agencies, and local providers of care.

This summation was developed independently from the authors.

Authors declared the following conflicts: no conflicts of interest.

For 2019, PsychU’s annual theme was data and technology to improve mental health. In keeping with PsychU’s goals of improving mental health care… together, PsychU hosted a National Forum: Future of Technology and Mental Health on June 25, 2019 in Chicago, IL. The forum brought together top digital health clinicians and researchers in the mental health community in order to discuss the current landscape of technology in mental health and what the future may hold.

The full day event was chaired by John Kane, M.D., the Senior Vice President for Behavioral Health Services at Northwell Health, and moderated by Chip Meyer, Ph.D., Otsuka Medical Science Liaison.  Please see Table 1 for the full list of attendees. The key objectives of the forum were to:

  • Understand the current use of technology in mental health, and barriers that may limit implementation
  • Discuss the future of implementing and advancing the use of technology in mental health
  • Gather key insights from technology and mental health experts to assist in the development of PsychU resources on technology in mental health

The discussion throughout the day centered on five key topic areas, and the takeaways from the meeting are included below:

Throughout the day the forum attendees had lively discussion on the topic of technology and mental health, sharing their expertise in this area. Below you can see several of the attendees give their response to some of the questions that were posed throughout the day. The group made several recommendations on key areas where PsychU could provide education and resources for health care professionals interested in the use of technology in mental health. With the help of the forum attendees, PsychU plans to further develop the Digital Health section based on these recommendations. Plans are already underway for a Webinar beginning with the basics of digital health and defining the landscape. A future video series hopes to bring health care professionals inside the daily workflow of those using technology in their practice as well as share the patient’s perspective of using these digital tools. Future on demand presentations will focus on the use of technology on adherence and within specific disease states such as depression, schizophrenia, and bipolar. Keep your eye out for these exciting presentations as well as other future updates to the PsychU Digital Health section.

John Kane, MD

 

Timothy Aungst, PharmD

 

Dror Ben-Zeev, PhD

 

Megan Coder, PharmD, MBA

 

Carmen Kosicek, MSN, APNP, PMHNP-BC

 

John Newcomer, MD

 

Mona Sobhani, PhD

 

 

Table 1

 

 

During this recording, Michael E. Thase, MD, examines the common metabolic side effects associated with antipsychotics, antidepressants, and combination therapy. Dr. Thase analyzes the importance of managing these side effects by highlighting lifestyle interventions and pharmacological options.

Michael E. Thase, MD, is a Professor of Psychiatry at the Perelman School of Medicine of the University of Pennsylvania. Dr. Thase is also Director of the Mood and Anxiety Disorders Section, and is a member of the medical staff at the Corporal Michael J. Crescenz Veterans Affairs Medical Center. He obtained his MD from Ohio State University and completed his residency at the Western Psychiatric Institute and Clinic.

Michael E. Thase is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Despite vast improvements in diagnosis and treatment over the last half-century, mental illness is underdiagnosed and undertreated.

The reasons are many and varied. Among them: a lack of access for individuals amid a shortage of care providers, the interference of social determinants of health such as transportation problems, and social stigma. All play a role.

But technology may offer a means to address these and other barriers. Consider just a few of its more recent contributions. As a McKinsey & Company paper points out, technology applied in health care settings has helped prevent adverse drug events, including medication errors, allergic reactions, and overdoses. Technology has been deployed successfully to increase individuals’ compliance with care recommendations, such as preventive checkups and medication refill information, improving their health.

And it has served to streamline diagnostic testing and other processes, saving significant cost. 1

Why is mental illness, despite its undeniable human and societal burden, so undertreated?

Today’s advanced technology aids mental health care via disparate approaches and tools that have the capacity to:

  • Aid clinical decisions.
  • Streamline processes, both on the back end and consumer facing. Examples include blood utilization and appointment scheduling.
  • Expand access to care and increase its timeliness.
  • Enhance transparency and communication between physician and patient.
  • Collect and interpret health data in real time, complementing that recorded in the doctor’s office.
  • Reduce costs.
  • Improve outcomes.

In short, technology – from telepsychiatry to wearable health devices to artificial intelligence–aided clinical decision support may accelerate the drive toward the Triple Aim: a better care experience, improved population health, and reduced costs.

PREVALENCE OF MENTAL ILLNESS

One in five American adults lives with mental illness. That prevalence is more concerning when one considers that fewer than half of individuals with mental illness—only 43%—received any treatment for their illness in the previous year, according to a 2018 Substance Abuse and Mental Health Services

Apps that seek to alter thought patterns and improve thinking skills, using CBT principles, tend to be targeted at people with more serious mental illness.

Administration (SAMHSA) study. And about one in 25 U.S. adults has a serious mental illness (SMI), such as schizophrenia, bipolar disorder, or major depressive disorder. Among individuals aged 18–25 years with an SMI, nearly half—46%—received no treatment in the previous 12 months.2 In addition to the human cost of untreated mental illness, there is an economic one as well: lost earnings in 2002 due to SMI cost the economy around $193 billion US dollars.3

BARRIERS TO CARE

Why is mental illness, despite its undeniable human and societal burden, so undertreated? Many factors come into play, such as underdiagnosis, stigma, a worrisome shortage of psychiatrists and other mental health care providers, and individuals’ personal logistical challenges. Among these barriers, one of the most significant is wide geographical variation in the availability of mental health care providers. Countrywide there is an average of one mental health provider for every 536 individuals.

But that average disguises a dramatic difference in access: the ratio in Massachusetts is 1:200, whereas in Alabama, it is 1:1260. More than 4,000 areas across the U.S., mostly rural and low-income locales, are designated mental health care professional shortage areas.4

Technology facilitates mental health care in multiple ways:

  • Mobile health (mHealth) sensors that collect health data.
  • Digital interventions and assessments.
  • Clinical-decision support systems.
  • Mobile apps for mental health.
  • Medication adherence technology.
  • Telepsychiatry and teletherapy.

OPENING ACCESS, INCREASING TIMELY CARE

According to a 2019 Pew study, 96% of U.S. adults have a smartphone.5 The prevalence of internet usage and the ubiquity of smartphones offer individuals an abundance of mental health care sites, functions, and apps. Estimates vary widely as to number, but internet sites and mobile apps number well into the thousands.

Their advantages are plain to see. Most are low-cost or free. They overcome access barriers, both spatial and temporal. Given societal stigma, some consumers with mental illness wish for anonymity; apps can provide that. They are convenient to access and use. Some even offer games and other fun ways to address mental health.

Some examples of the types of apps available for use in managing mental wellness:

  • Self-management apps: The user inputs personal data manually, and the app provides feedback of some kind. Apps in this category can prompt consumers to practice deep breathing when their anxiety climbs or take medication on schedule. Indeed, apps that support medication adherence could be very helpful, as it is well established that poor compliance with pharmacological therapy compromises treatment and results in poorer outcomes.
  • Apps for improving thinking skills: Cognitive behavioral therapy, or CBT, relies on the recognition that thoughts, feelings, and behaviors are intertwined; change thoughts, and feelings and behaviors will follow suit. Apps that seek to alter thought patterns and improve thinking skills, using CBT principles, tend to be targeted at people with more serious mental illness.
  • Attention-Controlling Games: According to the National Institute of Mental Health, apps in this category are being tested as a treatment for post-traumatic stress disorder (PTSD).
  • Video Games: One example of a video game accessible via app features a protagonist who confronts anxiety and depression. The user can identify with the game’s central character as that person confronts challenges complicated by mental illness.
  • Experimental: A major research university is currently studying how facial recognition technology can be used to predict schizophrenia.

HEALTH INFORMATION TECHNOLOGY

Much has been written about how health information technology has impacted medical care for the better. In the wake of the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 and the Patient Protection and Affordable Care Act (PPACA) in 2010, both of which incentivized the adoption of electronic health records, or EHRs, the majority of provider practices do now have patient records in digital form.

Along with those digitized records is the capacity to automate messages to the individuals treated by a practice, such as reminders to set up appointments for preventive or specialist care. Polypharmacy review is more easily accomplished when all an individual’s medical data from different providers is collected in the same place, thereby allowing analysis.

EHRs facilitate efforts to improve population health by allowing providers to identify all individuals with a particular condition, such as diabetes type 2, and target interventions at them.

One success story with health information technology is UCLA Health, which leveraged IT across the organization to improve processes and outcomes. For example, UCLA Health increased depression screenings performed by primary care physicians via automated notices to case management.

Another project UCLA Health tackled was blood utilization. Concerted national efforts and careful research have demonstrated that blood has been routinely overused in hospitals, compromising patient outcomes. What’s more, blood is high in cost, so overuse of blood translates not only to patients receiving suboptimal care but also to increases in the cost of care without a concomitant increase in quality. Guided by clinical decision support that aided clinicians in real time, UCLA Health optimized blood utilization across its organization.

So far-reaching were its accomplishments that UCLA Health was awarded the 2018 HIMSS Davies Enterprise Award for leveraging HIT to improve outcomes, a McKinsey paper reports.6

THERAPY VIA MOBILE OR COMPUTER

Whether treatment occurs via smartphone or computer, telepsychiatry and other mental health services performed online open access to mental health care in resource-poor regions by offering consumers a way to videoconference with a psychiatrist or other mental health care professional in real time. This synchronous therapy can be augmented by asynchronous communication between consumer and care professional.

Certainly, televisits for mental health are now in wide use. Consider this graphic showing the degree to which different payers reimburse for them:7

But some question whether those with SMIs can use mHealth apps and other technologies appropriately. Does the Pew research that found widespread ownership of computers and smartphones and use of the internet mean that these individuals are comfortable with technology?

The answer would seem to be yes. One study of individuals with SMI found broad acceptance of technology-aided treatment.

Key characteristics associated with successful use of digital health tools as identified by the authors’ research:

  • Interest in using state-of-the-art technology.
  • Resources, such as a smartphone or WiFi, that facilitate access to treatment.
  • Positive expectations about using a digital health tool.
  • Supportive social network.
  • Good occupational functioning.

Substance use and chaotic living situations were two factors that worked against successful use of digital technology in this population.8

This summation has been developed independently of the authors.

Authors have declared the following: no conflicts.

Dr. Manning provides an update on trends in behavioral health and their impact on primary care. To read about this update and more, check out the 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition report.

Sloan Manning, M.D., is a PsychU Primary Care Provider Section Advisor. He also serves as the Medical Director of Novant Health Urgent Care & Occupational Medicine; an Adjunct Associate Professor at the University of North Carolina School of Medicine; and Co-Director of the Mood Disorder Clinic at the Moses Cone Family Medicine Residency Program.

Sloan Manning, M.D. is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

For 2019, PsychU’s annual theme was data and technology to improve mental health. In keeping with PsychU’s goals of improving mental health care… together, PsychU hosted a National Forum: Future of Technology and Mental Health on June 25, 2019 in Chicago, IL. The forum brought together top digital health clinicians and researchers in the mental health community in order to discuss the current landscape of technology in mental health and what the future may hold.

The full day event was chaired by John Kane, M.D., the Senior Vice President for Behavioral Health Services at Northwell Health, and moderated by Chip Meyer, Ph.D., Otsuka Medical Science Liaison.  Please see Table 1 for the full list of attendees. The key objectives of the forum were to:

  • Understand the current use of technology in mental health, and barriers that may limit implementation
  • Discuss the future of implementing and advancing the use of technology in mental health
  • Gather key insights from technology and mental health experts to assist in the development of PsychU resources on technology in mental health

The discussion throughout the day centered on five key topic areas, and the takeaways from the meeting are included below:

Throughout the day the forum attendees had lively discussion on the topic of technology and mental health, sharing their expertise in this area. Below you can see several of the attendees give their response to some of the questions that were posed throughout the day. The group made several recommendations on key areas where PsychU could provide education and resources for health care professionals interested in the use of technology in mental health. With the help of the forum attendees, PsychU plans to further develop the Digital Health section based on these recommendations. Plans are already underway for a Webinar beginning with the basics of digital health and defining the landscape. A future video series hopes to bring health care professionals inside the daily workflow of those using technology in their practice as well as share the patient’s perspective of using these digital tools. Future on demand presentations will focus on the use of technology on adherence and within specific disease states such as depression, schizophrenia, and bipolar. Keep your eye out for these exciting presentations as well as other future updates to the PsychU Digital Health section.

John Kane, MD

 

Timothy Aungst, PharmD

 

Dror Ben-Zeev, PhD

 

Megan Coder, PharmD, MBA

 

Carmen Kosicek, MSN, APNP, PMHNP-BC

 

John Newcomer, MD

 

Mona Sobhani, PhD

 

 

Table 1

 

 

Traditionally, bipolar disorder type II (BDII) has been thought to be less severe—and less disabling—than bipolar disorder type I (BDI). Experts believe this characterization might be attributed to the fact that the mood elevation in BDII, known as hypomania, typically does not cause the significant impairment or psychosis caused by mania as is the case with BDI.

While previous research has addressed whether these two illnesses differ in ways other than how they are defined from a clinical standpoint, there have been few (and inconsistent) studies that captured the differences between these two illnesses. So a team of Swedish researchers—including Alina Karanti, Mathias Kardell, Erik Joas, Erik Pålsson, and Mikael Landén from the University of Gothenburg and Bo Runeson from the Karolinska Institut in Stockholm—set out to do just that.

Bipolar Research Background: At a Glance

Bipolar disorder is recurrent and chronic. It leads to functional impairment and has a tremendous effect on those who have it.

Overall, the symptoms of bipolar disorder can vary greatly. This differentiation led to the classification of two primary subgroups:

  • BDI, which features episodes of mania and depression
  • BDII, which features hypomania and episodes of depression

It is interesting to note that some researchers argue that mania and hypomania are not distinct, and therefore question the differentiation overall; in fact, some have suggested that bipolar disorder as a whole should be assessed on a continuum with varying levels of severity.

Despite the fact that BDII is traditionally seen as less severe, some recent studies have suggested that the total burden of illness in BDII may actually be more disabling than BDI. But as noted, few studies have compared the two, and results were inconsistent. In addition, most studies have been small and focused primarily on BDI (often on inpatients, specifically) versus focusing on both subgroups.

New Comparisons Are Enlightening

BDI and BDII Similarities…

Not surprisingly, Karanti and colleagues found that BDI and BDII shared certain commonalities. For example:

  • Sick Days and Somatic Illness: The number of sick days did not differ between BDI and In fact, the rate of physiological disorders was similar in the two subgroups (with the exception of endocrine, nutritional, and metabolic diseases, which were more common in BDI).
  • Home/Environment/Behavior: The household composition (single person versus shared) did not differ, nor did the occurrence of psychosocial and environmental problems. In addition, BDI and BDII patients did not differ with respect to being sentenced to prison/legal sanctions nor in criminal behavior (data included the 12 months before Bipolar registration; that is the Swedish national quality assurance registrar for bipolar disorder).
  • Functioning Assessment: Total scores on the Global Assessment of Functioning (GAF) scale did not differ between the two groups (although the BDII group scored slightly higher on the scale for functioning while BDI scored slightly higher for symptoms).

… And BDI/BDII Differences

But arguably, the more notable findings in the present study arose from the differences between BDI and BDII.

BDII patients were more likely to:

  • Have children, live in ordinary non-supported housing, and be working or studying
  • Have attained a higher level of education beyond high school
  • Be younger at first onset of a mental disorder (although BDI patients were younger at their first contact with a clinician due to mental health problems)
  • Have depressive episodes
  • Have a family history of suicide and a higher prevalence of suicide attempts
  • Exhibit psychiatric comorbid conditions like anxiety disorders, eating disorders, ADHD, and personality disorder (but not substance use disorders)

Conversely, BDI patients:

  • Have twice the rate of psychiatric hospitalizations. (The researchers noted that the high rate of hospitalization was expected given that manic episodes often require inpatient care.)
  • Experience twice the rate of hypomanic and manic episodes combined (although by definition, BDII patients can’t have manic episodes).
  • Are more likely to be men

Treatment Comparison: BDI versus BDII

Between individuals with BPI and those with BPII, there was not a statistically significant difference in what percentage received polytherapy. However, more than half of BDII patients received treatment with antidepressant drugs compared with one-third of BDI patients. (The researchers noted that this might be because BDII patients may have a greater number of depressive episodes than BD I.) BDII patients were also more likely to receive psychotherapy.

Conversely, the BDI group was more likely to receive electroconvulsive therapy (ECT), treatment with antipsychotics and mood stabilizers, and to have received psychoeducation.

For information on complete study findings, see the article referenced below.

Despite Similarities, Bipolar Disorder Type I and Type II Show Distinct Differences

Karanti et al.’s work clearly supports the identification of BDII as a distinct category within bipolar disorder. Whether BDI or BDII is more disabling/severe is open to interpretation, according to the research team. Indeed, the notable differences between the two support the idea that BDII is not a milder form of BDI as previously characterized, but rather is a more complex condition in terms of clinical course and comorbidity.

For while BDI groups showed more hospitalizations and lower psychosocial functioning and educational attainment, the BDII groups displayed a more complicated picture overall. This includes the earlier onset and more frequent comorbid conditions, depressive episodes, and suicide attempts. But regardless, the key point is that the team’s findings confirm BDI and BDII as having different clinical characteristics.

In respect to the treatment differences that they found, Karanti et al. contend that these might not only signal different medical needs but might also indicate that clinicians make treatment decisions based on predominant symptoms versus clear evidence-based guidelines. Looking at future treatment of BDII specifically, Karanti and her colleagues suggest that some of their study’s findings—such as the link between BDII’s onset with a history of eating disorders, anxiety disorders, ADHD, personality syndromes, or frequent depressive episodes—could, in fact, inform the diagnostic decisions that are made early in the course of that distinct illness.

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

This summary was developed independently of the study’s authors.

Authors declared the following conflicts: no conflicts of interest.

On December 12, 2019, the U.S. Federal Communications Commission (FCC) unanimously approved “988” as the official phone number for suicide prevention. The purpose in having a three-digit phone designation is to ease crisis service access while reducing the stigma associated with suicide and mental health conditions. Currently, crisis services are accessed by dialing 1-800-273-8255 (TALK). The process of implementing the phone designation began with the December 12 announcement. No information is available about the “go live” date.

The “988” designation was part of the National Suicide Hotline Improvement Act of 2018, which initiated a study to examined the effectiveness of the current number. The resulting report, released to congress in August 2019, found that a three-digit designation for the suicide hotline would likely ease access for individuals in crisis. It was also found that technical aspects of the designation change for “988” could be easily resolved in 18 months, with help from telecommunication companies.

Plans for the “988” implementation were released on December 16, 2019 in “Notice of Proposed Rulemaking: In the Matter of Implementation of the National Suicide Hotline Improvement Act of 2018.” It is estimated that the total cost of “988” implementation will be $745 million. Approximately $570 million of the funding will be spent in the first year for a public awareness campaign, and to put adequate staffing at crisis centers. It is believed that the return on investment of any costs incurred will be lives saved. The program has garnered some criticism for not including a text message option, which similar programs currently allow. This action by the FCC is supported by bipartisan bills in both the Senate and the House of Representatives. These bills would allow States to collect and allocate fees towards maintaining these crisis centers.

Before this implementation plan, the FCC’s Wireline Competition Bureau Office of Economics and Analysis reviewed reports from the Substance Abuse and Mental Health Services Administration (SAMHSA), the U.S. Veteran’s Administration (VA), and the North American Numbering Council (NANC). A summary of findings include:

  • Currently, SAMHSA funds the National Suicide Prevention Lifeline (Lifeline), which is a national network of 163 crisis centers linked by a toll-free number. This number is meant to be used by people experiencing suicidal crisis or emotional distress. The Lifeline is available 24 hours, any day of the year. Calls to this number are routed to the closest certified local crisis center to the person in need. In 2018, the Lifeline answered 2,205,487 calls.
  • The Veterans Crisis Line was established through a 2009 partnership between the SAMHSA and the VA. Veterans who call the Lifeline can select option “1” to receive assistance from the Veterans Crisis Line. The Veterans Crisis Line can also be accessed via text at 838255, and via online chat by visiting the Veterans Crisis Line website. Since these services were launched, the Veterans Crisis Line has answered more than 3.8 million calls; 439,000 chats; and almost 108,000 text messages.
  • The NANC considered expanding an existing N11 code, repurposing an existing N11 code, and using a non-N11 code to serve as a national suicide prevention and mental health crisis hotline system. NANC is a Federal Advisory Committee that was created to advise the Commission on numbering issues and to make recommendations that foster efficient and impartial number administration. After analyzing the existing N11 usage, the NANC determined that expanding the 211 code for community information and referral services to include suicide prevention and mental health crisis was the most expedient way to provide these services. However, the NANC also recommended that if a single-purpose code is preferred, a new three-digit dialing code could be deployed for the use of a national suicide prevention and mental health crisis hotline. As a result, the NANC made the recommendation of using 988 for this code.

Some challenges remain through the assignment of 988 as the three-digit dialing code for a nationwide suicide prevention and mental health crisis hotline. These challenges include:

  • Some wireline switches may be unable to support any new three-digit dialing code that is not an N11 code. However, a relatively small percentage of legacy switches cannot accommodate the 988 code, and legacy switches are continually being upgraded.
  • Switches that support 988 would require configuration and software upgrades to implement this new dialing code. However, these issues could be resolved quickly.

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

PsychU last reported on this topic in “FCC Recommends Designating ‘988’ For National Suicide Prevention Hotline,” which published on October 28, 2019. The article is available at https://www.psychu.org/fcc-recommends-designating-988-for-national-suicide-prevention-hotline/.

The Veterans Crisis Line Website is found at https://www.veteranscrisisline.net/.

For more information, contact: Will Wiquist, Deputy Press Secretary, Information Office, Federal Communications Commission, 445 12th Street Southwest, Washington, District of Columbia 20554; 202-418-0509; Email: will.wiquist@fcc.gov; Website: https://www.fcc.gov/

Dr. Croft provides insight into civilian medical and mental health service providers treating veterans with Post-Traumatic Stress Disorder (PTSD). Dr. Croft covers common misconceptions, presenting symptoms, and current evidence-based treatments of PTSD.

Harry Croft, MD, is a psychiatrist and medical educator in the San Antonio area. Dr. Croft is a Distinguished Life Fellow of the American Psychiatric Association with over 40 years of clinical experience and triple, board-certified in adult psychiatry, addiction medicine, and sexual therapy.

Speakers are paid consultants of Otsuka Pharmaceutical Development & Commercialization, Inc

This fact sheet, created by the National Alliance on Mental Health (NAMI), provides an overview of the different types of mental health professionals.

Resource:Types of Mental Health Professionals (PDF).

Download Resource

Provided by permission of the National Alliance on Mental Illness (NAMI). To learn more about NAMI, please visit their website at https://www.nami.org/.

 

Depression and Bipolar Support Alliance (DBSA) recognizes mood disorders affect millions of people, yet the stigma surrounding it causes barriers to communication and knowledge about mental health conditions.

“One out of ten people live with a mood disorder, which makes it likely that you or someone you know has to manage the day-to-day – sometimes minute-to-minute – challenges that living with a mood disorder poses. Learning how to navigate in an ever-changing world that is still relatively new to mental health treatment can be overwhelming and sometimes isolating, not only for those who live with a mood disorder, but also their friends and loved ones. “Depression and Bipolar Support Alliance (DBSA) I’m here” is a way, for both people living with a mood disorder and those who support, to open up a channel for communication and to say, “I’m here…” For more information and to access the “I’m Here” safety pins, please visit their website at https://www.dbsalliance.org/programs/im-here/.

Provided with permission from Depression and Bipolar Support Alliance (DBSA), a PsychU Supporting Organization. To learn more about DBSA, please visit their website at https://www.dbsalliance.org/.

Among those newly diagnosed with advanced-stage, non-small cell lung cancer (NSCLC), about one-third have moderate to severe symptoms of depression. NSCLC is the most common form of lung cancer and accounts for approximately 85% of all cases of lung cancer. About 8.1% of these individuals had severe depression, and 28.0% had moderate depressive symptoms.

Additional findings include:

  1. About 93.3% of those with NSCLC and severe depression said the depressive symptoms made it difficult to do their work, take care of things at home, and get along with other people.
  2. Those with NSCLC and moderate or severe depressive symptoms were more likely to have lower quality of life and worse disease outcomes, compared to those also diagnosed with lung cancer but with mild, or no depressive symptoms.
  3. About 11% of those with NSCLC and moderate depressive symptoms had moderate to severe generalized anxiety disorder (GAD), compared to 73% of those with severe depressive symptoms.
  4. About 44.1% of those with NSCLC and severe depressive symptoms reported extreme levels of cancer-related stress.
  5. Those with high levels of depressive symptoms were much more likely to report severe physical symptoms compared to other individuals with cancer; 73% said they experienced “quite a bit” or “very much” pain.

The researchers concluded that moderate to severe depression co-occurs with clinical levels of anxiety symptoms, traumatic stress, impaired functional status, and pain and other physical symptoms in those with NSCLC. They recommended that health care professionals quickly identify those with NSCLC and moderate-to-severe depression. These individuals should be referred for evaluation, and psychological or behavioral treatment, to maximize outcomes.

These findings were reported in “Newly Diagnosed Patients With Advanced Non-Small Cell Lung Cancer: A Clinical Description Of Those With Moderate To Severe Depressive Symptoms” by B.L. Andersen, T.R. Valentine, S.B. Lo, D.P. Carbone, C.J. Presley, and P.G. Shields. The researchers analyzed data from 186 individuals at who had been recently diagnosed with advanced-stage, non-small cell lung cancer at Thoracic Oncology clinics of an NCI-designated Comprehensive Cancer Center. These individuals completed a telephone survey measuring psychological and physical symptoms, stress, and day-to-day functioning. The goal was to determine the occurrence and severity of depression in those with newly diagnosed NSCLC.

The full text of “Newly Diagnosed Patients With Advanced Non-Small Cell Lung Cancer: A Clinical Description Of Those With Moderate To Severe Depressive Symptoms” was published in November 2019 by Lung Cancer. An abstract is available online at https://www.lungcancerjournal.info/article/S0169-5002(19)30729-9/fulltext (accessed December 23, 2019).

For more information, contact: Jeff Grabmeier, Senior Director, Research Communications, The Ohio State University, 190 North Oval Mall, 370 Bricker Hall, Columbus, Ohio 43210; 614-292-8457; Email: grabmeier.1@osu.edu; Website: https://ucom.osu.edu/directory/grabmeier.1.html

Brief cognitive behavioral therapy (BCBT) is a cost-effective intervention for active-duty soldiers who are at risk of suicide. Using the federal discount rate, it is estimated that the U.S. Department of Defense (DoD) might save between $15,000 to $16,630 per individual with BCBT, compared to treatment as usual. In the base-case analysis, BCBT was expected to avert approximately 23 to 25 more suicide attempts, and one to three more suicide deaths, per 100 individuals treated, compared to treatment as usual. Treatment as usual includes medication; individual or group psychotherapy; and intensive outpatient, partial hospitalization, and/or inpatient treatment.

Cognitive behavioral therapy (CBT) is a psycho-social intervention that focuses on challenging and changing unhelpful cognitive distortions and behaviors, improving emotional regulation, and developing personal coping strategies that target solving current problems. BCBT is a suicide-focused CBT, in which the CBT health professional and consumer analyze precipitants of the crisis, create and practice a crisis response plan, practice emotion regulation skills, and reduce cognitions associated with suicidal behavior (e.g., hopelessness).

There was some uncertainty in the results, but the researchers estimated that in the worst case scenario, BCBT might cost an additional $1,910 to $2,250 per individual, compared with treatment as usual, and would likely still reduce adverse events. Consequently, the researchers concluded that BCBT is a cost-effective intervention for active-duty soldiers with recent suicidal crises. Although using BCBT throughout the DoD would require additional costs in training and quality-control monitoring, these costs may be outweighed by the overall savings BCBT provides.

These findings were reported in ‘Economic Evaluation of Brief Cognitive Behavioral Therapy vs Treatment as Usual for Suicidal US Army Soldiers” by Samantha L. Bernecker, Ph.D.; Kelly L. Zuromski, Ph.D.; Justin C. Curry, Ph.D.; et al. The researchers created a decision analytic model that compared the effects and costs of BCBT to those of treatment as usual from a DoD perspective. Model input data were drawn from epidemiologic data sets and from a clinical trial among soldiers who were suicidal that was conducted from January 31, 2011 to April 3, 2014. Data were analyzed from July 3, 2018 to March 25, 2019. The goal was to determine specific costs and benefits of BCBT compared with existing treatments.

The full text of “Economic Evaluation of Brief Cognitive Behavioral Therapy vs Treatment as Usual for Suicidal US Army Soldiers” was published November 27, 2019 by JAMA Psychiatry. An abstract is available online at https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2756203.

PsychU last reported on this topic in “Short-Term CBT Reduces Suicide Attempts By 60% Among At-Risk Soldiers,” which published on March 9, 2015. The article is available at https://www.psychu.org/short-term-cbt-reduces-suicide-attempts-60-among-risk-soldiers/ .

For more information, contact: Samantha L. Bernecker, Ph.D., Postdoctoral Fellow, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, Massachusetts 02115; Email: samantha.bernecker@gmail.com; Website: https://hms.harvard.edu/

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

This podcast highlights Kathy Day’s experience as a caregiver to her relative with mental illness. Ms. Day answers questions concerning caregiver stigma and public awareness for people who may not understand mental illness.

Kathy Day, MPA, currently serves as a caregiver and advocate for a close family member who was diagnosed with schizophrenia in 2010. She also helps to manage online support groups for families coping with mental illness like schizophrenia, bipolar disorder, and major depression. Ms. Day received her MPA from Brandman University.

Elizabeth DiNapoli, PhD, is a Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc. Dr. DiNapoli earned her PhD from the University of Alabama.

Kathy Day is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Elizabeth DiNapoli is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

Dr. Mehdi Qalbani discusses his experience providing telepsychiatry in the Information Age. Topics include regulatory concerns, practice guidelines, and web-side manner when working remotely.

Mehdi Qalbani, MD, MSPH, is the Co-Founder of Integrated Behavioral Health, LLC. Dr. Qalbani received his medical degree from the Tulane University School of Medicine and completed his residency in psychiatry at the University of Illinois at Chicago.

Chip Meyer, PhD, is a Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc. Dr. Meyer received his PhD in Experimental Psychology from the University of Kentucky.

Medhi Qalbani is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Chip Meyer is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

Daily cannabis use lowers the odds by 50% that a consumer will use illicit opioids among those with chronic pain, compared to those who do not use cannabis. However, those who reported occasional use of cannabis were no more or less likely than non-users to use illicit opioids on a daily basis.

During a first interview in which pain was reported, 50.6% (583 of 1,152) of participants were using cannabis either occasionally (n = 322) or daily (n = 261). Daily cannabis users were significantly more likely than occasional users to report a number of therapeutic uses of cannabis, including addressing pain, stress, nausea, mental health, symptoms of HIV or side effects of HIV antiretroviral therapy, or improving sleep. About 23.4% of participants were using illicit opioids daily. Additional findings include:

  1. At baseline, 60.2% of participants self-reported a lifetime chronic pain diagnosis. Chronic pain diagnoses included bone, mechanical, or compressive pain (50.1%); inflammatory pain (48.8%); neuropathic pain (18.6%); muscle pain (7.8%); headaches/migraines (5.9%); and other pain (7.6%).
  2. Approximately 35.6% of individuals reported daily cannabis use throughout at least one six-month follow-up period of the study.
  3. Approximately 48.4% reported occasional cannabis use throughout at least one six-month follow-up period of the study.
  4. Approximately 39.5% reported daily illicit opioid use throughout at least one six-month follow-up period of the study.

The researchers concluded that there is an independent negative association between frequent cannabis use and frequent illicit opioid use among people who use drugs (PWUD) with chronic pain. These findings suggest that cannabis may serve as an adjunct to, or substitute for, illicit opioid use among PWUD with chronic pain. Researchers determined there is a need to design formal clinical evaluations of cannabis-based strategies for pain management, opioid use disorder treatment supports, and wider harm reduction initiatives.

These findings were reported in “Frequency of Cannabis and Illicit Opioid Use Among People Who Use Drugs and Report Chronic Pain: A Longitudinal Analysis” by Stephanie Lake, Zach Walsh, Thomas Kerr, Ziva D. Cooper, Jane Buxton, Evan Wood, Mark A. Ware, and M. J. Milloy. The researchers analyzed data from prospective cohorts of PWUD in Vancouver, Canada. The researchers assessed individuals who reported major or persistent pain from June 1, 2014 to December 1, 2017. Of those individuals, 1,476 volunteered to participate in the study. Of this group, 1,152 (78.0%) reported major or persistent pain during at least one six-month follow-up period, and were included in the analysis. The goal was to determine the relationship between daily (once or more per day) cannabis use and daily illicit opioid use.

The full text of “Frequency Of Cannabis And Illicit Opioid Use Among People Who Use Drugs And Report Chronic Pain: A Longitudinal Analysis” was published November 19, 2019 by PLOS Medicine. A copy is available online at https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002967 (accessed December 16, 2019).

PsychU last reported on this topic in “Opioid Prescriptions Lower In States With Legal Cannabis,” which published on May 4, 2018. The article is available at https://www.psychu.org/opioid-prescriptions-lower-states-legal-cannabis/ .

For more information, contact: M.J. Milloy, Research Scientist, British Columbia Centre on Substance Abuse, 400- 1045 Howe Street, Vancouver, British Columbia Canada; V6Z 2A9; 778-945-7616; Fax: 604-428-5183; Email: bccsu-mjm@bccsu.ubc.ca; Website: https://www.bccsu.ca/

A recent report from the U.S. Government Accountability Office (GAO) found that social determinants are a major impediment to managing care for high-cost Medicaid beneficiaries. The biggest impediments include a lack of transportation to medical appointments, lack of stable housing, and inconsistent access to food and other basic resources. Additionally, a study by Kaiser Permanente found that 68% of their members—across commercial, Medicare, and Medicaid—have an unmet social need (see The 68%). The challenge then for provider organizations is to figure out how to best address these needs and turn that skill into an opportunity for partnerships with a payer.

At The 2019 OPEN MINDS Technology & Informatics Institute, attendees had the chance to hear from two organizations that have implemented innovative programs to improve access to social support services during the session, Expanding Access Through Technology: Innovative Approaches For Improving Access To Care, featuring Jeremy Blair, Chief Executive Officer, WellStone and Ellie Zuehlke, MPH, Director, Community Benefit and Engagement, Allina Health.

Both Allina Health and Wellstone first identified a need to increase access to social services. The organizations then designed a program to address access to those services. Only then did the organizations choose a technology to support the solution. Importantly, that technology allows tracking of program outcomes through data. By carefully tracking program outcomes, the organizations are able to measure performance and program success. The “success” data also allows them to pitch the programs to community stakeholders and get much-needed community buy-in (monetary or otherwise).

The key to success? Engage program staff in devising solutions to community problems and ensure that your internal processes are as efficient as possible. This is a formula to optimize team member effectiveness and to expand consumer access to care.

Increasing Access To Social Services

Allina Health is a mid-size health system located in Minnesota and Wisconsin with 12 hospitals and more than 90 clinics. The health system was awarded an Accountable Health Communities cooperative agreement with the Centers for Medicare & Medicaid Services (CMS). AHC identifies individuals with social service needs through the AHC Health-Related Social Needs Screening Tool. Individuals with social service needs are referred to community organizations and high-risk individuals receive more traditional case management and help accessing resources. Allina Health contracted with NowPow, an outside technology organization, to provide software that supports community referrals. Ms. Zuehlke explained the reason for the contract – Allina Health found that their case managers each had personal lists that they used to refer individuals to social services. By using an external vendor, they are able to outsource list maintenance and automate development of community resource information lists tailored to individual patient needs.

Over the course of a year in the Allina system, there were 211,594 unique individuals who were eligible for screening, 79% of those individuals were offered a screening and 58% actually completed the screening. A total of 21,800 individuals had at least one social service need. 60% of individuals with an identified need were food insecure, 47% had housing instability, and 33% had unreliable transportation. During the pilot phase of the program, Allina Health found that approximately 50% of individuals followed up with the organizations on their referral sheet. The next step for Allina Health is to increase the number of value-based payment arrangements they have to assist in covering the cost of the social supports program.

Improving Access For Individuals In Jails

WellStone is a community mental health center (CMHC) in Madison County, Alabama. One of the county’s major challenges is the number of individuals in the county jail with mental health conditions. Data shows that individuals with mental health challenges spend 15 months longer in jail than individuals without mental health conditions (see The New Asylums)1. To address the problem, the Madison County Sheriff joined the national Stepping Up Initiative, which is focused on reducing the number of individuals with mental illness booked into jails, shortening length of stays, increasing the number of connected to treatment, and reducing recidivism (see Stepping Up: A National Initiative to Reduce the Number of People with Mental Illnesses in Jails)2.

The sheriff’s involvement with Stepping Up opened the door to conversations with Wellstone about connecting inmates to treatment to expedite release from jail. One of the major problems identified was that individuals with mental illness often lacked housing and other supports outside of the jail, which increased their length of stay in jail. Wellstone developed a program focused on helping inmates re-enter the community. The process involves identification and screening of eligible inmates; treatment planning; approval of the treatment plan by a judge and the District Attorney; and release of the inmate to participate in treatment.

The Wellstone re-entry program runs for 12 to 24 months. During the first six months, transitional or temporary housing is secured, treatment services are provided, financial assistance is secured, and inmates receive vocational training. For the next six to 24 months, the Wellstone team finds permanent housing for the inmates and treatment continues. Upon completion of the program, the team recommends an aftercare program to the courts.

Implemented in 2018, the program has served 84 individuals and saved the county $1.5 million – seven times the initial investment. The recidivism rate of program participants is less than 4%. Program savings demonstrate a need for these types of programs and has been instrumental in expanding the types of programs offered for justice-involved individuals with behavioral health needs. Wellstone is currently developing a telehealth program to help police officers divert a mental health crisis when they are in the field and their success data is also allowing them to make the case for building a 24/7 crisis center.

These two examples illustrate that well-planned social service supports improve lives and reduce health and human service costs. For more on developing services that meet the social support needs of complex consumers check out these resources:

  1. Addressing Social Determinants: Impacting Health & Wellness Beyond Traditional Medicine
  2. CVS Health Launches New Social Care Network With Unite Us
  3. Where Wellness & Prevention Fit In A Value-Based World

People with substance use disorder were 2.41 times more likely to die after undergoing valve surgery for endocarditis than people without substance use disorder. In a group of 228 people who had this operation, 86 died. The mortality rate at six months to five years after the surgery among those with substance use disorder was 48%, compared to 32% for those without substance use disorder.

Across the group of 228, 35% (80 individuals) had substance use disorder. During the study period, the overall mortality rate was 38%. Additional findings were as follows:

  • The average age of the 80 individuals with substance use disorder was 38 years. The average age was 60 years for the rest of those who had valve surgery.
  • Mid-term mortality rates from six months to five years post-surgery were 53% for those with substance use disorder and 31% for those without. However, between group differences in short-term or extended-term mortality could have been due to chance.

The researchers concluded that post-valve surgery morbidity and mortality was higher for people who had substance use disorder. They also concluded that vulnerability was highest during the mid-term post-operative period of six months to five years. The most common causes of death among those with substance use disorder were recurrent infective endocarditis, drug overdose, and liver failure.

These findings were reported in “Impact of Substance Use Disorder on Midterm Mortality after Valve Surgery for Endocarditis” by Alysse G. Wurcel, M.D., MS; Griffin Boll, M.D.; Deirdre Burke, MPH; Rani Khetarpal, MPH; Patrick J. Warner, M.D.; Alice M. Tang, Ph.D.; and Kenneth G. Warner, M.D. The researchers analyzed data for 228 valve surgeries for infective endocarditis at Tufts Medical Center from 2002 to 2016. They collected the consumer’s demographic and disease-related data, including timing of mortality subclassified as short-term (less than six months including operative), mid-term (six months to five years), and extended-term (more than five years). The goal was to investigate the impact of substance use disorder on post-valve replacement morbidity. Those with documented illicit drug use before the valve surgery were classified as having substance use disorder-related infective endocarditis. Deaths were confirmed through review of medical record and matching with the Massachusetts Vital Statistics Database.

The full text of “Impact of Substance Use Disorder on Midterm Mortality after Valve Surgery for Endocarditis” was published in October 2019 by The Annals of Thoracic Surgery. An abstract is available online at https://www.annalsthoracicsurgery.org/article/S0003-4975(19)31426-2/abstract (accessed November 13, 2019).

For more information, contact: Alysse G. Wurcel, M.D., Assistant Professor, Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, 800 Washington Street, Boston, Massachusetts 02111; 617-636-4605; Email: awurcel@tuftsmedicalcenter.org; Website: https://www.tuftsmedicalcenter.org/

Unsheltered homeless individuals are far more likely to report significant health concerns than sheltered homeless individuals. Approximately 50% of unsheltered people reported having a combination of a physical health condition, a mental health issue, and a substance abuse condition (what researchers call a state of tri-morbidity). By comparison, approximately 2% of sheltered homeless individuals would be classified as trimorbid, according to researchers with the California Policy Lab.

Additionally, unsheltered homeless people were:

  • More than four times as likely (46%) as sheltered people (11%) to report that their physical health conditions have contributed to a loss of housing.
  • Almost three times as likely (50%) as sheltered people (17%) to report that their mental health issues have contributed to a loss of housing.
  • More than eight times as likely (51%) as sheltered people (6%) to report that their use of drugs or alcohol has contributed to a loss of housing.
  • More likely to report that abuse and trauma had led to a loss of housing, with 80% of unsheltered women reporting that experiences with abuse and trauma caused their current spell of homelessness.

The researchers concluded that health, behavioral health, and trauma are significant contributing factors to a loss of housing. They recommend additional research to explore the impact of lack of access to adequate health and behavioral health care as a cause of unsheltered homelessness. They also recommend researching effective strategies to move homeless individuals into permanent housing.

These statistics were reported in “Health Conditions Among Unsheltered Adults in the U.S.” by Janey Rountree, Nathan Hess, and Austin Lyke from the California Policy Lab. The researchers analyzed responses to the Vulnerability Index Service Prioritization Decision Assistance Tool (VI-SPDAT) survey given to homeless individuals across the U.S. The VI-SPDAT allows communities to meet federal requirements for intake assessments, and is provided for free and widely used throughout the country. Data were analyzed for a total of 64,000 single adults, ages 25 and older, who were experiencing homelessness (both sheltered and unsheltered) in 15 states across the U.S. from 2015 through 2017. The goal was to understand more about people experiencing unsheltered homelessness in the U.S., and compare their experiences with homeless individuals in shelters.

The full text of “Health Conditions Among Unsheltered Adults in the U.S.” was published October 2, 2019 by California Policy Lab. A copy is available online at https://www.capolicylab.org/health-conditions-among-unsheltered-adults-in-the-u-s/ (accessed November 13, 2019).

PsychU last reported on this topic in “Florida Medicaid To Launch Behavioral Health Housing Pilot,” which published on May 20, 2019. The article is available at https://www.psychu.org/florida-medicaid-to-launch-behavioral-health-housing-pilot/.

For more information, contact: Sean Coffey, Director of Communications and Outreach, California Policy Lab, 2521 Channing Way, Berkeley, California 94720; 510-642-4813; Email: sean@capolicylab.org; Website: https://www.capolicylab.org/

In the 10 to 12 years following a diagnosis of diabetes, individuals who also have behavioral health disorders experience a risk of more severe medical complications than those without preexisting behavioral health disorders. During the first seven years following diagnosis, individuals with co-morbid diabetes and behavioral health disorders had significantly less severe complications associated with diabetes, as compared with those without preexisting behavioral health disorders. However, during those first seven years, the group with co-morbid diabetes and behavioral health disorders developed complications more quickly than those with only diabetes. A comparison of the complication rates projected that by 10 to 12 years post-diagnosis, the group with co-morbid diabetes and behavioral health disorders would have greater severity of medical complications than the group with only diabetes.

Researchers believe that established care from a primary care physician may be the reason that those with a preexisting behavioral health disorder have fewer medical complications shortly after diagnosis with diabetes. More than 90% of those with diabetes and behavioral health disorders had primary care visits before diabetes was diagnosed. By comparison, approximately 58% of those without behavioral health disorders had primary care visits before diabetes was diagnosed.

Overall, individuals with newly diagnosed diabetes had a mean Diabetes Complications Severity Index (DCSI) increase of 0.58 over seven years, rising from 0.84 to 1.42. Individuals with newly diagnosed diabetes who also had behavioral health disorder diagnoses had consistently lower DCSI scores over the seven-year period. Baseline DCSI scores were lower by 0.09 for those with addiction disorders, and lower by 0.13 for those with both addiction and mental health disorders.

DCSI scores progressed more rapidly for people with diabetes and behavioral health disorders during the seven-year study period. By 10 to 12 years after diagnosis, the estimated scores would have overtaken and likely be higher than the scores of those without the disorders.

The researchers concluded that it is essential to identify how to effectively promote long-term medical benefits for at-risk populations with diabetes, such as people with behavioral health disorders. Health care utilization patterns before the onset of diabetes is associated with health benefits post-diagnosis. This type of data can also inform treatment planning and population health management.

These findings were reported in “Patient and Health Care Factors Associated With Long-term Diabetes Complications Among Adults With and Without Mental Health and Substance Use Disorders” by Eric M. Schmidt, Ph.D.; James Barnes, M.D., MS; Cheng Chen, MS; et al. The researchers analyzed medical records from the U.S. Department of Veterans Affairs care systems for 122,992 adults ages 18 to 85 who received a new diabetes diagnosis in 2008. The goal was to analyze the association of preexisting mental health or addiction disorders and primary care utilization before and after a new diabetes diagnosis. Specifically, the analysis examined associations with the long-term severity of diabetes complications.

The full text of “Patient and Health Care Factors Associated With Long-term Diabetes Complications Among Adults With and Without Mental Health and Substance Use Disorders” was published September 25, 2019 by JAMA Network Open. An abstract is available online at http://jamanetwork.com/journals/jamanetworkopen/fullarticle/10.1001/jamanetworkopen.2019.12060 (accessed November 4, 2019).

For more information, contact: Eric M. Schmidt, Ph.D., Health Science Specialist, Program Evaluation Resource Center, Office of Mental Health and Suicide Prevention, Veterans Affairs, Palo Alto Health Care System, 795 Willow Road, MPD 152, Menlo Park, California 94025; Email: eric.schmidt4@va.gov; Website: https://www.mentalhealth.va.gov/suicide_prevention/

At least 8.4 million Americans provide care to an adult with an emotional or mental health issue.1 Caregivers have identified numerous challenges to providing care to their loved one, such as delayed time to an accurate diagnosis, difficulty with treatment compliance, and barriers to involvement in their loved one’s treatment. From an interpersonal perspective, caregivers often endorse challenges in effectively communicating with their relative suffering from a mental illness.

In this podcast, one caregiver, Kathy Day, will share her personal experiences with effectively communicating with a loved one, who has serious mental illness. Specifically, you’ll hear her talk about making conversations with a relative more productive and less frustrating.

1The National Alliance for Caregiving (NAC). (2019). On Pins and Needles: Caregivers of Adults with Mental Illness. Retrieved from https://www.caregiving.org/wp-content/uploads/2016/02/NAC_Mental_Illness_Study_2016_FINAL_WEB.pdf.

Kathy Day is a caregiver and advocate for her close family member who was diagnosed with schizophrenia in 2010. While providing for her family member, she became active in advocacy for people with serious brain disorders. She also helps run online support groups for families coping with brain disorders like schizophrenia, bipolar disorder, and major depression. Kathy is a former member of the Sacramento County Mental Health Board, a current member of the National Shattering Silence Coalition, and has been active in legislative reform at the local and federal levels. In 2017, Kathy earned her Master’s in Public Administration from Brandman University. She also holds a BA in Legal Studies and an AA in Interdisciplinary Studies of the Behavioral and Social Sciences.

PsychU Section Advisor Dr. Terence Ketter takes a moment to share his insights into treatment and science advances in the field of bipolar disorder research. He touches on risk evaluation and mitigation strategies (REMS); disruptive mood dysregulation disorder (DMDD); and the mixed features specifier within the Diagnostic & Statistical Manual of Mental Disorders 5th Edition (DSM-5).

Terence Ketter, M.D., is a PsychU Bipolar Disorder Section Advisor. He also serves as an Emeritus Professor of Psychiatry & Behavioral Sciences and Founder & Founding Chief of the Bipolar Disorder Clinic at Stanford University.

In January 2019, Dr. Joseph Goldberg and Dr. John Meyers presented a webinar entitled, “The Art Of Clinical Assessment In Patients With Bipolar Disorder”. As a follow-up to that webinar, our speakers conducted a mock interview, a fictitious example of what the clinical presentation of bipolar disorder may look like. The interview provides a unique perspective into initial assessment in the clinical setting.

Joseph Goldberg, MD, is an Emeritus Bipolar Disorder Section Advisor for PsychU. He also serves as a Clinical Professor in Psychiatry at the Icahn School of Medicine at Mount Sinai. Dr. Goldberg received his MD from Northwestern University Medical School. He completed his internship, psychiatric residency, and research fellowship in psychopharmacology at the Payne Whitney Clinic at New York Presbyterian Hospital.

John Meyers, MD, is certified in adult and forensic psychiatry and addiction medicine, and operates a practice in Norwalk, Connecticut. Dr. Meyers received his MD from Michigan State University College of Human Medicine. He completed a fellowship in forensic psychiatry at New York Presbyterian and a psychiatric residence at the New York Hospital / Cornell University.

Individuals living with mental health diagnoses are often marginalized by society, and stigmatization and discrimination may form a barrier to their recovery and social integration. There are a lot of strategies to help combat the stigma associated with mental illness, including sharing information about mental illness; talking openly about mental health; using person-first, non-discriminatory language; and showing compassion. One of the most important strategies is to empower the individual with the behavioral health diagnosis to share their personal story and journey.

In this interview, we’ll hear from one such individual, David, as he shares his personal journey from being diagnosed with bipolar disorder to recovery with Dr. Suresh Sureddi and Ms. Cathy Judd. He shares what mental illness feels like for him, the importance of familial and community supports to his recovery, and his experience of stigma related to his mental health condition.

At the end of the interview, our featured health care professionals provide a summary of the important messages for our listeners to take away from David’s personal experience.

David Swain, MBA is a marketing professional with extensive experience developing national campaigns and successfully forging and optimizing strategic alliances with established Fortune 500 companies and emerging corporate partners. Mr. Swain received his MBA from Southern Methodist University.

Suresh Sureddi, MD, currently serves as an Adjunct Clinical Assistant Professor in the Department of Physician Assistant (PA) Studies at the University of North Texas Health Science Center, as well as Clinical Faculty at a number of other universities in Texas. Dr. Sureddi received his MD from JJM Medical College.

Catherine Judd, MS, PA-C, CAQ-Psy, DFAAPA currently serves as a Senior PA for the Jail Mental Health Program at Parkland Health & Hospital System. She is also a Clinical Instructor and Psychiatry Preceptor in the Department of PA Studies at the University of Texas Southwestern Medical Center. Ms. Judd received her MS in Human Development from Peabody College Vanderbilt University and her PA from UT Southwestern Dallas.

To hear more from our speakers, check out their hour-long webinar, “Humanizing Bipolar Disorder: David’s Story Of Hope, Recovery, & Wellness” on PsychU at https://www.psychu.org/humanizing-bipolar-disorder-davids-story-hope-recovery-wellness/.

Throughout May each year, we celebrate Mental Health Awareness Month (MHAM). For 2019, Mental Health America (MHA) is celebrating 70 years of celebrating MHAM by sharing their MHAM Toolkit. They intend it to reach millions of individuals with message of health, wellness, prevention, and recovery through their theme #4Mind4Body.

Starting in March 2019, you can download the toolkit here: http://www.mentalhealthamerica.net/2019-mental-health-month-toolkit

Provided with permission from Mental Health America, a PsychU Supporter. To learn more about MHA, please visit their website at http://www.mentalhealthamerica.net.

During this question and answer session, Joseph Goldberg, MD, Clinical Professor at the Icahn School of Medicine at Mount Sinai, shared additional case studies and respond to unanswered questions from their March 28, 2018 Webinar entitled “Antidepressant Utilization In Bipolar Disorder: What Is The Evidence.”

Watch the full Virtual Forum here: https://www.psychu.org/antidepressant-utilization-bipolar-disorder-evidence/

Speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

Background & Methodology

Individuals with serious mental illnesses (SMI) have reduced life expectancies compared to those without mental illness, due in part to higher rates of behavioral risk factors and preventable conditions that may be exacerbated by medication side effects. It is possible that disparities in access to screenings and preventive health services may contribute to negative outcomes. Although there is a wealth of research on this topic, the wide variation in settings, populations, and measurement strategies has made it difficult to compare screening rates among different groups.

In a recent article entitled “Preventive Service Use Among People With and Without Serious Mental Illnesses,” Bobbi Jo H. Yarborough and colleagues sought to determine if preventive care disparities exist for people with SMI, and if so, what factors may account for those disparities. They examined electronic health record (EHR) data from 2012-2013 from patients in two different care settings: Kaiser Permanente Northwest (KPNW), a private not-for-profit integrated health plan, and federally qualified health centers and safety-net community health clinics (CHCs).

Participants were 803,276 adult patients within the two settings who were included if they had one or more health care visits during the study time. They were categorized in terms of mental health diagnosis (i.e., schizophrenia spectrum disorders, bipolar disorders and affective psychoses, anxiety disorders, unipolar depression, or the reference group comprised of patients having none of the identified mental health diagnoses). The outcome of interest was the “care gap rate,” which was the proportion of preventive services (e.g., annual influenza vaccine, diabetes screening, tobacco status) for which a patient was eligible but had not received by the end of the study period.

Background & Methodology

In the United States, emergency department (ED) visits due to mental health and substance abuse (MHSA) conditions have increased from an estimated 4-6% in 1992 to 12% of total ED visits in 2007. Many patients treated in the ED for MHSA-related issues make a quick return to acute care, a pattern that may represent avoidable health care utilization in some cases. To date, little is known regarding who presents in the ED for psychiatric care and which individuals are at increased risk for early return, knowledge that may assist both clinicians and policymakers alike.

In a recent article entitled “Predictors of Return Visits Among Insured Emergency Department Mental Health and Substance Abuse Patients, 2005-2013,” Sangil Lee and colleagues sought to provide answers using data from a national insurance-claims database (Optum Labs Data Warehouse) containing information for over 100 million enrollees in the United States.

The authors identified all ED visits for patients who presented with MHSA as the primary reason for seeking care between January 1, 2005 and November 30, 2013. ED visits that resulted in a hospital admission were excluded, as were visits for patients who had been seen for another MHSA-related ED visit within the prior 12 months (in order to accurately define the index visit). Covariates in analyses included age group, sex, number of chronic conditions, race/ethnicity, non-MHSA- related ED utilization within 12 months prior to the index visit, and MHSA as a primary diagnosis. The primary outcome was a return ED visit or inpatient admission within 3, 7, and 30 days of discharge.

This provider resource presents the importance of bipolar treatment, suggested treatment goals and considerations, an overview of psychosocial interventions and medication therapy, and considerations for monitoring treatment response.

Frameworks resources are intended for educational purposes only and are intended for health care professionals and/or payer representatives who may choose to share some of these resources with patients or their caregivers. Health care professionals should use independent medical judgment when considering Frameworks educational resources. Patients and caregivers should discuss Frameworks materials with a health care professional. They are not intended as, nor are they a replacement for, medical advice and treatment from a health care professional. Frameworks resources are not intended as reimbursement or legal advice. Users should seek independent, qualified professional advice to ensure their organization is in compliance with the complex legal and regulatory requirements governing health care services, and that treatment decisions are made consistent with the applicable standards of care. Frameworks is sponsored by Otsuka Pharmaceutical Development & Commercialization, Inc.

This provider resource discusses the role of stigma in care, potential strategies to combat stigma, and how to collaborate with patients to help address stigma.

Frameworks resources are intended for educational purposes only and are intended for health care professionals and/or payer representatives who may choose to share some of these resources with patients or their caregivers. Health care professionals should use independent medical judgment when considering Frameworks educational resources. Patients and caregivers should discuss Frameworks materials with a health care professional. They are not intended as, nor are they a replacement for, medical advice and treatment from a health care professional. Frameworks resources are not intended as reimbursement or legal advice. Users should seek independent, qualified professional advice to ensure their organization is in compliance with the complex legal and regulatory requirements governing health care services, and that treatment decisions are made consistent with the applicable standards of care. Frameworks is sponsored by Otsuka Pharmaceutical Development & Commercialization, Inc.

This provider resource discusses the spectrum of bipolar disorder, misdiagnosis and comorbidities, mania and hypomania, depression, evidence-based screening tools, and potential strategies for providers to help support diagnosis.

Frameworks resources are intended for educational purposes only and are intended for health care professionals and/or payer representatives who may choose to share some of these resources with patients or their caregivers. Health care professionals should use independent medical judgment when considering Frameworks educational resources. Patients and caregivers should discuss Frameworks materials with a health care professional. They are not intended as, nor are they a replacement for, medical advice and treatment from a health care professional. Frameworks resources are not intended as reimbursement or legal advice. Users should seek independent, qualified professional advice to ensure their organization is in compliance with the complex legal and regulatory requirements governing health care services, and that treatment decisions are made consistent with the applicable standards of care. Frameworks is sponsored by Otsuka Pharmaceutical Development & Commercialization, Inc.

This summary was developed utilizing the full recorded presentation of this webinar. You can access the full sourcing, polling results, recording, or presentation slides here: https://www.psychu.org/antidepressant-utilization-bipolar-disorder-evidence/.

On March 28, 2018, Dr. Gary Sachs and Dr. Joseph Goldberg convened to discuss a fictional case study for an individual with bipolar disorder (BD), focusing on hypothetical clinical decision points whereby the utilization of antidepressants may be considered as a treatment option. Speakers were paid consultants of Otsuka Pharmaceutical Development & Commercialization, Inc.

Gary Sachs, M.D., is a founder of the Bipolar Clinic & Research Program at Massachusetts General Hospital in Boston, Massachusetts. He received his medical degree from the University of Maryland School of Medicine. Dr. Sachs completed a residency and fellowship in psychiatry at Massachusetts General Hospital.

Joseph Goldberg, M.D., is a Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai in New York, New York. He received his medical degree from Northwestern University Medical School. Dr. Goldberg completed an internship, a residency in psychiatry, and a research fellowship in psychopharmacology at the Payne Whitney Clinic at New York Presbyterian Hospital.

The objectives of the presentation were to:

  • Provide an overview of antidepressant utilization in the treatment of BD
  • Examine treatment options and alternative scenarios that may influence treatment decisions through a fictional case study
  • Discuss the clinical evidence and remaining uncertainties surrounding the role of antidepressants in the treatment of BD

The presentation began with a polling question for the audience, “How often do you prescribe antidepressants for patients diagnosed with BD?” Results are depicted in Figure 1.

Dr. Sachs commented on the polling results. He noted the split between the top two answer choices – sometimes and never – and mentioned that the split results were indicative of the debate currently being waged within the larger mental health community about using antidepressants in the treatment of BD.

To further discuss the utilization of antidepressants for the treatment of BD, not just within the PsychU community but within the research literature, Dr. Goldberg began to explore literature findings. He presented results from a 2009 study published in Psychiatry of antidepressant use in the treatment of BD in real-world settings. The study indicated that among the population studied:

  • Between 30-50% received antidepressants
  • Modern antidepressants (e.g. selective serotonin reuptake inhibitors (SSRIs)) were prescribed more frequently than older antidepressants (e.g. tricyclic antidepressants (TCAs))
  • Antidepressant medication was most often prescribed in combination with mood stabilizers or atypical antipsychotics

As a related point, Dr. Goldberg pointed out that antidepressants are seldom used as a monotherapy in the treatment of BD. He posited that this could be due to concerns or perceptions within the health care provider community about whether antidepressants actually destabilize mood, or that they simply aren’t effective as a monotherapy in this patient population.

Though reducing depressive symptoms is often a main treatment target from the patient perspective, Dr. Goldberg stated considerations of utilizing antidepressants in the treatment of BD should be evidence-based and two-fold. He urged health care professional participants to frame their thinking for the remainder of the program in terms of two concepts: efficacy and safety.

In a discussion about efficacy, Dr. Goldberg mentioned that randomized trials have yielded mixed results for antidepressant utilization for the treatment of BD. Data presented from both a 2010 study published in Current Psychiatry and a 2005 study from Primary Care Companion Journal of Clinical Psychiatry indicated a patient response rate between 33-86% across TCAs, SSRIs, selective norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and norepinephrine-dopamine reuptake inhibitors (NDRIs). One caveat was mentioned: Dr. Goldberg stated that these results were difficult to interpret for several reasons, including that many of the studies were retrospective, nonsystematic, or utilized non-standardized measurements. As a general takeaway from the studies, he said that response rates indicated in the literature are not as robust as clinicians may like to see. Dr. Goldberg mentioned that each patient’s case is unique, and treatment decisions should continue on a case-by-case basis.

Dr. Sachs added that if clinicians were to examine placebo rates in addition to the medication classes previously discussed, that the response and switch rates may not appear significantly different. He mentioned that in addition to the studies presented, there have been full trials for antidepressant medication use in BD with adequate controls. However, the results of these studies are that none of the antidepressant classes mentioned has U.S. Food & Drug Administration (FDA) approval for the treatment of BD. He indicated that this fact further underlies the point that the evidence for antidepressant utilization in the patient population with BD is weak and that clinicians need to continue with careful considerations of their use for their patients. Dr. Goldberg agreed and mentioned that this was specifically true in the case of bipolar disorder I (BD I).

To cap the introductory section, Dr. Sachs explored a few factors that may influence treatment decisions. While he didn’t provide an in-depth discussion each individual factor listed (e.g. course of illness; episodic characteristics and presentation; experience of residual symptoms; patient gender; presenting comorbid psychiatric illnesses; biomarkers; prior personal treatment response; tolerance of adverse effects; general medication condition and risk factors; therapeutic priority; and the patient’s view of the treatment), he highlighted two specific factors as particularly important:

  1. Prior Personal Treatment Response – Dr. Sachs mentioned that this was particularly valuable if it is well-documented, prospective, and includes measured outcomes.
  2. Patient’s View Of Treatment – Dr. Sachs stated that this really gets at the heart of the patient’s insight into their illness and agreement upon whether or not they require treatment.

To further illustrate their importance, Dr. Sachs presented a simple schema for personalized medicine practice and discussed how different treatment decisions may fit within the model. The schema began with an accurate diagnosis, the crux of this presentation’s discussion. From there, the patient and provider decide if it’s reasonable to provide a medical intervention to address the symptoms. The next part of the decision making process is where personal factors really come into play. As part of the decision making process, providers should understand underlying factors that may present barriers or benefits to a patient’s treatment. By weighing the scientific evidence about those factors and their interaction in treatment, providers can then create a menu of reasonable treatment options that they can review with the patient. Once the patient is educated on their treatment option, the patient and provider can negotiate a plan and begin to implement treatment interventions. The final portion of the personalized medicine schema was related to measuring outcomes systematically, either through the use of formalized screening or other types of labs or self-report assessments. Dr. Sachs said that by analyzing these outcomes, providers can more fully understand the patient’s response to the treatment intervention, which could lead to augmenting, switching, or adjusting treatment in some other way. This systematic information allows providers to begin the decision making cycle anew with new information, in order to find the best outcome for their patients.

The speakers transitioned to the first part of their fictional case study, focused on a patient referred to as “Ms. A.” Participants were encouraged to imagine themselves as Ms. A’s treating clinician.

To clarify, the speakers re-stated that Ms. A stopped taking her mood stabilizer while trying to conceive, and did not reinstitute the medication as part of her treatment regimen after the initial course of treatment.

To provide additional context, Dr. Sachs then presented Ms. A’s fictional assessment scores under the Diagnostic Statistical Manual for Mental Disorders (DSM) for major depression criteria; on the Montgomery-Asberg Depression Rating Scale Computer – Simulated Rater (MADRS-CSR); under the DSM hypomania / mania criteria; and the Young Mania Rating scale Computer – Simulated Rater (YMRS-CSR). Full hypothetical scoring is presented in Figure 3.

Dr. Sachs clarified that the data depicted showed formal ratings from the MADRS and YMRS, and charted them against self-reported symptomology (perhaps recorded through a modified version of the Patient Health Questionnaire (PHQ)), and also against DSM criteria.

In a discussion of the depression symptomology, he noted that eight of the nine diagnostic criteria scores for Ms. A met the DSM threshold. Dr. Sachs also pointed out that the difference in intensity of the self-reported scores in comparison to the simulated rating scores for the MADRS, with the one exception being psychomotor functioning. When discussing mood elevation, Dr. Sachs noted that Ms. A has three significant symptoms measured by the YMRS, with a lower level rating for irritability and risk-taking.

He then plotted relevant information from Ms. A’s profile onto a Bipolarity Index, which has been used in the Systematic Treatment Enhancement Program for BD study (STEP-BD), to assess diagnostic confidence along five of the core dimensions or characteristics of BD (including factors like age of onset, course of illness, etc.). Convincing characteristics on such a chart are plotted by each factor on a scale from 0 – 20 where 20 would indicate a very convincing characteristic of BD presenting in the patient. Dr. Sachs indicated that a score of 50 or higher is the general threshold for high confidence of BD using the Bipolarity Index.

Before the speakers discussed their comprehensive assessment of Ms. A, they asked the audience to weigh in with their thoughts in a polling question: “Based on the evidence described for Ms. A, which do you believe to be the most likely diagnosis?” Results are depicted in Figure 4.

Dr. Goldberg commented on the participants’ results. He described his own assessment process in further detail. To begin, he stated that one of the issues in accurately assessing Ms. A’s case was the confounding factors present during her manic episodes, which make it difficult to understand just what was going on or what triggered the mania. In addition, Ms. A hasn’t had any spontaneous hypomania. For all of the criteria we do know about, Dr. Goldberg mentioned that based on the case study we only had confirmed mood swings. New DSM-5 criteria also elevate the role of energy as a necessary criterion for diagnosing mania or hypomania, and Ms. A scores low on this measure on the MADRS. On the other hand, he discussed compelling evidence that he would consider from the case study, particularly that Ms. A had a previous positive response to a mood stabilizer. He indicated that, while this factor doesn’t necessarily help make a diagnostic decision, it may help him during his treatment intervention decision making. Surprisingly, Dr. Goldberg stated that his diagnosis choice in this case study so far would be “none of the above,” because she exhibits many classical symptoms of BD, he would recommend monitoring this fictional patient closely.

He continued the presentation with a discussion on the nuances of potential strategies clinicians may employ to treating an individual with a non-textbook presentation. Dr. Goldberg reiterated a concept that Dr. Sachs discussed previously: that clinicians can construct an initial ‘menu’ of reasonable treatment options. He mentioned that in his own clinical practice, he often shares the rationale for his treatment choices with his patients. He urged participants to take into consideration evidence-based treatment and guideline recommendations for the particular presentation of the individual (e.g. mixed features versus pure depressed phases of illness), in order to personalize approaches. Dr. Goldberg mentioned that it’s important to revise this menu of treatment options based on measured results.

The speakers had a point-counterpoint conversation surrounding the considerations of factors for antidepressant treatment for hypothetical patient, Ms. A. Dr. Goldberg began with factors that may suggest standard antidepressants are appropriate for Ms. A. Dr. Sachs followed up with factors that suggest antidepressants are inappropriate for Ms. A. Key arguments are summarized in Table 1.

Alternative scenarios for Ms. A were then examined to see if they would affect treatment considerations. In the first scenario, participants were asked to imagine how their clinical decisions may have been impacted if a known positive response to a SSRI were part of the patient’s history. The speakers concurred that, in their opinion, and provided Ms. A had exhibited an unambiguous positive response previously, this scenario may provide additional evidence to the clinician in favor of beginning a similar course of treatment.

The second scenario revolved around if the case had led to a clinical diagnosis of bipolar disorder unspecified (formerly known as bipolar disorder NOS). Dr. Sachs indicated that an unspecified diagnosis would be sort of honest, given the manic episodes in Ms. A’s case are confounded by previous substance use. He stated that it’s not clear what might happen if she was prescribed antidepressant treatment to address her current symptomology, as her case is not clear cut. Under this scenario, Dr. Sachs described the importance of speaking with the patient and educating Ms. A on the risks and benefits of each treatment choice.

In the third scenario, participants were asked to imagine if Ms. A has a comorbid generalized anxiety disorder and panic disorder, and think about if this would affect their inclination to utilize an SSRI for a current major depressive episode. Dr. Goldberg stated that arguably 50% of more of patients living with BD have anxiety features. However, he mentioned that there was very little literature investigating anxiety as a primary outcome of BD. He stated that this scenario harkens back to the findings from STEP-BD, which is that you cannot assume an SSRI is going to treat a patient’s anxiety. Dr. Sachs added that there are a few studies that show a response on the anxiety scale for patients with BD treated with an atypical antipsychotic and also with SSRIs. He stated that the anxious distress specifier within the DSM is associated with a much more pernicious anxiety disorder than described in Ms. A’s case.

The final scenario provided a change to Ms. A’s self-report score was discordant with findings on the YMRS-CSR. The scenario increased the YMRS score from 9 to 35, but the YMRS score was shown to be higher than the patient’s self-reported data. Dr. Sachs stated that this discordance is typical for a patient in the midst of an elevated phase of BD. The speakers concurred that under this scenario, they’d be cautious prescribing an antidepressant to Ms. A, without additional collateral information.

The speakers provided summary statements to reiterate key points from the presentation.

The webinar concluded with a question and answer session in which the following were asked:

Is there a role for pharmacogenetics testing for deciding best antidepressant use for patients living with BD?

Dr. Goldberg said succinctly, “maybe.” He mentioned that the serotonin transporter gene has a local genetic variant that makes a long and a short form. There are a handful of studies arguing that inheriting the short allele may as much as quadruple the risk of having an antidepressant-induced mania. But the evidence is variable across the research. While he didn’t suggest only utilizing pharmacogenomics testing for deciding patient treatment options, Dr. Goldberg stated that it may provide additional supplementary evidence to consider.

            Dr. Sachs agreed, but also expressed his opinion that these tests were not quite ready for widespread utilization.

How would you assess whether or not an antidepressant was inducing hypomanic symptoms in a patient?

Dr. Sachs began, stating that while clinicians can say that hypomania was treatment emergent, it may be difficult to pinpoint exactly what caused or triggered the symptomology or episode. He mentioned that it isn’t quite possible to measure causality in a definitive way, but rather, would impact the confidence level of a treatment decision.

Dr. Goldberg echoed this comment and added that it’s the same on the other side of the spectrum as well – though experiences within the first four to six weeks of a treatment therapy could provide a high suspicion for causality for patient outcome improvement.

Key Messages

  • Long-term follow-up studies of specialized early intervention (SEI) programs following discontinuation have been contradictory.
  • OPUS II was the first prolonged SEI study beyond three years.
  • OPUS II reported that two years of SEI (plus three years treatment as usual) or five years of continuous SEI had similar outcomes on negative symptoms (primary outcome).
  • Continuous SEI treatment had no significant effect on additional outcomes.

Mental Health America (MHA), a leading nationwide nonprofit organization dedicated to promoting the mental wellness of all Americans, has released its latest report “The 2018 State of Mental Health in America.” To learn more about the report, PsychU interviewed Paul Gionfriddo, President & Chief Executive of MHA, who shares highlights of the report regarding mental health access, prevalence, and related trends seen across the nation and within individual states.

In this interview, Jehan Marino, PharmD, BCPP, Senior Medical Science Liasion for Otsuka Pharmaceutical Development & Commercialization, Inc., speaks with Joseph Goldberg, MD, PsychU Bipolar Disorder Section Editor, Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, and Director of the Affective Disorder Research Program at Silver Hill Hospital. Dr. Goldberg shares his perspective on the National Institute of Mental Health (NIMH) funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) Study, highlights the clinical implications of the study, and discusses how clinicians can apply results from this study to practice.

Background & Purpose

Research on the course of bipolar disorder has led to increased focus on inter-episodic mood instability, as many individuals with bipolar disorder exhibit significant day-to-day or week-to-week shifts in mood that are more severe than what is experienced by the general population. These subsyndromal mood swings have been shown to impair functioning and are associated with higher risk of relapse and hospitalization.

Close monitoring of mood instability could facilitate early intervention and perhaps prevention of relapse in some cases. Further, these tools may empower patients by enhancing insight and recognition of early warning signs of an impending mood episode. Typically, charting of mood has been accomplished through use of validated paper-and-pencil measures, but the usefulness of these questionnaires may be limited by low compliance and recall bias when patients batch their responses.

The use of e-tools instead of paper-and-pencil measures is on the rise, with the hope that these methods will increase usability and accuracy. However, it is not yet clear whether electronic self-monitoring tools are valid measures of mood when compared with paper-and-pencil measures. In a recent article entitled “Electronic Self-Monitoring of Mood Using IT Platforms in Adult Patients with Bipolar Disorder: A Systematic Review of the Validity and Evidence,” Maria Faurholt- Jepsen and colleagues examined the existing literature on this topic with two goals:

  1. To evaluate the validity of electronic self-monitoring tools compared to paper-and-pencil measures, and
  2. To evaluate whether electronic self-monitoring of mood affects clinical outcomes in randomized controlled trials (RCTs)

Background & Purpose

Sleep disturbance has been identified as an early warning sign of impending mood episodes, but there is evidence to suggest that sleep loss may in some cases trigger such episodes. This evidence has been somewhat inconsistent, in that not all individuals appear to share this vulnerability. One possible explanation for disparate findings is that vulnerability may differ depending on gender and subtype of the individual’s disorder.

A better understanding of the link between sleep loss and the onset of mood episodes could aid clinicians in identifying patients more likely to relapse as a result of sleep disturbance and could also provide potentially useful information for self-management of bipolar disorder. In a recent article entitled “Sleep Loss as a Trigger of Mood Episodes in Bipolar Disorder: Individual Differences Based on Diagnostic Subtype and Gender,” Katie Swaden Lewis and colleagues analyzed data from the Bipolar Disorder Research Network (BDRN) study to assess rates of both manic and depressive episodes triggered by sleep deprivation.

Key Messages

  • The World Health Organization (WHO) has reported that 50% of patients from developed countries with chronic disease do not use their medications as recommended.
  • In bipolar disorder (BD) non-adherence to medication has been associated with a range of poor clinical outcomes including higher rates of hospital admission, higher rates of suicide, and recurrence of acute episodes, particularly mania.
  • Rates of relapse in BD have been reported to be as high as 40% in the first year, 60% in the second year, and 73% over 5 years or more.
  • The studies demonstrated a positive outcome used psychoeducation, cognitive therapy and family -focused therapy, but there were other studies of these interventions that were unable to show an improvement in adherence.
  • The patient’s perception of the severity of the disorder, their beliefs about themselves and the impact of the disorder and their perception of treatment influenced their decisions to be adherent or not.
  • Providers who conveyed confidence in patient’s ability to participate in treatment and advocated keeping in regular contact, proved to be highly influential on adherence.

Key Messages

  • The present study evaluated the impact of residual symptoms on overall functioning and assessed the relationships between residual symptoms and specific functional domains in a sample of euthymic patients with bipolar disorder (BD).
  • Identification of factors related to specific domains of disability may allow clinicians to develop personalized treatment plans and target the domains where functioning is most impaired.
  • Residual depressive symptoms were found to be strongly associated with impairments in interpersonal and occupational functioning.
  • Cognitive dysfunction was associated with impairments in cognitive and professional functioning.
  • Stigma had effect on impairments in interpersonal, cognitive, and leisure functioning.

Key Messages

  • Major depressive disorder (MDD) and bipolar disorder (BD) are associated with high rates of medical and psychological comorbidities as well as functional impairment.
  • Exercise appears to be a promising adjunctive treatment for mood disorders and comorbid conditions.

In this presentation, Julleah Johnson, PhD, Senior Medical Science Liaison, summarized initial findings from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a national public health initiative designed to examine the effectiveness of treatments and their impact on the course of bipolar disorder.

An electrocardiogram (ECG) lasting 120 seconds can distinguish whether a person with depression symptoms has unipolar major depressive disorder (MDD) or bipolar disorder. The ECG detects heart rate variability due to vagal tone; the variability is produced when the parasympathetic nerve fibers carried in the vagus nerve control the heart rate. People with bipolar disorder have lower overall cardiac vagal tone than people with MDD.

An ECG detects respiratory sinus arrhythmia (RSA), characterized by sudden changes in heartbeat pattern that occur every two to eight seconds, and by low frequency (LF-HRV) that occurs every 10 to 25 seconds. These elements are controlled by the parasympathetic nerve fibers carried in the vagus nerve.

These findings were reported in “Low cardiac vagal tone index by heart rate variability differentiates bipolar from MDD” by Brandon Hage, Briana Britton, David Daniels, Keri Heilman, Stephen W. Porges, and Angelos Halaris. The researchers studied 64 people with MDD, and 37 people with bipolar disorder. All participants were verified for mood stabilization via pharmaceutical means throughout the study. Heart rate variability (HRV) was assessed by measuring the times between sequential heartbeats over a period of 10 to 15 minutes. The goal was to determine whether an electrocardiogram can distinguish MDD from bipolar disorder. Based on clinical symptoms of depression, nearly half of initial bipolar episodes meet criteria for MDD, and prior to onset of mania are often indistinguishable from unipolar depression.

For this study, the participants with bipolar disorder showed a lower overall cardiac vagal tone compared to those with MDD. Indicators of the lower vagal tone include:

  • Those participants with bipolar disorder also show significantly lower RSA compared to those with MDD. Baseline RSA in those with bipolar disorder traditionally measures around 5.12, compared to about 5.7 in those with MDD.
  • Those participants with bipolar disorder show a higher low-frequency (LF-HRV) than those with MDD. LF-HRV in those with bipolar disorder traditionally measures at about 4.20, compared to about 5.32 in those with MDD.
  • Those participants with bipolar disorder show significantly higher baseline levels of some individual inflammatory biomarkers (IL-6, IL-8, IL-10, TNF-a, IL-1b, MCP-1) than those with MDD. The largest differences occur between MCP-1, TNF-a, and IL-8 in those with bipolar disorder: those with bipolar disorder show significantly higher levels of these inflammatory biomarkers than those with MDD.

The researchers noted that although some of the bipolar participants were exposed to antipsychotics at the time of HRV measurement (first generation antipsychotics affect vagal tone more than atypical antipsychotics), the decreased HRV parameters in the bipolar disorder group could not be solely attributed to the antipsychotic medications. The participants with bipolar disorder who were taking an atypical antipsychotic as monotherapy had the highest HRV parameters of the three bipolar medication classes (atypical, anticonvulsant, or combination). The researchers concluded that the overall decreased HRV parameters observed across the entire group with bipolar disorder could not be only due to medication effects of a single medication class.

The full text of “Low Cardiac Vagal Tone Index By Heart Rate Variability Differentiates Bipolar From MDD” was published October 5, 2017, by The World Journal of Biological Psychiatry.

For more information, contact: Angelos Halaris, M.D., Ph.D., APA, ACNP, CINP, Professor, Psychiatry and Behavioral Neurosciences, Loyola Medicine, 2160 S 1st Avenue, Maywood, Illinois 60153; Email: ahalaris@lumc.edu

Key Messages

  • Physical and psychiatric comorbidities are common in bipolar disorder (BD), but they may not all be associated with long-term outcomes.
  • The risk of manic relapses in BD was increased by thyroid disease, specifically hypothyroidism, and may be specifically modulated by baseline thyroid-stimulating hormone (TSH).
  • The detection and treatment of hypothyroidism in BD should be considered a risk factor for manic relapse during the long-term progression of the disorder.

Background & Purpose

Individuals with mental disorders often experience sleep difficulties, but traditionally, these have been considered symptoms of the illnesses. As a result, interventions for sleep may be given low priority. There is an alternative hypothesis, however: sleep may be a significant contributing factor in the development and escalation of symptoms of mental illness. However, few studies have been adequately designed to evaluate a potential causal path.

In a recent study entitled “The Effects of Improving Sleep on Mental Health (OASIS): A Randomized Controlled Trial with Mediation Analysis,” Daniel Freeman and colleagues conducted a single-blind, randomized controlled trial to evaluate whether treating insomnia in college students was associated with reductions in symptoms of psychosis, among other mental health issues, compared with usual care.

Key Messages

  • Increasingly, evidence has shown that there is genetic overlap between psychiatric illnesses
  • A genome wide association study (GWAS) of 6447 bipolar disorder (BD) cases and 12639 controls was performed to test the heritability and genetic correlation of BD subtypes and investigate their genetic overlap with schizophrenia and major depressive disorder

Key Messages

  • The postsynaptic density (PSD) is a specialized ultrastructure located in the membrane of glutamatergic synapses where cross-talk between glutamate and dopamine signaling pathways can occur.
  • Abnormal expression and function of PSD proteins has been observed in several preclinical and clinical studies of diseases including schizophrenia, bipolar disorder, and autism.
  • Some preclinical studies have suggested that PSD proteins are involved in the mechanism of action of several classes of drugs used to treat neuropsychiatric illnesses and therefore PSD proteins are being investigated as potential therapeutic targets.
  • The exact role of PSD proteins in neuropsychiatric disease and the ability to successfully develop therapeutic strategies to target them remains unknown.

In this presentation PsychU Primary Care Providers’ Corner Section Editors, Sloan Manning, MD, Medical Director at Novant Health Urgent Care & Occupational Medicine; and Marla Moses, FNP, PMHNP, Owner of Moses Mental Health, discussed differential diagnosis of major depressive disorder (MDD) or bipolar disorder (BD) in the primary care setting. Key discussion points included:

  • Lifetime Prevalence & Burden Of MDD & BD
  • Misdiagnosis & Underdiagnosis Of BD
  • MDD Versus BD & Indicators Of BD Among Patients Presenting With MDD

In this short presentation, Dr. Joseph Goldberg, Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai New York, and PsychU Bipolar Disorder Section Editor, discusses the recent study “Poor Quality of Life and Functioning in Bipolar Disorder” and provides his expert point of view on the clinical implications of this article.

Dr. Goldberg is a paid consultant for Otsuka Pharmaceutical Development & Commercialization, Inc.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/pharmacogenomics-personalized-medicine-now-going/.

On August 8, 2017, two experts in psychiatry offered a virtual forum on the current state of the field of pharmacogenomics. Rif El-Mallakh, MD, is Professor and Director of the Mood Disorders Research Program in the Department of Psychiatry and Behavioral Sciences at the University of Louisville School of Medicine in Louisville, Kentucky. Henry A. Nasrallah, MD, is the Sydney W. Souers Professor and Chair of the Department of Psychiatry and Behavioral Neuroscience at Saint Louis University (St. Louis, MO), and he is the Editor-in-Chief of Schizophrenia Research and Current Psychiatry. Both speakers are compensated contractors of Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of this virtual forum were to:

  • Define precision medicine and its potential benefits in patient care
  • Review the history and basics of pharmacogenetics and pharmacogenomics
  • Discuss the role of biomarkers in precision medicine
  • Explore current developments in the use of pharmacogenomics and precision medicine in the psychiatric clinic
  • Address gaps in understanding and barriers to the successful implementation of precision medicine

Dr. Nasrallah began the forum by explaining the concept of precision medicine in psychiatry as an effort to tailor health care to the individual by integrating data from that person’s genetic makeup, epigenetic modifications, other biomarkers, clinical symptoms, and environmental exposures, with the goal of combining early diagnosis, targeted therapies, and more accurate prediction of disease susceptibility to reduce the morbidity and mortality of psychiatric conditions. He explained that there are two tools of precision medicine: pharmacogenomics and biomarkers.

Next, Dr. Nasrallah distinguished the terms pharmacogenetics and pharmacogenomics, noting that they are sometimes used interchangeably. He cited the definitions from the Pharmacogenomics Knowledge Base, explaining that pharmacogenetics is how variation in a single gene influences an individual’s response to a single drug.

Pharmacogenomics, in contrast, is how all genes influence an individual’s response to drugs. He stipulated that the goal is to promote efficacy and reduce side effects in patients, and that both pharmacogenetics and pharmacogenomics have the potential to identify patients genetically predisposed to not respond to therapy or to develop unacceptable toxicity. He also explained that much of the early work in pharmacogenomics has focused on the study of genetic variability to individual differences in drug metabolism.

He then discussed a class of enzymes called the Cytochrome P450 (CYP450) which catalyze a variety of reactions in the human body, including production and metabolism of endogenous compounds (e.g., CYP3A4 metabolizes estrogen), detoxification of food (e.g., CYP2D6 metabolizes plant alkaloids), and metabolism of foreign chemicals (drug metabolizing enzymes contribute to a series of chemical reactions that increase the water solubility of drugs). He explained that these enzymes evolved in humans over time as they inhabited environments such as forests and jungles where there was a high probability of ingesting toxic or carcinogenic substances. Genetic variability in this family of enzymes (polymorphisms) influences patients’ responses to certain drugs.

Dr. Nasrallah discussed some examples of how CYP450 polymorphisms affect responses to some psychiatric medications. CYP450 enzymes are responsible for 96% of reactions involved in the metabolism of drugs currently on the market or under development. Five specific cytochromes are responsible for 75% of those reactions: CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A4/5. He explained that variations in those enzymes accounts for four different drug metabolism phenotypes:

  • Poor metabolizers—they have nonfunctional genes, leading to greater risk of adverse effects.
  • Intermediate metabolizers—they have one functional and one nonfunctional gene and are an increased risk for adverse effects.
  • Extensive metabolizers—this is the most common phenotype, where individuals have two wild-type genes (the most common types of genes) and will experience an average amount of side effects.
  • Ultra-rapid metabolizers—they have extra copies of the gene and as a result, tend to have a low response to a drug and are at potential risk for high levels of metabolites.

Dr. Nasrallah explained that polymorphisms of CYP450 can influence the metabolism of certain drugs, and variations in the representation of different alleles is related to different ethnic populations with different evolutionary nutritional histories. He offered several examples, including that 51% of Asians have the CYP2D6*10 allele, which generates an unstable enzyme and contributes to an intermediate metabolizer phenotype (only 1-2% of Caucasians have this allele), and that African Americans are 1.5- to 2.1-fold more likely to have only one functional copy of CYP2D6 (poor / intermediate metabolizer) and 1.4- to 3.4-fold higher to have 3 or more copies of CYP2D6 (ultra-rapid metabolizer) compared with other ethnicities. This explains why some African American patients can fail to respond to medications or have side effects.

Dr. Nasrallah transitioned to a focus on genetic variations predicting susceptibility to certain disorders, which can be more powerful predictors of drug response than CYP450 polymorphisms. He offered several examples, beginning with the serotonin transporter gene, variations in which have been associated with poorer response to antidepressants for those with major depressive disorder (MDD). He also mentioned brain-derived neurotrophic factor (a polymorphism of which is associated with more severe forms of MDD), catechol-O-methyltransferase (a variant of which is associated with poor response to anti-depressant medication), and the dopamine receptor genes (variations of which are associated with schizophrenia and response to antipsychotic medication).

He spoke more in depth of the serotonin transporter gene, known as SERT, which exists in short or long form, reflecting the length of the promoter region. The short form, where a 44-base-pair deletion has occurred, leads to a decreased quantity of serotonin transporter in the brain, which is related to psychopathology. Dr. Nasrallah reviewed research showing that individuals who are hetero- or homozygous for the short form of SERT (meaning they have at least one copy, or two copies, of this gene) have an increased likelihood of developing depression when experiencing significant life adversity, and have a decreased and slower response to SSRI treatment. He also cited a study showing that individuals with bipolar disorder who are homozygous for the short form of the gene are more likely to have a history of rapid-cycling. The short-form allele is also associated with increased anti-depressant induced mania in individuals with bipolar. In light of these research findings, Dr. Nasrallah said that a case can be made for identifying the short-form allele of SERT and using the knowledge to guide treatment decisions with patients.

Dr. El-Mallakh asked Dr. Nasrallah: In your clinical opinion, how can short-form SERT information be used in a clinical setting? Dr. Nasrallah said that knowing which form of the allele a patient gives a prescriber information about whether the patient will respond to selective serotonin reuptake inhibitors (SSRIs), and that the patient may be more vulnerable to stressful life events.

Dr. El-Mallakh asked a follow-up question: If a prescriber knows ahead of time that a patient has the short form, would you recommend that they start with a medication that does not increase synaptic serotonin as its main mechanism? Dr. Nasrallah responded that he would recommend the prescriber try a different medication, perhaps a dual-action drug or one that focuses on norepinephrine or dopamine. Dr. El-Mallakh observed that this makes the number one class of drugs to treat depression (SSRIs) not the first choice for the 30-40% of individuals who have the short form of SERT, and Dr. Nasrallah agreed, and added that if a prescriber has this information, it prevents taking a trial and error approach to medication treatment and makes it more possible to help patients. He stated that this is what precision medicine is all about.

The first audience polling question was presented: How often do you use pharmacogenomic testing to guide treatment decisions in your practice?

Dr. El-Mallakh remarked that the results of the polling, showing that approximately half of respondents use pharmacogenomic testing and half do not, seem to reflect the current state of the field and the mindset of clinicians in this area. Dr. Nasrallah observed that the results are consistent with his professional experience that very few psychiatrists use these tests to guide treatment. This is in contrast with other medical specialties, like oncology, where pharmacogenomic testing to guide treatment is the norm. Dr. Nasrallah explained that psychiatry has come late to this approach for several reasons, but predicted that there will be rapid adoption of these practices in psychiatry as the results become more well-established. 

Dr. El-Mallakh resumed the presentation by talking about the potential impact of pharmacogenetic testing. He reviewed the results of a study examining whether pharmacogenetic testing predicted outcomes. The results showed that individuals who experienced adverse effects had a four-fold increase in the likelihood that they would have the “poor metabolizer” phenotype, while those who did not respond to the medication were five times more likely to have the “ultra-rapid metabolizer” phenotype, compared with the country’s population. He also noted additional research suggesting an increased hospitalization rate for poor metabolizers treated with antidepressant or antipsychotic medication, as well as an increase in adverse effects compared to extensive metabolizers. He noted that professionals working in inpatient settings are likely treating a disproportionate number of individuals who will be poor responders to medication and have increased risk for negative side effects as a result of their genotype.

He then discussed how best to use pharmacogenetic testing. He observed that a gene-by-gene approach has been shown to have limited clinical utility, and is more likely to confirm what is already suspected. He recommended a combinatorial approach, testing multiple genes. He cited findings from three studies of individuals with treatment- resistant depression, comparing the use of pharmacogenomic testing to guide treatment decisions versus unguided treatment. When clinicians had pharmacogenomic testing information for their patients, there was a 2.3-fold increase in the odds of a clinical response, 53% greater improvement in depressive symptoms, and a 1.7-fold relative improvement in response. He observed that obtaining this testing significantly reduces the cost of care, particularly in the primary care setting.

Dr. El-Mallakh moved the conversation to biomarkers in precision medicine. He offered a definition of a biomarker as a specific indicator of normal biological processes, pathogenic processes, or responses to an exposure or intervention, including therapeutic interventions. Molecular, histologic, radiographic, or physiologic characteristics are types of biomarkers. A biomarker is not an assessment of how a patient feels, functions, or survives. Dr. El-Mallakh stated that biomarkers offer information regarding what’s happening inside patients and allows prescribers to predict future outcomes for them. He noted that use of biomarkers is less common in psychiatry compared with other medical disciplines. He explained that the Food and Drug Administration (FDA) has divided biomarkers into seven classes according to clinical use: diagnostic monitoring, pharmacodynamic/response, predictive, prognostic, safety, and susceptibility/risk.

Dr. El-Mallakh reviewed several current findings of biomarkers for different clinical uses in psychiatry, all of which are currently under investigation by the FDA for use in psychiatry (with the exception of pharmacogenomic testing, which has already been qualified for use in the field). For example, in the monitoring category, blood concentrations of an addictive drug can be used to monitor abstinence and compliance in patients prone to substance abuse, and in the prognostic category, for patients age 60 or older with MDD, lower evening cortisol levels predicted poorer course at two-year follow-up. The short form of the SERT gene is also a prognostic biomarker.

Dr. El-Mallakh noted that currently, most clinical assessment of psychiatric disorders is limited to evaluating mental and behavioral symptoms. He stated that specific cognitive deficits can be assessed through neuropsychological testing, as research has shown that certain profiles of cognitive impairment are different among patients with schizophrenia, bipolar disorder, or major depression. He observed that the presence of neurological “Soft Signs” has been shown in a meta-analysis to be a reflection of the severity of illness in individuals with schizophrenia. In addition, certain physical and mental health comorbidities (such as cardiovascular disease) can help treaters understand underlying mechanisms involved in disorders.

The second audience polling question was presented: For those who answered “never” or “rarely”: What prevents you from implementing pharmacogenomic or biomarker testing?


The presenters acknowledged that there is currently a range of hurdles involved in adopting pharmacogenomic testing to guide treatment decisions, and Dr. El-Mallakh elaborated on some of the barriers to successful implementation of precision medicine. He began with gaps in understanding, noting that it can be difficult to interpret how multiple genetic factors coalesce to affect disease risk. It can be particularly complicated because the same condition can manifest in different ways, and this heterogeneity increases the difficulty of standardizing diagnosis and applying any biological tool across a wide range of patients. He also cited findings from a survey of psychiatrists showing that three-quarters of respondents believe genetic counseling should accompany any pharmacogenomic testing, although that brings a time burden that some may want to avoid given the limited time clinicians often have with their patients. Dr. El-Mallakh also acknowledged that many of the tools have been validated with Caucasian populations. 

Dr. El-Mallakh also outlined some barriers in the field of psychiatry, beginning with a lack of infrastructure and standardization, in that the companies that do genetic testing often have different approaches and interpretations. He also stated that clinician inexperience is an issue and emphasized the need for adequate exposure to this topic in clinical graduate medical education. He mentioned the Clinical Pharmacogenetics Implementation Consortium (CPIC) as a potential resource, but noted that there are only 33 drugs on their website with good data, pointing to the need for additional research, particularly prospective studies and randomized controlled trials. Dr. El-Mallakh indicated that he would like payers to understand that this type of testing can actually decrease the cost of care.

The forum concluded with a question and answer period, including the following questions:

How close are we to being able to utilize the genetic testing results that patients bring to us on a routine basis?

Dr. El-Mallakh stated that it’s important to realize that there is already sufficient data to make this not only a useful approach, but one that can improve patients’ lives and, in his opinion, has the potential to significantly reduce the cost of care.

Can we test for SERT?

Dr. El-Mallakh’s answer was “absolutely”. He explained that a lot of companies will allow tests for individual genes, though it’s generally easier and more valuable to test for an entire gene profile. He stated that most psychiatric gene profiles include SERT.

Dr. Nasrallah added that SERT has been in the literature for quite some time and is well known to researchers, and that it’s time for clinicians to transfer that knowledge into clinical practice. He reiterated that what they shared in the forum were examples of how SERT can be very useful for patients with depression in terms of predicting response or lack thereof, and predicting severity and vulnerability to stress. He encouraged colleagues to use it.

Are we at a point where not testing when it is clinically indicated is an ethical issue?

Dr. Nasrallah stated his opinion that it is too early to make it an ethical issue, but as data accumulates showing better outcomes, fewer adverse reactions, and reduced cost of care, the issue of ethics will become increasingly salient. He suggested that, at this time, it’s more important to focus on increasing clinicians’ usage of and experience with applying precision medicine principles.

How effective is the use of pharmacogenetics for depression?

Dr. El-Mallakh said that the best evidence available in terms of prospective studies involves treatment-resistant depression. He stated that use of pharmacogenomics does predict response in depression, particularly of that specific type.

Dr. Nasrallah added that many psychiatric illnesses (e.g., depression, schizophrenia, anxiety) are complex genetic disorders rather than single genes, so the etiological heterogeneity is important to recognize. Dozens of biomarkers have been identified, but they cannot be used easily in psychiatry because of that heterogeneity. He asserted that psychiatric disorders are syndromes, not diseases, and there are lab tests to identify the latter but not the former. He stated his hope that as more is known about biomarkers, there would be a possibility of recognizing specific diseases within these broader syndromes.

In this short presentation, Mauricio Tohen, MD, DrPH, MBA, PsychU Bipolar Disorder Section Editor and Professor and Chairman at the University of New Mexico Health Sciences Center Department of Psychiatry, provided an expert point of view on his co-authored research paper, published in the Journal of Affective Disorders, “Bipolar mixed features – Results from the comparative effectiveness for bipolar disorder (Bipolar CHOICE) Study. Key points covered included:

  • Mixed Features & DSM Criteria
  • Key Findings
  • Study Limitations

During this recorded presentation, Jane Guo, PharmD, PharmD, MBA, provided a brief overview of the clinical and economic impact of bipolar disorder. Key points included:

• Understanding the scope of bipolar disorder: its prevalence and potential underestimation due to misdiagnosis; and its occurrence with comorbid medical conditions
• Describing the cost to the health care system of bipolar disorder
• Discussing treatment adherence and non-adherence in bipolar disorder

This full live presentation, and others like it, are available for free for PsychU Members. To learn more or schedule a live program for your organization, please visit www.PsychU.org/events/custom-program-request.

Key Messages

  • Understanding the associated risk factors for substance use disorder (SUD) in patients with bipolar disorder (BD) is an important consideration when devising a therapeutic plan for a patient.
  • This review found that males, those with a history of more frequent manic episodes, and suicidality are major determinants of SUD risk in patients with BD.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/looking-beyond-mood-psychosis-a-focus-on-neurocognition/

On June 7, 2017, two experts in the field of neuropsychology presented a virtual forum on cognitive impairment in individuals with schizophrenia and bipolar disorder. Katherine Burdick, PhD, is an Associate Professor of Psychiatry at Harvard Medical School. She also serves as the Director of Mood and Psychosis Research and Director of Psychology Research at Brigham and Women’s Hospital. Philip D. Harvey, PhD, is the Leonard M. Miller Professor of Psychiatry and director of the Division of Psychology at the University of Miami Miller School of Medicine. He is also a VA Senior Health Scientist. Drs. Burdick and Harvey are compensated contractors of Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of this virtual forum were to:

  • Discuss the incidence and functional consequences of neurocognitive deficits in bipolar disorder and schizophrenia
  • Explore the use of cognitive remediation for patients with schizophrenia
  • Review and highlight the potential benefits of social cognitive interventions for those with schizophrenia

Dr. Burdick began the forum by explaining the history of neurocognition in bipolar disorder, beginning in 1898 with Emil Kraepelin’s division of psychosis into two separate conditions: dementia praecox (now termed schizophrenia) and manic-depressive psychosis (now termed bipolar disorder). The distinguishing factor was the belief that there was complete remission between affective episodes for patients with bipolar disorder, leaving schizophrenia as the only severe mental illness considered to have significant cognitive impairment. This resulted in very few papers being published on the topic of cognitive impairment in bipolar disorder during the 20th century, although over 200 papers on cognitive impairment in schizophrenia were published in the same time period. However, in the last two decades, far more study has been devoted to understanding the nature of cognitive impairment in bipolar disorder.

Dr. Burdick stated that the increase in research on that topic has grown from new understanding of the diagnostic overlap between bipolar disorders and other mental illnesses, including schizophrenia. She explained that although bipolar disorder is more episodic in nature when compared to the more chronic course of schizophrenia, complete functional recovery between episodes is not the norm for individuals with bipolar disorder. In addition, she described that there is symptomatic overlap between the two disorders, in that approximately 60% of individuals with bipolar disorder experience acute psychotic symptoms during manic and depressive episodes. Further, individuals with schizophrenia often exhibit affective symptoms, including full episodes of depression and, less commonly, mania. The interest in this overlap has been fueled by research showing that schizophrenia and bipolar disorder have shared neurobiological and genetic underpinnings, in that both are highly heritable, and that there is shared genetic risk. Because cognitive impairment represents one of the features present across several mental illnesses (including autism and attention deficit/hyperactivity disorder), Dr. Burdick stated that it may help to understand that those genetic factors may confer risk for multiple disorders, as opposed to just one disorder, via their effects on normal brain function measured at the level of cognition.

Dr. Burdick then addressed the idea of heterogeneity within specific disorders, including levels of functional impairment. She suggested that one useful way to understand that heterogeneity may be to examine cognitive functioning. She presented data showing functioning across seven cognitive domains (speed of processing, attention, working memory, verbal learning, visual learning, reasoning and problem-solving, and social cognition), and revealing that the pattern of deficits observed for individuals with bipolar disorder or schizophrenia were similar to each other and distinct from the pattern for healthy individuals. She continued to explain that as a group, individuals with schizophrenia tend to show more significant cognitive impairment than individuals with bipolar disorder. However, she noted that the data fail to take into account the substantial within-group heterogeneity, particularly among individuals with bipolar disorder. Approximately 60% of individuals with bipolar disorder who exhibit symptoms of psychosis also exhibit significant cognitive impairment, compared with approximately 40% of individuals with bipolar disorder who do not show symptoms of psychosis (and 85% of individuals with schizophrenia). She concluded by explaining that while approximately half of individuals with bipolar disorder show little, if any, cognitive impairment, a subgroup of individuals with bipolar disorder experience cognitive impairment that is as severe as that which is typically observed in individuals with schizophrenia.

Dr. Burdick stated that research has shown that cognitive deficits have a profound impact on functioning, primarily for schizophrenia, and to a lesser extent, for bipolar disorder. Such deficits are more strongly linked to community functioning than positive symptoms of schizophrenia such as hallucinations and delusions. In addition, medications to treat schizophrenia tend to ameliorate positive symptoms but do not fully address cognitive impairment at this time, something Dr. Burdick asserted is necessary, including for affected patients with bipolar disorder. This need can be seen in light of a recent meta-analysis that showed equally strong associations between cognitive ability and community functioning among patients with bipolar disorder or schizophrenia. Dr. Burdick suggested that effective cognitive remediation therapy could help impaired individuals with these disorders.

Dr. Burdick reviewed factors that contribute to the cognitive impairment observed in bipolar patients, including but not limited to the mood state, in that many patients who are not in the midst of acute episodes continue to exhibit deficits. Dr. Burdick also stated that there is research showing that there is a cumulative burden of cognitive impairment as the disorder progresses and more episodes occur. While less is known regarding the effects of associated factors such as sleep dysregulation and substance use, Dr. Burdick stated that it is likely that they also contribute to cognitive problems associated with the condition.

Dr. Harvey then asked Dr. Burdick a question: In your clinical experience, what’s the best way to assess neurocognitive deficits in patients with bipolar disorder and schizophrenia?

Dr. Burdick stated that, from a research standpoint, there are several batteries that have been put forth as being useful in identifying both the presence and severity of deficits, including the MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) Consensus Cognitive Battery and the more bipolar-specific ISBD-BANC (International Society for Bipolar Disorders-Battery for Assessment of Neurocognition). She explained that there is no real consensus regarding which batteries to use in research and, in particular, in the clinical realm, which she believes is an area of significant unmet need. Dr. Harvey said he believes that the best way to assess cognitive functioning in a clinical setting is neuropsychological testing, which can be abbreviated to key subcomponents. He also stated that interview-based assessments administered by trained interviewers can also yield useful information.

Dr. Harvey continued the forum by discussing cognitive impairment and remediation in schizophrenia, noting that cognitive impairment has been identified as a key feature of the disorder that manifests early (including in the prodromal phase prior to the formal diagnosis), is relatively stable throughout the course of the disorder, and is relatively consistent across patients of different intelligence levels. This impairment can make it difficult for individuals with schizophrenia to perform everyday tasks and engage in social interactions, but there are no FDA-approved treatments to address these cognitive deficits. Dr. Harvey stated that one of the options to address this impairment is cognitive remediation, along with other psychosocial support programs. He explained that cognitive remediation therapy (CRT) has been a topic of research since the 1960s, and can be delivered both via computer or in-person. Research has shown that the different modes of CRT delivery (computer vs. traditional) can be equally effective.

Dr. Harvey elaborated that CRT uses scientific principles of learning with the goal of improving functional outcomes, and he stated that the treatment is more effective when provided in a context (formal or informal) that provides support and opportunity for improving everyday functioning. He explained that CRT can range from solo drill-and-practice exercises to facilitator-guided group sessions and strategy coaching, and can be linked to a larger psychosocial rehabilitation approach. He noted CBT (Cognitive Behavioral Therapy) is not the same as CRT (Cognitive Remediation Therapy); CRT is directly targeted at cognition, CBT is targeted at attitudes and ways of thinking that are of a more complex and higher order than the skills targeted with CRT.

He then presented data from a short-term, randomized study of computerized CRT combined with functional skills training (other conditions provided 12 weeks of one treatment or the other, paired with 12 weeks of treatment as usual) showing that individuals who received the combined therapy showed the most significant improvements in everyday functioning after the intervention and demonstrated increased benefits 12 weeks post-intervention.

Dr. Harvey also discussed social cognition in schizophrenia, which has increasingly been a focus of research because it has been closely linked to functional impairment associated with the disorder, possibly more than neurocognition has. He defined social cognition as the mental operations underlying social interactions, including the ability to perceive, interpret, and respond to the intentions and dispositions of others. He cited a recent meta-analysis that showed that social cognition may improve in response to certain structured training interventions, resulting in improvements in real world social outcomes and functioning. Social cognition studies in schizophrenia is a growing field.

Dr. Burdick then asked Dr. Harvey the following question: In your clinical experience, have you found cognitive remediation or social cognitive interventions to be effective for most patients?

Dr. Harvey responded by saying that CRT definitely improves cognitive performance but requires effort and persistence, and some individuals with schizophrenia are unable to mount the effort required to train themselves as much as they need to. He said that it’s important to keep in mind that when CRT is combined with a psychosocial intervention, there is consistent empirical evidence of substantial real-world gains, even in fairly short-term time periods. Dr. Burdick agreed and stated that, though that there has not been enough research on which specific interventions are most effective with certain subgroups or individuals, there is evidence to suggest it is a helpful intervention overall.

The forum concluded with a question and answer session:

  • Are there physiological changes in the brain that occur when moods shift or when an individual experiences a state of psychosis?

Dr. Burdick: She stated that the question isn’t one the field has fully addressed to date, but that there are some hypotheses about what might go on in the brain during acute episodes, specifically involving bipolar disorder, such as changes in inflammatory markers (e.g., an upregulation of pro-inflammatory cytokines) during episodes of acute mania or (to a lesser extent) acute depression. She added that the data aren’t entirely consistent, but that this mechanism could represent an explanation for the cumulative cognitive burden that is observed after multiple episodes occur for individuals with bipolar disorder. Similarly, for schizophrenia, some have proposed that acute episodes of psychosis should be termed as “neurotoxic,” but the hypothesis has not been well-supported as yet.

Dr. Harvey: He stated that there is a series of studies that have shown that there are critical periods, at the beginning of the illness and then later in life, when psychosis may have its greatest neurotoxic effect. Those studies showed that, over time, when patients stopped their medication and relapsed early in the course of their illness before getting re-treated, there is a measurable loss of gray matter, while patients who take medication consistently and do not relapse do not experience such neurological changes. He also cited studies from his own research group showing that older patients with treatment-resistant schizophrenia (who don’t respond well to antipsychotic medication) are at highest risk for cognitive decline over a five-year period.

  • Does a patient with a mental health disorder develop dementia earlier than the general population?

Dr. Harvey: He first specified that dementia is a behavioral term describing cognitive impairment and impairment in everyday functioning. In people without schizophrenia, this would represent a change in functioning, but people with schizophrenia are often impaired enough to meet those criteria earlier. He stated that there is a subgroup of patients with lifetime poor functional outcomes, who do show changes in their cognitive ability over time, but schizophrenia in and of itself does not increase the risk of dementia-related conditions such as Alzheimer’s disease. Therefore, he stated, if a practitioner has a patient with schizophrenia who experiences rapid cognitive decline, that patient should be further evaluated for cortical dementia.

Dr. Burdick: She added that the data are similar for patients with bipolar disorder, such that higher rates of Alzheimer’s and other types of dementia have not been observed, and that the declines in cognitive functioning she mentioned in answer to the previous question are not tied to the aging process, but to the course of the illness itself. For this reason, providers should try to help patients reduce the number of acute episodes they experience, in order to preserve cognitive functioning and prevent decline.

  • Are you aware of any specific counseling techniques that can aid a person with these types of impairments when they need to engage in decision-making?

Dr. Harvey: He stated that it is clear that older people with schizophrenia have impaired decisional capacity. He stated that it is important to assess decisional capacity in individuals with severe mental illness, as it is related to judgment, memory, and organization. Decisional capacity and the related aspects of functioning can be targets of cognitive remediation, but he stated that there is not sufficient data to show this is an effective strategy yet.

Dr. Burdick: She added that the data is similar for individuals with bipolar disorder. With regard to decision making, she observed that the one difference is the more episodic nature of the impairment in bipolar disorder compared with schizophrenia, such that individuals experiencing acute mania show highly impaired decision making. Therefore, paying close attention to the course of the illness and the affective symptoms may help in alleviating some of that impairment.

  • Who is the correct health care professional to go to if you want to have a teenager undergo a comprehensive neurocognitive assessment?

Dr. Burdick: She stated that the appropriate professional is a clinical neuropsychologist. Depending on the age of the individual and the other presenting issues, it may be preferable to choose a provider with more of a psychiatric background as opposed to a more neurological background.

  • Who does these sorts of therapies and where do we direct our patients for this, and will insurance cover it?

Dr. Harvey: He stated that cognitive remediation therapy is offered at a number of specialty clinics. He offered some examples, such as services at Columbia University and the University of Miami, and added that veterans’ hospitals provide comprehensive vocational rehabilitation services. He explained that insurance generally covers cognitive remediation for traumatic brain injuries but not severe mental illness. However, rehabilitation services usually are covered (depending on the policy), and cognitive remediation is often part of a rehabilitation service.

  • Could you provide an example of the computerized cognition programs available?

Dr. Harvey: He explained that they are trying to avoid discussion of commercially available programs, but the system that has the most empirical support, including from randomized controlled trials, is the Posit Science Brain Fitness Intervention. He stated that this is only one part of the intervention, and research has shown that people with schizophrenia can self-administer cognitive remediation, but that activity alone does not improve their everyday functioning.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/looking-beyond-mood-psychosis-a-focus-on-neurocognition/

On June 7, 2017, two experts in the field of neuropsychology presented a virtual forum on cognitive impairment in individuals with schizophrenia and bipolar disorder. Katherine Burdick, PhD, is an Associate Professor of Psychiatry at Harvard Medical School. She also serves as the Director of Mood and Psychosis Research and Director of Psychology Research at Brigham and Women’s Hospital. Philip D. Harvey, PhD, is the Leonard M. Miller Professor of Psychiatry and director of the Division of Psychology at the University of Miami Miller School of Medicine. He is also a VA Senior Health Scientist. Drs. Burdick and Harvey are compensated contractors of Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of this virtual forum were to:

  • Discuss the incidence and functional consequences of neurocognitive deficits in bipolar disorder and schizophrenia
  • Explore the use of cognitive remediation for patients with schizophrenia
  • Review and highlight the potential benefits of social cognitive interventions for those with schizophrenia

Dr. Burdick began the forum by explaining the history of neurocognition in bipolar disorder, beginning in 1898 with Emil Kraepelin’s division of psychosis into two separate conditions: dementia praecox (now termed schizophrenia) and manic-depressive psychosis (now termed bipolar disorder). The distinguishing factor was the belief that there was complete remission between affective episodes for patients with bipolar disorder, leaving schizophrenia as the only severe mental illness considered to have significant cognitive impairment. This resulted in very few papers being published on the topic of cognitive impairment in bipolar disorder during the 20th century, although over 200 papers on cognitive impairment in schizophrenia were published in the same time period. However, in the last two decades, far more study has been devoted to understanding the nature of cognitive impairment in bipolar disorder.

Dr. Burdick stated that the increase in research on that topic has grown from new understanding of the diagnostic overlap between bipolar disorders and other mental illnesses, including schizophrenia. She explained that although bipolar disorder is more episodic in nature when compared to the more chronic course of schizophrenia, complete functional recovery between episodes is not the norm for individuals with bipolar disorder. In addition, she described that there is symptomatic overlap between the two disorders, in that approximately 60% of individuals with bipolar disorder experience acute psychotic symptoms during manic and depressive episodes. Further, individuals with schizophrenia often exhibit affective symptoms, including full episodes of depression and, less commonly, mania. The interest in this overlap has been fueled by research showing that schizophrenia and bipolar disorder have shared neurobiological and genetic underpinnings, in that both are highly heritable, and that there is shared genetic risk. Because cognitive impairment represents one of the features present across several mental illnesses (including autism and attention deficit/hyperactivity disorder), Dr. Burdick stated that it may help to understand that those genetic factors may confer risk for multiple disorders, as opposed to just one disorder, via their effects on normal brain function measured at the level of cognition.

Dr. Burdick then addressed the idea of heterogeneity within specific disorders, including levels of functional impairment. She suggested that one useful way to understand that heterogeneity may be to examine cognitive functioning. She presented data showing functioning across seven cognitive domains (speed of processing, attention, working memory, verbal learning, visual learning, reasoning and problem-solving, and social cognition), and revealing that the pattern of deficits observed for individuals with bipolar disorder or schizophrenia were similar to each other and distinct from the pattern for healthy individuals. She continued to explain that as a group, individuals with schizophrenia tend to show more significant cognitive impairment than individuals with bipolar disorder. However, she noted that the data fail to take into account the substantial within-group heterogeneity, particularly among individuals with bipolar disorder. Approximately 60% of individuals with bipolar disorder who exhibit symptoms of psychosis also exhibit significant cognitive impairment, compared with approximately 40% of individuals with bipolar disorder who do not show symptoms of psychosis (and 85% of individuals with schizophrenia). She concluded by explaining that while approximately half of individuals with bipolar disorder show little, if any, cognitive impairment, a subgroup of individuals with bipolar disorder experience cognitive impairment that is as severe as that which is typically observed in individuals with schizophrenia.

Dr. Burdick stated that research has shown that cognitive deficits have a profound impact on functioning, primarily for schizophrenia, and to a lesser extent, for bipolar disorder. Such deficits are more strongly linked to community functioning than positive symptoms of schizophrenia such as hallucinations and delusions. In addition, medications to treat schizophrenia tend to ameliorate positive symptoms but do not fully address cognitive impairment at this time, something Dr. Burdick asserted is necessary, including for affected patients with bipolar disorder. This need can be seen in light of a recent meta-analysis that showed equally strong associations between cognitive ability and community functioning among patients with bipolar disorder or schizophrenia. Dr. Burdick suggested that effective cognitive remediation therapy could help impaired individuals with these disorders.

Dr. Burdick reviewed factors that contribute to the cognitive impairment observed in bipolar patients, including but not limited to the mood state, in that many patients who are not in the midst of acute episodes continue to exhibit deficits. Dr. Burdick also stated that there is research showing that there is a cumulative burden of cognitive impairment as the disorder progresses and more episodes occur. While less is known regarding the effects of associated factors such as sleep dysregulation and substance use, Dr. Burdick stated that it is likely that they also contribute to cognitive problems associated with the condition.

Dr. Harvey then asked Dr. Burdick a question: In your clinical experience, what’s the best way to assess neurocognitive deficits in patients with bipolar disorder and schizophrenia?

Dr. Burdick stated that, from a research standpoint, there are several batteries that have been put forth as being useful in identifying both the presence and severity of deficits, including the MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) Consensus Cognitive Battery and the more bipolar-specific ISBD-BANC (International Society for Bipolar Disorders-Battery for Assessment of Neurocognition). She explained that there is no real consensus regarding which batteries to use in research and, in particular, in the clinical realm, which she believes is an area of significant unmet need. Dr. Harvey said he believes that the best way to assess cognitive functioning in a clinical setting is neuropsychological testing, which can be abbreviated to key subcomponents. He also stated that interview-based assessments administered by trained interviewers can also yield useful information.

Dr. Harvey continued the forum by discussing cognitive impairment and remediation in schizophrenia, noting that cognitive impairment has been identified as a key feature of the disorder that manifests early (including in the prodromal phase prior to the formal diagnosis), is relatively stable throughout the course of the disorder, and is relatively consistent across patients of different intelligence levels. This impairment can make it difficult for individuals with schizophrenia to perform everyday tasks and engage in social interactions, but there are no FDA-approved treatments to address these cognitive deficits. Dr. Harvey stated that one of the options to address this impairment is cognitive remediation, along with other psychosocial support programs. He explained that cognitive remediation therapy (CRT) has been a topic of research since the 1960s, and can be delivered both via computer or in-person. Research has shown that the different modes of CRT delivery (computer vs. traditional) can be equally effective.

Dr. Harvey elaborated that CRT uses scientific principles of learning with the goal of improving functional outcomes, and he stated that the treatment is more effective when provided in a context (formal or informal) that provides support and opportunity for improving everyday functioning. He explained that CRT can range from solo drill-and-practice exercises to facilitator-guided group sessions and strategy coaching, and can be linked to a larger psychosocial rehabilitation approach. He noted CBT (Cognitive Behavioral Therapy) is not the same as CRT (Cognitive Remediation Therapy); CRT is directly targeted at cognition, CBT is targeted at attitudes and ways of thinking that are of a more complex and higher order than the skills targeted with CRT.

He then presented data from a short-term, randomized study of computerized CRT combined with functional skills training (other conditions provided 12 weeks of one treatment or the other, paired with 12 weeks of treatment as usual) showing that individuals who received the combined therapy showed the most significant improvements in everyday functioning after the intervention and demonstrated increased benefits 12 weeks post-intervention.

Dr. Harvey also discussed social cognition in schizophrenia, which has increasingly been a focus of research because it has been closely linked to functional impairment associated with the disorder, possibly more than neurocognition has. He defined social cognition as the mental operations underlying social interactions, including the ability to perceive, interpret, and respond to the intentions and dispositions of others. He cited a recent meta-analysis that showed that social cognition may improve in response to certain structured training interventions, resulting in improvements in real world social outcomes and functioning. Social cognition studies in schizophrenia is a growing field.

Dr. Burdick then asked Dr. Harvey the following question: In your clinical experience, have you found cognitive remediation or social cognitive interventions to be effective for most patients?

Dr. Harvey responded by saying that CRT definitely improves cognitive performance but requires effort and persistence, and some individuals with schizophrenia are unable to mount the effort required to train themselves as much as they need to. He said that it’s important to keep in mind that when CRT is combined with a psychosocial intervention, there is consistent empirical evidence of substantial real-world gains, even in fairly short-term time periods. Dr. Burdick agreed and stated that, though that there has not been enough research on which specific interventions are most effective with certain subgroups or individuals, there is evidence to suggest it is a helpful intervention overall.

The forum concluded with a question and answer session:

  • Are there physiological changes in the brain that occur when moods shift or when an individual experiences a state of psychosis?

Dr. Burdick: She stated that the question isn’t one the field has fully addressed to date, but that there are some hypotheses about what might go on in the brain during acute episodes, specifically involving bipolar disorder, such as changes in inflammatory markers (e.g., an upregulation of pro-inflammatory cytokines) during episodes of acute mania or (to a lesser extent) acute depression. She added that the data aren’t entirely consistent, but that this mechanism could represent an explanation for the cumulative cognitive burden that is observed after multiple episodes occur for individuals with bipolar disorder. Similarly, for schizophrenia, some have proposed that acute episodes of psychosis should be termed as “neurotoxic,” but the hypothesis has not been well-supported as yet.

Dr. Harvey: He stated that there is a series of studies that have shown that there are critical periods, at the beginning of the illness and then later in life, when psychosis may have its greatest neurotoxic effect. Those studies showed that, over time, when patients stopped their medication and relapsed early in the course of their illness before getting re-treated, there is a measurable loss of gray matter, while patients who take medication consistently and do not relapse do not experience such neurological changes. He also cited studies from his own research group showing that older patients with treatment-resistant schizophrenia (who don’t respond well to antipsychotic medication) are at highest risk for cognitive decline over a five-year period.

  • Does a patient with a mental health disorder develop dementia earlier than the general population?

Dr. Harvey: He first specified that dementia is a behavioral term describing cognitive impairment and impairment in everyday functioning. In people without schizophrenia, this would represent a change in functioning, but people with schizophrenia are often impaired enough to meet those criteria earlier. He stated that there is a subgroup of patients with lifetime poor functional outcomes, who do show changes in their cognitive ability over time, but schizophrenia in and of itself does not increase the risk of dementia-related conditions such as Alzheimer’s disease. Therefore, he stated, if a practitioner has a patient with schizophrenia who experiences rapid cognitive decline, that patient should be further evaluated for cortical dementia.

Dr. Burdick: She added that the data are similar for patients with bipolar disorder, such that higher rates of Alzheimer’s and other types of dementia have not been observed, and that the declines in cognitive functioning she mentioned in answer to the previous question are not tied to the aging process, but to the course of the illness itself. For this reason, providers should try to help patients reduce the number of acute episodes they experience, in order to preserve cognitive functioning and prevent decline.

  • Are you aware of any specific counseling techniques that can aid a person with these types of impairments when they need to engage in decision-making?

Dr. Harvey: He stated that it is clear that older people with schizophrenia have impaired decisional capacity. He stated that it is important to assess decisional capacity in individuals with severe mental illness, as it is related to judgment, memory, and organization. Decisional capacity and the related aspects of functioning can be targets of cognitive remediation, but he stated that there is not sufficient data to show this is an effective strategy yet.

Dr. Burdick: She added that the data is similar for individuals with bipolar disorder. With regard to decision making, she observed that the one difference is the more episodic nature of the impairment in bipolar disorder compared with schizophrenia, such that individuals experiencing acute mania show highly impaired decision making. Therefore, paying close attention to the course of the illness and the affective symptoms may help in alleviating some of that impairment.

  • Who is the correct health care professional to go to if you want to have a teenager undergo a comprehensive neurocognitive assessment?

Dr. Burdick: She stated that the appropriate professional is a clinical neuropsychologist. Depending on the age of the individual and the other presenting issues, it may be preferable to choose a provider with more of a psychiatric background as opposed to a more neurological background.

  • Who does these sorts of therapies and where do we direct our patients for this, and will insurance cover it?

Dr. Harvey: He stated that cognitive remediation therapy is offered at a number of specialty clinics. He offered some examples, such as services at Columbia University and the University of Miami, and added that veterans’ hospitals provide comprehensive vocational rehabilitation services. He explained that insurance generally covers cognitive remediation for traumatic brain injuries but not severe mental illness. However, rehabilitation services usually are covered (depending on the policy), and cognitive remediation is often part of a rehabilitation service.

  • Could you provide an example of the computerized cognition programs available?

Dr. Harvey: He explained that they are trying to avoid discussion of commercially available programs, but the system that has the most empirical support, including from randomized controlled trials, is the Posit Science Brain Fitness Intervention. He stated that this is only one part of the intervention, and research has shown that people with schizophrenia can self-administer cognitive remediation, but that activity alone does not improve their everyday functioning.

Key Messages

  • This study measured rates of medical illnesses in patients with bipolar disorder (BD) and assessed potential associations between medical disease burden and the clinical course of BD.
  • Compared with controls, patients with BD had significantly higher rates of asthma, type 2 diabetes mellitus, elevated lipid levels, epilepsy, gastric ulcers, hypertension, kidney disease, osteoarthritis, and thyroid disease (all P < 0.001). BD-related characteristics that best predicted the presence of a high burden of medical illness included having mood episodes with a typically acute onset and having a lifetime history of anxiety disorder, attempted suicide, or rapid cycling.
  • Knowledge of the risks of medical comorbidities in individuals with BD may help to improve diagnosis and management approaches, ultimately leading to better physical- and mental-health outcomes.

Key Messages

  • This study assessed the prevalence of comorbid anxiety and explored risk factors that contribute to anxiety symptoms in patients with depression, bipolar disorder, and schizophrenia spectrum disorders.
  • Overall, in the 3 diagnostic subgroups, 2−55.6% of patients reported experiencing anxiety frequently or constantly and 41.2−43.8% felt anxiety as severe or extreme; anxiety and anxiety-related avoidance behavior were less frequent in patients with schizophrenia spectrum disorders than in patients with mood disorders.
  • In all subgroups, anxiety symptoms correlated most strongly with symptoms of depression and neuroticism.

Key Messages

  • Psychiatrist−patient shared understanding has been associated with improved therapeutic relationships in the treatment of psychosis. At the time of publication, this was the first study to assess an intervention for psychiatrists aimed at enhancing their communication with patients with psychosis.
  • Twenty-one psychiatrists were randomized to receive a 4-week communication training or no training. The primary endpoint was “self-repair,” a characteristic of speech that is indicative of engagement with the patient and of efforts on the speaker’s part to establish shared understanding with the patient.
  • Assessment approximately 5 months after the intervention showed significant improvements in the number of self-repairs per 1000 words (adjusted mean difference 6.4 self-repairs per 1000 words, P < 0.011 vs control group), psychiatrists’ self-confidence about communicating with patients with psychosis (mean increase of 1.7 points on 0–10 scale, P < 0.01), and the quality of the therapeutic relationship, as assessed by participating psychiatrists (mean difference of 0.20 points on the Scale To Assess Therapeutic Relationship [STAR], P = 0.022) and patients (mean difference: 0.21, P = 0.043).
  • The authors concluded that shared understanding is important for improving the therapeutic relationship in the treatment of psychosis and can be targeted in training.

Key Messages

  • Bipolar disorder (BD) is a chronic illness with inter-episodic periods that are associated with frequent persistence of residual symptoms, such as residual depression symptoms,
    cognitive impairment, or emotional dysregulation that can cause risk of recurrence and long-term disability.
  • Modern treatments have not always provided a favorable outcome in BD patients as the course of illness still involves multiple recurrences and impaired psychosocial functioning.

Key Messages

  • Inflammation and neuroimmune mechanisms may play a role in the pathophysiology of bipolar disorder.
  • Results reported elevations of select cerebrospinal (CSF) markers of neuroinflammation and neuronal injury were not associated with clinical outcomes in bipolar patients, however, may be involved in the immune process and reflect the vulnerable state of this patient population.

Key Messages

  • The initial presentation of bipolar disorder (BD) is often depression which may lead to the diagnosis of major depressive disorder (MDD). Once manic symptoms are present, the diagnosis is converted to BD.
  • Research has shown that mean time from a diagnosis of MDD to BD is approximately 10 years, during which time optimal treatment is often not prescribed.
  • Studies have suggested that patients who have been diagnosed with MDD are more likely to be diagnosed with BD if they had an early onset of depression, are unresponsive to antidepressant treatment, and have a family history of affective disorders.

Behavioral health home enrollees had fewer total psychiatric hospitalizations than non- enrollees among individuals receiving treatment for a primary psychotic disorder or bipolar disorder. When pre- and post-intervention utilization was compared, the behavioral health home enrollees’ total emergency room visits were reduced compared to their non-enrolled counterparts, whose emergency room utilization increased. There were no differences in medical hospitalizations between the two groups.

These findings were reported in “Mind the Gap: Developing an Integrated Behavioral Health Home to Address Health Disparities in Serious Mental Illness” by Miriam C. Tepper, M.D.; Alexander M. Cohen, M.S.W., M.P.H.; Ana M. Progovac, Ph.D.; Andrea Ault-Brutus, Ph.D.; H. Stephen Leff, Ph.D., Brian Mullin, B.S.; Carrie M. Cunningham, M.D.; M.P.H.; and Benjamin Lê Cook, Ph.D., M.P.H. The researchers compared emergency room, psychiatric hospital, and medical hospital utilization changes between 424 ambulatory behavioral health home enrollees and a control group of 1,521 non- enrollees receiving usual outpatient mental health and general medical care. Included in the study were individuals receiving treatment for a primary psychotic disorder or bipolar disorder. Data was collected from electronic health records in a Massachusetts urban safety-net institution during a pre-intervention 12-month period, extending from September 2014 to August 2015, and a post-intervention 12-month period, extending from September 2015 to August 2016.

Enhancements in the behavioral health home intervention included on-site medical care, health promotion, support for care coordination and transitions, and peer-to-peer engagement. Health home enrollees’ care also included improved electronic health record (EHR) functionality such as provider alerts for patient transactions through emergency room or inpatient units, a registry for monitoring individuals’ health status and service delivery, and acute care discharge reports to facilitate follow-up care. Three new positions — a medical nurse practitioner, a care manager, and a program manager — supplemented existing staff in the behavioral health home. Behavioral health home clinic practice shifted to fully integrated team-based care, group therapy modalities, chronic disease screening and monitoring, social inclusion, and population management. Usual care for the control group included psychotherapy and psychopharmacology without enhanced EHR functionality.

Additional findings were as follows:

  • When the control and treatment groups were compared overall, the total number of ED visits per capita decreased significantly among the treatment group, a reduction of 1.45 visits to 1.19 visits, compared to the control group, who had an increase from 0.99 visits to 1.16 visits.
  • Total psychiatric hospitalizations per capita declined for the treatment group from 0.22 to 0.10, but did not change for the control group, who remained stable at 0.15 hospitalizations per capita.
  • The number of psychiatric hospitalizations per capita among those with at least one hospitalization decreased significantly for the treatment group, from 1.78 to 1.22, compared with the control group, who had an increase from 1.31 to 1.43 visits.
  • There was no significant difference in general medical hospitalizations between pre- and post- intervention time periods for the two groups.

The study’s authors suggest that the improvements in emergency room and psychiatric hospital utilization among behavioral health home enrollees may stem from the social support and connectedness provided by the health homes. Noting that the reduced utilization was driven by a decrease in the visits per individual rather than the number of individuals receiving care, the authors propose that health homes may help to stabilize users of acute services.

For more information, contact: H. Stephen Leff, Ph.D., Psychologist, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104; 800- 879-2467; Email: leff@email.chop.edu

Key Messages

  • The authors conducted a post hoc analysis of 10 randomized, placebo-controlled trials that evaluated the value of early partial symptomatic improvement for predicting later response or remission in patients with bipolar depression.
  • A total of 60% of patients receiving an active drug and 47% of those receiving placebo showed early improvement, defined as a reduction of ≥20% in depression symptom severity within 2 weeks.
  • Early improvement predicted response and remission at 7−10 weeks with moderate sensitivity.
  • Lack of early improvement in depressive symptoms was a stronger predictive factor for a subsequent lack of response or remission.
  • The authors concluded that absence of improvement during the first 2 weeks of treatment may be a reliable indicator of eventual non-response to treatment, offering clinicians the opportunity to make an early change to treatment.

Key Messages

  • This systematic review and meta-analysis measured syndromal recovery, symptomatic recovery, and recurrence rates in patients with bipolar disorder (BD) following a first episode of mania.
  • A total of 8 articles met inclusion criteria, representing 734 evaluable patients with BD type I (BD-1). Syndromal recovery rate was 77.4% at 6 months, and 84.2% at 1 year after a first manic episode. Symptomatic recovery rate at 1 year was considerably less (62.1%), and 41.0% and 59.7% of patients experienced recurrence after 1 and 4 years, respectively. A strong association between being at a younger age at first episode and increased risk of recurrence after 1 year was also identified.
  • Although high, the recurrence rate following a first episode of mania appeared to be somewhat lower than that observed in cohorts of patients with BD-1 at varying stages of illness. Subsequently, the authors suggested that the period following a first episode may be a critical point at which to provide intensive intervention strategies.

The Mood Disorder Questionnaire is a brief self-administered tool to screen (not diagnose) for bipolar disorder. It takes about five minutes to complete and should be followed by a comprehensive evaluation. The MDQ is available to all members of the PsychU community for download.

This scale is available with the permission of RMA Hirshfeld, MD.

A group of researchers from the United Kingdom and Sweden developed a tool to predict the risk of violence in people with schizophrenia spectrum or bipolar disorder. A report “Identification of low risk of violent crime in severe mental illness with a clinical prediction tool (Oxford Mental Illness and Violence tool [OxMIV]): a derivation and validation study” provides the details of how the tool was developed and tested, as well as results of the tool’s ability to predict violence. The study was published online May 4, 2017 by Lancet Psychiatry; the authors are Seena Fazel, Achim Wolf, Henrik Larsson, Paul Lichtenstein, Susan Mallett, and Thomas R. Fanshawe.

When people with mental illness are involved in violent acts, it contributes to stigma and increases their risk of entering prison.

This study is important because research shows that five to ten percent of people with schizophrenia or bipolar disorder may commit a violent crime within five years of their diagnosis. The authors believe that when people with mental illness are involved in violent acts, it contributes to stigma against them and increases their risk of entering prison; thus predicting the risk of violence may contribute to their wellbeing.

Various structured risk assessment tools are already being used, such as checklists and decision trees, to stratify individuals into low- or high-risk groups. The information is used to target resources and to tailor treatment and risk management strategies. However the authors believe tools currently in use are only low-to-moderately accurate, use poor reporting standards, and rely on inconsistent definitions of high risk. In addition the tools were not developed using individuals with psychosis or take too long to implement. The researchers agreed with the recommendation of the American Psychiatric Association taskforce that an easier and simpler tool to predict violence in people with schizophrenia or bipolar disorder was needed. The researchers named the newly developed measure the Oxford Mental Illness and Violence [OxMIV] tool.

Researchers conducted a study in Sweden with 75,158 participants who were 15–65 years old with a diagnosis of severe mental illness (schizophrenia spectrum or bipolar disorder). Collectively the cohort experienced 574,018 inpatient or outpatient services (referred to as patient episodes). Episodes occurring from January 1, 2001 to December 31, 2008 were included in the analysis, and only one episode was selected at random as the index episode for each participant. Patients were tracked from the day of their index episodes until the first time they committed a violent act, died, emigrated, or reached the 12-month follow-up period designated for the study.

Researchers developed an algorithm for a 16-item predictive tool using information obtained for each patient on previous criminal history, sociodemographic information, psychiatric diagnoses, dispensed medications, receipt of welfare or disability benefits, and other clinical risk factors (e.g. previous alcohol or drug disorders, hospitalizations, diagnosis of bipolar or schizophrenia, or self-harm) through linkage with population-based registries. In addition researchers identified family members through the Multi-Generation Register to include in the analysis data on parental drug or alcohol use, parental violent crime, sibling violent crime, parental psychiatric hospitalization, parental suicide, and recent death of a family member (within six months preceding discharge), as well as if the patient shared a household with any children. Conviction data were used for the previous criminal history component because the Swedish criminal code does not take into account a mental disorder or plea bargaining when determining guilt. Violent acts were defined as homicide, assault, robbery, arson, any sexual offence (rape, sexual coercion, child molestation, indecent exposure, or sexual harassment), or illegal threats and harassment.

The primary outcome for the analysis was a violent act within 12 months of the patient episode. Researchers used logistic regression to analyze the data, excluding covariates with more than 30% missing values. However, missing values for treatments were imputed because this information was not available through the Prescribed Drug Register until it was implemented in 2006. Researchers felt this explanation justified imputing the data. The predictive accuracy of the tool was determined through bootstrapping. Validation of the tool tested for:

  • Ability of the model to distinguish between those who do and do not commit a violent crime
  • Model goodness of fit—whether or not the predicted risk is systematically off target
  • How well a model rightly or wrongly reclassifies patients compared with alternative models
  • Sensitivity and specificity based on a 5% threshold of predicted probability

The model can predict with 99.5% accuracy that a patient is unlikely to commit a violent crime, but the model is only 11% accurate in predicting that a patient will commit a violent crime.

The analysis showed that the strongest predictors of violent offending within 12 months of the index episode were a past violent crime conviction, male sex, and age, with the probability of violent offending highest for the youngest population groups. Personal income and receipt of social benefits were weak predictors of violent offending. The model can predict with 99.5% accuracy that a patient is unlikely to commit a violent crime, but the model is only 11% accurate in predicting that a patient will commit a violent crime. For this reason the OxMIV may be most beneficial in screening for low violence risk in general adult psychiatric services. Additionally, because the tool’s sensitivity was 62% (with a 5% threshold), it may be used to group patients into low- and high-risk groups, because nearly two-thirds of all those who do violently offend can be identified.

Finally, the researchers developed a free web calculator which provides both a risk classification (low or high) and a probability of violent offending within the next 12 months.

The authors noted that OxMIV is intended to complement clinical decision making with an evidence-based approach, something they believe is lacking in tools currently being used. The score can be used to guide treatment decisions among patients, caregivers and health care professionals. While OxMIV may be used by any health care professional at any point in a patient’s treatment plan, the authors suggest that only clinical staff administer it with patients because the tool must take into account diagnostic and treatment information.

The authors recommend that future research should assess whether or not use of this prediction model improves outcomes for individuals with severe mental illness by reducing their risk of violent offending.

There are some limitations to the study; e.g., it was validated in only one country, and researchers discovered a miscalibration for individuals at the highest risk of violence, but this was corrected by setting a maximum risk of 20% for all patients. The model does not include risk factors that could be collected during an interview, like specific symptoms, premorbid conduct problems, anger, victimization, and comorbid personality disorder; even though this information could improve the accuracy of the tool, the cost and time to do so is prohibitive. Additionally, they point out that although they used violent crime as the primary outcome, the rate of reported violent crime is low and the risk calculator provides a conservative estimate.

The full text of “Identification of low risk of violent crime in severe mental illness with a clinical prediction tool (Oxford Mental Illness and Violence tool [OxMIV]): a derivation and validation study” was published online May 4, 2017 by Lancet Psychiatry.

During this question and answer session, Paul Cotton, BA, Director of Federal Affairs at the National Committee for Quality Assurance (NCQA), and Elizabeth Arend, MPH, Quality Improvement Advisor at the National Council for Behavioral Health, two experts in initiatives that improve health care quality, respond to unanswered questions from their Virtual Forum entitled “The MACRA Quality Payment Program: What Behavioral Health Care Professionals Should Know.”

You can watch the full recorded video presentation and download the slide deck of the Virtual Forum at https://www.psychu.org/macra-quality-payment-program-behavioral-health-care-professionals-know/.

Between 2005 and 2014, opioid-related hospitalizations increased by 75% among women and by 55% among men. The rate of such hospitalizations among women rose from 127.8 per 100,000 in 2005 to 224.1 per 100,000 in 2014. For men, the rate increased from 145.6 per 100,000 in 2005 to 225.0 per 100,000 in 2014.

During the same time period, the rate of opioid-related emergency department visits increased by 94.8% among women and 103.1% among men. The rate among women rose from 78.6 per 100,000 in 2005 to 153.2 per 100,000 in 2014. For men, the rate increased from 99.9 per 100,000 in 2005 to 202.8 per 100,000 in 2014.

These findings were reported in “Patient Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014” by Audrey J. Weiss, Ph.D.’ Molly K. Bailey; Lauren O’Malley; Marguerite L. Barrett, M.S.; Anne Elixhauser, Ph.D.; and Claudia A. Steiner, M.D., M.P.H. The researchers analyzed data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) Fast Stats online tool. This report builds on an earlier AHRQ Statistical Brief which reported that in 2014, across the states, the rates of opioid-related inpatient stays varied more than five-fold and the rate of opioid-related emergency department visits varied more than ten-fold. This current report presents data on the rate of opioid-related hospital inpatient stays and emergency department visits by patient sex and age group from 2005 to 2014. Findings are presented for the 44 states the District of Columbia that provided inpatient data for 2014.

There was substantial variation across the states variation in the age group with the highest rate of opioid-related inpatient stays. Overall, from 2005 to 2014, the highest rates of opioid-related inpatient stays nationally were among people aged 25 to 44 and those aged 45 to 64 years. Among those ages 25 to 44, the rate rose by 54.5%, from 207.7 per 100,000 to 321.0 per 100,000. Among ages 45 to 64, the rate rose by 64.0%, from 193.6 per 100,000 to 317.4 per 100,000.

Across all states, people aged 25 to 44 years had the highest rate of opioid-related emergency department visits. Among this age group, the rate increased by 109.1%, from 160.8 per 100,000 in 2005 to 336.2 per 100,000 in 2014. The increase was nearly as high, 108.1%, among people ages 44 to 64, although the absolute rates were much lower, at 90.3 per 100,000 in 2005 rising to 187.9 per 100,000 in 2014.

Across all sex and age groups in 2014 opioid-related inpatient stays were lowest in Iowa, Nebraska, Texas, and Wyoming and highest in Massachusetts. Opioid-related emergency department visits were lowest in Arkansas and Iowa and highest in Maryland.

PsychU reported on the earlier AHRQ findings in “Opioid-Related Hospitalizations Up 64% Nationwide From 2005 To 2014,” which published on February 13, 2017.

For more information, contact: Alison Hunt, Media Contact, Office of Communications and Knowledge Transfer, Agency for Healthcare Research and Quality, 540 Gaither Road, Suite 200, Rockville, Maryland 20850; 301-427-1244; Email: alison.hunt@ahrq.hhs.gov; Website: https://www.ahrq.gov/.

I left our 2017 OPEN MINDS Strategy & Innovation Institute last month with a couple major takeaways. One of them is that making integrated care coordination work – and making any forward movement with collaborative care – is a difficult journey.

This was also the theme of remarks made by Ian A. Shaffer, M.D., MMM, CPE, Vice President & Executive Medical Director of Behavioral Health at Healthfirst, in his opening keynote address, “Keys To Success With Integrated Care Models For Consumers With Complex Behavioral Disorders.” (And reiterated in other sessions on integrated and collaborative care models – see Improving The State Of Collaborative Care, What Health Plans Are Looking For? Hint: It’s Not A Bigger Provider Network, and Think Health Homes Are Only For Medicaid?.)

He presented his work at Healthfirst, which recently implemented transactional integration in one of their programs. The organization, a provider-sponsored health insurance organization that serves more than 1.2 million members in New York, is owned by a number of hospital systems within the downstate area. Of the many consumer populations they serve, Healthfirst operates a Medicaid managed care program specific to consumers with serious mental illness (SMI) and/or a serious substance abuse diagnosis (in New York, these plans are called Health and Recovery Plans, or HARPs).

There were a couple big themes in Dr. Shaffer’s remarks. First, that if specialist provider organizations want the responsibility of care coordination in an integrated market, they are going to need to step outside their traditional “lanes” – and to do that there needs to be more “transactional integration.” This concept means that all team members working with the consumer participates in all aspects of that consumer’s care. Another way of looking at this is, if a consumer has a specific support or medical need when they are meeting with a behavioral health professional or a medical professional, that professional takes care of those issues — even if it isn’t part of their typical role. (For more on this concept, check out, Is ‘Transactional Integration’ The Key To Integration Success?)

The other theme in Dr. Shaffer’s remarks was the challenge of addressing consumer housing needs. Housing is a major limitation to best practice care coordination and Dr. Shaffer described their care coordination team as “competing” to get their consumers in every available slot (see For Supportive Housing, Creativity Required and Is Housing Health Care? for more on the housing issue.)

In his remarks, Dr. Shaffer also discussed the move to value-based payment arrangements – and the challenges for both Healthfirst and its provider organizations. To meet the reporting requirements of the state and optimize their care coordination systems, Healthfirst is in the process of moving to a new electronic health record (EHR) platform. And, for the Healthfirst network provider organizations in the New York HARP initiatives, there are 36 different performance metrics on the table – and the plan is to link six to eight of those metrics to provider organization payments. For enhanced payment, the provider organizations must hit four of the measures.

The evolution of consumer care coordination at Healthfirst is a great example of how the optimal systems are increasingly consumer-centric – with a requirement for a broader understanding of behavioral, medical, and social needs of consumers. And, as care coordination is integrated into health plan clinical operations, fee-for-service case management as a standalone billable clinical service is likely to be replaced with this more integrated care coordination model.

President Donald Trump has nominated Jerome Adams, M.D., Indiana’s State Health Commissioner, as the United States’ new Surgeon General. Adams, if appointed, will replace former Surgeon General Vivek Murthy, M.D., who was fired by the current administration in April.

As Indiana’s health commissioner, Adams led efforts in support of what he believed to be life-saving syringe exchange programs for the state. Previous to accepting his appointment as Indiana’s health commissioner in 2014, Adams had served at the Indiana University School of Medicine as a staff anesthesiologist and assistant professor of anesthesia.

If Adams’ nomination is confirmed by Senate, he will be the second top health official from Indiana to be appointed by the current administration. Adams has long focused on a wide range of health issues, including opioid addiction, infant mortality, and the HIV epidemic.

This was reported by FierceHealthcare on June 30, 2017.

Contact Information: Department of Health & Human Services Office of the Surgeon General, 1101 Wootton Parkway, Rockville, Maryland 20852; (240)-276-8853 ; ashmedia@hhs.gov; www.surgeongeneral.gov

Contact Information: Dr. Jerome M. Adams, M.D., 720 Eskenazi Avenue, Indianapolis, Indiana 46202; (317)-233-7400; jeadams@isdh.in.govwww.in.gov/isdh

Key Messages

  • Tools that would facilitate early diagnosis, intervention, and prevention of new bipolar episodes may be of benefit to patients with bipolar disorder or who may develop bipolar disorder and their healthcare providers.
  • Neurocognitive assessments in family members of patients with bipolar disorder have identified deficits in executive function; response inhibition; verbal memory; learning and fluency; and processing speed that could be used as potential risk markers for developing bipolar disorder.
  • Future studies with large sample sizes and well-defined, controlled populations that examine structural and functional changes in the brain, neurocognitive functioning, and neurochemical modulation may help elucidate biological markers for risk of bipolar disorder.

During this question and answer session, Paul Cotton, BA, Director of Federal Affairs at the National Committee for Quality Assurance (NCQA), and Elizabeth Arend, MPH, Quality Improvement Advisor at the National Council for Behavioral Health, two experts in initiatives that improve health care quality, respond to unanswered questions from their Webinar entitled “The MACRA Quality Payment Program: What Behavioral Health Care Professionals Should Know.”

You can watch the full recorded video presentation and download the slide deck of the Webinar here.

More than 84% of caregivers would like more support with caregiving tasks, particularly from their family. About two-thirds of unpaid caregivers for someone with dementia feel isolated or alone in their situation. More than 40% of caregivers feeling like their efforts were undervalued by their family and/or the person with dementia.

These findings were reported in the topline results of the 2017 “Alzheimer’s and Family Dynamics Survey” by the Alzheimer’s Association. The Alzheimer’s Association commissioned a 15-minute online survey among a sample of 1,502 U.S. adults ages 18 and older. The respondents were split into three groups, based on their caregiver status. The groups included 250 people currently giving care to someone with Alzheimer’s or some other type of dementia, 252 previously having given care to someone with Alzheimer’s and 1,000 having never been caregivers. The survey took place between April 19 and April 25, 2017. An estimated 15 million Americans provide unpaid care for someone with Alzheimer’s or dementia. An estimated 1.5 million people are living with Alzheimer’s or other dementia.

Additional survey findings were as follows:

  • 61% of caregivers say that familial relationships became strained due to caregiving needs.
  • 70% of people worry about being unable to care for themselves or to support themselves financially, but only 24% have planned financially to prepare for any future care needs.
  • 74% of people said they would prefer a paid caregiver in an Alzheimer’s situation, but only 15% have financially planned for one.
  • 20% of those surveyed said they had not discussed mental health care with a spouse or other family member.

The survey respondents who were not currently caregivers for someone with dementia were asked why. About 62% said they do not live close enough to the person with dementia. About 74% said they felt another family member had taken on that responsibility.

For more information, contact:

  • Mike Lynch, Media Contact, Alzheimer’s Association, 225 North Michigan Avenue, Floor 17, Chicago, Illinois 60601-7633; 312-335-4078; Email: mlynch@alz.org
  • Public Relations, Alzheimer’s Association, 225 North Michigan Avenue, Floor 17, Chicago, Illinois 60601-7633; 312-335-4078; Email: media@alz.org

There is a lot of discussion about “collaborative care” – generally referring to integrating behavioral health and primary care services. We’ve certainly written about it a lot in recent months – Collaborative Mental Health & Primary Care Benefit Older Adults With Sub-Clinical Depression, Collaborative Care For Depressed Adolescents Improved Outcomes With Only Minor Cost Increase, and Medicare To Pay For Behavioral Health Delivered By Collaborative Care Teams.

But if the discussion a couple weeks ago at The 2017 OPEN MINDS Strategy & Innovation Institute is any indication, collaborative care is not “smooth sailing” on the front line. During my session, Collaborative Care In Major Depressive Disorder: The Frameworks Model As An Approach, with Heidi Waters, Ph.D., the Director of Outcomes Management at Otsuka Pharmaceutical Development & Commercialization, Inc., the discussion focused on the work needed to make collaborative care models work for consumers and clinical professionals. The participating executives provided a complex picture of the challenges in the field:

1. There are problems in getting primary care professionals (PCPs) to make behavioral health referrals
2. There is a need for improved electronic communication between the PCPs and behavioral health professionals (for example, in a FQHC, behavioral health reports are faxed, scanned, put in consumers electronic medical records – but rarely reviewed)
3. The “warm handoff” process is key to getting consumer acceptance of referrals but doesn’t happen most of the time

While there is almost unanimous endorsement of the concept, the process – from operational design to education to communication – needs work.

The current data support the anecdotal perception of the problems. Only 50% of cases of major depressive disorder (MDD) are identified and often with significant delays. This view is supported by a recent study that found limited use of standardized screening tools – 4.2% Of Adults Receive Depression Screening In Primary Care. And the reasons (and solutions) are many – Poor Depression Screening Is The Challenge — What’s The Solution? and What’s With The 4.2%?.

Collaborative care is a work in progress and many managers need to step back and rethink their processes. Special attention needs paid to the education of – and communication between – stakeholders. This was the focus of the remarks by Dr. Waters. She highlighted the need for alignment and education of health plan managers, clinical professionals, and consumers with approaches like emphasizing consumer wellness and adherence to treatment plans (see Using Technology To Move Human Services From A Program Focus To A Consumer Focus).

Look for more on this issue in the year ahead. Throughout the institute, health plan managers pointed out the important of The Healthcare Effectiveness Data and Information Set (HEDIS) from the National Committee for Quality Assurance, paying particular attention to “Depression Remission or Response for Adolescents and Adults,” a first year measure collected using electronic clinical data systems. This measure assesses the percentage of members 12 years and older who were screened for clinical depression using a standardized tool and, if screened positive, received appropriate follow-up care (see NCQA Proposes Change To HEDIS Measures To Allow Telehealth For 7-Day Follow-Up To Inpatient Psychiatric Discharge). The measure is also being considered as a potential addition for the Centers for Medicare and Medicaid Services (CMS) STARS ratings for Medicare Advantage.

Check out these resources from the PsychU Resource Library:

  1. Poor Depression Screening Is The Challenge — What’s The Solution?
  2. Hot Spotting, Medical Neighborhoods & New Business Opportunities
  3. Is ‘Transactional Integration’ The Key To Integration Success?
  4. Provider/Health Plan Relationships Moving From Dependence To Interdependence

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/engaged-practice-methods-managing-complexity-bipolar-disorder-related-conditions/.

On April 18, 2017, two experts in the field of psychiatry presented a live virtual forum to discuss how providers can manage the complexities of treating bipolar disorder and related conditions using engaged practice. Gary Sachs, MD, was the founder and director of the Bipolar Clinic and Research Program and an Associate Professor of Psychiatry at the Harvard Medical School until 2010. Paul Keck, MD, is the President & Chief Executive Officer of the Lindner Center of HOPE. He is also the Craig and Frances Lindner Professor of Psychiatry and Neuroscience and Executive Vice Chairman of the Department of Psychiatry at the University of Cincinnati College of Medicine. The presenters were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of this virtual forum were to:

  • Discuss the challenges associated with managing the complexity of bipolar disorder and related conditions
  • Review the concept of engaged practice and methods for optimizing work flow
  • Demonstrate the efficacy of utilizing a disease management model for diagnosis

Dr. Keck began the presentation by noting that it is often a substantial challenge to accurately diagnose bipolar disorder and treat it in an outpatient setting. He then asked Dr. Sachs to explain his approach to “engaged practice.” Dr. Sachs replied that he thinks about engaged practice as a common set of principles accepted by the patient, the treatment team, and any involved stakeholders (including payers) in an effort to deliver a better outcome for all involved. He said that this process of collaboration begins with concordance, which is agreeing on the objective of the treatment. After agreement is reached regarding goals, another important factor is provider preparation, including readiness to measure symptoms that will be managed. Another aspect of engaged practice is to identify prospective outcomes that can be used to guide treatment decisions.

Dr. Keck went on to say that time is often the biggest constraint in providing care, explaining that psychiatrists are trying to help as many people as possible during a busy day of practice. He asked Dr. Sachs how he optimizes care using the engaged practice approach. Dr. Sachs stated that in each 15-minute visit, his goal is to be prepared, engage the patient, assess symptoms, provide the intervention, and document the contact. He acknowledged that achieving this is difficult and there is often not time for some of the other activities he would like to do, including taking formal measures of symptoms, providing patient education, and doing care coordination. As a result, the provider is faced with the choice of doing whatever seems possible in the allotted time, scheduling another clinic visit, deferring action and continuing the present treatment, or looking for alternatives. He revealed that he has found that he can achieve a higher level of efficiency using a cloud-based, asynchronous pre-assessment.

Dr. Sachs stated that such asynchronous pre-assessment does not replace interacting with a patient, but instead positions the provider to use their best skills. He then described the pre-assessment, explaining that it begins one to five days prior to the scheduled appointment, when the patient is asked to log on to the system to provide information regarding how they have functioned and what they have experienced since their last appointment. This shifts the time required to gather the information to the patient, who can complete the task at home at a time that is most convenient for them. The provider can then review the information before the patient’s appointment. The computer program has organized and sorted the information into a form that can be quickly scanned by the provider. Therefore, when the provider is interacting with the patient, they have easily translatable and sharable information.

Dr. Sachs offered examples of the information he collects, such as psychoactive substance use, when the patient last menstruated, and scores on formal symptom and quality of life measures, which a computer program can then synthesize and compare against Diagnostic & Statistical Manual of Mental Disorders (DSM) criteria. He explained that by using the information provided, he can interpret the patient’s most recent symptoms and use that to assist in making some diagnostic decisions. Dr. Keck remarked that such information can be used not only to form a working partnership with a patient, but also in offering the provider a longitudinal view of the course of symptoms. Dr. Sachs agreed that this is an advantage of collecting quantitative measures over time, in that it can also show the provider how the patient has responded to certain interventions.

Dr. Sachs stated that there are two main things that are the core of a psychiatrist’s responsibility: diagnosis and treatment. Using a computer system and engaged work flow like the one he described eases the time burden on the provider both for the initial assessment and in collecting integrated measures that enhance provision of care. This saves the provider from having to use appointment time to “interrogate” the patient about symptoms, enabling the provider to use higher level skills, and allowing them to be more present with the patient.

Dr. Keck inquired as to how Dr. Sachs uses the collected information specifically to assist in diagnostic decision-making. Dr. Sachs expressed the opinion that psychiatrists owe it to their patients to provide a formal diagnosis. He explained that DSM field trials showed diagnostic reliability to be modest to poor, and that his system helps to assess symptoms, and improves his own diagnostic confidence. Dr. Keck remarked that the Index of Diagnostic Confidence (a tool described in a 2004 publication by Dr. Sachs) is innovative and useful in its assessment of dimensions not included in the DSM. Dr. Sachs outlined the five dimensions of this tool: age of onset, family history, course of illness, response to treatment, and signs and symptoms. The Index quantifies these dimensions, enabling the provider to score each from 0- 20 in terms of how convincing the characteristic is, and to assess how many dimensions are diagnostically convincing with regard to a specific diagnosis.

Dr. Keck suggested they examine case examples to show how the engaged practice approach works in the real world. During these vignettes, Dr. Sachs pointed out that collecting detailed measures can enable a provider to look past obvious symptoms of depression to, for example, potentially overlooked signs of hypomania. He also stated that the computer display can allow patients a graphic depiction of what they are experiencing, facilitating productive discussion. He explained how to use the Index to gauge confidence in a potential diagnosis, which also helps patient communication.

In summarizing the overall process, Dr. Sachs presented a simple schema for practicing personalized medicine which involves reaching a critical diagnostic decision point, examining available evidence, then offering the patient a menu of reasonable treatment choices framed in terms of efficacy and tolerability. Following the patient’s choice, which is facilitated by education and negotiation with the provider, the chosen intervention is implemented, along with data collection to enable assessment of its effectiveness with this particular patient. Dr. Sachs stated that the process can then return to the decision point phase, with the provider refining the strategy over time to achieve a successful outcome for the patient.

In constructing the menu of treatment choices, Dr. Sachs advised providers to always offer a proven treatment first, and then to refine the menu based on measured results. Dr. Sachs briefly reviewed the different tiers of quality evidence, beginning with double blind placebo-controlled trials with adequate samples. He asserted that psychiatrists should be aware of which treatments are supported by this kind of evidence, and should use those treatments first before moving to treatments with lower levels of evidence if the proven treatment is not effective with a specific patient. He explained the process of clinical empiricism as first taking a retrospective view, both in terms of empirical evidence supporting use of a specific intervention and in terms of the patient’s prior experiences of what was effective for them in treatment. Subsequent decisions would be made based on prospective results unique to the patient.

The question and answer session included these questions from the audience. The presenters’ responses are summarized below.

What is a pearl to distinguish between very high anxiety and hypomania in bipolar disorder?

Dr. Keck began by noting that anxiety disorders are highly comorbid with bipolar disorder. He said that it is therefore important to distinguish whether anxiety is more typical and caused by psychomotor agitation or “code” for mixed affective symptoms including irritability, agitation, and depression. He remarked that it can be useful to use some of the non-DSM dimensions in the Index of Diagnostic Confidence to get a better picture of what might be going on (e.g. family history, onset of illness).

Dr. Sachs suggested that the real pearl might be that it is not possible to accurately distinguish between very high anxiety and mixed affect symptoms, as the two are “mixed together.” He asserted that the best a provider can do is to look at the longitudinal factors in collected data, and if the only time the patient is reporting anxiety is when they are in the midst of an affective episode, then anxiety can be treated, but it might not be as useful to try to parse it from the bipolar illness.

How do you manage a patient who is inconsistent with receiving care?

Dr. Sachs harkened back to the principle of concordance, the degree to which the patient and provider are in agreement about what it is they are trying to accomplish together. He said that when patients are inconsistent, it is important to go back and see whether concordance really exists in that partnership. He stated that he tries to assess why the patient is in treatment, whether consistency is something the patient would like to address, and if the patient believes that the provider-recommended intervention is the way to achieve the desired outcome. He explained that it is not uncommon for patients who score high on a measure of agreeability to initially say yes to interventions but not follow through, and that members of their support system might become angry at them for this inconsistency rather than addressing the disconnect. He said it’s important to build in additional external supports for agreed-upon interventions to achieve goals.

Dr. Keck added that lack of insight is one of the most pernicious symptoms of bipolar disorder and presents one of the biggest challenges to treatment. He stated that the engaged practice model is useful in that it endorses a patient-provider partnership, and he said that he tells his own patients that they are the ultimate decision-makers, so they need to understand why the provider’s recommendations are valid, as well as what the pros and cons are. He also reminds his patients to do three things: take the medication faithfully without missing doses, avoid drugs and alcohol, and get a good night’s sleep. He stated that when patients comply, they tend to do better and see the therapeutic value in what the provider is trying to achieve.

What evidence-based practices have proven most effective in treating bipolar disorder with co-occurring substance abuse?

Dr. Keck stated that there is very little research in this area, so what providers are left with is to make sure they maintain awareness of all the problems a patient is experiencing, meaning that if someone has both bipolar disorder and an addiction to a substance, the provider does not ignore one in favor of the other. In that context, the provider can then apply evidence-based treatment for bipolar disorder in combination with evidence-based treatment for substance abuse or dependence.

Dr. Sachs stated that comorbidity between bipolar disorder and substance abuse/dependence is a frequent presenting issue. He offered that the success rate for treatment is much lower if the provider insists upon abstinence from substance use at the outset of treatment. Instead, he recommends acknowledging that the patient is likely to keep using the substance and then takes a “let’s see what happens” approach to the issue. If the provider also continues to measure related symptoms, they are in the position to point out to the patient how the substance may be affecting progress or lack thereof. If there is evidence that substance use is impeding progress, the provider can then suggest abstinence for a short period (e.g., one to three months) and use the computer-collected measures to assess whether the rate of progress changes. The data can then be presented to the patient as evidence for ongoing abstinence.

How can primary care physicians work with local psychiatrists to ensure they are using established evidence-based tools such as the Young Mania Rating Scale or the PHQ-9?

Dr. Sachs recommended that they start by asking how the psychiatrist is tracking the identified outcome. He stated his opinion that most psychiatrists would be open to using formal report measures to track outcomes, because it will be an asset to treatment and allow doctors to communicate clearly about what’s going on.

What are some of the effective ways to help bipolar individuals seek treatment and get their medications?

Dr. Keck noted that many people with bipolar disorder only seek treatment when they are depressed, which makes the engaged practice model even more important, because patients do worse if the diagnosis of bipolar disorder is missed. He then said that when patients present with a manic episode, it is typically a medical emergency, treated in the hospital. In outpatient settings, it can be challenging when patients present with mixed symptoms or do not recall hypomanic symptoms, which makes gathering information as described in the engaged practice model all the more useful when trying to gain an accurate diagnostic picture.

Dr. Sachs stated that it can be helpful to stay focused on the goals and symptoms that are priorities for the patient, such as improving the quality of sleep, rather than emphasizing a specific diagnosis. He stated that he always shares his diagnostic impression with patients but never requires them to accept a label.

During this question and answer session, William Lopez, MD, CPE, Senior Medical Director, and Lisa Kay, MBA, MSW, Clinical Program Manager on the Clinical Program Development Team focusing on behavioral health integration in medical settings, both from Cigna Healthcare’s Behavioral Health Division, respond to unanswered questions from their Virtual Forum entitled “Identifying Populations For Care Coordination Interventions: The Health Plan Perspective”.

You can watch the full recorded video presentation and download the slide deck of the Virtual Forum at https://www.psychu.org/identifying-populations-care-coordination-interventions-health-plan-perspective/.

During this question and answer session, Drs. Rebecca Roma and Robert Nelson, respond to unanswered questions from their Virtual Forum entitled “Co-Occurrence Of Substance Use Disorders With Mood Disorders & Psychosis”.

You can watch the full recorded video presentation and download the slide deck of the Virtual Forum at https://www.psychu.org/co-occurence-substance-use-disorders-mood-disorders-psychosis/.

Speakers are paid consultants of Otsuka Pharmaceutical Development & Commercialization, Inc.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/engaged-practice-methods-managing-complexity-bipolar-disorder-related-conditions/.

On April 18, 2017, two experts in the field of psychiatry presented a live virtual forum to discuss how providers can manage the complexities of treating bipolar disorder and related conditions using engaged practice. Gary Sachs, MD, was the founder and director of the Bipolar Clinic and Research Program and an Associate Professor of Psychiatry at the Harvard Medical School until 2010. Paul Keck, MD, is the President & Chief Executive Officer of the Lindner Center of HOPE. He is also the Craig and Frances Lindner Professor of Psychiatry and Neuroscience and Executive Vice Chairman of the Department of Psychiatry at the University of Cincinnati College of Medicine. The presenters were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of this virtual forum were to:

  • Discuss the challenges associated with managing the complexity of bipolar disorder and related conditions
  • Review the concept of engaged practice and methods for optimizing work flow
  • Demonstrate the efficacy of utilizing a disease management model for diagnosis

Dr. Keck began the presentation by noting that it is often a substantial challenge to accurately diagnose bipolar disorder and treat it in an outpatient setting. He then asked Dr. Sachs to explain his approach to “engaged practice.” Dr. Sachs replied that he thinks about engaged practice as a common set of principles accepted by the patient, the treatment team, and any involved stakeholders (including payers) in an effort to deliver a better outcome for all involved. He said that this process of collaboration begins with concordance, which is agreeing on the objective of the treatment. After agreement is reached regarding goals, another important factor is provider preparation, including readiness to measure symptoms that will be managed. Another aspect of engaged practice is to identify prospective outcomes that can be used to guide treatment decisions.

Dr. Keck went on to say that time is often the biggest constraint in providing care, explaining that psychiatrists are trying to help as many people as possible during a busy day of practice. He asked Dr. Sachs how he optimizes care using the engaged practice approach. Dr. Sachs stated that in each 15-minute visit, his goal is to be prepared, engage the patient, assess symptoms, provide the intervention, and document the contact. He acknowledged that achieving this is difficult and there is often not time for some of the other activities he would like to do, including taking formal measures of symptoms, providing patient education, and doing care coordination. As a result, the provider is faced with the choice of doing whatever seems possible in the allotted time, scheduling another clinic visit, deferring action and continuing the present treatment, or looking for alternatives. He revealed that he has found that he can achieve a higher level of efficiency using a cloud-based, asynchronous pre-assessment.

Dr. Sachs stated that such asynchronous pre-assessment does not replace interacting with a patient, but instead positions the provider to use their best skills. He then described the pre-assessment, explaining that it begins one to five days prior to the scheduled appointment, when the patient is asked to log on to the system to provide information regarding how they have functioned and what they have experienced since their last appointment. This shifts the time required to gather the information to the patient, who can complete the task at home at a time that is most convenient for them. The provider can then review the information before the patient’s appointment. The computer program has organized and sorted the information into a form that can be quickly scanned by the provider. Therefore, when the provider is interacting with the patient, they have easily translatable and sharable information.

Dr. Sachs offered examples of the information he collects, such as psychoactive substance use, when the patient last menstruated, and scores on formal symptom and quality of life measures, which a computer program can then synthesize and compare against Diagnostic & Statistical Manual of Mental Disorders (DSM) criteria. He explained that by using the information provided, he can interpret the patient’s most recent symptoms and use that to assist in making some diagnostic decisions. Dr. Keck remarked that such information can be used not only to form a working partnership with a patient, but also in offering the provider a longitudinal view of the course of symptoms. Dr. Sachs agreed that this is an advantage of collecting quantitative measures over time, in that it can also show the provider how the patient has responded to certain interventions.

Dr. Sachs stated that there are two main things that are the core of a psychiatrist’s responsibility: diagnosis and treatment. Using a computer system and engaged work flow like the one he described eases the time burden on the provider both for the initial assessment and in collecting integrated measures that enhance provision of care. This saves the provider from having to use appointment time to “interrogate” the patient about symptoms, enabling the provider to use higher level skills, and allowing them to be more present with the patient.

Dr. Keck inquired as to how Dr. Sachs uses the collected information specifically to assist in diagnostic decision-making. Dr. Sachs expressed the opinion that psychiatrists owe it to their patients to provide a formal diagnosis. He explained that DSM field trials showed diagnostic reliability to be modest to poor, and that his system helps to assess symptoms, and improves his own diagnostic confidence. Dr. Keck remarked that the Index of Diagnostic Confidence (a tool described in a 2004 publication by Dr. Sachs) is innovative and useful in its assessment of dimensions not included in the DSM. Dr. Sachs outlined the five dimensions of this tool: age of onset, family history, course of illness, response to treatment, and signs and symptoms. The Index quantifies these dimensions, enabling the provider to score each from 0- 20 in terms of how convincing the characteristic is, and to assess how many dimensions are diagnostically convincing with regard to a specific diagnosis.

Dr. Keck suggested they examine case examples to show how the engaged practice approach works in the real world. During these vignettes, Dr. Sachs pointed out that collecting detailed measures can enable a provider to look past obvious symptoms of depression to, for example, potentially overlooked signs of hypomania. He also stated that the computer display can allow patients a graphic depiction of what they are experiencing, facilitating productive discussion. He explained how to use the Index to gauge confidence in a potential diagnosis, which also helps patient communication.

In summarizing the overall process, Dr. Sachs presented a simple schema for practicing personalized medicine which involves reaching a critical diagnostic decision point, examining available evidence, then offering the patient a menu of reasonable treatment choices framed in terms of efficacy and tolerability. Following the patient’s choice, which is facilitated by education and negotiation with the provider, the chosen intervention is implemented, along with data collection to enable assessment of its effectiveness with this particular patient. Dr. Sachs stated that the process can then return to the decision point phase, with the provider refining the strategy over time to achieve a successful outcome for the patient.

In constructing the menu of treatment choices, Dr. Sachs advised providers to always offer a proven treatment first, and then to refine the menu based on measured results. Dr. Sachs briefly reviewed the different tiers of quality evidence, beginning with double blind placebo-controlled trials with adequate samples. He asserted that psychiatrists should be aware of which treatments are supported by this kind of evidence, and should use those treatments first before moving to treatments with lower levels of evidence if the proven treatment is not effective with a specific patient. He explained the process of clinical empiricism as first taking a retrospective view, both in terms of empirical evidence supporting use of a specific intervention and in terms of the patient’s prior experiences of what was effective for them in treatment. Subsequent decisions would be made based on prospective results unique to the patient.

The question and answer session included these questions from the audience. The presenters’ responses are summarized below.

What is a pearl to distinguish between very high anxiety and hypomania in bipolar disorder?

Dr. Keck began by noting that anxiety disorders are highly comorbid with bipolar disorder. He said that it is therefore important to distinguish whether anxiety is more typical and caused by psychomotor agitation or “code” for mixed affective symptoms including irritability, agitation, and depression. He remarked that it can be useful to use some of the non-DSM dimensions in the Index of Diagnostic Confidence to get a better picture of what might be going on (e.g. family history, onset of illness).

Dr. Sachs suggested that the real pearl might be that it is not possible to accurately distinguish between very high anxiety and mixed affect symptoms, as the two are “mixed together.” He asserted that the best a provider can do is to look at the longitudinal factors in collected data, and if the only time the patient is reporting anxiety is when they are in the midst of an affective episode, then anxiety can be treated, but it might not be as useful to try to parse it from the bipolar illness.

How do you manage a patient who is inconsistent with receiving care?

Dr. Sachs harkened back to the principle of concordance, the degree to which the patient and provider are in agreement about what it is they are trying to accomplish together. He said that when patients are inconsistent, it is important to go back and see whether concordance really exists in that partnership. He stated that he tries to assess why the patient is in treatment, whether consistency is something the patient would like to address, and if the patient believes that the provider-recommended intervention is the way to achieve the desired outcome. He explained that it is not uncommon for patients who score high on a measure of agreeability to initially say yes to interventions but not follow through, and that members of their support system might become angry at them for this inconsistency rather than addressing the disconnect. He said it’s important to build in additional external supports for agreed-upon interventions to achieve goals.

Dr. Keck added that lack of insight is one of the most pernicious symptoms of bipolar disorder and presents one of the biggest challenges to treatment. He stated that the engaged practice model is useful in that it endorses a patient-provider partnership, and he said that he tells his own patients that they are the ultimate decision-makers, so they need to understand why the provider’s recommendations are valid, as well as what the pros and cons are. He also reminds his patients to do three things: take the medication faithfully without missing doses, avoid drugs and alcohol, and get a good night’s sleep. He stated that when patients comply, they tend to do better and see the therapeutic value in what the provider is trying to achieve.

What evidence-based practices have proven most effective in treating bipolar disorder with co-occurring substance abuse?

Dr. Keck stated that there is very little research in this area, so what providers are left with is to make sure they maintain awareness of all the problems a patient is experiencing, meaning that if someone has both bipolar disorder and an addiction to a substance, the provider does not ignore one in favor of the other. In that context, the provider can then apply evidence-based treatment for bipolar disorder in combination with evidence-based treatment for substance abuse or dependence.

Dr. Sachs stated that comorbidity between bipolar disorder and substance abuse/dependence is a frequent presenting issue. He offered that the success rate for treatment is much lower if the provider insists upon abstinence from substance use at the outset of treatment. Instead, he recommends acknowledging that the patient is likely to keep using the substance and then takes a “let’s see what happens” approach to the issue. If the provider also continues to measure related symptoms, they are in the position to point out to the patient how the substance may be affecting progress or lack thereof. If there is evidence that substance use is impeding progress, the provider can then suggest abstinence for a short period (e.g., one to three months) and use the computer-collected measures to assess whether the rate of progress changes. The data can then be presented to the patient as evidence for ongoing abstinence.

How can primary care physicians work with local psychiatrists to ensure they are using established evidence-based tools such as the Young Mania Rating Scale or the PHQ-9?

Dr. Sachs recommended that they start by asking how the psychiatrist is tracking the identified outcome. He stated his opinion that most psychiatrists would be open to using formal report measures to track outcomes, because it will be an asset to treatment and allow doctors to communicate clearly about what’s going on.

What are some of the effective ways to help bipolar individuals seek treatment and get their medications?

Dr. Keck noted that many people with bipolar disorder only seek treatment when they are depressed, which makes the engaged practice model even more important, because patients do worse if the diagnosis of bipolar disorder is missed. He then said that when patients present with a manic episode, it is typically a medical emergency, treated in the hospital. In outpatient settings, it can be challenging when patients present with mixed symptoms or do not recall hypomanic symptoms, which makes gathering information as described in the engaged practice model all the more useful when trying to gain an accurate diagnostic picture.

Dr. Sachs stated that it can be helpful to stay focused on the goals and symptoms that are priorities for the patient, such as improving the quality of sleep, rather than emphasizing a specific diagnosis. He stated that he always shares his diagnostic impression with patients but never requires them to accept a label.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/identifying-populations-care-coordination-interventions-health-plan-perspective/.

On April 11, 2017, three experts in the area of integrated healthcare presented a live virtual forum entitled Identifying Populations for Care Coordination Interventions: The Health Plan Perspective. William M. Lopez, MD, CPE, Senior Medical Director for Behavioral Health at Cigna Healthcare and Lisa Kay, MSW, MBA, Clinical Program Manager for Behavioral Health at Cigna Healthcare presented a case study focused on integrating behavioral health into medical settings. The forum was moderated by Samantha Sweeney, PharmD, MBA, a Senior Managed Market Liaison at Otsuka Pharmaceutical Development & Commercialization Inc.

The objectives of this virtual forum were:

  • To understand the concept of care coordination and its potential importance to individuals with complex needs, especially behavioral health disorders
  • To understand how stakeholders, especially payers, are involved in care coordination activities
  • To learn how one large insurance company –Cigna Healthcare – identifies members in need of care coordination interventions

Dr. Sweeney began by offering a definition of care coordination provided by the Agency for Healthcare Research and Quality: Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. She explained that this means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people to guide the delivery of safe, appropriate, and effective care to the patient.

She then posed a question to Dr. Lopez: “In your experience, which patient populations are most challenging when it comes to care coordination?” Dr. Lopez replied that some of the more challenging populations are those who do not acknowledge having a mental illness. He explained that this lack of acknowledgement may be due to stigma or to lack of insight. He said that one thing providers can do when confronted with this kind of situation is to tell the patient that the provider will be available if and when they do decide to seek help. Ms. Kay added that patients who have significant medical and behavioral comorbidities that require input from a multidisciplinary team can also be difficult to coordinate care for because of the intensive level of communication required among the various specialist providers and even additional community services that may be involved.

Dr. Sweeney discussed how the value of care coordination can be thought of from both a humanistic and a cost perspective. For patients, good care coordination can reduce negative outcomes such as serious complications and preventable hospital readmissions. For payers, care coordination could result in approximately $240 billion in annual health care savings, according to the Institute of Medicine. Dr. Sweeney went on to explain that care coordination is specifically important in behavioral health because mental health and substance use disorders rarely occur in isolation, as such individuals may also have conditions such as heart disease, diabetes, cancer, or other neurological disorders. Without sufficient collaboration, Dr. Sweeney stated that patients’ health and recovery is jeopardized.

The first polling question was posed to the audience: What is the most expensive medical condition in terms of total spending?

  1. Heart conditions (2%)
  2. Cancer (7%)
  3. Diabetes (9%)
  4. Mental disorders (81%)

Dr. Sweeney stated that the correct answer was mental disorders, which cost $201 billion in 2013. In that context, she reviewed the components of care coordination, which include establishing accountability and agreeing on responsibility among all providers, communicating/sharing knowledge with providers and with the patient, helping with transitions of care, assessing patient needs and goals, creating a proactive care plan, supporting patients’ self-management goals, and linking to community resources.

She then posed the second polling question to the audience: Do you work in an organization that provides care coordination for people with behavioral health disorders?

  1. Yes (84%)
  2. No (13%)
  3. Not sure (3%)

Dr. Sweeney then introduced the case study to be presented by Dr. Lopez and Ms. Kay by asking the following question: “Why are payers involved in care coordination?” Ms. Kay stated that payers would like to function as health services organizations rather than just being payers, attempting to engage “the whole person,” collaborate closely with providers, and provide maximum value to customers. Dr. Lopez added that Cigna has been working on internal care coordination for some time, but now they are expanding the scope outside the organization to work with provider groups and other members of the patient treatment team.

Ms. Kay reviewed Cigna’s preferred model of patient-centered care, the health ecosystem, which includes the medical provider, embedded behaviorist, hospital, pharmacist, workplace, community, support systems, and payer, all working with the specific patient. Dr. Lopez and Ms. Kay then presented a case study to illustrate the complications and costs (e.g., the patient receiving more health services than she would like to consume, reduced productivity at work, negative long-term outcomes, etc.) that arise with individuals who present with both a medical condition (e.g., lower back pain) and a mental illness (e.g., anxiety). Dr. Lopez described how, in a clinical model for behavioral health integration, there are three components that act as the foundation: the medical provider acts as the “quarterback,” who makes sure all necessary services are in place along with the embedded behaviorist; the pharmacist, who monitors medication compliance and makes sure there are no contraindications if multiple medications are prescribed; and the embedded behaviorist. The embedded behaviorist’s role is to be part of the treatment team, focused on psychosocial factors influencing medical conditions, doing screenings, coordinating appointments, and making sure the patient understands their benefits and has access to appropriate providers, all with the goal of providing a holistic approach to patient care.

Dr. Sweeney then asked the following question: “Are there any populations, for example with specific health conditions or groups of people, where you could see this model being helpful?” Dr. Lopez stated that patients with chronic, complicated illnesses that required more intense treatment like diabetes and asthma benefit most, particularly those with comorbid behavioral health conditions. Ms. Kay talked about the importance of screening for conditions such as depression and anxiety, in order to be able to identify patients for whom more care coordination might provide important benefits. She stated that many practices already provide such services, though they often refer out for behavioral health services. She explained that at Cigna, the ideal model is one in which the behavioral health provider is fully integrated into the practice, such that there is consistent screening, case management, consultation of varying types, and linking to more advanced psychiatric consultation when necessary.

Dr. Lopez then presented on how Cigna is supporting an integrated clinical model. They provide clinical supports such as a resource phone line and helping patients access services and get appointments. They assist with the release of behavioral health information in ways that protect patient confidentiality while enabling efficient coordination, for example, by streamlining the release process. They are trying to expand their support of local behavioral health networks. They are also looking for ways of providing more supportive reimbursement, such as value-based models that offer some compensation for activities like screening or having a behavioral health provider for consultation. Ms. Kay then talked about Cigna’s vision for care coordination for complex patients. She stated that they are completing a pilot study of customers who were identified through risk factors and claims data as being at risk for opioid overdose, with the goal of engaging those patients proactively and getting providers involved in providing care coordination.

The presentation transitioned to the question and answer period:

This question is from an attendee who currently practices in a patient-centered behavioral healthcare specialty practice. They’re having some difficulty engaging the medical providers who serve their clients in a collaborative integrated care model. Can you provide some insight as to how to better engage these medical providers?

Dr. Lopez recommended beginning with a face-to-face meeting to have a conversation about what the providers’ needs are with regard to behavioral health, and how those needs can be met through collaboration. He acknowledged that coordination efforts work both ways between behavioral health and medical providers, and said it’s important to understand what factors might be contributing to any resistance.

What are the recommended qualifications for an embedded behaviorist?

Ms. Kay stated that typically the embedded behaviorists should have the credentials to be paneled with insurance companies, particularly when a part of their responsibility is providing short-term therapy. She explained that there are certainly some care coordination activities, such as those described earlier in the presentation, that do not require independent licensure. However, having an independently functioning behaviorist provides the most options, especially when this professional is one of only a few behaviorists in the practice. She also noted that behaviorists should be able to advocate well for the patients regarding behavioral health conditions and translate complex medical and behavioral needs in a discussion with a patient in order to determine what the patient’s priorities are.

Is the family involved as an important part of this collaborative care team? What would be their role?

Dr. Lopez referred to the depiction of the health ecosystem that included social support as one of the key elements, and explained that the family is a part of that. Having that communication and gaining their perspective is crucial, he said, for patients to have success in the community. Families provide support, transportation, and financial means in some cases, so they should definitely be part of the process.

Ms. Kay agreed and added that family involvement is a situation where it’s important for everyone to understand the limits and allowances regarding release of information related to the patient’s behavioral health condition, and what the policies are within the practices.

Is it difficult sometimes to draw the line as to how much a care coordinator can do with or for a patient before it is seen as enabling? When do you say when?

Ms. Kay acknowledged that it is a fine line, including how long a care coordinator might follow someone. She said there are times when a patient has become very accustomed to having that support, and sometimes the care coordinator is someone they’re really looking to talk to, so it is important to set some guidelines. She specified that it’s important to have an identified plan and to know what the team is working toward from a care coordination perspective. As long as the team is working toward attainment of the patient’s goals, there is opportunity for continued traction. She noted that it’s a red flag when the team is working toward those goals but the patient isn’t actively participating, however. In that situation, she said it’s important for the care coordinator to regroup with the treatment team in an effort to understand why the patient is not actively working toward their own goals.

Dr. Lopez, can you share some of your biggest lessons learned regarding workflow development and implementation?

Dr. Lopez stated that some of the challenges are finding resources, and as one works toward establishing a program, they may not have the financial or human resources to implement it, but they still must find a way to make it happen and learn to work with what’s available. Therefore, he explained, it is important to be creative.

For locations that can’t physically integrate a behaviorist at their site, what do you recommend?

Ms. Kay referred to Dr. Lopez’s point about getting creative and paying attention to the details. For example, if a medical group that has a significant interest in integrating doesn’t have the physical space or the funding resources to hire someone, they might find a local behavioral practice or professional who has a similar philosophy, then hammer out the details regarding what co-management looks like (e.g., with regard to release of information) when everyone isn’t located in the same office. She offered the example of the outside behavioral group providing in-service education with the medical staff and vice versa, as well as finding other ways to develop a meaningful collaboration.

Can you speak to some of the strategies that may improve compliance with the care plan for folks who have serious mental illness?

Dr. Lopez said that is what care coordination is about. Taking a team approach and a holistic view of the patient to address barriers to compliance such as taking medications and attending appointments is the essence of this strategy, and the goal is to prevent avoidable outcomes such as visits to the emergency room with uncontrolled medical conditions and unaddressed behavioral health conditions.

This interview with William Gilmer, MD, is part 3 of the 3-part module series on Bipolar Disorder from the Psychopharmacology Collection. Dr. Gilmer is a Professor of Clinical Psychiatry & Behavioral Sciences at the Northwestern University Feinberg School of Medicine, and Board Chair of the Depression & Bipolar Support Alliance.

Key Messages

  • As little research has been done to characterize the information available to users of mental health-related smartphone applications (apps), the authors performed a content analysis of descriptions of the first 20 apps encountered after searching 10 common mental health terms in Apple iTunes and Google Play stores. The following features were inferred from app descriptions:
    • More than half of the apps appeared to be aimed at either symptom relief (85 of 208 apps [41%]) or general mental health education (37 [18%]).
    • Relaxation and stress management were the most common approaches to improving mental health.
    • 59% of apps did not state a source of information supporting app use.
  • The authors concluded that most mental health-related smartphone apps were for symptom relief and contained approaches to improving mental health that may benefit only milder symptoms.

On June 1, 2017, ECHO Autism, a University of Missouri (MU) program, announced it was expanding the program to Extension for Community Healthcare Outcomes (ECHO) Autism partner sites serving Alabama, Alaska, and under-served Navajo communities in New Mexico and Arizona. The program connects primary care clinics to a panel of university-based autism experts who provide training via high-quality, secure video conferencing technology to help primary care professionals diagnose and manage autism spectrum disorders in a primary care setting.

The expansion actually began in September 2016 and will continue through December 2017. Every three months, two new locations will launch their ECHO Autism clinics. The program is also working with non-research study sites that are launching at different times. Each research location will recruit 15 primary care professionals from underserved practices in their geographic area. The New Mexico ECHO Autism expansion, with the University of New Mexico took place in April 2017. The Alaska expansion began in May 2017 with the University of Alaska-Anchorage. The Alabama expansion took place in June 2017 with the University of Alabama-Birmingham. Non-research study sites may recruit unlimited primary care professionals. There is no cost to the participating primary care professionals. Many expansion sites offer no-cost continuing medical education and some offer maintenance of certification (MOC) credit.

Launched in March 2015, ECHO Autism is a partnership between the MU Thompson Center for Autism and Neurodevelopmental Disorders, MU Health, and the Missouri Telehealth Network Show-Me ECHO program. ECHO Autism clinics are conducted using high-quality, secure video conferencing technology to connect participating primary care clinics to a panel of experts. Since the program launched, it has trained nearly 250 health care professionals on best practices for handling diagnosis and care for individuals with autism. A recent review of the program, “ECHO Autism: Using Technology and Mentorship to Bridge Gaps, Increase Access to Care, and Bring Best Practice Autism Care to Primary Care” by Kristin Sohl, M.D.; Micah O. Mazurek, Ph.D.; and Rachel Brown, M.D., found that after participating in ECHO Autism primary care professionals demonstrated significant improvements in confidence across all sectors of health care for children with autism. The program helped them improve screening and identification, assessment and treatment of medical and psychiatric conditions, and knowledge of and referral to available resources.

ECHO Autism is modeled after Project ECHO at the University of New Mexico. The ECHO model launched in New Mexico to focus on improving care for hepatitis C; the model expanded to mental health and other chronic health conditions in 2013. The ECHO model uses a secure Internet-based audio-visual network to connect primary care professionals with medical specialists to expand community health systems’ capacity to deliver high-quality care for patients with complex, chronic health conditions. Project ECHO trains physicians, nurses, physician’s assistants, and other clinical professionals in rural and underserved areas to work collaboratively to manage patients’ diseases and conditions.

The original ECHO Autism clinic at the University of Missouri is funded by a Missouri legislative appropriation to the Missouri Telehealth Network. The research expansion sites are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under cooperative agreement UA3 MC11054 – Autism Intervention Research Network on Physical Health. Non-research expansion sites have variable funding sources.

The full text of “ECHO Autism: Using Technology and Mentorship to Bridge Gaps, Increase Access to Care, and Bring Best Practice Autism Care to Primary Care” was published in June 2017, by Clinical Pediatrics.

PsychU reported on Project ECHO in “Billings Clinic Launches Statewide Telepsychiatry Consultation Pilot For The Montana Department Of Corrections,” which published on March 16, 2016.

For more information, contact: Kristin A. Sohl, M.D., FAAP, Associate Professor, Child Health, Director, ECHO Autism, Thompson Center for Autism and Neurodevelopmental Disorders, 205 Portland Street, Columbia, Missouri 65211; 573-884-7544; Email: echoautism@missouri.edu; Website: https://thompsoncenter.missouri.edu/autism-training/echo-autism/.

Pending approval from the federal Centers for Medicare & Medicaid Services, the Wisconsin Department of Health Services (DHS) intends to require childless adults seeking BadgerCare (Wisconsin Medicaid) benefits to be screened for drug use, and submit to a drug test, if necessary. The individual will not be responsible for the cost of the drug test. The screening and drug test will become a new condition of eligibility, but a negative screen/test is not mandatory. Those who test positive, or who indicate on the screening assessment that they are ready to enter a treatment program, will be offered access to addiction treatment. For those offered treatment, Medicaid eligibility is linked to participation in treatment. Those who opt out of treatment will be ineligible for Medicaid, but will be eligible to reapply if they consent to testing and treatment.

The drug screening requirement is linked to a second proposed new requirement: participation in job training. The goal is to ensure that childless adults receiving Medicaid benefits are more fully prepared to reenter the workforce. As announced on April 19, the waiver amendment includes the following changes, in addition to drug screening, to coverage for childless adults covered by BadgerCare:

  • Imposes time-limited benefits: Benefits are limited to 48 months for able-bodied adults ages 19 to 49 who are not participating in worker training programs or working at least 80 hours per month. Members who reach the 48-month limit will lose program eligibility for six months. After six months, the individual can reapply to enroll, if he/she meets all other eligibility requirements; at which time another 48-month time limit count will begin.
  • Launches work requirements linked to time-limited benefits: Wisconsin is seeking federal matching funds for costs related to job training. Months in which an able-bodied adult, age 19 to 49, is working or participating in a worker training program for at least 80 hours per month will not counted toward the 48-month time limit. The work requirement will not apply to those who are physically or mentally unable to work, including those diagnosed with a mental illness, or receiving Social Security Disability Insurance (SSDI), or taking part in an alcohol or other drug abuse (AODA) treatment program. The work requirements will also not apply to those who are receiving or have applied for unemployment insurance, those who are enrolled in high school or an institution of higher learning at least half-time, or those who are the primary caregiver for a person who cannot care for himself or herself.
  • Establishes monthly premiums of $0 to $8 per household, based on income. Individuals earning up to 50% of the federal poverty level (FPL) would have no monthly premium; those earning up to 100% FPL would have a monthly premium of $8 per household.
  • Allows premium reductions to encourage healthy behaviors: The monthly premiums may be reduced by up to 50% based on responses to a health risk assessment (HRA) that indicate the member is engaged in healthy behaviors and/or actively trying to manage or quit health risk behaviors. Healthy behaviors include: wearing a seatbelt, maintaining a healthy weight, not smoking, not abusing or misusing drugs, and no excessive use or abuse of alcohol. Members with health conditions beyond his or her control that affects a health risk behavior may be eligible for a 50% reduction in their monthly premium payments if they attest that they have the underlying condition that raises their health risk. Members can update their HRA annually; premium requirements would be recalculated at that time.
  • Encourages careful emergency room use by increasing the per-visit copayment for emergency room visits to $8. Cost-sharing exemptions from copays for the American Indian and Alaska Native population will be applied to this policy.
  • Expands Medicaid coverage of residential addiction treatment for substance use disorder. Currently, the state Medicaid program covers five levels of addiction treatment: outpatient treatment (assessment and counseling by substance abuse counselors); day treatment (structured assessment/planning, and at least 12 hours of counseling provided under physician supervision; psychosocial rehabilitation (services to support independent living in the community); medication assisted treatment (assessment, drug screening, prescription and administration of opioid dependency agents, and substance abuse counseling), and inpatient (medically necessary acute care in a hospital).

The state believes that the reforms will prepare childless adult beneficiaries for participating in the workforce, and becoming eligible for employer-sponsored health benefits. For those currently receiving BadgerCare benefits, the 48-month count will begin on the month the policy is implemented. Prior time in the program will not be counted toward this limit. If the member enrolls in the program after the policy is implemented, the time limit count begins at the time of his or her initial enrollment.

DHS released the draft plans on April 19, 2017, and accepted public comment through May 19, 2017.

For more information, contact: Wisconsin Department of Health Services, 1 West Wilson Street, Madison, Wisconsin 53703; 608-266-1683; Email: Wisconsin1115CLAWaiver@dhs.wisconsin.gov; Website: https://www.dhs.wisconsin.gov/badgercareplus/waivers-cla.htm.

As of May 2017, the Oregon Health Authority (OHA) has not yet completed an annual Medicaid eligibility determination for about 8% of enrolled beneficiaries, representing about 86,000 people. The missing eligibility determinations were discovered during an audit of the state’s three-year transition from the failed Cover Oregon computer system to a new one.

Cover Oregon is the state-run health insurance marketplace run by the Oregon Department of Consumer and Business Services (DCBS). The original platform was built by Oracle, but the system had multiple technical problems and catastrophic software failures; it never worked as planned. Since November 2014 the state has been using the Healthcare.gov enrollment platform. The state pays 2% of premiums to use the platform. In September 2016, the state reached a settlement that calls for Oracle to provide the state with a total of $100 million in cash, customer service support, and license agreements.

The lag in eligibility determinations for 2017 was reported in “The Oregon Health Authority May Be Providing Medicaid Benefits to Ineligible Recipients” by the Oregon Secretary of State. This document said that in its audit of the software transition, OHA discovered that about 14,100 people have been sent renewal notifications but have not returned applications, plus another 71,600 beneficiaries whose eligibility had not been verified. The preliminary analysis did not clearly identify why the remaining 71,600 have not been redetermined.

The Secretary of State recommended that OHA work with federal authorities to ensure federal Medicaid funding is not jeopardized while OHA resolves the eligibility determination issues. Further, the Secretary of State recommended that the state Legislature require OHA to report on its efforts to resolve these issues and on fiscal impacts no later than September 30, 2017. The Secretary of State’s office will issue two audits to examine these Medicaid-related issues: the first, to be released in spring 2018, will discuss controls that exist for two critical Medicaid information systems; a later audit will analyze improper Medicaid payments, including resulting work on the issue of the ineligible enrollees.

For more information, contact: Kip Memmott, Director, Oregon Audits Division, Secretary of State, Dennis Richardson, 900 Court Street NE, Salem, Oregon 97310; 503-986-1523; Email: oregon.sos@state.or.us; Website: http://sos.oregon.gov/

KidsPeace has launched an improved and expanded TeenCentral service, giving teens an updated place to find online therapeutic support. The free and safe resource offers young people the opportunity to anonymously post their issues or concerns and receive a response within 24-hours.

The updated site features a contemporary visual concept, multifaceted and supported responses, more clinically driven content, and the TeenCentral Toolbox for printable tools. The website can be found at www.teencentral.com.

This was reported by KidsPeace on June 7, 2017.

Contact Information: KidsPeace, 4085 Independence Drive, Schnecksville, Pennsylvania  18078; 480-464-5764; Website: www.canyonvista.com

The California Department of Health Care Services (DHCS) is creating a capitated payment methodology for its federally qualified health centers (FQHCs). Under the proposed payment model, the Medi-Cal (California’s Medicaid program) managed care plans will pay the FQHCs an actuarially sound, capitated rate for each Medicaid beneficiary served. Each FQHC will be responsible for providing all services for the member that falls under its scope of services, including physical health services, as well as behavioral health services, obstetrics, and pharmacy if provided.

The Medi-Cal managed care organizations (MCOs) already include FQHCs in their provider organization networks. For the pilot, the MCOs can continue to contract other primary care provider organizations such as independent physician associations. For the pilot, consumers will be permitted to chose their primary care professionals.

Currently the Medi-Cal managed care plans are allowed to set their own rates for FQHC payments; they must reimburse FQHCs at a rate equal to the rates paid to similarly contracted non-FQHC provider organizations. However, under federal rules since 2001, FQHCs have been reimbursed using a prospective payment system (PPS) methodology. The Medi-Cal managed care plans are not required to pay the PPS rate. To fill in the difference between the Medi-Cal managed care plan rates and the mandated PPS, DHCS directly reimburses FQHCs through a “wrap-around” payment, which is the difference between its per-visit PPS rate and the payment made by the managed care plan.

In October 2016, DHCS submitted the concept paper to the Centers for Medicare & Medicaid Services (CMS). If approved by CMS, DHCS has proposed testing the optional methodology in a three-year pilot to start no sooner than January 1, 2018. The pilot methodology is designed to give FQHCs more effective incentives to provide higher quality care at lower costs while helping consumers achieve better health status.

Currently California has 1,310 FQHCs and RHCs; they serve multiple vulnerable populations including medically underserved communities, and uninsured individuals. About a quarter of the clinics, 293, are RHCs. The PPS-per visit rate is equal to 100% of the clinic’s average cost-per-visit, adjusted annually by Medicare Economic Index.

The state’s proposed plans were reported in “Advancing Payment Innovation Within Federally Qualified Health Centers: Lessons from California” by Greg Howe, Kathy Moses, and Tricia McGinnis, of the Center for Health Care Strategies (CHCS). The issue brief describes the pilot development process and proposed payment methodology, and outlines early lessons. California’s experience may help inform other states exploring alternative payment models for FQHCs.

The proposed APM pilot has the following elements:

  • The four largest categories of Medicaid FQHC users will be included: children, adults, seniors and persons with disabilities, and adults in the Medicaid expansion population (low-income, uninsured, childless adults ages 19 to 64). Qualifying Medicaid beneficiaries that are participating in a managed care plan and assigned to a primary care professional who works at a participating FQHC health center will be enrolled.
  • The per-member per-month (PMPM) rate will cover all of the services that a health center includes in its current PPS rate. Services could include obstetrics and other specialty services, as well as behavioral health services for mild to moderate mental health conditions, if those services are currently offered at the health center. Under the pilot, health centers will have the flexibility to provide services that are currently not reimbursed, such as: integrated primary and behavioral health visits on the same day; group visits; email or phone visits; community health worker contacts; case management; and care coordination across systems.
  • For the initial pilot year, the PMPM will be set using historical data from the individual health centers. The goal is to ensure that the capitated payment will be equivalent to the amount it would have received under PPS. Additional data to be collected for the rate development process will include enrollment, utilization, and cost information, as well as the category of aid.
  • For subsequent years two and three, DHCS will use experience for the traditional services and alternative new services not billable under the PPS to help inform the rates. The not billable services can include those to increase consumer engagement, improve consumer outcomes, and allow better coordinated and integrated care.
  • DHCS will make a PMPM clinic-specific payment to the health plan for members assigned to the participating health center, and the health plan will pay the participating FQHCs an actuarially sound, clinic-specific capitated payment. This clinic-specific capitated payment will eliminate the existing plan payment, wraparound payment, and reconciliation payment, and replace it with one capitation payment equivalent to what they would have received under the previous payment system, making the reimbursement and workflow administratively simpler.
  • Reconciliation would be triggered when actual traditional utilization for the health center falls outside of the expected traditional utilization levels. For the first year, 5% higher than traditional utilization will trigger reconciliation. For the second year, the reconciliation trigger is 7.5% higher utilization growth. For the third year, utilization growth of 10% or more will trigger reconciliation. For less-than-expected traditional utilization, the trigger is set at 30% for each of the three years of the pilot.
  • The health plan capitation rates will be adjusted annually to reflect changes to the FQHC PPS rates or scope of services. Capitation payments from the state to the health plan will be adjusted monthly to reflect changes to the health plan’s assigned members. DHCS will establish a risk corridor to protect the health plans from the averaging nature of the capitation because the rates for different FQHCs will vary and the overall capitation could potentially be too high or too low, based on actual member assignment to each clinic.

To launch the pilot, DHCS will develop the application process and criteria for selecting health centers interested in participating in the pilot. It may also impose additional eligibility criteria to prefer FQHCs with adequate membership to drive transformation, as well as organizational experience with strategic practice transformation and commitment to transforming primary care, data capabilities, staffing and capacity, and a strategy to move to the new payment model.

Under the Patient Protection and Affordable Care Act (PPACA) Medicaid changes, California’s Medicaid population increased by roughly 35%. Many in the expansion population are enrolled in managed care and receive primary care services through an FQHC. In total, Medi-Cal serves 13.5 million beneficiaries, with about 79.6% enrolled in a Medicaid managed care plan.

The full text of “Advancing Payment Innovation Within Federally Qualified Health Centers: Lessons from California” was published May 2017 by the Center for Health Care Strategies.

For more information, contact:

  • Center for Health Care Strategies, Inc., 200 American Metro Boulevard, Suite 119, Hamilton, New Jersey 08619; 609-528-8400; Email: media@chcs.org; Website: http://www.chcs.org/
  • Ralph Zavala or Ryan Witz, Health Care Financing Division, California Department of Health Care Services, 1501 Capitol Avenue, MS 0000, Post Office Box 997413, Sacramento, California 22042-5101; Email: Ralph.zavala@dhcs.ca.gov or Ryan.witz@dhcs.ca.gov; Website: http://www.dhcs.ca.gov

Quality is the word every behavioral health care organization wants as part of their value proposition. But how do organizations portray their value? One way is through the validation by an accrediting organization. During this podcast you will hear from Julia Finken, RN, BSN, MBA, CSSBB, CPHQ, executive director of Behavioral Health Care and Psychiatric Hospital Accreditation at The Joint Commission.

Ms. Finken has 25 years of experience working closely with behavioral, ambulatory, home health, hospice, long term care and pharmacy providers to improve their daily operations, quality of care, financial performance, and business and marketing strategies. Previously she was an associate director of Home Care Accreditation at The Joint Commission, and a surveyor for 9 years at the organization. Ms. Finken received her master’s degree in business administration from the Paul Merage School of Business at the University of California, Irvine, California, and a bachelor’s degree in nursing with a minor in business economics from California State University, Long Beach, California. She is a Certified Professional in Healthcare Quality® and an American Society for Quality Certified Six Sigma Black Belt.

Key Messages

  • Compared with healthy individuals, patients with bipolar I disorder (BD I) experience cognitive deficits, including impairment of sustained attention, memory, and executive function. These deficits have been observed in all phases of illness, including euthymia. Deficits in cognitive function may be associated with illness severity, current state (manic, depressive, euthymic, or mixed), and polarity of previous episodes. Clinical assessments of cognitive function should be applied to assess the stability or evolution of cognitive impairment over time.
  • Given the diversity of cognitive impairment across patients with BD I, neurocognitive rehabilitation programs should be tailored according to individual patients’ needs.

Key Messages

  • This study, which examined experiences of discrimination from the patient’s perspective among 50 people living with severe and persistent mental illness, found that discrimination is encountered in many everyday aspects of life, including physical and mental healthcare, and that internalized stigma leads to high rates of anticipated discrimination.
  • Being avoided or shunned was the most common experience of discriminatory behavior (50% of participants), followed by discrimination by neighbors (48%) and family members (46%). The most common experience of anticipated discrimination was feeling the need to conceal a mental health diagnosis (50% of participants).
  • Almost one-fifth of participants reported experiencing discrimination from general healthcare professionals, and at least 8% reported discrimination from mental health staff (excluding issues relating to community treatment orders).

In this interview following up one year after PsychU’s Stigma Forum, Michael Townsend, LMSW dispelled common myths about mental health, discussed societal attitudes about those with mental illnesses, and explained how his organization combats stigma. Michael Townsend is Deputy Chief Executive Officer at Gateway Counseling Center, Inc and a board member for MHA in New York State.

The 21st Century Cures Act is considered one of the most wide-reaching laws enacted to date to enrich opportunities for innovation in treating diseases, developing medical devices, and opening the doors to new therapies for mental health. During this presentation you will hear from Athena Mandros, Market Intelligence Manager at OPEN MINDS, who provided an overview of the Act and its importance to behavioral health.

Athena is a subject matter expert in policy and financing of health and human services across all payers, with a focus on behavioral health, developmental disabilities, long-term care, and corrections. In addition, Athena produces the Market Intelligence Report and the Behavioral Health System 50-State Profiles. She received a Bachelor of Arts in English and Environmental Studies from Gettysburg College.

On June 17, 2016, PsychU sponsored the National Stigma Forum, held at the Marriott Metro Center in Washington DC. The overall objectives of this meeting included discussion of the current state of stigma toward individuals with mental illness, identification of the gaps that exist in past and present stigma initiatives, and to brainstorm and identify collaborative initiatives to address these gaps leveraging the PsychU community.

Today we are following up with Sita Diehl, Director of State Policy and Advocacy at National Alliance on Mental Illness (NAMI), who was an attendee of the first PsychU National Stigma Forum, to see what she and her organization have done in the past year to alleviate stigma in mental health.

About 62% of military personnel discharged for misconduct from 2011 through 2015 had been diagnosed with certain mental health conditions or traumatic brain injury (TBI) that could be associated with misconduct during the two years prior to discharge. During this period, of the 754,388 total separations (discharges from service), 12% (91,764 discharges) were for misconduct. Of the 91,764 misconduct discharges, about 62% (57,141 discharges) of individuals had a condition such as post-traumatic stress disorder (PTSD), TBI, or certain other conditions such as adjustment and alcohol-related disorders. The remaining 34,623 (38%) were not diagnosed with specific conditions.

Of the 57,141 discharges of service members diagnosed with certain mental health conditions or TBI, 14,816 (26%) were diagnosed with post-traumatic stress disorder (PTSD) or TBI, and 42,325 (74%) were diagnosed with other behavioral health conditions, such as adjustment disorder, alcohol, anxiety, depression, bipolar, personality disorders, or addiction disorder. The 14,816 discharges of service members diagnosed with PTSD or TBI accounted for 2% of all separations from service, and 16% of all misconduct discharges. The 42,325 service members diagnosed with other behavioral health conditions and discharged for misconduct represented 5.6% of all separations from service and 46% of all misconduct discharges.

These findings were reported in “DOD Health: Actions Needed to Ensure Post-Traumatic Stress Disorder and Traumatic Brain Injury Are Considered in Misconduct Separations” by the Government Accountability Office (GAO). The GAO analyzed data and from the Department of Defense (DOD) about service separations during 2011 through 2015. For the review, GAO analyzed DOD data; reviewed applicable policies; interviewed DOD, Army, Marine Corps, Air Force, and Navy officials; visited two Army and one Marine Corps sites selected on factors such as separation rates; and reviewed a nongeneralizable sample of Army and Marine Corps servicemember misconduct separation documents.

The GAO conducted the review to comply with a provision of the 2015 National Defense Authorization Act. For this report, the GAO examined the number of servicemembers separated for misconduct who were diagnosed with PTSD, TBI, or certain other conditions and were potentially ineligible for Department of Veterans Affairs (VA) benefits and services. The GAO also examined the extent to which the military services’ policies to address the impact of PTSD and TBI on separations for misconduct are consistent with DOD’s policies. The review also included an analysis of the extent to which Army and Marine Corps have adhered to their policies, and the extent to which the DOD, Army, and Marine Corps monitor adherence to the policies.

Of the 57,141 servicemembers diagnosed with a behavioral health disorder who were discharged for misconduct, 23% (13,283 servicemembers), received an “other than honorable” characterization of service, making them potentially ineligible for VA health benefits. Just 3% received an honorable discharge and were eligible for full VA benefits; another 40,390 (71%) got a general discharge. For another 3% the nature of their discharge was uncharacterized or of an unknown type.

The GAO found that the military services’ policies to address the impact of PTSD and TBI on separations for misconduct are not always consistent with DOD policy. Navy policy does not require a medical examination or screening for service members who request separation via administrative discharge rather than court martial to assess whether a PTSD or TBI diagnosis is a mitigating factor in the misconduct charged.

Two of the four military services have TBI training polices that are inconsistent with DOD policy. The Army and Marine Corps may not have adhered to their own screening, training, and counseling policies related to PTSD and TB. In the sample of Marine separations, 18 of the 48 packets reviewed lacked documentation showing that the servicemember had been screened for PTSD and TBI. In 11 of the 48 separation packets for Army servicemembers who requested separation in lieu of trial by court-martial, there was no documented evidence, or the evidence was unclear, as to whether the servicemembers received counseling that the administrative separation would result in ineligibility for VA benefits and services.

During interviews with Army officers, GAO found that some officers may not have received training to identify mild TBI symptoms, despite Army policy that all servicemembers should be trained. The GAO found that the Army and Marine Corps have some data on servicemembers’ screenings, training, and counseling, the services do not use these data to routinely monitor whether they are adhering to relevant policies.

The GAO recommended that the DOD direct the military services to address inconsistencies in their separation policies. Of the GAO’s five recommendations, the DOD agreed with four that called for monitoring adherence to military service screening, training, and counseling. However, the DOD did not agree to address inconsistencies in training policies.

For more information, contact: Randall B. Williamson, Director, Health Care, U.S. Government Accountability Office, 441 G Street, NW, Washington, District of Columbia 20548; 202-512-7114; Email: williamsonr@gao.gov; Website: http://www.gao.gov/; or Chuck Young, Managing Director, Public Affairs, U.S. Government Accountability Office, 441 G Street NW, Room 7149, Washington, District of Columbia 20548; 202-512-4800; Email: youngc1@gao.gov; Website: http://www.gao.gov/.

In February 2017, the Health Transformation Alliance (HTA), which includes 38 large self-insured corporations, launched the first of several arrangements to reduce health care costs by transforming inefficient health care and pharmacy purchasing and contracting systems. HTA partnered with pharmacy benefit managers (PBMs) CVS Health and OptumRx for a pharmacy initiative, and partnered with UnitedHealthcare and Cigna for a medical network purchasing arrangement.  To identify additional opportunities to improve purchasing and employee health care, HTA and its members partnered with IBM Watson Health to provide descriptive, predictive, and cognitive analysis for more proactive health management of medical and pharmacy utilization.

The HTA was launched in February 2016 by the non-profit American Health Policy Institute and 20 initial member corporations. Its members now include: American Express Company, American Water, BNSF Railway Company, Brunswick Corporation, Caterpillar Inc., The Coca-Cola Company, Corning, I. du Pont de Nemours & Company, Eaton, FedEx, HCA Inc., The Hartford Financial Services Group Inc.,IBM Corporation, Ingersoll Rand, International Paper Company,  Johnson & Johnson, Kaiser Permanente, Lincoln Financial Group, Macy’s Inc., Marriott International Inc., NextEra Energy Inc.,Pitney Bowes Inc., Shell Oil Company, Verizon Communications Inc., Walgreen, and Weyerhaeuser Company. The goal is to transform the corporate health care benefit marketplace by creating greater market efficiency, analyzing pooled data to improve health care supply chain effectiveness, and providing employees with better tools to make health care choices.

For the pharmacy initiative, CVS Health and OptumRx will implement prescription plan management reforms intended to result in lower medication pricing. The reforms include better formularies, and new tools to help individuals select the most appropriate and cost-effective medications.  HTA projects that beginning January 1, 2018, the prescription drug reforms will save the HTA member companies, their workers, and covered retirees at least $600 million over the next three years.

For the medical network initiative, UnitedHealthcare and Cigna will administer new medical benefit plans and new partnerships will be developed directly with health care providers beginning with type-2 diabetes, treatment for back pain, and hip and/or knee replacement. These four conditions account for 40% of health care spending by the HTA-member companies. The plan offerings will launch in Dallas/Fort Worth, Texas; Phoenix, Arizona; and Chicago, Illinois.

For more information, contact: 

  • Heidi Werth, Communications, Health Transformation Alliance, 1342 Florida Avenue NW, Washington, District of Columbia 20009; 202-770-6547; Email: hwerth@htahealth.com; Website: http://www.htahealth.com
  • E.R. Anderson, Vice President, Communications, American Health Policy Institute, 1100 13th Street NW, Suite 850, Washington, District of Columbia 20005; 202-375-2792; Fax: 202-789-0064; Email: contact@americanhealthpolicy.org; Website: http://www.americanhealthpolicy.org/

Today was the final day of The 2017 OPEN MINDS Strategy & Innovation Institute – and it has been another great year in New Orleans. Over the past few days, 400+ executive thoughtleaders gathered to discuss their innovation successes (and frustrations) – and this afternoon I closed out the institute with my keynote, “There Is No “Plan B” Alternative To Value: Creating A Value-Focused Competitive Strategy In A Changing Market.” My focus – how to use innovation in developing a sustainable strategy.

I started the discussion with a simple concept – executive teams need to rethink what they know about the forces shaping the market landscape. Traditional thinking about “competition forces” needs to change – there are new organizations in the mix; the importance of consumer experience is on the rise; and the potential of technological substitution.

The New Competition – So who is the new competition? The competition for behavioral health revenue includes a new cast of characters – provider organizations acquired by health plans, health system ACOs, national specialty care organizations, and “virtual care” organizations.

The Changing Face of Consumer Preference – This is the “Amazon” and “Uber” phenomenon. Consumers want convenience, and they want it in the form of 24/7 access with “one click.” And there are a host of organizations that are stepping into this space, differentiating their service offering with “on demand” convenience.

The Substitution Effect Of New Technology – How much technology will replace “live” services remains to be seen. But there are new organizations offering services that replace therapy, replace billable case manager time, and traditional diagnostic testing.

The question for executives of health plans and provider organizations – are these new “players” competitors or potential partners? As management teams sort out of the questions of “unique selling proposition” (see The Goal: Be A Golden Brand) and “competitive advantage” (see ‘Agile Innovation’ Needed For The Challenges Ahead and No System Too Big? No Niche Too Small? Strategy Challenges Ahead), the effect that these organizations have on strategy will become more apparent.

The Medicaid carve-out market is shifting. Last month, a Michigan House appropriations panel approved two new financing pilot models to help the state integrate Medicaid physical and behavioral health services by 2020 (see Michigan Legislative Panel Approves Financing Models For Integrated Care Pilot Projects). Currently, Michigan operates a Medicaid carve-out for behavioral health services, which are managed by 10 regional mental health authorities structured as prepaid inpatient health plans (PIHPs). In the new financing models, one would be a statewide prepaid inpatient health plan (PIHP) to manage behavioral health services (replacing the 10 regional mental health authorities); and in the other, Kent County will pilot a fully integrated model involving a community mental health service provider organization and a Medicaid managed care organizations.

In January, Arizona announced that its Medicaid program is planning to fully integrate behavioral health and physical health into its managed care contracts by October 1, 2018; the integration includes members with autism spectrum disorders and members that qualify for Children’s Rehabilitation Services (CRS). The state’s current contract structure includes a behavioral health services carve-out for most members. The Arizona Health Care Cost Containment System (AHCCCS) intends to offer fully integrated contracts to manage the whole individual with the next contracting cycle for each population, starting with the acute managed care program and CRS. The integrated contractors will offer behavioral health (including mental health and addiction disorder services) and physical health services to children and adult Medicaid consumers determined not to have serious mental illness (SMI). Contractors may include acute care managed care organizations (MCOs) and current regional behavioral health authorities (RBHAs) (see Arizona Medicaid To Integrate Behavioral Health Into Managed Care, Including Autism & Children’s Rehabilitation Services).

Over the last five years, we have seen a steady and clear trend – the number of state Medicaid plans with the typical primary behavioral health benefit carve-out has decreased, and health plans are becoming increasingly responsible for managing these benefits. The number of these traditional carve-outs has dropped from 17 in 2013 to only 11 at the beginning of 2017.

While the Medicaid primary carve-outs of behavioral health benefits are on the decline, it doesn’t mean that there are no behavioral health carve-outs – it’s just that the model is shifting. There is still a robust use of behavioral health carve-outs in health plans. In 2017, there are 24 states with any type of traditional specialty carve-out, 36 with a total carve-in, and three with a vertical consumer-specific carve-out. At last scan, my colleague Athena Mandros found that out of 300 contacts with 286 health plans in 34 states, 40% (or 113) had a secondary carve-out and 60% (or 173) managed behavioral health benefits within the health plan.

There is also the emergence of the specialty or vertical health plan concept. Currently there are three states with vertical carve-outs for the population with serious mental illness (SMI), and an additional five states that serve other consumer-specific populations through a vertical carve-out. And then there is the Medicare Advantage SNP enrollment – of the 19.5 million consumers enrolled in Medicare Advantage, about 2.3 million (nearly 12%) are enrolled in specialty plans. About 1.9 million (10%) are dually eligible for Medicaid and are enrolled in a Dual Eligible Special Needs Plan (D-SNP) (see Medicare Managed Care Is On The Increase – At Consumer Request).

And there is the increase in the use of “specialty” medical homes (health homes) focused on consumers with specific issues – a population-based integrated care service delivery model for individuals with chronic conditions and serious mental illness. In 2016, there were 20 states with health homes – which enroll about 1.25 million consumers – for an increase of 25% over the one million consumers enrolled in May, 2015.

This shift in how behavioral health benefits is being managed is both an increase in complexity and an increase in opportunity. Where there is change – and lots of unnecessary resource use – there is opportunity to be part of the solution. (But, for some stakeholders, their revenue is part of that “unnecessary” resource use.) For effective strategy, managers need to know the payers and health plans in their markets – and map out both the contracting models and the stakeholders. For more on those changing roles and how to adapt, check out this essential list from the OPEN MINDS Industry Library:

  1. An Update On The State Medicaid Behavioral Health Carve-Out Landscape
  2. No System Too Big? No Niche Too Small? Strategy Challenges Ahead
  3. A Carve-Out By Any Other Name
  4. California & The Mental Health Carve-Out
  5. The New Carve-Out & More Seismic Change
  6. Carve-Out Or No

The Ethel & James Flinn Foundation (Flinn Foundation) is accepting proposals from both governmental agencies, and nonprofit organizations, for mental health care and services for children and young people (up to the age of 21), either exclusively or as a component of its overall services. Two grants of up to $75,000 will be awarded for children’s mental health evidence-based practices programs. Priority will be given to programs that improve access to effective mental health prevention, screening, early identification, and treatment for those under 21 years of age.

Applying organizations will ideally be located in the Southeast Michigan counties of Wayne, Oakland, Macomb, or Washtenaw, however the Flinn Foundation may consider other programs that benefit much of the state. Applying organizations must also either be a governmental agency or a non-profit organization that provides mental health care and services for children, youth, adolescents, and young people (birth to age 20) either exclusively or as a component of its overall services in southeast Michigan. 

Deadlinie for applications is Thursday, July 13, 2017.

The Ethel and James Flinn Foundation is committed to improving the quality, scope and delivery of mental health services in Michigan.

This was reported by Philanthropy News Digest on June 3, 2017.

Contact Information: Ethel & James Flinn Foundation, 333 West Fort Street, Suite 1950, Detroit, MI 48226-3167; 313-309-3436; Email: info@flinnfoundation.org; Website: www.flinnfoundation.org

IBM’s Watson Health will team with MAP Health Management (“MAP”) to address the problem of relapse in those battling substance abuse. The predictive methodology will come from a combination of technologies and implementation into a known network. Watson’s cognitive technologies will be integrated into the MAP Recovery Network Platform to improve consumer risk models to better predict and prevent relapse potential in the U.S. Aetna Behavioral Health is expected to deploy the new platform, once complete.

MAP develops technology-enabled solutions that improve clinical and financial outcomes for chronic behavioral health disorders such as substance use disorder. MAP empowers treatment providers, health insurance companies, health systems, and patients with the right data at the right time to improve clinical and financial outcomes.

IBM Watson Health works to empower clients with value-based solutions to optimize performance, engage consumers, deliver effective care, and manage a population’s health.

This was reported by PR Newswire on May 16, 2017.

Contact Information: IBM Watson Health, One New Orchard Road, Armonk, New York 10504-1722; 800-426-4968; Website: www.ibm.com/watson/health/

Contact Information: MAP Health Management, LLC, 1114 Lost Creek Blvd., Fifth Floor, Austin, TX 78746; 855-627-1010; Website: www.thisismap.com/

Todd Hastings, PhD, RN is the lead investigator and author of a new report “Can Completing a Mental Health Nursing Course Change Students’ Attitudes?” During this interview Dr. Hastings shares his insights into his study which elicited information from 310 nursing students on their knowledge of mental illness, their perceptions about people with mental illness, and what drives their interest in choosing to work in the mental health field. Dr. Hastings is an Assistant Professor at Cedar Crest College in the Nursing Department, where his focus is psychiatric mental health nursing. He has a PhD in Nursing Education from the University of Phoenix, a Master’s degree in Psychiatric Nursing (Clinical Nurse Specialist) from Wilkes University, as well as an Associate’s Degree in Nursing from Luzerne County Community College.

On May 10, 2017, the Illinois State Senate approved a bill that would raise wages to $15 per hour for direct support professionals (DSPs) caring for people with intellectual/and developmental disabilities (I/DD). The legislation, Senate Bill (SB) 0955, is now under consideration by the House. SB 0955 amends the Mental Health and Developmental Disabilities Administrative Act and the Illinois Public Aid Code. It directs the Illinois Department of Human Services (DHS) to “establish reimbursement rates which build toward livable wages” for front-line personnel in residential and day programs and service coordination agencies serving persons with I/DD, including, but not limited to, intermediate care facilities for persons with developmental disabilities (ICF/DD), community integrated living arrangements, developmental training programs, employment, and other residential and day programs for persons with I/DD.

The bill specifically provides that DHS should increase rates and reimbursements to provider organizations so that DSPs earn a base wage of not less than $15 per hour and so that other front-line personnel earn a commensurate wage.

On May 30, 2017, the House filed a fiscal note that estimates the cost of SB 0955 at $317 million. The note clarifies that DHS currently provides an hourly rate of $10.71 for Community Integrated Living Arrangements (CILA) rate model for DSPs and $11.05 for ICF/DD staff. Raising front-line staff rates to a minimum of $15 per hour would constitute a 40% increase. The estimated cost assumes that other categories of staff, such as front-line supervisors, qualified intellectual disabilities professionals, and nurses, will also receive a commensurate wage increase of 40%.

By raising the minimum wage for DSPs serving people with I/DD, the legislature seeks to improve the state’s compliance with the 2011 Ligas v. Norwood Illinois consent decree. The consent decree monitor reported in late 2016 that the DHS reimbursement rates paid by DHS are insufficient for provider organizations to attract and retain DSPs to the point that the state is out of compliance with the consent decree. In the consent decree, DHS agreed to make improvements to the developmental disability system to provide opportunities for people with developmental disabilities to live integrated in the community. Because the state has failed to pass a budget for the past two years, and all spending is frozen at pre-impasse levels, and because the state is out of compliance, on April 7, 2017, the plaintiffs in the 2011 Ligas v. Norwood consent decree sued the state to enforce the terms. The plaintiffs, represented by advocacy organization Equip for Equality, asked the judge to compel the state to provide the resources necessary to comply with the consent decree.

For more information, contact:

  • Heather A. Steans, Senator, 7th District, State Senate, Illinois General Assembly, 623 Capitol Building, Springfield, Illinois 62706; 217-782-8492; Fax: 217-782-1631; Website: http://www.ilga.gov/senate/Senator.asp?MemberID=2360
  • Robyn Gabel, 18th District Representative, Illinois General Assembly, 248-W Stratton Office Building, Springfield, Illinois 62706; 217-782-8052; Email: staterepgabel@robyngabel.com; Website: http://www.ilga.gov/house/rep.asp?GA=99&MemberID=2177
  • Rachel M. Weisberg, Employment Rights Helpline Manager and Attorney, Equip for Equality, 20 North Michigan Avenue, Suite 300, Chicago, Illinois 60602; 312-895-7319; Email: rachelw@equipforequality.org; Website: http://www.equipforequality.org/
  • Meg Cooch, Executive Director, The Arc of Illinois, 20901 S LaGrange Road, Suite 209, Frankfort, Illinois 60423; 815-464-1832; Website: https://www.thearcofil.org/

Medicare beneficiaries who participated in a care management program used by a Pioneer Medicare accountable care organization (ACO) had 8% fewer hospitalizations, and 6% fewer emergency department visits and their Medicare costs were lower by 6%. Participation in the care management program was associated with reductions, compared to pre-participation levels, in rates for hospitalizations and all emergency emergency department visits. The participants’ utilization and costs were also lower compared to a group of beneficiaries who were eligible for the care management program, but had not yet started the program.

These findings were reported in “Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO” by John Hsu, Mary Price, Christine Vogeli, Richard Brand, Michael E. Chernew, Sreekanth K. Chaguturu, Eric Weil, and Timothy G. Ferris. They analyzed Medicare data from 2009 through 2014 for the Pioneer ACO formed by the Partners HealthCare System. The analysis focused on outcomes of its care management program.

One of the hospitals in the Partners ACO, Massachusetts General Hospital, had participated in the Medicare Care Management for High Cost Beneficiaries Demonstration and had developed an intensive care management program. The Partners ACO extended the program throughout the Partners HealthCare System. The care management program was the ACO’s key strategy for meeting its cost and quality goals under the Pioneer ACO program. The care management program targeted a subset of beneficiaries with elevated but modifiable risks for future spending.

The study population included beneficiaries who had been identified in any year between 2012 and 2014 by their primary care physicians as likely to benefit from the program, and who participated. By the end of 2014, due to capacity constraints, only about one-third of those who were identified had participated. About 20% to 30% of those who participated each year were dually eligible for Medicare and Medicaid.

Overall participation in the care management program was associated with a reduction in Medicare spending of $101 PMPM, about 6% less. Among beneficiaries assigned to the Partners ACO, but who did not participate in the care management program, generally participation in the ACO was associated with a reduction in Medicare spending of $14 per member per month (PMPM), about 2% less.

The researchers concluded that the program approach of targeting beneficiaries with modifiable high risks to shift care away from the emergency department represented a viable mechanism for altering ACO spending. They said the findings provide evidence of the effects of payment system changes that are still ongoing, and that the findings demonstrate the importance of giving the changes time to show results over the long-term.

The full text of “Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO” was published in the May 2017, issue of Health Affairs.

For more information, contact: John Hsu, M.D., MBA, Director of the Clinical Economics and Policy Analysis Program, Massachusetts General Hospital Mongan Institute Health Policy Center, 50 Staniford Street, 9th Floor, Suite 909, Boston, Massachusetts 02114; 617-724-4243; Email: john.hsu@mgh.harvard.edu; Website: http://www.massgeneral.org/monganhealthpolicycenter/

A couple weeks ago, news in Pennsylvania caught my eye – Pennsylvania is joining the Stepping Up Initiative (SUI) to reduce the number of people with mental illnesses in county jails. My colleague Monica E. Oss covered that development in, ‘Stepping Up’ To The Problem Of Mental Illness In Corrections Facilities.

If you are unfamiliar with it, the Stepping Up Initiative is a national effort to divert consumers with behavioral health issues (including those with co-occurring substance use disorders, as well as serious mental illness or serious and persistent mental illness) from jails and into treatment (see Pennsylvania Jails To Launch Stepping Up Initiative To Reduce Number Of Inmates With Mental Illness). As part of the program, SUI provides strategic planning and service implementation assistance to provider organizations with a heavy focus on metrics-based management.

As part of this planning and implementation assistance, the SUI program asks six questions that county leadership can use to craft a local plan: Is our leadership committed?; Do we conduct timely screening and assessments?; Do we have baseline data?; Have we conducted a comprehensive process analysis and inventory of services?; Have we prioritized policy, practice, and funding improvements?; Do we track progress?

I think any initiative to reduce the inappropriate incarceration of people with mental illnesses is a good idea. But, based on my experience, I wonder whether counties really have the capacity to take this on and what the challenges are to getting voluntary collaborative agreements like this up and running – and sustaining them long-term. In my work with these systems, I have found there are a few key issues to keep in mind:

  1. Counties are often challenged by limited budgets and resources that restrict action beyond their basic statutory responsibilities
  2. County Sheriff’s often face significant budget issues that challenge the sheriffs’ ability to juggle needed corrections officers, road patrol personnel, and administrative supports
  3. Corrections personnel are continually challenged by the dual goals of keeping tight internal controls and meeting the basic needs of inmates. Trying to expand or bring in resources may raise concerns about controlling the jail environment and subsequent threats to safety and security
  4. While training jail staff may help them to more appropriately work with mental health inmates, some form of professional staff will be needed to support their efforts

All the above being said, counties and jails should have an incentive to participate in efforts to address the mental health needs of inmates due to increases in “critical incidents” involving mental health inmates and subsequent lawsuits for harm to inmates including deaths (see Delaware Prison Officials Settle Class Action Lawsuit Over Solitary Confinement Of Offenders With Mental Illness and Alabama Corrections Agrees To Improve Conditions For Inmates With Disabilities).

Programs such as crisis intervention teams and mental health courts are examples of programs likely to help reduce the number of individuals (or at least the number of days) in jail. Many communities are working in partnership with local law enforcement to address the issue this way.

What are the keys to developing functional relationships between law enforcement/corrections officers and behavioral health provider organizations? I have four suggestions:

  1. Create formal and informal opportunities for both groups of professionals to talk and get to know one another on a personal level
  2. Create opportunities for behavioral health professionals to hear the circumstances and issues that law enforcement faces in dealing with inmates with mental health needs
  3. Create opportunities for law enforcement to hear and learn more about some of the clinical profiles they are seeing on the streets and in jails, and how their attitudes and behaviors can either escalate or mitigate disruptive/dangerous behaviors
  4. Develop opportunities for law enforcement/corrections officers and behavioral health professionals to discuss the common values and beliefs around dealing with mental health issues in law enforcement – examples include increasing the safety of the community and the mental health consumer; increasing the safety of law enforcement/corrections personnel; preventing “critical incidents” related to harm in law enforcement situations and during whatever jail time occurs; and preventing legal action that might arise out of critical incidents

Once these foundational relationships have developed, then the greater the chance of meaningful planning and ongoing collaborative relationships.

This initiative is focused specifically on diverting consumers with mental illness away from jail – but the overall lesson is one that I think is quintessential for the overall health and human services market space. Metrics and data sharing between social services, behavioral health provider organizations, and a funding source – and a commitment to innovate and monitor performance based on that data – is the path forward for coordinated care management and utilization. This is a lesson that applies to all those institutions that come into contact with individuals suffering significant health and mental health disorders, including our law enforcement and criminal justice systems.

On May 11, 2017, Iowa enacted HF 233: a law to reform health insurer fail-first policies for medication step-therapy to require that the insurers provide override exceptions upon request from physicians and consumers. The law goes into effect for health benefit plans that are delivered, issued for delivery, continued, or renewed in Iowa on or after January 1, 2018. The new provisions do not apply to the state’s Medicaid managed care organizations (MCOs).

Currently, insurers in Iowa can limit access to more costly medications by requiring step-therapy, in which their members demonstrate, via fail-first trials, that less expensive medications are not effective, unsafe, or have too many unpleasant side effects. Insurers with step-therapy policies will only consider authorizing a physician’s originally prescribed therapy option after the member completes a series of unsuccessful fail-first trials with preferred medications.  Insurers have been permitted to impose step-therapy even in cases where consumers were stable on a specific medication, and had in the past completed multiple fail-first trials before stabilizing with the specific medication.

HF 233 requires health insurance carriers, but not Medicaid MCOs, to provide the prescribing health care professional and covered consumer access to a clear, accessible, and convenient step-therapy override exception process so that the originally prescribed therapy can be obtained.  While HF 233 will not eliminate step therapy, it deters harm through the inclusion of safeguards surrounding an exceptions process. It will also not prohibit health insurance carriers from requiring generic versions of medications, it will only prohibit completely different medications from the prescribed therapy.

For more information, contact: Communications & Media Department, Iowa Insurance Division, 601 Locust Street, 4th Floor, Des Moines, Iowa 50309; 515-242-5179; Website: https://iid.iowa.gov/contact.

On May 2, 2017, the Mississippi Department of Mental Health (DMH) announced that a state budget cap on spending has halted enrollments for the intellectual disability/developmental disability (ID/DD) Home- and Community-Based Services (HCBS) waiver. Enrollments will remain at the 2,515 currently funded waiver slots. New applicants for waiver services will be added to the waiting list, which currently has 1,300 people. The average wait for waiver services is eight years.

DMH is addressing the impact of a $19.7 million reduction in its funding for fiscal year (FY) 2018, which begins on July 1, 2017. The ID/DD waiver program is under pressure due to an expected increase in the reimbursement rates paid to provider organizations and to the loss of the enhanced Medicaid matching funds through the Balancing Incentive Program funding. The FY 2018 budget caps spending for the HCBS waiver slots at $28.5 million, and DMH says it is already close to that limit.

In addition to ceasing enrollment in the ID/DD waiver program, DMH halted admissions to the five IDD Regional Programs (Hudspeth Regional Center, Boswell Regional Center, Ellisville State School, South Mississippi Regional Center, and North Mississippi Regional Center). Admissions have ceased to the nursing homes located at East Mississippi State Hospital and Mississippi State Hospital. However, nursing home services and ID/DD programs continue to be offered by other provider organizations throughout the state.

PsychU reported on this topic in “Mississippi Department Of Mental Health Implementing Cuts To Address $19.7 Million Cut To Funding For Fiscal Year 2018,” which published on June 6, 2017. 

For more information, contact: Adam Moore, Director of Communications, Mississippi Department of Mental Health, 239 N Lamar Street, 1101 Robert E. Lee Building, Jackson, Mississippi 39201; 601-359-1288; Fax: 601-359-6295; Email: Adam.Moore@dmh.ms.gov; Website: http://www.dmh.ms.gov/.

The challenges to timely strategic decisions in health and human service organizations has long been the topic of much discussion among the OPEN MINDS senior advisor team. Over my career, I’ve seen the “role” of non-profit specialty provider organizations in local health and human service systems shift from “a partner extending government policy,” to “a competitive vendor to government.” And I’ve seen the market shift from “guaranteed” funding for serving as part of the local safety net, to competing for funding or contracts with health plans (for Medicaid and Medicare). These are not small changes, but rather significant changes in both mission, role in the value chain, and business model.

This point was driven home to me in some commentary on our articles, from Scot Adams, Vice President for Advancement at Notre Dame Sisters and the former director of the Nebraska Department of Health and Human Services’ Division of Behavioral Health. He drew a fine point on the issue – that there were previous expectations that health and human service provider organization executives would run their organizations like a government or public entity. Those expectations have shifted, and non-profit executives are being asked to behave more like their private sector counterparts. He wrote:

Your article reminds me of how very different government is from the private sector. Rather than an environment of taking the risk and willingness to fail and adapt, the decisionmaking of government executives is more focused on risk avoidance. More typical is a response to the effect “We must act so that ‘it’ never happens again.” And it is not usually said within a learning framework: more often retributive, regulatory, and restrictive.

Generally, government executives operating from a core value of equality. Government is not the private sector and people who think government should be run like a business know too little about which they speak.

The current question is the complementary nature of government and private sector relationships. Each needs the other.

We need our executives in the private sector to be savvy to government’s useful and necessary world view, which is often focused on handling the “crisis du jour.” This is because the core, fundamental value for government is to provide equality through sameness. Government will generate regulations to tamp down inequalities or perceptions of inequalities – but it may also tamp down the innovations we want.

The private sector can generate good ideas on value – and we need good executives to keep these coming because some will get through eventually. You can get good top executives in government to break ice on new ideas and visions. The Centers for Medicare and Medicaid Services (CMS) had a great one, SAMHSA has had some very good visionaries in recent times. But the risk is that the antagonists get too much attention and government then has to reduce scope or the unevenness of programming.

I’m not entirely sure of the way out, but I think niche programming brought to scale over time in the private sector – both provider organizations and payers – is the better bet to see change emerge in systems. I think this will happen because, eventually, cost will win out when culture conflicts. Just be prepared that this will take time and be uneven – causing uproar for some.

I think we have seen the effects of “niche programming brought to scale over time” from the private sector in health and human services and this is the root of the transition of roles for the majority of non-profit service organizations. At a macro-level, the adoption of “managed care” by Medicaid plans and Medicare is a private sector innovation adopted by the public sector. There is the use of private sector funding in financing pay-for-success initiatives (see Managed Care Comes To Social Services – Some Advice From The Field). Public hospitals have been closed in favor of the use of private-sector provided services. Generally, county governments provide fewer health care services than they have in the past, choosing to purchase many of those services from private organizations.

I think it is not as simple as “non-profit organizations need to develop new strategies and a new business model.” They also need to re-invent their role in the community and their board governance model – and their executives needs to develop a new framework for leadership (for more, check out Courage As The Leadership Differentiator).

On June 17, 2016, PsychU sponsored the National Stigma Forum, held at the Marriott Metro Center in Washington DC. The overall objectives of this meeting included discussion of the current state of stigma toward individuals with mental illness, identification of the gaps that exist in past and present stigma initiatives, and to brainstorm and identify collaborative initiatives to address these gaps leveraging the PsychU community.

Today we are following up with Kent Alford, RN, BSN, Chief Nursing Officer on the Adventist Healthcare Behavioral Health and Wellness Executive Leadership Team, who was an attendee of the first PsychU National Stigma Forum, to see what he and his organization have done in the past year to alleviate stigma in mental health.

In this series of interviews, PsychU supporters and section editors discusses Mental Health Awareness Month and how the community can combat stigma together.

An Issue Brief from Mathematica Policy Research entitled “Behavioral Health Integration in Primary Care: A Review and Implications for Payment Reform” emphasizes the importance of behavioral health integration (BHI) in improving patient care for individuals with mild to moderate behavioral health conditions that can be treated in primary care settings. The issue brief also focuses on the financial barriers to implementing BHI and acknowledges other barriers to BHI integration, such as regulatory challenges and the historical siloed nature of primary care and behavioral health professionals. The report was authored by Kara Zivin, Ann O’Malley, JudyAnn Bigby, Jonathan Brown, and Eugene Rich; it was published June 2016 by Mathematica. The Agency for Healthcare Research & Quality (AHRQ) provided funding to Mathematica for their research study and report.

Figure 1 below shows the commonly-accepted definition of integrated care, as promulgated by AHRQ. The authors noted several reasons why BHI is important. They believe the high prevalence of behavioral health disorders and rate of comorbidity with physical health conditions suggest that treatment for these conditions should be addressed under a comprehensive primary care model such as BHI. The report cited 2014 data from the Substance Abuse and Mental Health Services Administration (SAMHSA) showing an estimated 43.8 million Americans age 18 or older had a mental illness in the past year, representing 18.5 percent of all adults in the United States. BHI could be a way to effectively deliver health care to people with mild to moderate behavioral health conditions because it has been shown to lower overall health care costs and increase efficiency of care by helping individuals adopt self-care and improve medication adherence. According to the authors, various studies have proven the effectiveness of BHI, including a meta-analysis of 79 randomized controlled trials covering 24,000 patients, which found collaborative care was better at improving depression and anxiety for up to two years compared to usual care.

Collaborative care has strict clinical features which may contribute to its success, including:

  • A standardized screening tool, such as the two- and nine-question Patient Health Questionnaires (PHQ-2 and PHQ-9) for depression
  • A medical diagnosis for patients who screen positive
  • Evidence-based, “stepped” depression care
  • Care managers
  • Patient and family education
  • Clinical and administrative staff training
  • Ongoing tracking of patient status by using PHQ-9 scores
  • A designated psychiatrist who consults with the care manager and the primary care physician
  • Continuous performance measurement and improvement

Based on various studies reviewed and presented by the authors in the report, they concluded that an effective BHI model shares these common features:

  • Clear screening processes
  • Decision support to help PCPs interpret screening results and move patients to the next step of treatment
  • Warm handoffs, by which the PCP directly introduces the client to the behavioral health provider at the time of the client’s medical visit
  • Colocation of PCPs and behavioral health providers
  • Processes for tracking progress by using empirically validated tools
  • Staff training and feedback
  • Ongoing decision support when medications or psychotherapy are no longer working or when they have achieved the treatment goal
  • Shared EHRs and other forms of communication between PCPs and behavioral health providers

In spite of evidence showing the effectiveness of BHI, financial challenges may limit its widespread implementation. For example, Medicare paid through fee-for-service (FFS) arrangements does not offer generous behavioral health benefits, and the FFS payments themselves do not provide incentives for providing comprehensive, coordinated, and accessible care. In addition, some communities have discrete private or public funding streams for medical and behavioral health services, for example in managed care arrangements that carve out behavioral services, making collaboration difficult. Dually-eligible Medicare and Medicaid beneficiaries would be affected under that scenario. In some circumstances, due to unique billing or credentialing requirements for behavioral health services, primary care and behavioral health practices may be administered separately, further complicating attempts to coordinate care. Traditional payment models can undermine care coordination, a hallmark of BHI, thereby limiting its broad adoption as a delivery model. Some changes to traditional payment models are beginning to emerge. Since 2015 care management activities for Medicare beneficiaries with two or more significant chronic conditions, including behavioral health disorders, are reimbursed when they are provided outside of a face-to-face office visit.

Over the years there have been changes in federal health policy that might serve to support the wider adoption of BHI. The Medicare Improvements for Patients and Providers Act of 2008 lowered the copayments for psychotherapy from 50 percent to 20 percent to bring them in line with medical services. Medicare Advantage plans saw benefit limitations for mental health or substance use disorder brought into parity with medical or surgical benefits under the Mental Health Parity and Addiction Equity Act of 2008. The Patient Protection and Affordable Care Act of 2010 increased access to insurance, redesigned the delivery system by instituting patient-centered medical homes and accountable care organizations (ACOs), and made mental health services an essential health benefit.

The Medicare Access and CHIP Reauthorization Act (MACRA), passed in 2016, creates two different ways for quality-based reimbursement, which in turn could help with wider adoption of BHI.

  • Merit-Based Incentive Payment System (MIPS) – Applies up to a nine percent increase or decrease to FFS payments to physicians, based on composite scores for the physician’s quality measures, resource use, clinical improvement, and use of electronic health records. The quality measures can include those that incentivize integrated care practices, such as cross-training clinicians or groups taking part in integrated care, co-location of behavioral health and primary services, and shared records for behavioral health and primary care. MIPS doesn’t create new Physician Fee Schedule payments for services related to BHI, so additional payments to support BHI would still be needed to significantly improve care.
  • The Alternative Payment Model (APM) – This model encourages providers to take part in an APM such as an ACO, bundled payment model, or patient-centered medical home by providing a bonus equal to five percent of their Medicare PFS payments. Providers would also receive higher annual increases in reimbursements for all of their services than providers in MIPS would receive. In addition, providers in APMs are exempt from MIPS. APMs can support BHI by:
    1. Rewarding physician practices for delivering services that are not currently billable but  that support BHI
    2. Developing condition payments specific to behavioral health
    3. Developing bundled payments that recognize the roles of multiple providers
    4. Developing other payments that support BHI

Although none of the current APMs being tested by Centers for Medicare & Medicaid Innovation (CMMI) specifically target BHIs, CMMI is investigating the effectiveness of delivering comprehensive primary care at home, as well as testing all-payer APMs that include individuals covered by Medicare and other payment types, something that would be beneficial to providers who serve individuals with various types of payment.

The authors believe BHI, with its collaborative and patient-centered elements, is essential to improving quality and reducing costs. In addition, researchers at AHRQ noted that even though the effectiveness of BHI has been proven, new payment models that provide incentives for effective and efficient care are necessary to sustain it.

The full text of “Behavioral Health Integration in Primary Care: A Review and Implications for Payment Reform” was published by Mathematica Policy Research on June 17, 2016.

On April 19, 2017, a Michigan House appropriations panel approved two new financing models to help the state integrate Medicaid physical and behavioral health services by September 30, 2020. In one, the Michigan Department of Health and Human Services (MDHHS) would create a statewide prepaid inpatient health plan (PIHP) to manage behavioral health services; the statewide PIHP would replace the 10 regional mental health authorities. The other would take place in Kent County, and would pilot a fully integrated model. MDHHS would work with a willing community mental health service provider organization in Kent County and willing Medicaid managed care organizations (MCOs). After the budget is finalized, MDHHS intends to start planning for the pilots.

Currently, Michigan operates a Medicaid carve-out for behavioral health services, which are managed by 10 regional mental health authorities structured as prepaid inpatient health plans (PIHPs); the PIHPs manage Medicaid and non-Medicaid mental health, addiction treatment, and developmental disability support services. Physical health services are managed by regional Medicaid MCOs. More than 350,000 state residents are served through the public behavioral health system at a cost of $2.6 billion.

In 2016, the legislature rejected a provision in the governor’s budget to integrate behavioral health services with physical health care as of September 30, 2017, by ending the carve-out and adding behavioral health to the MCO contracts. The legislature directed MDHHS to launch a statewide effort to integrate physical and behavioral health service financing and delivery. In March 2016, MDHHS created a workgroup called the Section 298 Facilitation Workgroup in honor of the section of budget code that called for ending the carve-out. The workgroup issued its final report to the legislature on March 15, 2017. It calls for the legislature to consider the results of current demonstrations or pilots and the results of up to three new pilots of integrated care models yet-to-be proposed.

PsychU reported on this topic in “Michigan DHHS Workgroup Recommends Retaining Mental Health Carve-Out System,” which published on January 11, 2017.

For more information, contact: Jennifer Eisner, Public Information Officer, Michigan Department of Health and Human Services, 201 Townsend Street, Capitol View Building, Lansing, Michigan 48913; 517-241-2112; Email: EisnerJ@michigan.gov

The majority of children diagnosed with autism are male, but the breadth of the gender disparity is three males to each female, which is narrower than previous estimates of four males to one female. The disparity may be due in part to diagnostic gender bias because females with autism exhibit their behavior symptoms differently than males, who tend to display stereotypical behaviors associated with autism.

These findings were reported in “What Is the Male-to-Female Ratio in Autism Spectrum Disorder? A Systematic Review and Meta-Analysis” by Rachel Loomes, DClinPsy; Laura Hull, MSc; and William Polmear Locke Mandy, DClinPsy, Ph.D. The researchers conducted a meta-analysis of autism prevalence studies published between 1992 and 2011, and that used the Diagnostic and Statistical Manual, 4th Edition, and the International Classification of Diseases, Tenth Revision, and that reported prevalence by gender. They analyzed 54 studies that included 13.7 million participants. Within this group, 53,712 had autism, a 0.4% prevalence rate, with 43,972 boys (0.3%) and 9,740 girls (less than 0.1%). The researchers compared the odds of being male in the autism group to the odds of being male in the non-autism group.

Key findings are reported as the male-to-female odds ratio of being diagnosed with autism. Across the 54 studies, males were 4.20 times more likely to be diagnosed with autism than females. However, in studies that screened the general population to identify participants regardless of whether they already had an autism diagnosis, males were only 3.25 times more likely to be diagnosed with autism. In studies that included only participants with a pre-existing autism diagnosis, males were 4.56 times more likely to have an autism diagnosis.

The researchers concluded that girls who meet criteria for autism are at disproportionate risk of not receiving a timely clinical diagnosis. They may be misdiagnosed, identified late, or never diagnosed.

The full text of “What Is the Male-to-Female Ratio in Autism Spectrum Disorder? A Systematic Review and Meta-Analysis” was published April 4, 2017, by Journal of the American Academy of Child and Adolescent Psychiatry.

For more information, contact: William Polmear Locke Mandy, Ph.D., DClinPsy, Research Department of Clinical, Educational and Health Psychology, University College of London, Gower Street, London, WC1E 6BT; England; 44 (0) 20 7679 2000; Email: w.mandy@ucl.ac.uk; Website: https://www.ucl.ac.uk/.

Three Maryland telehealth pilot programs focused on remote patient monitoring (RPM) resulted in reducing hospital and emergency department utilization. The participating consumers reported high levels of satisfaction with the RPM technology and program services. The pilots were funded through 18-month grants totaling $80,000 awarded in June 2015 by the Maryland Health Care Commission (MHCC) to Crisfield Clinic, LLC; Lorien Health Systems; and Union Hospital of Cecil County (UHCC).

The projects and outcomes were as follows:

  • Crisfield, a rural family practice clinic in Somerset County assessed consumer baselines on certain health indicators, such as maintaining A1C blood sugar levels, rescue inhaler use, weight, and measured improvement over time. One of the objectives was to decrease baseline rescue inhaler use by 50% among participants with asthma. Crisfield’s project used mobile devices to help middle school and high school-aged patients manage chronic health conditions, including asthma, diabetes, obesity, and behavioral health issues. Crisfield consumers were able to avoid emergency department encounters, and had improved health, as well as increased activity levels. The participants avoided preventable emergency department encounters. Crisfield was able to show an improvement in the health of their patients and an increase in activity level throughout the project. The program reports no data relative to emergency department utilization or hospitalization.
  • Lorien, a skilled nursing facility and residential service agency, used telemonitoring technology to provide 24/7 access to care among consumers who were discharged from the skilled nursing facility to home with chronic heart failure, hypertension, and uncontrolled diabetes. Information was collected daily through a blood pressure peripheral device. The pilot assessed if they maintained or improved their risk classification score. Lorien’s 22 participants had fewer hospital readmissions as compared to their readmission rate prior to the project. It demonstrated a reduction in A1C values for participants with uncontrolled diabetes. Hospital admissions dropped from 2.27 per person in the 12 months before the study started to 0.95 per person.  Hospital all-cause readmissions within 30 days were 4.5% among participants, as compared to the state average of 15.95%.
  • UHCC focused on reducing 30-day readmission rates of patients with chronic conditions and frequent hospital encounters. Information about readmissions was collected through a notification service, and care managers assessed consumer data through a dashboard. The project used mobile tablets and peripheral devices to monitor consumers with chronic health conditions post discharge to reduce prevention quality indicators (PQI). UHCC participants had fewer readmissions as compared to other hospital users. UHCC participants also had a lower 30-day readmission rate. There were 44 potential 30-day readmissions avoided as a result of this program; however, the program reported no other data related to emergency department utilization.

The outcomes were reported in “Remote Patient Monitoring Telehealth Grants: Brief and Final Reports” by the Center for Health Information Technology and Innovative Care Delivery, which is part of the MHCC. Since 2014, the MHCC has awarded over $450,000 in telehealth grants to 11 organizations over five funding rounds. For its RPM grants, the MHCC awarded a combined total of $80,000 to the three grantees over an 18-month period. The RPM grants sought to assess the impact of this type of technology on reducing hospital encounters, improving clinical care, and decreasing health care costs. The MHCC defines RPM as the use of digital technologies that collect health information from a patient in one location and electronically transmits that information to a health care professional or provider organization in a different location for assessment and recommendations.

The grant recipients are required to meet financial match requirements. The three organizations’ projects explored the effect of RPM on consumer populations with varying health conditions and in different settings. The three grantees’ projects shared a common goal of reducing hospital encounters using telehealth technologies. Each grantee was required to use a nationally certified electronic health record (EHR) and services of the state-designated health information exchange (HIE), which is called the Chesapeake Regional Information System for our Patients (CRISP). This report provides information on the three grantees’ implementation of RPM and lessons learned from their telehealth projects.

The MHCC reported that a key lesson from the projects is that defining only clinical objectives and measures is not sufficient in designing an RPM project. The authors noted that determining the impact of RPM on workflows, communications, provider and patient satisfaction, and care coordination is equally important. Project performance goals were clinically based and most participants’ conditions either improved slightly or remained the same. Further, the grantees reported an increase in participant awareness of their health and a willingness to become more engaged in self-care.

For more information, contact: Angela Evatt, Chief, Health Information Exchange, Maryland Health Care Commission, 4160 Patterson Avenue, Baltimore, Maryland 21215; 410-764-3574; Fax: 410-358-1236; Email: angela.evatt@maryland.gov; Website: http://mhcc.maryland.gov/; or Erin Dorrien, Chief, Government and Public Affairs, Maryland Health Care Commission, 4160 Patterson Avenue, Baltimore, Maryland 21215; 410-764-3284; Email: erin.dorrien@maryland.gov; Website: http://mhcc.maryland.gov/

Partnerships between physicians and community-based pharmacists are needed to create community-clinical linkages to improve care for consumers with chronic health conditions. In such partnerships, pharmacists go beyond filling prescriptions to provide team-based disease management via pharmacist-directed medication therapy management (MTM), collaborative drug therapy management (CDTM), health assessments, referrals to physicians, or triage into primary care after identifying medication-related problems. Community-clinical linkages can be effective and sustainable without the need for an additional payment because the services provided are often with the scope of the health care professionals’ daily activities.

These are the findings of “Creating Community-Clinical Linkages Between Community Pharmacists and Physicians.” To encourage the growth of this strategy to improve consumer care, the American Pharmacists Association (APhA) and the American Medical Association, with the Centers for Disease Control and Prevention (CDC) developed guidelines, called the LINKAGE Framework, for establishing the partnerships. The guidelines were described in “Creating Community-Clinical Linkages Between Community Pharmacists and Physicians” by the Centers for Disease Control and Prevention (CDC) Division for Heart Disease and Stroke Prevention. The guide was developed in collaboration with the American Pharmacists Association (APhA) and the American Medical Association. LINKAGE is an acronym that stands for the strategies used to build links between community pharmacists and physicians, as follows:

  • Learn about the community and clinical sectors
  • Identify and engage key stakeholders from the community and clinical sectors
  • Negotiate and agree upon goals and objectives of the linkage
  • Know which operational structure to implement
  • Aim to coordinate and manage the linkage
  • Grow the linkage with sustainability in mind
  • Evaluate the linkage

The goal is to encourage pharmacists, physicians, and other community resources to share their knowledge and identify ways to collaborate to improve population health. The guide also discusses common barriers to and potential solutions for creating community-clinical linkages between community pharmacists and physicians, particularly the reimbursement mechanism for pharmacists. However, the guide does not attempt to resolve the payment and reimbursement issues that face clinical pharmacy practice. It notes that pharmacists could seek to establish community-clinical linkages with an accountable care organization (ACO) to seek reimbursement for clinical services. State health departments could work with their Medicaid agency, Medicaid managed care organizations (MCOs), or private payers to create a payment structure for clinical pharmacy services or for supporting community health workers who connect consumers with health care and community resources. To maximize resources and create comprehensive and sustainable systems of care for consumers with chronic diseases, all stakeholders and partners need to be considered.

For more information, contact: Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, Georgia 30329-4027; or American Pharmacists Association 2215 Constitution Avenue NW, Washington, District of Columbia 20037; 202-628-4410; Fax 202-783-2351.

Between 2004 and 2014, the number of telemental health visits (telemedicine visits for mental health issues) made by Medicare beneficiaries living in rural areas increased by 45% annually, rising from 2,365 visits in 2004 to 87,120 visits in 2014. The number of visits among beneficiaries with serious mental illness rose by 49% annually, from 1,040 in 2004 to 50,050 in 2014. The visit rate increased from 0.2 telemental health visits per 100 beneficiaries in 2004, to 5.3 telemental health visits per 100 beneficiaries in 2014.

Telemental health visits are defined as interactive audio or video teleconferencing with a specialty mental health clinical professional. Telemedicine visits are considered a way to overcome access limitations for rural-area consumers (such as lack of mental health specialists in their area, or transportation/cost issues).

These findings were reported in “Rapid Growth In Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States” by Ateev Mehrotra, Haiden A. Huskamp, Jeffrey Souza, Lori Uscher-Pines, Sherri Rose, Bruce E. Landon, Anupam B. Jena, and Alisa B. Busch. The researchers analyzed 2004-2014 Medicare Part B claims for a 20% sample of fee-for-service Medicare beneficiaries. The analysis focused on visits made by beneficiaries diagnosed with mental illness living in rural areas eligible for Medicare coverage of telemedicine services and who made at least two outpatient visits or had one inpatient admission in a given year. Additional findings regarding telemental services for mental illness include:

  • Telemental health use in 2014 varied across states. For example, three states—Connecticut, Delaware, and Rhode Island—had no telemental health visits, while two states—Iowa and South Dakota—had more than 10 visits per 100 beneficiaries with any mental illness.
  • In 2014, states with a telemedicine parity law had a higher rate of telemental health visits (5.9 visits per 100 beneficiaries) than states without such laws (4.8 visits per 100 beneficiaries). Telemedicine parity laws require that health plans reimburse clinical professionals for telemedicine services at the same rate as an office visit.
  • The rate of growth in telemental health visits from 2004 to 2014 was similar for states with and without telemental parity laws.
  • States with high grades from the American Telemedicine Association for their telemental health regulatory environments for psychologists had higher rates of telemental health visits (8.1 per 100 beneficiaries in states with A grades) than those states with lower grades (4.6 visits per 100 beneficiaries in states with B grades, and 4.2 visits per 100 beneficiaries in states with C or F grades).
  • About 5% of the clinical professionals delivering telemental health services were in the same states as the beneficiaries who consulted them in 2014.
  • The mean distance between the beneficiaries’ residences and their telemental health providers was 103 miles in 2014.
  • Younger beneficiaries (under age 65) were more likely to use telemental services than older beneficiaries in 2014.
  • Medicare beneficiaries under age 65 with a disability were more likely to use telemental services than other Medicare beneficiaries.
  • Caucasian beneficiaries were markedly more likely to take advantage of telemental services (84.8 per 100) than those of other races (10 per 100 “black” beneficiaries, and 5.2 per 100 “other” beneficiaries).

The study provided evidence that telemental health use among rural Medicare beneficiaries is growing quickly. However, only small minority of beneficiaries diagnosed with mental illness received a telemental visit, and rates of use varied across the states.

The full text of “Rapid Growth In Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States” was published in the May 2017 issue of Health Affairs.

For more information, contact: Ateev Mehrotra, Associate Professor of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Department of Health Care Policy, Boston, Massachusetts 02115; 617-432-3905; Fax: 617-432-0173; Email: Mehrotra@hcp.med.harvard.edu; Website: https://www.hcp.med.harvard.edu/.

I just read “The Greater New Brunswick Hotspotting Project Report” by the Robert Wood Johnson Medical School and had two immediate thoughts — hot spotting gives a structure to the medical neighborhood concept and opens up new business opportunities for provider organizations.

First, what is hot spotting? This approach collects geospatial data that combines outcomes data with location data, often to identify and implement preventative care for consumers with complex health care needs and high resource use (aka “super utilizers”). Recent headlines show that the approach is being used often in health care and social services – see Harvard’s “‘Hot-Spotting,’ How Gun Violence Spreads, & Living In America On $2 A Day” and NJSpotlight’s “Students Learn Hotspotting To Help Patients While Reducing Costs.”

The Greater New Brunswick Hotspotting Project analyzed utilization patterns of consumers who visited Robert Wood Johnson University Hospital and Saint Peter’s University Hospital in the city of New Brunswick and in Franklin County in New Jersey through the use of hot spotting. What did the study find?

  1. Of 43,000+ consumers visiting the two local hospitals, 3% were “high utilizers” – defined as 5+ emergency department visits or 3+ hospitalizations in two years
  2. The cost for those consumers totaled $14 million – about one-fifth of the $44.2 million in Medicaid costs for hospital visits in the area, with average two-year costs for the group at $18,000, and ranging as high as $38,000
  3. This population had multiple comorbid conditions including behavioral health conditions – and a higher percentage of consumers with “extreme” emergency department use had behavioral disorders
  4. The analysis identified ten Census blocks and eight buildings/apartment complexes as having a high proportion of the high utilizer population

The geographic density of the group of high-needs consumers made me think of the medical neighborhood concept. It is a group of health care organizations, clinical professionals, and social service organizations that operate in a geographic area under a collaborative care agreement delineating a set of principles and expectations – with requisite systems and processes – to provide coordinated care for all consumers in the area.

This construct is the goal of medical homes and specialty medical homes – with the assumption that the provider organization serving as the medical home manager will organize just such a “medical neighborhood”.

When I think about this specific hot spotting analysis in New Jersey – and hot spotting analysis as a tool – what comes to mind is an even more refined approach to business development for provider organization strategy and marketing planning. Hot spotting becomes another tool in identifying “gaps” in the service delivery system – and an opportunity to engage health plans in a discussion about geographically-specific solutions for consumers with some very specific health and social support needs. I think this is a great example of moving the health and human service organizations away from the “transactional” nature of the field to more “transformational” practices. In Deloitte Insight’s “Rethinking Human Services Delivery,” authors B. J. Walker and Tiffany Dovey Fishman note:

Health and human service agencies, by design, take a program-centric view of the world and are often more transactional in nature than transformational. Rather than identifying and addressing the problems that bring individuals and families into contact with the social safety net, human service programs instead tend to see people through the lens of eligibility… This program-centric view is a lingering byproduct of the way health and human service programs were originally created – as a stand-alone programs rather than an integrated safety net… Analytics holds the potential for transforming the entire human services delivery cycle, from how human services agencies define and target problems, to how they use data to inform how case workers approach their day-to-day work, to how they challenge long-standing beliefs about what works and then use what they learn to reform their policies and practices…”

This is exactly the “transformation” that is being driven by the move to value-based reimbursement and pay-for-success initiatives. Executive teams need to develop the link between data and analytics, strategy, solution, and new service line development to gain market advantage (see Child Welfare System Is Changing, But Slowly).

Key Messages

  • This review article examined evidence that supports a bidirectional relationship between medical illness and mood disorders. This relationship involves a complex interplay of shared and specific etiological factors, the exact nature of which may vary between individual patients. Heightened stress responses in particular may be a key shared etiological factor in the comorbidity of depression and medical illness.
  • The authors indicated that an “inclusive” approach to assessing depression in the medically ill, whereby all depressive symptoms are counted irrespective of whether they are related to medical illness, is generally considered to be the best approach to avoid underdiagnosis of comorbid depression.
  • The authors suggested that comorbid depression be treated in accordance with current depression guidelines, focusing on both the psychiatric condition and the contributing medical illness and taking into account potential drug−drug interactions and drug−illness interactions.

Key Messages

  • There is a lack of data regarding predictors of illness course following a first episode of depression in adults, and no prospective studies have investigated factors that may predict conversion of a first depressive episode to bipolar disorder (BD).
  • This prospective study (N = 301) described the course of illness in adult patients discharged from inpatient or outpatient care for a first episode of depression. During five years’ follow-up, 83.3% of patients achieved remission after first depression, 31.5% experienced a recurrence of depression, and 8.6% converted to BD.
  • Significant risk factors for conversion to BD were family history of affective disorders, resistance to three or more antidepressant therapies, and comorbid drug or alcohol abuse.
  • Knowledge of risk factors for a poorer course of illness may help clinicians personalize therapy in patients presenting with a first episode of depression.

Key Messages

  • Poor treatment adherence is common among patients with bipolar disorder (BD). There is a lack of robust data on factors that negatively influence adherence behavior.
  • This multicenter study investigated adherence behavior in a large, well-characterized cohort of patients with BD but without the confounding effect of substance use disorder (SUD).
  • Female patients and those with shorter illness duration were significantly more likely to display poor adherence behavior. Patients with BD type II or BD “not otherwise specified” (NOS) showed poorer attitudes toward taking medication than patients with type I.
  • In particular, the presence of residual depressive symptoms and a greater frequency and severity of treatment side effects were significant predictive factors for poor adherence. The authors suggested that these two factors should be monitored to optimize adherence behavior.

Key Messages

  • Timely and accurate diagnosis of bipolar disorder (BD) is essential to ensure early introduction of appropriate treatment to maximize functionality.
  • This 10-year, single-center study showed a 6.1% rate of BD diagnosis among patients assessed after referral to shared-care psychiatry services.
  • Of the patients referred on suspicion of BD, 37% subsequently received a main diagnosis of BD.
  • There was only moderate agreement between general practitioner (GP) suspicion of BD and subsequent psychiatrist diagnosis, and the level of agreement did not improve over the 10-year study. GP−psychiatrist agreement was greater for BD type I than for type II.
  • The authors concluded that the process of establishing an accurate diagnosis of BD remains complex, and, despite increased awareness, BD does not appear to be overly suspected in primary care.

Key Messages

  • Bipolar disorder (BD) has the highest rate of suicide among the major psychological disorders. The risk for death by suicide is approximately 60 times higher for patients with BD compared with people in the general population.
  • This systematic review identified a range of risk factors for suicidal behavior in patients with BD, including sociodemographic factors, biological characteristics, substance and drug use, psychological factors, genetic factors, and religious/spiritual beliefs.
  • Findings from this review suggested that suicidal behavior may result from a combination of individual illness features and precipitating factors, making the assessment of suicide risk in any given patient difficult. However, awareness of possible risk factors, including bipolar depression, and effective management may help improve prognosis in BD cases at risk for suicidal behavior.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/inflammation-metabolic-disturbances-metastasize-brain-implications-disease-modeling-novel-approaches-psychiatry-part-1-2/.

Robert McIntyre, MD, FRCPC, presented information on the effects of inflammation and metabolic disturbances on mood disorders during a PsychU live virtual forum held on February 14, 2017. Dr. McIntyre is a Professor of Psychiatry and Pharmacology at the University of Toronto, and Head of the Mood Disorder Psychopharmacology Unit at the University Health Network, Toronto, Canada. He is a paid consultant for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the presentation were to:

  • Describe the importance of cognitive symptoms as psychiatric targets
  • Review immune and metabolic systems associated with cognitive deficits and mood disorders
  • Discuss innovative approaches that may target these symptoms

Dr. McIntyre began with the statement that there is no cure or disease modification available for depression, schizophrenia, bipolar disorder, or other related disorders. There are psychosocial and pharmacologic treatment options that can reduce symptoms and improve outcomes for patients, but, he stated too few people benefit from modification, cure, or recovery from these diseases. Therefore he focused his presentation on understanding the effector systems, in this case inflammation and metabolic changes that metastasize to the brain, causing cognitive dysfunction. Cognitive symptoms such as memory dysfunction, decreased processing speed, and difficulties with executive function and attention are common across different types of mental health conditions (e.g., major depressive disorder, schizophrenia, Alzheimer’s disease) and scientists from National Institutes of Health have identified this domain as a priority therapeutic target.

Citing a study that examined cognitive dysfunction in people with diabetes mellitus, Dr. McIntyre noted that although diabetes is an insulin-glucose homeostatic disturbance it greatly affects the brain’s cognitive abilities, similar to the symptoms seen in adults with mood disorders. He also called attention to a study conducted in his clinical practice that looked at body mass index (BMI) as a significant moderating factor for cognitive function, in which they found that people with higher BMI were more likely to have cognitive impairments.

The moderator asked Dr. McIntyre, “Do we know how mood disorders and metabolic disorders are related? Do they have the same underlying cause?” Dr. McIntyre said yes, that they typically begin with the social determinants of health (e.g., economics, housing dislocation, exposure to high-crime areas). Next he explained there are substrates that are common in the two conditions, like disturbances in the hypothalamic-pituitary-adrenal system, at the molecular level. He continued by explaining the association between metabolic and neuropsychological phenotypes, implicating inflammation, metabolism, oxidative stress, and behaviors such as consumption of high empty calorie food. These may lead to sustained disturbances in glucose-insulin homeostasis, along with inflammation, which leave the brain vulnerable to harm. He continued with a chart showing how adipose tissue increases inflammation, caused by peptides called adipokines produced by the adipose sites. People who have mood disorders and are overweight are more likely to exhibit elevated C-reactive peptides and pro-inflammatory cytokines interleukin-1 or 6 in their peripheral blood stream. Dr. McIntyre observed that inflammation is a cause, consequence, and concurrent condition in people with mood disorders; and obesity can be the cause, consequence, and concurrent condition of people with inflammatory disorders. He postulated that inflammation, when gone awry, leaves a person at risk for obesity, diabetes, and mood disorders.

Dr. McIntyre presented another study wherein he and colleagues observed that exposure to early childhood adversity (e.g., physical or sexual abuse) increased the risk of cardiovascular disease, obesity, diabetes, and other metabolic syndromes. He said this is similar to what he’s seen in general population studies. This prompts him to ask every patient, without exception, about histories of early trauma. He then counsels them about the possible risk factors of cardiovascular disease, being overweight, and obesity. He believes that sustained activation of the stress response leaves these individuals at risk for obesity, diabetes, major depression, and bipolar disorder.

The moderator asked, “Do we have any idea how this occurs? Are there any specific pathways involved that you can talk about?” Dr. McIntyre replied that the stress response system is abnormal in people who’ve been exposed to chronic, uncontrollable, pathological stressors like physical and sexual abuse. The stress system is in interplay with the innate immune-inflammatory system and regulatory systems such as for endocrine-based systems; eventually the effector system becomes abnormal. People who come to Dr. McIntyre’s clinic have depressive symptoms, obesity, and metabolic changes that are brought about by psychosocial events.

Next Dr. McIntyre explained hippocampal volume changes in people with diabetes or major depression. The longer the duration of depression, and the longer an individual has diabetes, the more hippocampal volume is reduced. He also pointed out that people with schizophrenia, autism, bipolar disorder, and depression experience alterations in brain connectivity as shown in diffusion tensor imaging, as do people with diabetes and obesity. In his clinical experience, these patients can’t focus, can’t regulate their moods, and are impulsive, which is evidence of the presence of brain-connectivity abnormalities. His next slide focused on the mechanisms of neuro-inflammation – in the form of activated microglia that release pro-inflammatory cytokines in the brain — which increase when individuals have major depression, bipolar disorder, schizophrenia, and trauma-based disorders such as post-traumatic stress disorder (PTSD). In addition, pro-inflammatory markers can cause fatigue as seen in people with a common cold, metabolic diseases, and mood disorders. In light of this information, Dr. McIntyre believes someone with a brain-based illness should be treated for somatic morbidities in addition to mental health problems.

The next part of the presentation focused on metabolic or inflammation-based treatments for people with conditions such as depression or bipolar disorder. Dr. McIntyre believes that an anti-inflammatory approach can work against depression. He gave the example of people with metabolic conditions who are more likely to be depressed than people without metabolic conditions. When people with dyslipidemia take statins – which have an anti-inflammatory and antioxidant effect — they are less likely to be depressed than people who do not take statins for dyslipidemia. Dr. McIntyre doesn’t think doctors should measure people’s inflammatory proteins as a way to inform or stratify treatment because there isn’t enough evidence for a baseline marker to support it, although it is a promising approach. He also discussed the possibility of inoculations for depression involving gut biome or gut biota, which are known to be relevant to disease and health in humans. People with schizophrenia or other mood disorders have shown improved symptoms when given an antibiotic. He continued by saying there are other approaches to anti-inflammation including getting a good night’s sleep because it normalizes circadian rhythm, a nutritional diet, and exercise, especially a combination of aerobic exercise and resistance training, which has proven to be anti-depressant and pro-cognitive. Dr. McIntyre reminded the audience about the important role of social determinants of health as it affects an individual’s metabolism and level of inflammation. For example, air pollution, exposure to high calorie food, high crime environments, and high unemployment are all linked to pro-inflammatory outcomes. He suggests that a multisystem approach to target social, biological, and individual factors is needed.

Dr. McIntyre believes that when treating someone for mental disorders, professionals need to counsel the individual about risk factors for metabolic diseases like cardiovascular disease. He said, “…treat the patient not only from the neck up, but the neck down” to help them achieve mental and physical wellness.

The question and answer session included these questions from the audience. The presenter’s responses are shown below.

  • Considering the relationship between adverse childhood events and physical, emotional, and social disorders, including inflammation, it would seem that primary prevention starts well before adulthood. What are your thoughts on that?

Dr. McIntyre indicated that you can look even further upstream. In utero exposure to infections like herpes, cytomegalovirus, or toxoplasmosis increases the risk that the individual or offspring will have a mood or psychotic condition, autism, or a learning disorder. This speaks to the importance of antepartum care. He also spoke about sugary drinks consumed by children, which when consumed in excess can cause obesity but can also cause trauma to the brain.

  • The information you’ve presented today makes the negative impact on metabolics from anti-psychotic therapy all the more concerning. Can you share your thoughts on this?

Dr. McIntyre referred to the Florida Medicaid Treatment guidelines, which contain very clear statements about the deleterious effects of obesity and diabetes on brain health and how people with mental disorders are disproportionately affected by these (metabolic) conditions. He believes we should prioritize and use psychotropic medications that do not have the liability of weight gain and other metabolic effects.

  • Could you just briefly share any thoughts that you have on the role of epigenetics on any of the systems you discussed?

Dr. McIntyre explained that epigenetics refers to the modification of genetic transcription on the basis of environmental exposure. As an example, people who have been exposed to trauma are also exposed to a change in their biological milieu that alters the way the genes are transcribed. There are efforts to look at novel ways of treating depression and cognitive impairment through epigenetics. One way is to restrict calorie intake, which reduces inflammatory transcription. Dr. McIntyre also believes that sleep and the normal circadian rhythm, as well as aerobic exercise, can target the epigenetic systems.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/inflammation-metabolic-disturbances-metastasize-brain-implications-disease-modeling-novel-approaches-psychiatry-part-1-2/.

Robert McIntyre, MD, FRCPC, presented information on the effects of inflammation and metabolic disturbances on mood disorders during a PsychU live virtual forum held on February 14, 2017. Dr. McIntyre is a Professor of Psychiatry and Pharmacology at the University of Toronto, and Head of the Mood Disorder Psychopharmacology Unit at the University Health Network, Toronto, Canada. He is a paid consultant for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the presentation were to:

  • Describe the importance of cognitive symptoms as psychiatric targets
  • Review immune and metabolic systems associated with cognitive deficits and mood disorders
  • Discuss innovative approaches that may target these symptoms

Dr. McIntyre began with the statement that there is no cure or disease modification available for depression, schizophrenia, bipolar disorder, or other related disorders. There are psychosocial and pharmacologic treatment options that can reduce symptoms and improve outcomes for patients, but, he stated too few people benefit from modification, cure, or recovery from these diseases. Therefore he focused his presentation on understanding the effector systems, in this case inflammation and metabolic changes that metastasize to the brain, causing cognitive dysfunction. Cognitive symptoms such as memory dysfunction, decreased processing speed, and difficulties with executive function and attention are common across different types of mental health conditions (e.g., major depressive disorder, schizophrenia, Alzheimer’s disease) and scientists from National Institutes of Health have identified this domain as a priority therapeutic target.

Citing a study that examined cognitive dysfunction in people with diabetes mellitus, Dr. McIntyre noted that although diabetes is an insulin-glucose homeostatic disturbance it greatly affects the brain’s cognitive abilities, similar to the symptoms seen in adults with mood disorders. He also called attention to a study conducted in his clinical practice that looked at body mass index (BMI) as a significant moderating factor for cognitive function, in which they found that people with higher BMI were more likely to have cognitive impairments.

The moderator asked Dr. McIntyre, “Do we know how mood disorders and metabolic disorders are related? Do they have the same underlying cause?” Dr. McIntyre said yes, that they typically begin with the social determinants of health (e.g., economics, housing dislocation, exposure to high-crime areas). Next he explained there are substrates that are common in the two conditions, like disturbances in the hypothalamic-pituitary-adrenal system, at the molecular level. He continued by explaining the association between metabolic and neuropsychological phenotypes, implicating inflammation, metabolism, oxidative stress, and behaviors such as consumption of high empty calorie food. These may lead to sustained disturbances in glucose-insulin homeostasis, along with inflammation, which leave the brain vulnerable to harm. He continued with a chart showing how adipose tissue increases inflammation, caused by peptides called adipokines produced by the adipose sites. People who have mood disorders and are overweight are more likely to exhibit elevated C-reactive peptides and pro-inflammatory cytokines interleukin-1 or 6 in their peripheral blood stream. Dr. McIntyre observed that inflammation is a cause, consequence, and concurrent condition in people with mood disorders; and obesity can be the cause, consequence, and concurrent condition of people with inflammatory disorders. He postulated that inflammation, when gone awry, leaves a person at risk for obesity, diabetes, and mood disorders.

Dr. McIntyre presented another study wherein he and colleagues observed that exposure to early childhood adversity (e.g., physical or sexual abuse) increased the risk of cardiovascular disease, obesity, diabetes, and other metabolic syndromes. He said this is similar to what he’s seen in general population studies. This prompts him to ask every patient, without exception, about histories of early trauma. He then counsels them about the possible risk factors of cardiovascular disease, being overweight, and obesity. He believes that sustained activation of the stress response leaves these individuals at risk for obesity, diabetes, major depression, and bipolar disorder.

The moderator asked, “Do we have any idea how this occurs? Are there any specific pathways involved that you can talk about?” Dr. McIntyre replied that the stress response system is abnormal in people who’ve been exposed to chronic, uncontrollable, pathological stressors like physical and sexual abuse. The stress system is in interplay with the innate immune-inflammatory system and regulatory systems such as for endocrine-based systems; eventually the effector system becomes abnormal. People who come to Dr. McIntyre’s clinic have depressive symptoms, obesity, and metabolic changes that are brought about by psychosocial events.

Next Dr. McIntyre explained hippocampal volume changes in people with diabetes or major depression. The longer the duration of depression, and the longer an individual has diabetes, the more hippocampal volume is reduced. He also pointed out that people with schizophrenia, autism, bipolar disorder, and depression experience alterations in brain connectivity as shown in diffusion tensor imaging, as do people with diabetes and obesity. In his clinical experience, these patients can’t focus, can’t regulate their moods, and are impulsive, which is evidence of the presence of brain-connectivity abnormalities. His next slide focused on the mechanisms of neuro-inflammation – in the form of activated microglia that release pro-inflammatory cytokines in the brain — which increase when individuals have major depression, bipolar disorder, schizophrenia, and trauma-based disorders such as post-traumatic stress disorder (PTSD). In addition, pro-inflammatory markers can cause fatigue as seen in people with a common cold, metabolic diseases, and mood disorders. In light of this information, Dr. McIntyre believes someone with a brain-based illness should be treated for somatic morbidities in addition to mental health problems.

The next part of the presentation focused on metabolic or inflammation-based treatments for people with conditions such as depression or bipolar disorder. Dr. McIntyre believes that an anti-inflammatory approach can work against depression. He gave the example of people with metabolic conditions who are more likely to be depressed than people without metabolic conditions. When people with dyslipidemia take statins – which have an anti-inflammatory and antioxidant effect — they are less likely to be depressed than people who do not take statins for dyslipidemia. Dr. McIntyre doesn’t think doctors should measure people’s inflammatory proteins as a way to inform or stratify treatment because there isn’t enough evidence for a baseline marker to support it, although it is a promising approach. He also discussed the possibility of inoculations for depression involving gut biome or gut biota, which are known to be relevant to disease and health in humans. People with schizophrenia or other mood disorders have shown improved symptoms when given an antibiotic. He continued by saying there are other approaches to anti-inflammation including getting a good night’s sleep because it normalizes circadian rhythm, a nutritional diet, and exercise, especially a combination of aerobic exercise and resistance training, which has proven to be anti-depressant and pro-cognitive. Dr. McIntyre reminded the audience about the important role of social determinants of health as it affects an individual’s metabolism and level of inflammation. For example, air pollution, exposure to high calorie food, high crime environments, and high unemployment are all linked to pro-inflammatory outcomes. He suggests that a multisystem approach to target social, biological, and individual factors is needed.

Dr. McIntyre believes that when treating someone for mental disorders, professionals need to counsel the individual about risk factors for metabolic diseases like cardiovascular disease. He said, “…treat the patient not only from the neck up, but the neck down” to help them achieve mental and physical wellness.

The question and answer session included these questions from the audience. The presenter’s responses are shown below.

  • Considering the relationship between adverse childhood events and physical, emotional, and social disorders, including inflammation, it would seem that primary prevention starts well before adulthood. What are your thoughts on that?

Dr. McIntyre indicated that you can look even further upstream. In utero exposure to infections like herpes, cytomegalovirus, or toxoplasmosis increases the risk that the individual or offspring will have a mood or psychotic condition, autism, or a learning disorder. This speaks to the importance of antepartum care. He also spoke about sugary drinks consumed by children, which when consumed in excess can cause obesity but can also cause trauma to the brain.

  • The information you’ve presented today makes the negative impact on metabolics from anti-psychotic therapy all the more concerning. Can you share your thoughts on this?

Dr. McIntyre referred to the Florida Medicaid Treatment guidelines, which contain very clear statements about the deleterious effects of obesity and diabetes on brain health and how people with mental disorders are disproportionately affected by these (metabolic) conditions. He believes we should prioritize and use psychotropic medications that do not have the liability of weight gain and other metabolic effects.

  • Could you just briefly share any thoughts that you have on the role of epigenetics on any of the systems you discussed?

Dr. McIntyre explained that epigenetics refers to the modification of genetic transcription on the basis of environmental exposure. As an example, people who have been exposed to trauma are also exposed to a change in their biological milieu that alters the way the genes are transcribed. There are efforts to look at novel ways of treating depression and cognitive impairment through epigenetics. One way is to restrict calorie intake, which reduces inflammatory transcription. Dr. McIntyre also believes that sleep and the normal circadian rhythm, as well as aerobic exercise, can target the epigenetic systems.

Written by Kristin Pareja, PharmD, BCPS, Managed Market Liaison with Otsuka Pharmaceutical Development & Commercialization, Inc., and Laura Anguiano, PhD, Medical Science Liaison with Otsuka Pharmaceutical Development & Commercialization, Inc.

On April 19, 2017, PsychU sponsored the workshop, “Bridging the Gaps in Mental Health Care Coordination,” held in Oklahoma City, Oklahoma. This meeting was the result of a partnership between PsychU and the University of Oklahoma College of Pharmacy’s Pharmacy Management Consultants.

The objectives for the workshop were to:

  • Identify and discuss barriers, challenges, and gaps to successful transitions facing Oklahoma patients with severe mental illness between health care and community settings
  • Develop potential collaborative solutions to overcome these barriers, challenges, and gaps to successful transitions for Oklahoma patients, and
  • Initiate an ongoing stakeholder workgroup to develop practical recommendations to bridge identified barriers, challenges, and gaps to successful transitions

In addition to the objectives described above, participants were asked what else they would you like to learn from the live meeting. Comments included learning about what other organizations are doing to reduce barriers in care coordination, how to better communicate with providers and allow them to understand the law enforcement perspective of the basic issues. A third and commonly voiced comment was how to determine what solutions will make the largest impact with the least amount of funding given that many of the identified issues are not caused by lack of awareness or willingness to serve, but rather by inadequate funding for the most vulnerable citizens.

The meeting was moderated by Tammy L. Lambert, Pharm.D., Ph.D., Clinical Assistant Professor from the University of Oklahoma College of Pharmacy, Kristin Pareja, Pharm.D., BCPS, Managed Market Liaison from Otsuka Field Medical Affairs and Laura Anguiano, Ph.D., Medical Science Liaison from Otsuka Field Medical Affairs. The workgroup participants included members of organizations such as National Alliance on Mental Illness (NAMI), Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), local Community Mental Health Centers (CMHCs), inpatient and outpatient facilities, Oklahoma Health Care Authority, Oklahoma Police Department’s Crisis Intervention Team, St. Anthony Behavioral Health Unit, Patient Aligned Care Teams (PACT), Mental Health Association of Oklahoma, the Texas Medical Foundation (TMF) Health Quality Institute, the Oklahoma County Crisis Intervention Center, and the Oklahoma State Department of Health. Collectively, the participants were representative of a diverse group of stakeholders from the Oklahoma community. Other participants included members of the Oklahoma College of Pharmacy and Otsuka Medical Affairs.

The program opened with a brief introduction to PsychU, followed by a presentation of the results of a survey administered to the attendees prior to the meeting (see results in Figures 1-3 (below)). All attendees felt there are existing barriers to successful transitions of care which were perceived as being a major or moderate problem. Barriers perceived as most problematic included alcoholism or drug addiction, financial instability, co-morbid medical conditions, unstable housing, unstable transportation, and inability to maintain established care. Meeting participants were gathered into small groups for round table discussions of the high priority barriers and solutions to address these barriers. Questions addressed included challenges the participants face with the barriers, obstacles standing in the way of removing the barriers, how communication and collaboration both within their organization and between facilities can be improved, how participants can collaboratively and effectively implement changes across systems of care, and how participants can take the learnings from the workshop and implement into clinical practice around the Oklahoma City area.

In addition to discussion around barriers, participants also discussed examples of initiatives from participant organizations and highlighted best practices to share with the group. The meeting concluded with discussion of proposals for the most actionable solutions to improve care transitions and a call for volunteers to champion an ongoing workgroup. This live meeting was the initial step toward bridging the gaps in care coordination and through the formation of an ongoing workgroup, a collaborative team will continue the efforts in the Oklahoma City area. The next steps in bridging the gaps will involve compilation and analysis of solutions to barriers, continued communication, collaboration, and partnership between stakeholders in Oklahoma City and throughout the state and ongoing meetings with workgroup champions to further the efforts to improve transitions of care.

Figure 1

 

Figure 2

When thinking of the process of transferring care for patients with severe mental illness to another entity, please select how problematic the following barriers are for the transferring care for mental health patients.

Figure 3

Referring to the list of barriers, if you could fix one thing about the provision of mental health services in Oklahoma, what do you think would make the most difference?

Transition Of Care Barriers Participant Response (%)
Unstable housing 19.2
Alcoholism or drug addiction 11.5
Inability to follow treatment recommendations 11.5
Inability to maintain established care 11.5
Length of time to outpatient follow-up 7.7
Financial instability 7.7
Lack of outpatient providers 3.8
Incarceration 3.8
Other co-morbid medical conditions 3.8
Inconsistent requirements for reimbursement 3.8
Lack of positive social support 3.8
Limited range of services covered by payer 3.8
Continuity between independent systems 3.8
Other 3.8

Referring to the list of barriers, if you could fix one thing about the provision of mental health services in Oklahoma, what do you think could be the easiest to solve?

Transitions Of Care Barriers Participant Response
Continuity between independent systems 19.2
Inability to maintain established care 15.4
Length of time to outpatient follow-up 15.4
Low health literacy 11.5
Encounters with law enforcement 7.7
Lack of medication continuity 7.7
Unstable transportation 7.7
Lack of outpatient facilities 3.8
Inconsistent requirements for reimbursement 3.8
Lack of outpatient providers 3.8
Other 3.8

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/macra-quality-payment-program-behavioral-health-care-professionals-know/.

This virtual forum, held on February 23, 2017, had three objectives:

  1. Understand the framework and goals of The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program (QPP)
  2. Understand how Medicare Part B reimbursement will be re-structured under the QPP, specifically
    1. Alternative Payment Models (APMs)
    2. Merit Based Incentive Payments system (MIPS)
  3. Review essential strategies, and assess clinician readiness, for participation in the QPP

The presenters were Paul Cotton, BA, Director of Federal Affairs for the National Committee for Quality Assurance (NCQA); and Elizabeth Arend, MPH, Quality Improvement Adviser for the National Council for Behavioral Health.

The first audience polling question was asked:

How would you rate your level of understanding of the MACRA QPP, and how it will affect your practice or organization?

  1. High – Understand the QPP rule and how our practice or organization will participate (6%)
  2. Medium – Understand the general provisions of QPP, unsure of what our practice or organization needs to do (30%)
  3. Low – Unclear about the provisions of QPP or how it may affect my practice or organization (64%)

Ms. Arend began the presentation by explaining MACRA was the result of bipartisan legislation to repeal the Sustainable Growth Rate (SGR) formula and to create the QPP. The goals of MACRA are to:

  • Offer different methods of risk and reward to encourage paying for value
  • Increase opportunities to all types of providers to participate in APMs and minimize reporting burdens for these models
  • Promote an understanding for each practitioner’s status regarding MIPS or APMs
  • Support multi-payer initiatives in Medicaid, Medicare Advantage, and other payer arrangements

Even though MACRA currently affects Medicare Part B payments, Ms. Arend stated that she expects it to be applicable to other payer arrangements in the future. She discussed that the QPP, created under MACRA, is designed to move payment from volume to value through the Merit-Based Incentive Payments System (MIPS) and Alternative Payment Models (APMs). While, Ms. Arend mentioned, only certain health care professionals are affected by the QPP in 2017: most behavioral health organizations that bill Medicare Part B using the physician fee schedule, such as physicians and psychiatrists, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. She stated that exceptions for this initial group include:

  • Clinical psychologists and licensed clinical social workers
  • First-year Medicare providers
  • Qualifying Advanced APM clinicians
  • Hospitals and facilities
  • Providers who serve less than 100 Medicare recipients or bill Medicare less than $30,000 per year (known as low-volume threshold), and clinicians who are not paid under the physician fee schedule, such as federally qualified health centers and partial hospital programs. Ms. Arend indicated the low-volume threshold might change in the future.

Ms. Arend pointed out that non-participation by eligible professionals in 2017 will result in an automatic 4% reduction in their reimbursement for 2019.

The moderator asked Ms. Arend how she thought other types of health care professionals, that is administrators and quality managers, would be affected. Ms. Arend started by addressing a misconception that MACRA is a billing issue or something for the financial department to be concerned about. She stated MACRA will affect everyone from the front line staff to the “C Suite”, and even though the program is starting with a selected list of clinicians, she thinks other types of providers will be affected in the near future. She recommends voluntarily participation to test out the program so providers and management can get feedback on performance before any risk or penalties are applied. Mr. Cotton commented that to get good performance scores under a new value-based payment system, practices should work together as a team to achieve the highest quality. He mentioned collaborative models like medical homes and patient centered practices where staff functions at the top of their license to deliver the highest quality patient experiences and clinical care.

Mr. Cotton continued by explaining the two-track QPP; (1) MIPS, which adjust fee-for-service (FFS) payments based on performance in the key categories of quality, cost, clinical practice improvement activities, and advancing care, which is a revision to meaningful use of electronic health record (EHR) technology; and (2) APMs, which focuses on population-based payments and structures bonuses on additional financial risk assumed, loss and savings sharing, and use of certified EHR technology. Mr. Cotton explained that advanced APMs (AAPMs) require participating clinicians and groups to meet certain thresholds for revenue and number of patients: through 2019 the thresholds are considered relatively low, and practices must receive at least 25% of their Medicare Part B payments through the AAPM, or see at least 20% of their Medicare patients through the AAPM. These practices may be eligible to receive an annual 5% bonus. Mr. Cotton and Ms. Arend commented that the idea is behind the programs is to move all payers involved towards APMs. For 2017, the speakers explained that there are seven specific APMs eligible for the 5% bonus:

  1. Comprehensive Primary Care Plus
  2. Medicare Shared Savings Program (MSSP) Tracks 2 & 3 (Track 1 is pending)
  3. Next Gen ACOs (Accountable Care Organizations)
  4. Oncology Care Model (2-sided risk)
  5. Comprehensive End Stage Renal Disease (ESRD) Model (2-sided risk)
  6. Comprehensive Joint Replacement Model
  7. Vermont Medicare ACO Initiative

Mr. Cotton used a decision tree diagram to demonstrate how eligible clinicians may determine if they are in the MIPS or APM track. For example, clinicians may be considered for the MIPS track if 2017 is the clinical practice’s first year of Medicare reimbursement or if the practice meets the low volume threshold. If the practice is eligible for an APM (referring to the list above), it is excluded from MIPS. He discussed the maximum adjustments for MIPS payments, which begin at +4% for 2017 – applied in 2019 – and Mr. Cotton reminded the audience that if clinicians do not participate at all during 2017 they are subject to a 4% penalty. Those penalties and bonuses increase to +5% in 2020, +7% in 2021, and +9% in 2022 and beyond. He stated that eligible clinicians may pick their own pace for participation during 2017 (known as the “transition year”). Clinicians who report any measures at all during 2017 will avoid the 4% penalty, and Mr. Cotton anticipates that any bonuses – which are generated from penalties — will be small because the program is budget neutral. If clinicians report measures in one 90-day period, they may qualify for a bonus depending on their performance. He further explained the stepped reporting process: in 2018, clinicians must do full reporting on quality and resource use, but may report partial performance on the other categories; but beginning in 2019 clinicians must report full-year data.

The next audience polling question was asked.

Overall, what percent of providers are expected by CMS to receive a bonus or not penalty in the 2019 payment year?

  1. 10% (18%)
  2. 25% (21%)
  3. 50% (21%)
  4. 90% (40%) (Correct)

Mr. Cotton discussed scoring for MIPS during 2017-2018: 60% will be based on clinical quality measures (evidence-based quality measures), 15% on clinical practice improvement activities (attestation to participation in activities that improve clinical practice), and 25% on advancing care information (promoting patient engagement and electronic exchange of information using EHRs). Cost measures (measures of total per capita costs for all attributed beneficiaries, and a Medicare Spending per Beneficiary measure) will not be included during the transition year, but once it’s included, it will account for 30% of the MIPS score, and the measures for clinical quality will be 30% as well.

To put MACRA in a broader context, Ms. Arend first defined value as outcomes divided by cost, then discussed the trend of the health care industry’s move to value-based purchasing, which can take many forms such as performance-based contracts, bundled payments, shared savings arrangements, and other arrangements with large percentages of financial risk. Her graphical presentation of this trend showed that these arrangements exist on a spectrum and indicated that most payments are still through FFS. In spite of this trend, she noted FFS will not go away completely, but instead providers will take on nominal risk, as in the MIPS, which incentivizes efficient, high quality, and patient-centered care.

Mr. Cotton addressed behavioral health measures that can be reported under MIPS and APMs (e.g., coordination of care for adult patients with major depressive disorder and comorbid medical conditions, utilization of the PHQ-9 tool for monitoring depression, tobacco use and help with quitting for adolescents). He indicated NCQA is especially interested in MACRA and quality measures for behavioral health because the organization has not seen much improvement in measures for these conditions. NCQA is currently developing new measures for screening, medication adherence, and treatment initiation for behavioral health, as well as measures to monitor side effects (e.g., diabetes, cardiac) of some of the drugs for mental illness, and measures for opioid use and abuse. Mr. Cotton believes MIPS will bring needed attention to improving behavioral health outcomes, especially since this population tends to have higher physical health care costs than people without behavioral health disorders.

At this point the moderator asked the presenters what their thoughts on how MACRA and the QPP, which are designed for Medicare physicians’ payments, might affect commercial and Medicaid health care organizations. Ms. Arend observed, “Where CMS goes, all payers are sure to follow.” She thinks MACRA and MIPS are blueprints for value-based payments that eventually will be adopted by all payers. Mr. Cotton agreed and added that Congress put the multi-payer APM options into MACRA because they want to include commercial and Medicaid payers as well. Both presenters agreed that the FFS system is unsustainable and MACRA is being championed by the nation’s largest and most influential health insurance program (Medicare).

The topic of virtual groups was discussed next by Mr. Cotton, who indicated that under MACRA, it’s difficult to get statistically valid measurements with a single clinician. Therefore Congress allows clinicians to join in groups of 10 to get valid results on quality measures and helps the health care community to work together, which is also the first step in participating in an APM. Congress is allocating $20 million each year for five years to support virtual groups, but the infrastructure is not yet in place to make it happen. MACRA also promotes Patient-Centered Medical Homes (PCMH) and Patient-Centered Specialty Practices (PCSP), both of which afford automatic full credit for the clinical practice improvement activities category, worth 15% of the MIPS score. Mr. Cotton cited evidence that these models promote quality by coordinating care across settings via electronically shared information, and he believes they are the key to success under MACRA.

The moderator asked this question of Ms. Arend: “How is your organization preparing for the next phases of MACRA and the QPP?” Mr. Cotton shared that NCQA is working on an online toolkit to show how patient-centered care is the key to success under MACRA, MIPS, and APMs. This model provides the best way to meet patients’ needs and goals. He believes it’s important to develop more measures for behavioral health, currently lacking, that can meet the needs of patients and providers alike. Ms. Arend indicated she’s been working on the Centers for Medicare and Medicaid (CMS) four-year Transforming Clinical Practice Initiative in her capacity at the National Council for Behavioral Health. There she’s a practice coach in a network called the Care Transitions Network for People with Serious Mental Illness (SMI), one of 29 (out of 100) practice transformation networks exclusively focused on supporting primary care and behavioral health care providers who treat people with SMI. A large part of her responsibilities are to prepare practices to maximize their performance regardless of which reporting options they choose for 2017; this includes eligible clinicians and other professionals who will be eligible in the near future (e.g., licensed clinical social workers and clinical psychologists). Her organization also provides one-on-one practice coaching because of the uniqueness of each clinical practice.

How to demonstrate quality under the QPP was the next topic discussed, and Ms. Arend reiterated the importance of administrators and other staff preparing for reporting quality measures. Practices must report on six quality measures – worth 60% of the MIPS score — in 2017; one has to be a high-priority or outcome measure as defined by CMS (i.e. appropriate use, care coordination, patient experience, and patient safety). The measure set will be updated over time, and it is hoped more behavioral health measures will be added. Ms. Arend pointed out there is a specialty set for behavioral health measures that practices can use, and she encouraged the audience to take a look at the measures to become familiar with them.

The use of EHR technology is worth 25% of the MIPS score in 2017, but Ms. Arend believes the weight of this measure will decrease over time as more practices adopt EHRs. Practices can check on the CMS website whether their EHR is certified to 2014 or 2015, which will then determine which measure set to use. The measures relate to clinical effectiveness, information security, patient safety, patient engagement, and health information exchange across providers and with patients.

Measures for continuous quality improvement are new in 2017 and are comprised of nine large categories housing over 90 improvement activities. Integrated behavioral and mental health is one of the categories. Ms. Arend pointed out the Transforming Clinical Practice Initiative is on the list, so if a clinical practice participates in this activity for 90 days in 2017, they’ll avoid the penalty in 2019.  She also thinks these measures provide an excellent opportunity for practices to get credit for what they’re already doing to improve their practices, engage patients, improve patient safety, and strengthen care coordination.

For 2017, the cost of care category is not weighted for MIPS, but Ms. Arend believes it will increase over time, perhaps up to 30% of the MIPS score in a few years. She expects CMS to put emphasis on total per capita costs for all attributed beneficiaries, Medicare spending per beneficiary, and 10 episodes of care measures that CMS has not yet revealed. Therefore she recommends that practices get to understand how their costs of care are determined and what can be done to reduce costs while still improving quality.

The last part of the presentation was about preparing for participation in the QPP. Ms. Arend said the first step is to determine if the practice is eligible for the QPP; CMS was to have notified clinicians by letter in January of their eligibility. If eligible, practices should pick their participation pace, and she encouraged all practices to at least submit part-year data. She walked through an example of a practice that had never participated in the Physician Quality Reporting System (PQRS) and were notified they may receive a penalty in 2017 for nonparticipation. In the example, the practice was currently adopting and EHR. In this fictional example, Ms. Arend stated that it might make sense for the practice to report bare minimum measures and attest to participation in the Transforming Clinical Practice Initiative in 2017 to avoid a penalty in 2019, while they spend time getting their EHR into place, easing the burden of reporting in the future. Ms. Arend mentioned that administrators should consider the quality measures they’ll report on in the future and make sure their systems are ready for participation in 2018; practices without an EHR might be able to get a hardship exemption from CMS, but would need to request exemptions each year.

The question and answer session included these questions from the audience. The presenter’s responses are shown below.

  • Do we know when it will be decided whether or not licensed clinical social workers or psychologists will be included in MACRA?

Ms. Arend: We expect them to be added in 2019 for the 2019 reporting year, but they may voluntarily report now and get feedback on their performance.

  • How will quality measures be reported?

Mr. Cotton: There are two different methods. One used to be called GPRO (Group Practice Reporting Option); ideally practices should report electronically, and if they report “end to end electronic reporting” they will receive bonus points. Electronic data will allow for richer analyses. Practices may also report via claims, qualified clinical data registries, and IT health vendors and other IT third parties.

  • How does this impact providers who serve Medicare Advantage patients?

Mr. Cotton: It doesn’t directly affect them because Medicare Advantage (Part C) is different from Part B FFS. The goal of MACRA is to get all payers in alternative payment models, so beginning in 2021 all payers, including Medicare Advantage, will be included. In fact, many Medicare Advantage plans have already been experimenting with alternative payment models.

  • Knowing there are many co-occurring mental health and IDD disorders, are there measures for IDD providers through value-based care and billing?

Mr. Cotton: He was not sure if there are measures for this population, but for example, practices can apply preventive measures (e.g., screenings or flu shots) to this population.

Ms. Arend: There are no IDD measures on the QPP website, and no specialty category for IDD.

  • What is the eligibility determination period for fiscal year 2017? What period do we base our data on to determine if a provider meets the eligibility for participation criteria?

Ms. Arend: She thinks the question refers to low volume threshold and whether or not a practice is above or below it; it is important to receive the confirmation letter from CMS (the confirmation is based on claims analysis). She doesn’t recommend that practices do their own claim analysis to determine eligibility.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/macra-quality-payment-program-behavioral-health-care-professionals-know/.

This virtual forum, held on February 23, 2017, had three objectives:

  1. Understand the framework and goals of The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program (QPP)
  2. Understand how Medicare Part B reimbursement will be re-structured under the QPP, specifically
    1. Alternative Payment Models (APMs)
    2. Merit Based Incentive Payments system (MIPS)
  3. Review essential strategies, and assess clinician readiness, for participation in the QPP

The presenters were Paul Cotton, BA, Director of Federal Affairs for the National Committee for Quality Assurance (NCQA); and Elizabeth Arend, MPH, Quality Improvement Adviser for the National Council for Behavioral Health.

The first audience polling question was asked:

How would you rate your level of understanding of the MACRA QPP, and how it will affect your practice or organization?

  1. High – Understand the QPP rule and how our practice or organization will participate (6%)
  2. Medium – Understand the general provisions of QPP, unsure of what our practice or organization needs to do (30%)
  3. Low – Unclear about the provisions of QPP or how it may affect my practice or organization (64%)

Ms. Arend began the presentation by explaining MACRA was the result of bipartisan legislation to repeal the Sustainable Growth Rate (SGR) formula and to create the QPP. The goals of MACRA are to:

  • Offer different methods of risk and reward to encourage paying for value
  • Increase opportunities to all types of providers to participate in APMs and minimize reporting burdens for these models
  • Promote an understanding for each practitioner’s status regarding MIPS or APMs
  • Support multi-payer initiatives in Medicaid, Medicare Advantage, and other payer arrangements

Even though MACRA currently affects Medicare Part B payments, Ms. Arend stated that she expects it to be applicable to other payer arrangements in the future. She discussed that the QPP, created under MACRA, is designed to move payment from volume to value through the Merit-Based Incentive Payments System (MIPS) and Alternative Payment Models (APMs). While, Ms. Arend mentioned, only certain health care professionals are affected by the QPP in 2017: most behavioral health organizations that bill Medicare Part B using the physician fee schedule, such as physicians and psychiatrists, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. She stated that exceptions for this initial group include:

  • Clinical psychologists and licensed clinical social workers
  • First-year Medicare providers
  • Qualifying Advanced APM clinicians
  • Hospitals and facilities
  • Providers who serve less than 100 Medicare recipients or bill Medicare less than $30,000 per year (known as low-volume threshold), and clinicians who are not paid under the physician fee schedule, such as federally qualified health centers and partial hospital programs. Ms. Arend indicated the low-volume threshold might change in the future.

Ms. Arend pointed out that non-participation by eligible professionals in 2017 will result in an automatic 4% reduction in their reimbursement for 2019.

The moderator asked Ms. Arend how she thought other types of health care professionals, that is administrators and quality managers, would be affected. Ms. Arend started by addressing a misconception that MACRA is a billing issue or something for the financial department to be concerned about. She stated MACRA will affect everyone from the front line staff to the “C Suite”, and even though the program is starting with a selected list of clinicians, she thinks other types of providers will be affected in the near future. She recommends voluntarily participation to test out the program so providers and management can get feedback on performance before any risk or penalties are applied. Mr. Cotton commented that to get good performance scores under a new value-based payment system, practices should work together as a team to achieve the highest quality. He mentioned collaborative models like medical homes and patient centered practices where staff functions at the top of their license to deliver the highest quality patient experiences and clinical care.

Mr. Cotton continued by explaining the two-track QPP; (1) MIPS, which adjust fee-for-service (FFS) payments based on performance in the key categories of quality, cost, clinical practice improvement activities, and advancing care, which is a revision to meaningful use of electronic health record (EHR) technology; and (2) APMs, which focuses on population-based payments and structures bonuses on additional financial risk assumed, loss and savings sharing, and use of certified EHR technology. Mr. Cotton explained that advanced APMs (AAPMs) require participating clinicians and groups to meet certain thresholds for revenue and number of patients: through 2019 the thresholds are considered relatively low, and practices must receive at least 25% of their Medicare Part B payments through the AAPM, or see at least 20% of their Medicare patients through the AAPM. These practices may be eligible to receive an annual 5% bonus. Mr. Cotton and Ms. Arend commented that the idea is behind the programs is to move all payers involved towards APMs. For 2017, the speakers explained that there are seven specific APMs eligible for the 5% bonus:

  1. Comprehensive Primary Care Plus
  2. Medicare Shared Savings Program (MSSP) Tracks 2 & 3 (Track 1 is pending)
  3. Next Gen ACOs (Accountable Care Organizations)
  4. Oncology Care Model (2-sided risk)
  5. Comprehensive End Stage Renal Disease (ESRD) Model (2-sided risk)
  6. Comprehensive Joint Replacement Model
  7. Vermont Medicare ACO Initiative

Mr. Cotton used a decision tree diagram to demonstrate how eligible clinicians may determine if they are in the MIPS or APM track. For example, clinicians may be considered for the MIPS track if 2017 is the clinical practice’s first year of Medicare reimbursement or if the practice meets the low volume threshold. If the practice is eligible for an APM (referring to the list above), it is excluded from MIPS. He discussed the maximum adjustments for MIPS payments, which begin at +4% for 2017 – applied in 2019 – and Mr. Cotton reminded the audience that if clinicians do not participate at all during 2017 they are subject to a 4% penalty. Those penalties and bonuses increase to +5% in 2020, +7% in 2021, and +9% in 2022 and beyond. He stated that eligible clinicians may pick their own pace for participation during 2017 (known as the “transition year”). Clinicians who report any measures at all during 2017 will avoid the 4% penalty, and Mr. Cotton anticipates that any bonuses – which are generated from penalties — will be small because the program is budget neutral. If clinicians report measures in one 90-day period, they may qualify for a bonus depending on their performance. He further explained the stepped reporting process: in 2018, clinicians must do full reporting on quality and resource use, but may report partial performance on the other categories; but beginning in 2019 clinicians must report full-year data.

The next audience polling question was asked.

Overall, what percent of providers are expected by CMS to receive a bonus or not penalty in the 2019 payment year?

  1. 10% (18%)
  2. 25% (21%)
  3. 50% (21%)
  4. 90% (40%) (Correct)

Mr. Cotton discussed scoring for MIPS during 2017-2018: 60% will be based on clinical quality measures (evidence-based quality measures), 15% on clinical practice improvement activities (attestation to participation in activities that improve clinical practice), and 25% on advancing care information (promoting patient engagement and electronic exchange of information using EHRs). Cost measures (measures of total per capita costs for all attributed beneficiaries, and a Medicare Spending per Beneficiary measure) will not be included during the transition year, but once it’s included, it will account for 30% of the MIPS score, and the measures for clinical quality will be 30% as well.

To put MACRA in a broader context, Ms. Arend first defined value as outcomes divided by cost, then discussed the trend of the health care industry’s move to value-based purchasing, which can take many forms such as performance-based contracts, bundled payments, shared savings arrangements, and other arrangements with large percentages of financial risk. Her graphical presentation of this trend showed that these arrangements exist on a spectrum and indicated that most payments are still through FFS. In spite of this trend, she noted FFS will not go away completely, but instead providers will take on nominal risk, as in the MIPS, which incentivizes efficient, high quality, and patient-centered care.

Mr. Cotton addressed behavioral health measures that can be reported under MIPS and APMs (e.g., coordination of care for adult patients with major depressive disorder and comorbid medical conditions, utilization of the PHQ-9 tool for monitoring depression, tobacco use and help with quitting for adolescents). He indicated NCQA is especially interested in MACRA and quality measures for behavioral health because the organization has not seen much improvement in measures for these conditions. NCQA is currently developing new measures for screening, medication adherence, and treatment initiation for behavioral health, as well as measures to monitor side effects (e.g., diabetes, cardiac) of some of the drugs for mental illness, and measures for opioid use and abuse. Mr. Cotton believes MIPS will bring needed attention to improving behavioral health outcomes, especially since this population tends to have higher physical health care costs than people without behavioral health disorders.

At this point the moderator asked the presenters what their thoughts on how MACRA and the QPP, which are designed for Medicare physicians’ payments, might affect commercial and Medicaid health care organizations. Ms. Arend observed, “Where CMS goes, all payers are sure to follow.” She thinks MACRA and MIPS are blueprints for value-based payments that eventually will be adopted by all payers. Mr. Cotton agreed and added that Congress put the multi-payer APM options into MACRA because they want to include commercial and Medicaid payers as well. Both presenters agreed that the FFS system is unsustainable and MACRA is being championed by the nation’s largest and most influential health insurance program (Medicare).

The topic of virtual groups was discussed next by Mr. Cotton, who indicated that under MACRA, it’s difficult to get statistically valid measurements with a single clinician. Therefore Congress allows clinicians to join in groups of 10 to get valid results on quality measures and helps the health care community to work together, which is also the first step in participating in an APM. Congress is allocating $20 million each year for five years to support virtual groups, but the infrastructure is not yet in place to make it happen. MACRA also promotes Patient-Centered Medical Homes (PCMH) and Patient-Centered Specialty Practices (PCSP), both of which afford automatic full credit for the clinical practice improvement activities category, worth 15% of the MIPS score. Mr. Cotton cited evidence that these models promote quality by coordinating care across settings via electronically shared information, and he believes they are the key to success under MACRA.

The moderator asked this question of Ms. Arend: “How is your organization preparing for the next phases of MACRA and the QPP?” Mr. Cotton shared that NCQA is working on an online toolkit to show how patient-centered care is the key to success under MACRA, MIPS, and APMs. This model provides the best way to meet patients’ needs and goals. He believes it’s important to develop more measures for behavioral health, currently lacking, that can meet the needs of patients and providers alike. Ms. Arend indicated she’s been working on the Centers for Medicare and Medicaid (CMS) four-year Transforming Clinical Practice Initiative in her capacity at the National Council for Behavioral Health. There she’s a practice coach in a network called the Care Transitions Network for People with Serious Mental Illness (SMI), one of 29 (out of 100) practice transformation networks exclusively focused on supporting primary care and behavioral health care providers who treat people with SMI. A large part of her responsibilities are to prepare practices to maximize their performance regardless of which reporting options they choose for 2017; this includes eligible clinicians and other professionals who will be eligible in the near future (e.g., licensed clinical social workers and clinical psychologists). Her organization also provides one-on-one practice coaching because of the uniqueness of each clinical practice.

How to demonstrate quality under the QPP was the next topic discussed, and Ms. Arend reiterated the importance of administrators and other staff preparing for reporting quality measures. Practices must report on six quality measures – worth 60% of the MIPS score — in 2017; one has to be a high-priority or outcome measure as defined by CMS (i.e. appropriate use, care coordination, patient experience, and patient safety). The measure set will be updated over time, and it is hoped more behavioral health measures will be added. Ms. Arend pointed out there is a specialty set for behavioral health measures that practices can use, and she encouraged the audience to take a look at the measures to become familiar with them.

The use of EHR technology is worth 25% of the MIPS score in 2017, but Ms. Arend believes the weight of this measure will decrease over time as more practices adopt EHRs. Practices can check on the CMS website whether their EHR is certified to 2014 or 2015, which will then determine which measure set to use. The measures relate to clinical effectiveness, information security, patient safety, patient engagement, and health information exchange across providers and with patients.

Measures for continuous quality improvement are new in 2017 and are comprised of nine large categories housing over 90 improvement activities. Integrated behavioral and mental health is one of the categories. Ms. Arend pointed out the Transforming Clinical Practice Initiative is on the list, so if a clinical practice participates in this activity for 90 days in 2017, they’ll avoid the penalty in 2019.  She also thinks these measures provide an excellent opportunity for practices to get credit for what they’re already doing to improve their practices, engage patients, improve patient safety, and strengthen care coordination.

For 2017, the cost of care category is not weighted for MIPS, but Ms. Arend believes it will increase over time, perhaps up to 30% of the MIPS score in a few years. She expects CMS to put emphasis on total per capita costs for all attributed beneficiaries, Medicare spending per beneficiary, and 10 episodes of care measures that CMS has not yet revealed. Therefore she recommends that practices get to understand how their costs of care are determined and what can be done to reduce costs while still improving quality.

The last part of the presentation was about preparing for participation in the QPP. Ms. Arend said the first step is to determine if the practice is eligible for the QPP; CMS was to have notified clinicians by letter in January of their eligibility. If eligible, practices should pick their participation pace, and she encouraged all practices to at least submit part-year data. She walked through an example of a practice that had never participated in the Physician Quality Reporting System (PQRS) and were notified they may receive a penalty in 2017 for nonparticipation. In the example, the practice was currently adopting and EHR. In this fictional example, Ms. Arend stated that it might make sense for the practice to report bare minimum measures and attest to participation in the Transforming Clinical Practice Initiative in 2017 to avoid a penalty in 2019, while they spend time getting their EHR into place, easing the burden of reporting in the future. Ms. Arend mentioned that administrators should consider the quality measures they’ll report on in the future and make sure their systems are ready for participation in 2018; practices without an EHR might be able to get a hardship exemption from CMS, but would need to request exemptions each year.

The question and answer session included these questions from the audience. The presenter’s responses are shown below.

  • Do we know when it will be decided whether or not licensed clinical social workers or psychologists will be included in MACRA?

Ms. Arend: We expect them to be added in 2019 for the 2019 reporting year, but they may voluntarily report now and get feedback on their performance.

  • How will quality measures be reported?

Mr. Cotton: There are two different methods. One used to be called GPRO (Group Practice Reporting Option); ideally practices should report electronically, and if they report “end to end electronic reporting” they will receive bonus points. Electronic data will allow for richer analyses. Practices may also report via claims, qualified clinical data registries, and IT health vendors and other IT third parties.

  • How does this impact providers who serve Medicare Advantage patients?

Mr. Cotton: It doesn’t directly affect them because Medicare Advantage (Part C) is different from Part B FFS. The goal of MACRA is to get all payers in alternative payment models, so beginning in 2021 all payers, including Medicare Advantage, will be included. In fact, many Medicare Advantage plans have already been experimenting with alternative payment models.

  • Knowing there are many co-occurring mental health and IDD disorders, are there measures for IDD providers through value-based care and billing?

Mr. Cotton: He was not sure if there are measures for this population, but for example, practices can apply preventive measures (e.g., screenings or flu shots) to this population.

Ms. Arend: There are no IDD measures on the QPP website, and no specialty category for IDD.

  • What is the eligibility determination period for fiscal year 2017? What period do we base our data on to determine if a provider meets the eligibility for participation criteria?

Ms. Arend: She thinks the question refers to low volume threshold and whether or not a practice is above or below it; it is important to receive the confirmation letter from CMS (the confirmation is based on claims analysis). She doesn’t recommend that practices do their own claim analysis to determine eligibility.

During this recorded presentation, Samantha Sweeney, PharmD, MBA, provided a brief overview of the importance of quality in behavioral health care. Key points included:

  • Understanding the burden of behavioral health disorders on all stakeholders
  • Describing the growing importance of value-based care in behavioral health care
  • Defining behavioral health quality measures; why and how payers rely on them
  • Discussing the payer role in quality improvement including challenges and strategies for success

This full live presentation, and others like it, are available for free for PsychU Members. To learn more or schedule a live program for your organization, please visit www.PsychU.org/events/custom-program-request.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/co-occurence-substance-use-disorders-mood-disorders-psychosis/.

During a live PsychU virtual forum on January 12, 2017, two experts in the field of psychiatry discussed the prevalence and impact of substance use disorders in the general population as compared to individuals with mental health disorders. Rebecca Roma, MD, MBA, is a psychiatrist and medical director of the community treatment team at Mercy Behavioral Health in Pittsburgh, Pennsylvania; and Robert Nelson, MD, a psychiatrist in Wyomissing, Pennsylvania, is affiliated with DRG Behavioral Health, LLC and Caron Treatment Centers. Speakers were paid consultants to Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the presentation were as follows:

  • Discuss the prevalence, complexity, and clinical impact of co-occurring mental illness and substance use
    disorders (SUDs)
  • Address the specific challenges and treatment considerations in co-occurring SUDs and psychosis
  • Address the specific challenges and treatment considerations in co-occurring substance use and mood disorders

The presentation started with the first audience polling question:

In your clinical opinion, which of the following drugs of abuse have most widely impacted your community and practice?

  1. Heroin (32%)
  2. Cocaine or “crack” (2%)
  3. Alcohol (27%)
  4. Prescription Opioids (29%)
  5. Methamphetamine (11%)

Dr. Roma opened by presenting statistics on co-occurring SUD and mental illness: patients with SUD are 4.5 times more likely to be diagnosed with comorbid psychiatric disorders than patients without SUD; for adults (those 18 or older) with any mental illness, 18% have SUD, but for those with serious mental illness, the prevalence of SUD is 23%. Next she discussed the prevalence of specific SUDs among psychiatric disorders. Referring to data from a psychiatric disorder survey from NESARC (2001-2002), she noted mood and anxiety disorders can influence the transition from substance use to abuse and dependence, while schizophrenia can influence transition from abstinence to use, particularly marijuana. Alcohol is the most oft-abused substance among people with psychiatric disorders.

Dr. Roma discussed behavioral therapies for patients with SUD and indicated this population may need psychotropic drugs to treat mental illness but also may need behavioral therapies to address some of their behaviors and symptoms of SUD. She pointed out that one of the commonly-used treatments for this population is integrated dual diagnosis treatment (IDDT), which is designed especially for dually-diagnosed SUD and mental illness. IDDT consists of clinical and rehabilitative interventions in a collaborative treatment plan, using a multidisciplinary team. In her experience, the goal of IDDT is harm reduction, not necessarily abstinence. Dr. Roma also mentioned the following behavioral therapies: family behavior therapy, motivational interviewing, cognitive behavioral therapy, contingency  management, and self-help with support groups.

Dr. Nelson continued the presentation by speaking about the multifaceted nature of comprehensive treatment for patients with SUD. He used a chart to depict the numerous components of comprehensive treatment to include: behavioral therapy and counseling; substance use monitoring; child care services; financial services; and medical and mental health services. He noted that people with co-occurring SUD and psychiatric disorders tend to be sicker, relapse more, and are hospitalized more than people without co-occurring disorders. He also said there are times when treating a patient that the doctor is not aware of an underlying SUD diagnosis, which can lead to poor outcomes. He turned to a study comparing the costs of care for Medicaid beneficiaries with mental illness, with and without co-occurring SUD that showed beneficiaries with mental illness and co-occurring SUD are more expensive to treat (regardless of whether the SUD is actually treated) than beneficiaries with mental illness and no SUD. He stated that there is an unmet need in terms of diagnosing (and treating) both conditions. Both presenters discussed the dilemma of getting treatment for both conditions; patients with mental illness are often not accepted into halfway houses, and people with SUD may not be accepted in outpatient services for mental health.

The presentation continued with the next audience polling question:

In your clinical experience, what percentage of your patients with psychotic disorders have a co-occurring SUD?

  1. <10% (3%)
  2. 11% to 25% (14%)
  3. 26% to 50% (38%)
  4. 51% to 75% (35%)
  5. >75% (11%)

Dr. Roma reported the lifetime prevalence of SUD for people with schizophrenia is around 50%, higher than the general population; people with schizophrenia are most likely to use cannabis, alcohol, and cocaine. She also presented information on the challenges of diagnosing and treating co-occurring SUDs and psychosis; pointing out that in her practice people with co-occurring schizophrenia and SUD are often referred from the forensic system and have never had mental health treatment.

Dr. Nelson asked Dr. Roma if, in her practice, she stratifies patients based on where they are in their recovery, or by the severity of their psychosis. Dr. Roma gave the example of how she stages patients with respect to their substance use recovery (and mental health) under the assertive community treatment (ACT) team. Both speakers also discussed club and synthetic drugs and how these drugs might affect treatment choices for psychosis. Dr. Roma handles these situations on a case-by-case basis and remarked that using drugs may be the tipping factor for someone who is vulnerable to psychosis but has not yet developed it.

The next audience polling question was asked:

In your clinical experience, what percentage of your patients with mood disorders have a co-morbid SUD?

  1. <10% (2%)
  2. 11% to 25% (18%)
  3. 26% to 50% (36%)
  4. 51% to 75% (31%)
  5. >75% (1%)

Dr. Nelson referred to a series of studies on prevalence and risk factors of co-occurring SUDs and mood disorder that demonstrate the lifetime prevalence of SUD among people with mood disorders was estimated at 32% and for those with bipolar disorder, the co-occurrence rate increased to an estimate of 56%. He discussed predictive factors for co-occurrence such as younger age, male sex, history of anxiety, and genetic factors. He also indicated that poor outcomes can be related to being male, having poor response to antidepressants, recovery from SUD, and other factors. He discussed treatment options for co-occurring mood disorders and SUD, as well as its challenges, such as inability to diagnose major depressive disorder or bipolar disorder with a valid biomarker. He also pointed out that some people do not seek treatment because they think their psychosis is substance-induced when in fact they really do have a mental disorder.

The question and answer session included these questions from the audience. The presenters’ responses are shown below.

  • In your clinical experience, how often do mood disorders and psychotic disorders precede substance use disorder?
    Dr. Nelson: It is fairly common. He has seen people develop a substance use problem after many years of depression. It is also very common to have the conditions concurrently, or for mental health disorders to follow substance abuse. He thinks it’s harder when the mental health diagnosis follows the substance use diagnosis because substance use can make a patient look like they have a mental disorder. He suggests treating people with co-occurring conditions early rather than wait to see if the mental disorder will go away once the substance use ends.
    Dr. Roma: Sometimes the mental health diagnosis is a way for patients to not take responsibility for their substance use disorder, putting the responsibility on the medical team to treat the patient’s anxiety or depression.
  • What advice do you have for patients with mood disorders and/or psychosis who choose to use cannabis or marijuana, especially now that it’s being legalized?
    Dr. Roma: Legalization doesn’t matter because patients will access marijuana. She tells her patients it will exacerbate their symptoms.
    Dr. Nelson: Agreed with Dr. Roma. Marijuana is very pervasive in states regardless of whether it is legal. The political decisions to make it legal aren’t looking at it medically. In some states patients ask their doctors to sign a form saying the patient has PTSD so they can get marijuana from a dispensary. He thinks marijuana can be short-term helpful but long-term harmful. With marijuana the person’s brain becomes more anxious, and the substance can contribute to psychosis.

Right now, we’re seeing a perfect storm for growth in telemental health, and it’s due to a combination of three factors: a workforce shortage of psychiatrists, consistently good outcomes for consumers, and increasing acceptance by payer organizations.

Interest in telemental health isn’t new. Payer and provider organizations have seen its benefits for years. For example, when Foley & Lardner surveyed health care executives back in 2014, 52% said development of telemedicine services was “very important” for the future success of their organizations, and another 32% said it was just “important” (see their “2014 Telemedicine Survey Executive Summary”).

But new developments have emerged in the years since to make telemental health even more primed for growth. We discussed this topic last month at The 2017 OPEN MINDS Performance Management Institute in the session, “Alignment Of Care Delivery & Value Based Programs: Integrated Care Models To Produce Improved Outcomes Within Complex Populations”. In the session, speakers Orville Mercer, MSW, Vice President, Behavioral Health, Chestnut Health Systems, and President, IBHHC LLC; Bill Guptail, Senior Vice President, Payor Relations, Genoa a QOL healthcare company; Mona Darwich, Program Director, LaFrontera Southwest; Shahzad Rashid, DO, Psychiatrist, Genoa Telepsychiatry; and Amy Rice, Director of Behavioral Health Services, Optum Behavioral Health covered the trends that are driving the use of telemental health – and making it a good strategic bet as a service line for the future:

Fewer Psychiatrists

Ms. Rice pointed out that there’s a growing gap between the number of U.S. adults with diagnosable mental health issues in a given year — about 1 in 5 in 2015, according to the National Institute of Mental Health (see “Post by Former NIMH Director Thomas Insel: Mental Health Awareness Month: By the Numbers”) — and the number of young people choosing psychiatry as a career. Ms. Rice went through the numbers on the latter in her presentation, which included the following breakdown:

If that gap continues to widen, we can expect access to psychiatric services to become an even bigger issue in mental health. As Ms. Rice pointed out, the growing shortfall of professional psychiatrists will likely limit access to in-person mental health services in the future as more areas become underserved. However, telemental health offers a way for them to figuratively and literally expand their reach, delivering those services to people in more remote and unpopulated areas.

Positive Telemental Health Outcomes

Customer service and other value-oriented outcomes have become more critical for provider organizations. Consequently, one concern has been that telemedicine — despite its efficiency — could lead to a precipitous drop in satisfaction and successful treatment rates among large numbers of consumers who would have otherwise thrived in face-to-face interactions. That hasn’t really happened, as much of the research around telemedicine shows.

For instance, in a report published in May 2015 in Addiction Science & Clinical Practice, the authors found studies in “videoconferencing for addiction services have found no difference in the results or patient satisfaction of care provided in person or by video” (see “Trends In Telemedicine Use In Addiction Treatment”). And a 2015 study from Software Advice found that among survey respondents who had used telemedicine, 67% said it either “somewhat” or “significantly increases” satisfaction with care overall (see “Patient Interest In Adopting Telemedicine”). During the presentation, Ms. Darwich and Dr. Rashid noted that at LaFrontera, an Arizona-based behavioral health provider organization, their model of using telepsychiatry within their integrated care team has created a more holistic consumer care experience, and resulted in both improved clinical outcomes and consumer satisfaction.

A Payer Push Toward Telemedicine

In a report released last year, the Center for Connected Health Policy said 44 states introduced more than 150 pieces of legislation during 2016 legislative sessions that were somehow related to telehealth. Many of those bills included provisions that altered reimbursement laws in favor of telemedicine (see “State Telehealth Laws & Medicaid Program Policies”). In addition, because the Centers for Medicare & Medicaid Services (CMS) and more state Medicaid organizations are promoting direct-to-consumer services, as Ms. Rice pointed out, telemedicine is looking more and more appealing.

Taken together, the above offer a great outlook for the prospects of telemental health. Positive outcomes, consumer support, payer coverage — these factors combined make it easy to predict that we’ll continue to see a greater adoption of telehealth in the future. It’s up to provider organizations now to find a sustainable way to incorporate telemental health into their service delivery models by partnering with payers and other organizations.

To learn more about the current and future market for telemental health, see What To Make Of The Popular Press Romance With Tech-Delivered Therapy.

 

This video is part 2 of a series on Bipolar Disorder, from the Psychopharmacology Collection. This video briefly reviews some of the potential molecular (eg, genetics), cellular (eg, ion dysregulation, immune system contributions, and glial-neuronal interactions), systems-level (eg, HPA axis hyperactivity, and monoaminergic pathway, regional brain anatomy, and neurocircuitry contributions), and behavioral (eg, cognitive function and circadian rhythm) factors thought to be involved in the pathophysiology of Bipolar Disorder, and concludes by putting these elements together to provide an overview of the proposed course of Bipolar Disorder.

Key Messages

  • Although psychiatric medication is a critical component of treatment for bipolar disorder (BD), pharmacotherapy alone does not maintain most patients in remission or euthymia.
  • In combination with medication, adjunctive psychotherapy interventions have been shown to be effective in reducing depressive and anxiety symptoms and preventing relapse.
  • In an assessment of randomized, controlled studies assessing the use of psychotherapy in patients with BD, psychoeducation, cognitive behavioral therapy, and family therapies were the most efficacious at improving outcomes such as reducing depressive symptoms, improving medication adherence, and improving quality of life.
  • Preliminary research indicates that dialectical behavior therapy and mindfulness-based cognitive therapy may also be effective therapies, although further research is needed to evaluate efficacy in patients currently experiencing severe depressive symptoms.

Key Messages

  • Despite receiving treatment focused on resolving manic or depressive symptoms, many patients with bipolar disorder (BD) may still demonstrate impaired psychosocial functioning.
  • The ability to fulfill expectations at work, home, and school and have quality interpersonal relationships may be more important to patients with BD and their families than syndromic outcomes.
  • Resolving depressive symptoms (including subsyndromal states) and persistent neurocognitive impairments is important for reducing functional impairments associated with BD.
  • Possible treatment interventions that may enhance function in patients with BD include aggressive mood stabilization and depression treatment, use of pharmacotherapies that target cognition, and adjunctive psychosocial interventions.

Key Messages

  • When measured using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition, the prevalence of bipolar I disorder (BD I) was similar to previous estimates and may be influenced by sociodemographic characteristics including race-ethnicity, age, marital status, education, and family income.
  • Psychiatric comorbidities significantly associated with BD I included substance use disorder, anxiety, posttraumatic stress disorders, and personality disorders.
  • Respondents with BD I reported lower quality of life scores compared with respondents without BD I.
  • Despite the effect of BD I on quality of life and the societal burden of the disease, a treatment gap exists and continuity of care is not consistent, which highlights a need to destigmatize BD I and develop new therapeutic options that are more accessible and acceptable to people with BD I.

In this presentation, Jessie Chambers, PhD, Medical Science Liaison on the Field Medical Affairs team for Otsuka Pharmaceutical Development & Commercialization, Inc., was joined by Ken Minkoff, MD, Senior System Consultant for ZiaPartners, and part-time Assistant Professor of Psychiatry at Harvard; Christie Cline, MD, MBA, President of ZiaPartners and former Behavioral Health Medical Director for the State of New Mexico; and Margie Balfour, MD, PhD, Vice President for Clinical Innovation and Quality at ConnectionsAZ, Assistant Professor of Psychiatry at the University of Arizona, and overseer of clinical operations at the Crisis Response Center in Tuscon, Arizona. They discussed the basic strategies of continuous quality improvement in behavioral health care, both as a vital organizational design strategy, as well as a set of practical technologies for improving value and managing complex populations. The objective of this presentation were to understand what quality improvement in behavioral health care is about, and how to implement it.

Key Messages

  • This study evaluated cognitive function in men with bipolar disorder (BD) during mood disorder episodes and remission compared with healthy control participants.
  • Using various assessment tools, the investigators found poorer cognitive outcomes overall (including impairments in attention, memory, learning, and information processing) among patients with BD with a current manic or depressive mood episode compared with patients in remission or healthy control participants.
  • In patients with a current mood episode, findings suggested that memory function impairment was not exclusively attributable to impairment of attention function.

Key Messages

  • Depressive symptoms in patients with bipolar disorder (BD) may initially be misdiagnosed as major depressive disorder (MDD).
  • While patients with BD may experience distinct episodes of depression, mania, and hypomania, subsyndromal depressive symptoms that impair functioning have been more frequently observed.
  • The authors suggested that patients presenting with depression should be asked about their experience with manic symptoms and other symptoms indicative of bipolar, rather than unipolar, depression (eg, hypersomnia, hyperphagia, concurrent substance abuse, psychotic features).
  • The authors further suggested that correct diagnosis of bipolar depression may enable appropriate implementation of treatments specific to BD, which may help to optimize patient outcomes.

Just when you finished your performance dashboard, it looks like the performance measurement set is going to change. Last month, the National Quality Forum’s (NQF) Measure Applications Partnership (MAP) recommended that the federal government remove 51 health care quality measures from the 240 sets used in federal health care value-based purchasing, public reporting, and other programs (see NQF Recommends Updated Quality Measures For HHS). This includes seven measures specifically related to behavioral health.

If you’re unfamiliar with it, the MAP is a partnership between 90 private-sector organizations and seven federal agencies that recommends measures for private sector payers and advises the U.S. Department of Health and Human Services (HHS) on the selection of performance measures for federal health programs and payers.

Of the behavioral health measures, I thought the proposed changes to measures specific to inpatient mental health services were most interesting. The report included recommendations for changes to these seven measures from the Inpatient Psychiatric Facility Quality Reporting Program:

  • Follow-Up After Hospitalization for Mental Illness (FUH): MAP recommended that this measure be re-specified for acute care and submitted for NQF endorsement.
  • Tobacco Use Screening: MAP noted the importance of tobacco cessation but recommended that CMS prioritize measures that will better address the quality of mental health care.
  • Tobacco Use Treatment Provided or Offered and the subset measure, Tobacco Use Treatment: MAP noted the importance of tobacco cessation but recommended that CMS prioritize measures that will better address the quality of mental health care.
  • Tobacco Use Treatment Provided or Offered at Discharge and the subset measure, Tobacco Use Treatment at Discharge: MAP noted the importance of tobacco cessation but recommended that CMS prioritize measures that will better address the quality of mental health care.
  • Alcohol Use Screening: MAP noted the importance of addressing substance abuse but recommended that the Centers for Medicare & Medicaid Services (CMS) prioritize measures that will better address the quality of mental health care.
  • Alcohol Use Brief Intervention Provided or Offered and Alcohol Use Brief Intervention: MAP noted the importance of addressing substance abuse but recommended that CMS prioritize measures that will better address the quality of mental health care.
  • Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and Alcohol & Other Drug Use Disorder Treatment at Discharge: MAP noted the importance of addressing substance abuse but recommended that CMS prioritize measures that will better address the quality of mental health care.

It’s important to note that these changes are recommendations that could be taken up by any organization (most notably HHS). But the rationale for changing these measures includes a notation from MAP that programs should measure outcomes more directly related to the quality of care — and in the case of the examples listed above for behavioral health, inpatient psychiatric care.

Harold Pincus, M.D., professor and vice chair of psychiatry at Columbia University and co-chair of the MAP Coordinating Committee, released this perspective as part of the recommendations, “Getting to measures that matter for improving patient care without creating unnecessary administrative burdens is a balancing act. To get it right, we need more feedback from patients, frontline doctors, and other health care professionals on what works and what needs improvement in health care quality measurement” (see “NQF’s Measure Applications Partnership Identifies Opportunities to Reduce Measure Burden in Federal Healthcare Programs” from the National Quality Forum).

To help unpack these changes a little, I reached out to OPEN MINDS Advisory Board Member and Grafton Integrated Health Network Chief Executive Officer Jamie Stewart. He writes:

Follow up on discharge from inpatient psych stay seems an interesting removal since for other services recidivism within 30 days causes a payback penalty. I find it interesting they do not feel some measurement is appropriate for psych stays but that may say more about how disconnected the outpatient system in behavioral health is from the inpatient system and that the stay cannot be aligned with community-based services.

The other seven all have to do with some form of substance use (if we consider tobacco a substance). First, I find it interesting that the NQF had chosen these things as a needed follow-up related to the inpatient psych stay to begin with. Unless the patient was presenting because of the substance use or it was a contributing cause it would seem to not be a factor in that acute stay need and more of a long-term health need. But, again, what I find more interesting is no mention of items to address post discharge from a community-based service model and how that should stabilize a patient and diminish further inpatient stays for psych needs.

Maybe the better question to ask for behavioral health is does anyone on the 90 NQF agencies really understand behavioral health and how it is run, versus an academic perspective of behavioral health. I am pretty sure if asked community mental health centers (CMHC) leaders could come up with quality standards that would have somewhat broad support.

Having said all that, I do agree that they should look for ways to “measure outcomes more directly related to the quality of the inpatient care.”

It sounds to me like they are trying to segment the mental health service population. From this wording “that inpatient follow-up care measures need a wording change to distinguish an acute care discharge from a long-term placement discharge” they are saying that SMI and the persistently mentally ill need a separate set of standards from someone identified as more acute mental health needs. I am not sure if I like this or not.

At first glance I like that maybe SMI and those served consistently are being recognized as different. I think our outcomes and expectations for them should be different because they do need a different level of community-based support that our CMHC’s should deliver. But, I do fear the SMI could get lost in the shuffle if the attention goes only to truly acute inpatient stays.

Personal health and wellness apps on mobile devices are here to stay. Because of the proliferation of mobile technologies and consumer demand, there’s no putting that genie back in the bottle (see The Problems With Bringing Apps To The Consumer Experience? The Volume, The Evidence & The Model and Consumer-Directed Therapies – Where Consumer Use Has Outpaced Science). That said, the creators of these apps, which increasingly includes payer and provider organizations, are in a grey area. What app functions need licensure or approval? What app functions pose liabilities for the producer or sponsors?

To date, the U.S. Food and Drug Administration (FDA) hasn’t shown much interest in establishing rigorous regulation and enforcement around mobile health apps, which we’ve reported on before. Last fall the FDA did release draft guidelines to clarify the department’s position on mobile medical devices and mobile medical apps — they are making moves to “establish principles for clinical evaluation of scientific validity, clinical performance, and analytical validity” for the clinical algorithms that power apps, or software-as-a-medical device (see Answering The Question Of What Digital Medicine Works). Apps that are currently in the FDA’s sights are limited — and they include medical apps that are intended to be used as an accessory to a regulated medical device and those that transform a mobile platform into a regulated medical device.

But, now states are getting into the action. As a recent Wired magazine article pointed out (see “Wellness Apps Evade the FDA, Only to Land In Court”), the New York Attorney General’s office settled last month with three health app makers that allegedly misrepresented their products to consumers and had troubling practices and policies around privacy. And these weren’t “fly by night” shops: One of the companies that settled was Runtastic, a subsidiary of athletic apparel company Adidas; another, Cardiio, came out of the Massachusetts Institute of Technology’s Media Lab.

The terms of the settlement themselves weren’t particularly significant — the three companies agreed to pay $30,000 in penalties altogether and adjust the language in their ads and privacy policies. So why is this important? Because it could represent a new precedent in legal oversight for these apps. What this could mean is that after this settlement, it could become more common for prosecutors representing the states to bring lawsuits against makers of these apps for failing to deliver promised results and/or offering appropriate disclaimers. And other government entities — such as the FDA or Federal Trade Commission (FTC), the regulatory agency for consumer fraud protection — could get more involved in due course.

If your organization is looking at sponsoring some type of branded app, or endorsing an app made by others, what should you consider? Answering that involves two different lines of strategy. First you can select an app that already exists on the market — for more on that check out App Potential.

Second, you can create your own app, and as I mentioned from the Wired article, those apps may someday have to comply with a vast new collection of regulations that vary from state to state. Whether that actually comes to pass or not, here are three precautionary tips for any behavioral and mental health provider organizations or payer organizations that venture into the world of apps development:

  1. Watch Your Language: Particularly, in any promotional or descriptive copy you develop for the app, don’t unequivocally make guarantees if there’s a chance your product won’t be able to deliver on them.
  2. Consult Your Lawyer(s): Have in-house attorneys or an external legal representative review promotional copy. Also, you should have them write and review terms and conditions, privacy policies, and other legal documents related to the product.
  3. Be Transparent About Data: If you’re collecting substantial amounts of consumer data through the app for any reason (be it research, future promotions, etc.), let users know why you’re doing it as clearly as possible.

For more on the subject of mobile health technologies, check out these resources from the OPEN MINDS Industry Library:

  1. Digital Health – What Physicians & Consumers Want
  2. Fitting ‘Invisibles’ Into Your Tech Planning
  3. Consumer Health Tech: If You Build It, Will They Come?

Is there evidence that peer support specialists enhance the recovery of individuals with behavioral health disorders? During this interview Patrick Hendry, Vice President of Peer Advocacy, Supports, and Services at Mental Health America provides examples of the effectiveness of peer support specialists from his experience of assisting in the development of numerous peer-run programs and organizations across the country. His areas of expertise include peer provided services and certification, self-directed care, social inclusion, and recovery based trainings. He led the creation and release of Mental Health America’s National Certified Peer Specialist credential, the first national advanced mental health certification in the nation.

Do children/adolescents diagnosed with bipolar disorder usually keep this same diagnosis as adults?

In DSM-5, age is not a criterion for the diagnosis of bipolar disorder.1 A patient who experiences mania/hypomania during childhood and remains asymptomatic as an adult will have the diagnosis of “bipolar disorder, in remission.”DSM-5 includes a new diagnosis under depressive disorders for children, a condition called disruptive mood dysregulation disorder. The specified age of onset needs to be under 10 and the diagnosis not be made before age 6 or after age 18. Its conception was triggered by the concern that children with mood and behavioral symptoms were being over-diagnosed with bipolar disorder.1 The validity of this diagnosis remains to be established.

Reference

  1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. American Psychiatric Publishing, Washington DC.

Can an individual suffer from both major depressive disorder and bipolar disorder at the same time or is it simply a transition from one diagnosis to the other?

According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), bipolar 1 disorder is defined by the presence or history of a manic/hypomanic episode.1 The vast majority of patients with bipolar 1 disorder also experience major depressive episodes. However, having a major depressive episode is not needed to have a diagnosis of bipolar disorder. In patients with a history of only major depressive episodes, once a manic/hypomanic episode appears, the diagnosis changes to bipolar disorder. When a patient with bipolar disorder has a major depressive episode, the diagnosis is “bipolar disorder, depressed type.”1

Reference

  1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. American Psychiatric Publishing, Washington DC.

What role can trauma or PTSD play in bipolar disorder diagnosis?

The prevalence of post-traumatic stress disorder (PTSD) in patients with bipolar disorder is higher than in the general population.1 It has been estimated that 16% (as reported for a weighted mean of 8 studies, representing 1214 patients)1 to >40% (as self-reported in a large, multisite, randomized, controlled trial)2 of patients with bipolar disorder also suffer from PTSD. The causality of the association remains to be determined. It is, however, possible that being a victim of trauma may contribute to an early emergence of bipolar disorder.1,3

References

  1. Otto MW, et al. Bipolar Disord. 2004;6(6):470-9.
  2. Bajor LA, et al. J Affect Disord. 2013;145(2):232-9.
  3. Aas M, et al. Int J Bipolar Disord. 2016;4(1):2.

What rating scales can be used to screen for, or assess symptoms of, bipolar disorder?

Scales in bipolar disorder include screening scales such as the Mood Disorder Questionnaire (MDQ),1 which is the most widely utilized.Symptom rating scales can be utilized to determine the efficacy of treatments.2 The most widely utilized is the Young Mania Rating scale (YMRS),3 other scales include the Bipolar Disorder Symptom Scale (BDSS),4 and the Bipolar Inventory of Symptoms Scale (BISS).There are also scales for bipolar depression, such as the Bipolar Depression Rating Scale (BDRS),6 and scales for children, such as the Child Bipolar Questionnaire (CBQ).Symptom rating scales can also be utilized to measure course and outcome, as recommended by a task force from the International Society for Bipolar Disorders.2

References

  1. Hirschfeld RM, et al. Am J Psychiatry. 2000;157(11):1873-5.
  2. Tohen M, et al. Bipolar Disord. 2009;11(5):453-73.
  3. Young RC, et al. Br J Psychiatry. 1978;133:429-35.
  4. Dennehy EB, et al. Psychiatry Res. 2004;127(1-2):137-45.
  5. Bowden CL, et al. Acta Psychiatr Scand. 2007;116(3):189-94.
  6. Berk M, et al. Bipolar Disord. 2007;9(6):571-9.
  7. Papolos D, et al. J Affect Disord. 2006;95(1-3):149-58.

What is the role of diet, exercise, or sleep for patients with bipolar disorder?

A healthy diet, exercise, and good sleep habits are all essential for optimal physical and mental health. Bipolar disorder is not an exception for these variables to have an effect.1,2 Epidemiological and treatment studies have reported that diets high in omega-3 fatty acids (contained in fish) are associated with lower prevalence rates of mood disorders, including bipolar disorder.3 Despite this, findings regarding the use of omega-3 fatty acids in the treatment of bipolar disorder are not conclusive.4The role of exercise in bipolar disorder has been reported in the literature, suggesting that routine exercise may improve the outcome in patients suffering from the condition.5 A number of studies have shown that sleep is impaired in patients with bipolar disorder. Studies have also suggested that poor sleep habits may impact symptom burden in those suffering from the condition.1

References

  1. Gold AK, Sylvia LG. Nat Sci Sleep. 2016;8:207-14.
  2. Bauer IE, et al. J Psychiatr Res. 2016;74:1-7.
  3. Parker G, et al. Am J Psychiatry. 2006;163(6):969-78.
  4. Turnbull T, et al. Arch Psychiatr Nurs. 2008;22(5):305-11.
  5. Melo MC, et al. J Affect Disord. 2016;198:32-8.

Like most technologies in the health and human service space, return-on-investment (ROI) depends on the stakeholder and the situation. The recent ROI studies of telehealth are a great example. On the plus side of the ledger, rural health care, transportation costs, and readmissions cost offsets. On the negative side of the equation, increased costs due to increased access to care. The data is interesting.

Telehealth decreases costs for hospitals in rural health settings

According to a March report from NTCA–The Rural Broadband Association, the ROI for telehealth in rural communities is good (see “Anticipating Economic Returns Of Rural Telehealth”), and it can save hospitals in rural parts of the country an average of $81,000 annually, while saving consumers $24,000 in travel costs and $17,000 in lost wages. The national average estimates for annual cost savings include:

  • $5,718 in consumer travel expense savings
  • $3,431 in consumer lost wages savings
  • $20,841 in hospital cost savings

Traveling savings were estimated using average distance traveled per consumer, the average cost per mile, and the number of encounters per year. Lost wages were estimated using the average cost per mile and distance with the average hourly wage rate and time spent raveling, per consumer. For hospital savings, estimates were made by applying rural specialists’ salaries from the Physician Compensation and Production Survey to the reduced number of days per week specialist would work once replaced with telehealth. ROI for telemedicine was assumed based on telemedicine involving mainly upfront costs that are mostly one-time expenditures, and cost savings are ongoing over time.

Telehealth decreases transportation costs for provider-to-provider care

A study from the Center for Information Technology Leadership (CITL) found that provider-to-provider telehealth supplied saving by eliminating the need for inter-emergency department transfers ($1.39 billion), correctional transfers ($270.3 million); and nursing transfers ($806 million) — see “The Value Of Provider-To-Provider Telehealth Technology.”

CITL projected the costs for telehealth adoption over 10 years, including acquisition costs, recurring costs (20% of capital costs), occurring in years one through 10. CITL also assumed that stakeholders realize 50% telehealth benefits in the first year, and reached 100% benefits by the sixth year. Costs for transportation between provider organizations included travel between emergency facilities, and from nursing homes and correctional facilities to both emergency departments and physician offices. Savings were estimated on the reduction of transports from one emergency department (ED) to another emergency department, thanks to the use of telehealth.

Telehealth reduces costs for hospitals by decreasing readmissions

Results in recent years have shown telehealth as a way to reduce hospital readmissions. Essentia Health, a 16-hospital and 68-clinic system, has successfully used telehealth to reduce readmission rates for consumers with congestive heart failure to just 2%. Nationally, this percentage is 25% (see “Essentia Health Slashes Readmissions With Population Health Initiative, Telehealth” from Healthcare IT News).

Essentia achieved this reduction by giving tele-scales to 300 consumers in the hospital’s congestive heart failure program – these scales cost $70-$110 per month and “digitally report via landline or cellular phone service a patient’s weight every day as well as how that person responds to questions the scale literally asks aloud.”

Telehealth increases costs for the California Public Employees’ Retirement System by increasing utilization

But the news on telehealth ROI hasn’t been all good — namely because like any new health care tool, you have to know how you are using it, along with how you’re calculating ROI. Case in point: A couple of recent reports in Health Affairs (see “Analysis Of Teladoc Use Seems To Indicate Expanded Access To Care For Patients Without Prior Connection To A Provider” and “Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending”) found that in some circumstances, telehealth can increase costs.

In a study of the telehealth services provided to the California Public Employees’ Retirement System, beneficiaries showed increased annual spending on acute respiratory illness by $45 per telehealth user. Considering that spending per episode for this group was actually lower for direct-to-consumer telehealth visits ($79) than for either physician office ($146) or emergency department (ED) visits ($1,734), it begs the question: Why did annual costs go up? The answer was that most of the consumers who used the telehealth were what the report called “new utilization” — that is, they used telehealth, but not as a substitute for in-office visits. In this case, telehealth caused people to use additional services.

I think the lesson executive teams need to take away is that telehealth is proving itself as a powerful cost-reduction tool, but you need to figure out how it can replace (if only partially) other, more expensive options. This is a challenge you should meet head-on with a well-crafted strategic plan, a method for gauging possible ROI (see More Tools For Tech ROI), and analytics to monitor adoption efforts (see Provider Organization Tech Investments Predicted To Double – What Tops The List & Why?).

In this interview Jason DeShaw, country singer and songwriter, shares his lived personal experience of bipolar disorder and alcoholism and his thoughts on mental illness, education, and stigma. After listening to the interview, check out Jason’s full music video, which is also posted below.

Check out the full music video filmed live at Otsuka:

For the 2018 reporting year, which starts July 2017, the National Committee for Quality Assurance (NCQA) has proposed changes to Healthcare Effectiveness Data and Information Set (HEDIS) measures to allow telehealth for follow-up visits for inpatient psychiatric discharges. The changes would allow telehealth visits to satisfy the seven-day follow-up visit measure, and the 30-day follow-up measure. An additional change related to inpatient psychiatric discharges follow-up would remove same-day “bridge” visits as options for satisfying the 7-day and 30-day follow-up visit measures. A “bridge” visit is a discharge preparation visit with a community-based behavioral health professional that takes place before the consumer is actually discharged to the community. A final decision will be made during the spring of 2017.

HEDIS is a quality measurement tool used by more than 90% of America’s health plans to measure performance on important dimensions of care and service. If adopted as proposed, the changes would affect commercial health plans, Medicaid managed care plans, and Medicare Advantage plans. NCQA released the proposed changes for public comment from February 22, to March 22, 2017. NCQA has taken down the proposed changes to analyze the comments and revise the proposals. If the proposed changes are ultimately adopted, they would apply to care starting on or after July 1, 2017, and will be reported in 2018.

An NCQA spokesperson provided details about the proposal related to inpatient psychiatric discharge follow-up visits. The reason NCQA is considering allowing telehealth visits to satisfy the follow-up visit requirement is that timely access to behavioral health services is constrained in many communities, particularly in rural health settings. The spokesperson noted that the use of telehealth services in behavioral health has a long history of use, and of evidence supporting its efficacy. To draft the proposed measure changes, NCQA subject matter experts examined all its Behavioral Health measures with regard to evidence for care provided by telephone or by video conference. The proposal included the following:

  • A telehealth encounter can satisfy both the 7-day and 30-day follow-up visit measures. No in-person office visit is required.
  • If both follow-up visits are conducted via telehealth, the two encounters can be conducted by two different mental health professionals. It is not required that they be conducted by the same professional.
  • The professional qualifications are the same for the mental health professionals conducting in-person and telehealth follow-up visits.

The overall proposed HEDIS changes for the 2018 reporting year included six new measures, revisions to five existing measures, and potential strategies to address issues that apply across various measures, plus updates to the Electronic Clinical Data Systems (ECDS) guidelines. The use of telehealth in behavioral health measures was among the potential strategies to address cross measure topics. Specifically, NCQA sought comment on the recommended inclusion of telehealth in seven HEDIS and two proposed behavioral health measures. Further, NCQA sought public comment on the proposed approach for evaluating other HEDIS measures outside the behavioral health domain for inclusion of telehealth.

Other potential strategies to address cross-cutting topics included methods for accounting for socioeconomic status (SES) in the Medicare population and how to account for those enrolled in Institutional Special Needs Plans (I-SNP).

  • SES: NCQA is exploring whether changes to select HEDIS measures to account for SES are warranted, and sought comment on a strategy stratify Medicare plan measure reporting by beneficiary SES for four measures: Colorectal Cancer Screening, Breast Cancer Screening, Diabetes Eye Exam, and Plan All-Cause Readmissions.
  • I-SNPs: NCQA is considering changes related to quality measures for I-SNP members because HEDIS measures that were designed and intended for a general adult population may not be appropriate for evaluating quality of care in the long-term institutional dwelling population. NCQA proposed excluding I-SNP members from the following HEDIS measures: Breast Cancer Screening, Colorectal Cancer Screening, and Osteoporosis Management in Women Who Had a Fracture.

The six new measures focus on potentially inappropriate use of opioids, follow-up after emergency department visits for patients with multiple chronic conditions, transitions of care for discharged patients, pneumococcal vaccination status, and screening and follow-up for depression and unhealthy alcohol use.

  1. Use of Opioids at High Dosage or From Multiple Providers: Assesses whether health plan members 18 years and older receive long-term opioids at high dose; opioids from multiple prescribers or multiple pharmacies; or long-term, high-dose opioids from multiple prescribers and multiple pharmacies.
  2. Follow-Up After Emergency Department (ED) Visit for People With Multiple Chronic Conditions: Assesses the percentage of ED visits for Medicare members 18 years and older who have multiple chronic conditions and had follow-up service within 7 days of the ED visit.
  3. Transitions of Care: Assesses the percentage of inpatient discharges for Medicare members 18 years and older who had each of the following during the measurement year: Notification of Inpatient Admission, Receipt of Discharge Information, Patient Engagement After Inpatient Discharge and Medication Reconciliation Post-Discharge.
  4. Depression Screening and Follow-Up for Adolescents and Adults: Assesses the percentage of members 12 years and older who were screened for clinical depression using a standardized tool and, if screened positive, received appropriate follow-up care.
  5. Pneumococcal Vaccination Status for Older Adults: Assesses the percentage of members 65 years and older who have received the recommended series of pneumococcal vaccines: 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine.
  6. Unhealthy Alcohol Use Screening and Follow-Up: Assesses the percentage of members 18 years of age and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care within two months.

The revisions to five existing measures affect assessments for adolescent immunizations, alcohol and other drug dependence and related utilization, readmissions, and screening for breast cancer.

  1. Immunizations for Adolescents: NCQA proposes revising the human papillomavirus vaccine rate to align with the updated Advisory Committee on Immunization Practices guidelines, which permit a two-dose vaccination schedule for adolescents.
  2. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment and Identification of Alcohol and Other Drug Services: NCQA proposes adding Medication-Assisted Treatment as an appropriate modality for those with alcohol and opioid dependence, and stratifying the measure rates by alcohol, opioid and other drug dependence diagnosis.
  3. Plan All-Cause Readmissions: NCQA proposes to develop a strategy to include the Medicaid product line in HEDIS 2018 for the Plan All-Cause Readmissions measure.
  4. Breast Cancer Screening: NCQA seeks comments on whether to allow digital breast tomosynthesis to be numerator compliant.

PsychU reported on this topic in “New NCQA Health Plan Accreditation Standards Address Behavioral Health Access,” which published on February 18, 2016.

For more information, contact: Cindy Peña, Media Contact, National Committee for Quality Assurance, 1100 13th Street NW, Suite 1000, Washington, District of Columbia 20005; 202-955-3500; Fax: 202-955-3599; Email: pena@ncqa.org; Website: http://www.ncqa.org/.

Truven Health Analytics (Truven), part of the IBM Watson Health business, released its findings, which identify their annual 100 Top Hospitals in the United States. Truven completes a five-year trend analysis annually to determine performance trends in the hospital industry and evaluate hospitals based on set criteria. Analysis on 2011-2015 data showed improvement for the country’s hospitals in areas such as inpatient mortality and complication rates, 30-day readmissions, and lengths of stay.

Since 1993, Truven has completed this independent, comprehensive, and academically driven study which evaluates clinical and operational performance; hospitals do not apply for awards, and winners do not pay to market the outcomes. Evaluations take place in 11 areas, addressing: inpatient mortality; 30-day mortality rate; complications; core measures; 30-day risk-adjusted readmission rate; severity-adjusted average length of stay; mean emergency room throughput; inpatient expense per discharge; Medicare spend per beneficiary; adjusted operating profit margin; and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score (patient rating of overall hospital performance). To conduct this year’s 100 Top Hospitals study, Truven Health researchers evaluated 2,740 short-term, acute care, non-federal hospitals using public information and patient satisfaction data from the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website.

Along with the 100 Top Hospitals, Truven analyzes data to determine comprehensive state/region performance and performance comparisons for geographic areas, performance comparisons for each category, and a comprehensive list of all 100 Top Hospitals winners throughout the years. To see a complete listing of winners and the full data analysis report, this year’s 100 Top Hospitals Study can be found at http://100tophospitals.com/studies-winners/100-top-hospitals.

Truven Health Analytics provides health care information, analytic tools, benchmarks, research, and services to the health care industry, including hospitals, government agencies, employers, health plans, clinicians, pharmaceutical, biotech, and medical device companies.

This was reported by PRNewswire on March 6, 2017.

Contact Information: Truven Health Analytics, 100 Phoenix Drive, Ann Arbor, MI 48108; 734-913-3000; Website: www.truvenhealth.com/

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/paying-value-mental-health-services-perspectives-field/.

During a live PsychU Virtual Forum on August 4, 2016, Deborah Adler, Senior Vice President for Optum’s Network Strategy Department in Minneapolis, Minnesota, and Maurice Lelii, Director of Outpatient & Managed Care for Gracepoint in Tampa, Florida, provided their insight on paying for value in mental health services. The speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the virtual forum were to:

  • Understand why models of reimbursement are moving from volume- to value-based
  • Understand the role of payers in value-based purchasing and what tools payers offer to providers to meet quality goals
  • Understand the responsibilities of providers in value-based delivery and what providers are doing to meet the expectations of payers and consumers.

Mr. Lelii started the virtual forum by discussing how change is necessary to improve the value of care, and providers should continually look for better ways to deliver quality care for the best price – hence the shift from the traditional pay-for-volume model. He mentioned high rates of uninsured people, high health care costs, low levels of consumer satisfaction, limited access to care, and increasing employer cost and tax burden from health care has provided much of the impetus for change.

Ms. Adler began the presentation by discussing the impact of the Patient Protection and Affordable Care Act (ACA) on improving value. She described how the ACA has changed health care organization, delivery, and funding in the United States, including three key ACA supports:

  • Testing new models of health care delivery
  • Shifting from a reimbursement system based on the volume of services provided to one based on the value of care
  • Investing in resources for system-wide improvement.

Mr. Lelii discussed the changes required by the shift towards value-based reimbursement for consumers and provider organizations. He stated that every stakeholder has changing responsibilities and involvement in the evolving health care process brought about by a strong focus on wellness: consumers have increased cost sharing and more requirements for engagement in their treatment, while for provider organizations, there is a strategic re-engineering in the value chain exemplified by more access to care through innovative programs like telehealth, integrating medical and behavioral health care, and mobile health.

Ms. Adler offered her views on changes affecting professionals and health plans as a result of pay-for-value models. For example, the new norm for professionals requires participation in population health management and standardization of care, as well as significant pressure to achieve quality outcomes. For health plans, these changes are bringing about downward pressure on rates, increased competition from other health plans, backward integration, gain-sharing reimbursement arrangements with providers, smaller subsidies and more stringent ratings for private health exchanges, Medicaid, and Medicare populations.

Ms. Adler continued by reviewing the role of payers in value-based purchasing from Optum’s managed care organization (MCO) perspective. She defined value-based purchasing as any purchasing practice aimed at improving the value of health care services, where value is a function of both quality and cost. Ms. Adler believes plans should implement programs that will lead to higher quality care and better health (e.g. consumer information campaigns) and the use of financial incentives / cost sharing to encourage the selection of health care organizations and providers that are able to document their high-quality of care. She also stated that quality standards should be incorporated into contracts with health plans or care systems.

Ms. Adler discussed how Optum uses certain tools to drive quality and cost savings, including:

  • Pay-For-Performance Shared Savings Contracts With Qualified Facilities & Outpatient Providers: Metrics on inpatient and outpatient services such as Healthcare Effectiveness Data and Information Set (HEDIS) measures and wellness assessments are regularly collected from providers, as are case-mix adjusted per episode costs and utilization measures. Results include lower readmission rates and improved follow-up after hospitalization.
  • Medication Assisted Therapy for Substance Use Disorders: Readmission rates and per episode costs are tracked for providers of these services; resulting in reduced readmissions and an increase in people living in the community.
  • Accountable Care Organizations (ACOs) & Medical-Behavioral Integration In Health Homes: Metrics from a variety of services are collected from the providers (e.g. care coordination, care transition, referral management, health promotion, individual support, family/caregiver support). Implementation of these services has strengthened patient engagement with primary care providers and improved assistance to patients with needed social services.

Ms. Adler stated that Optum’s appointment reminder program is one of the tools they have found most effective in helping patients adhere to their appointments. In addition, the Achievements in Clinical Excellence Program, or ACE, guides and rewards providers for delivering services more effectively and efficiently by:

  • Gathering unbiased, risk-adjusted data that is benchmarked against regional clinicians and facilities
  • Pinpointing and eliminating variations in practice patterns that drive costs and create poor outcomes
  • Assigning specific tier designations and incentivize providers and facilities to achieve and maintain high performance

Other tools for consumers include efforts in transparency for members, the “Bridge on Discharge” program, and peer coaches. Optum has developed a 24-item outpatient member assessment tool that they have put on their website. Ms. Adler pointed out there are limited national assessment tools available to behavioral health professionals.

Mr. Lelii then discussed the responsibility of providers in value-based delivery. He gave an overview of Gracepoint (formerly Mental Health Care Inc.), which is a private, non-profit behavioral health care organization founded in 1949 by the Tampa Junior League. Gracepoint annually provides services to more than 21,000 individuals (2015) in Hillsborough County, and employs 600 staff members. Aside from routine services provided to clients there are a number of special services offered such as central intake, a children’s crisis stabilization unit, family infant wellness, a 60-bed adult crisis stabilization unit, intensive case management, and a community action team.

Gracepoint recently began offering value-added services to their clients, including a partnership with a federally qualified health center (FQHC) and a full-time primary care physician. A full-time pharmacy, laboratory, and telehealth services are available in-house. His advice on success as a value-based program included implementing a strong network, facilities, and accredited clinical team to provide
full continuum of care services.

Both presenters provided their insight into the anticipated changes in the market in the next five years: Ms. Adler said that the Centers for Medicare and Medicare Services (CMS) will be instrumental in defining future requirements. She also believes that ACOs will take a greater role in pay for value. Mr. Lelii believes the industry itself will drive changes in the future. He mentioned that providers and payers need to work together to provide effective, necessary care.

The question and answer session included these five questions from the audience. The presenters’ responses are summarized below.

  • What quality measures does Gracepoint use?
    Mr. Lelii stated that Gracepoint uses readmissions rates, HEDIS, length-of-stay (LOS), satisfaction surveys, case management, and inpatient utilization measures.
  • What data should a practice have to be prepared and readily available to be a strong partner with health plans?
    Ms. Adler said they receive proposals from providers that indicate how they track outcomes, quality measures, inpatient residential data, and HEDIS scores. She recommended that health plans and providers share data.
  • What are the different payment models that are being used in behavioral health?
    Mr. Lelii stated his preference for a blend of both capitation and fee-for-service.
  • What is the difference between pay-for-performance and pay-for-value?
    Ms. Adler said that clarity is needed when using these terms: pay-for-value is based on improvement in member outcomes; pay-for-performance is based on improving processes like coordinating care.
  • How is risk adjustment measured at Gracepoint?
    Mr. Lelii explained that they calculate risk adjustment using severity of illness, age, gender, and other factors, such as if the client is under a public health system.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/managing-financing-specialty-health-plans-smi-population/.

During a live PsychU Virtual Forum on September 8, 2016, Don Fowls, MD, President of Don Fowls & Associates, LLC, and Monica E. Oss, MS, Chief Executive Officer of OPEN MINDS, provided their insights into managing and financing specialty health plans for the serious mental illness (SMI) population. Don Fowls is a nationally-known psychiatrist and health care consultant for managed care, provider-based and information technology organizations. Dr. Fowls completed his residency in psychiatry at the University of California Los Angeles (UCLA), practiced psychiatry in Southern California for 10 years, and has held executive positions with several health care organizations related to behavioral health. Ms. Oss, is the founder and Chief Executive Officer of OPEN MINDS. For the past two decades, Ms. Oss has led OPEN MINDS and its research on health and human service market trends and its national consulting practice and is well known for her numerous books and articles focused on the strategic and marketing implications of the evolving health and human service field. She has unique expertise in payer financing models, provider rate setting, and service pricing.

The objectives of the virtual forum were to:

  • Understand high-needs, high-cost consumers, specifically who they are and strategies for managing their care, including:
    • Integrated care for consumers with SMI
    • Value-based purchasing
  • Understand how one county implemented integrated care for its SMI population

The overall presentation addressed integrated care coordination models that seek to better meet the needs of high-needs consumers, and the need for value-based reimbursement to facilitate these models. In addition, Dr. Fowls discussed the evolution of the integrated care model in Maricopa County, Arizona over the past three years to bring a real-world reference to the audience.

Ms. Oss gave an overview on the national market perspective on high-needs, high-cost consumers. She first mentioned the many forces that converged in the time period from 2008 to 2012:

  • The Patient Protection & Affordable Care Act (PPACA) of 2010 put pressure on providers to increase quality of care, and reduce costs, specifically for the 5% of non-institutionalized individuals that account for nearly 50% of health care spending, many of whom have SMI
  • Intensive coordinated care models like heath homes, waiver-based home- and community-based services (HCBS), and specialty care management programs were implemented where performance risk was evaluated along with financial penalties instituted for poor performance
  • The increasing use of value-based purchasing (VBP) to replace traditional fee-for-service reimbursement in order to hold health care providers accountable for both the cost and quality of care they provide.

Ms. Oss explained that a lot of attention is being paid to specialized populations in health care (e.g. individuals with SMI) because they represent a small percentage of the general population but have the highest health care costs. VBP is designed to address both of these factors.

Ms. Oss discussed the movement over time in the health care industry to VBP. She presented financial risk systems and provider involvement as being low, medium, or high risk. The traditional fee-for-service model is seen as low risk and low involvement by providers; medium risk is seen in shared savings / shared risk plans where providers become more accountable; and the high financial risk systems which include capitation and performance based contracting require the provider to assume full accountability. Case rates are bundled payments representing a predetermined amount of money paid to a provider organization to cover the average costs of all services needed to achieve a successful outcome for a predefined episode of care. Ms. Oss then discussed the different capitation (population health) arrangements that health plans use:

  • Behavioral Health Carve-Out Capitation: Per member per month (PMPM) for behavioral health treatment benefits (or other cognitive disability support services)
  • Medical Home/Health Home Capitation: PMPM to cover the cost of care coordination and preventative services
  • Primary Care Capitation: PMPM for primary care services (assess, prescribe, refer)
  • Global Capitation: PMPM for cost of delivering all (or some) of the care for a group of consumers

Ms. Oss explained that she believes pay-for-performance models impact the care received by consumers in that they offer them fewer services. However more coordination of care should create better consumer experiences especially for people with SMI. Dr. Fowls added that the models do work; however, they have to be implemented correctly.

Dr. Fowls described the driving force behind Maricopa County’s decision to embrace integrated care for individuals with SMI when there was a ground swell across the county and state to address high-cost, high-needs population. He stated that Mercy Maricopa decided that an integrated care model based on VBP would be a solution to these issues. According to Dr. Fowls, Mercy Maricopa Integrated Care (MMIC) is owned by three health systems and administered by Aetna Medicaid. It contracts with Arizona Health Care Cost Containment System, the Medicaid agency in Arizona, as the Regional Behavioral Health Authority in Maricopa County. MMIC has a budget of over $1.2 billion and more than 884,000 members: 859,000 member non-SMI adults and children with behavioral health benefits and 25,000 members with SMI. The three categories of high-cost, high-need members are members with SMI, members who are general mental health/substance abuse (GMHSA) adults, and children and adolescents. These specialty groups have complex physical and behavioral needs and require critical psychosocial support.

Dr. Fowls provided examples of strategies that have been helpful for MMIC, including:

  • Identifying members with integrated clinical data analytics
  • Meeting members where they are
  • Ensuring accurate assessment are given by experienced experts
  • Implementing multidisciplinary teams with a leader
  • Facilitating proactive communication supported by technology
  • Addressing psychosocial factors like housing and employment
  • Measuring performance towards outcomes
  • Sharing data
  • Training and supporting staff

The key principles for success using VBP according to Dr. Fowls are being member-focused, aligning payment with outcomes, and integrating clinical, operational, and financial systems. Dr. Fowls stated that defining performance measures are critical to program success and should:

  • Target a desired result
  • Include behavioral health, medical, and psychosocial measures
  • Include Healthcare Effectiveness Data and Information Set (HEDIS) and compliance measures
  • Address unnecessary emergency department and hospital stays
  • nitially include processes but move toward outcomes
  • Support integration and management

Dr. Fowls provided a few strategies to transition from block funding including: the need to focus on member outcomes and make outcomes public; align data analytics with incentives; develop a capitated model; and base new payment models on performance measures. Dr. Fowls stated that the biggest challenge faced by MMIC was culture; initially teams did not work together. Primary care physicians had to be brought into the behavioral clinics since individuals with SMI are not used to going to primary care clinics. Also, data interpretation is different for medical versus behavioral health professionals.

The question and answer session included these four questions from the audience. The presenters’ responses are summarized below.

  • Have any useful studies been produced from these different reimbursement and integrated models?
    Dr. Fowls stated there have not been any large scale studies to date but he hopes within a year or two there will be. Ms. Oss agreed and offered that there are a few small scale studies that point to different reimbursement and integrated models.
  • What cultural changes must be implemented to get staff on board?
    Dr. Fowls explained that leadership must make a made a conscious decision to get everyone involved, from providers to the state. In his experience, online training has some potential to educate staff and the use of subject matter experts from outside the county to present to staff has also showed promise.
  • Was the biggest challenge culturally for Mercy Maricopa related to VBP or integrated care or both?
    Dr. Fowls said the biggest challenge was related to both VBP and integrated care.
  • If you look back three years, how has the role of a psychiatrist changed at Mercy Maricopa, if at all, in this new environment?
    Dr. Fowls indicated the role of the psychiatrist has not changed enough but it is changing. In the 23 clinics serving 25,000 individuals with SMI in the county, psychiatrists cannot simply act as prescribers anymore; they need to be part of the treatment team, which did not occur in the past. The county is trying to get better reimbursement for psychiatrists so they can spend the time they need to with a patient and get paid for the effort in a reasonable manner. In addition, too many psychiatrists are leaving the public sector in Maricopa County because of the administrative paperwork required to practice.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/telepsychiatry-enhancing-access-mental-health-care/.

Jonathan Evans, President and CEO, and Meera Narasimhan, MD provided their insight during a live PsychU Virtual Forum on July 12, 2016 on enhancing mental health care through telepsychiatry. Mr. Evans is the Founder, President, and CEO of InnovaTel Telepsychiatry, a private telepsychiatry provider servicing community based clinics; and CEO of Safe Harbor Behavioral Health, a public behavioral health clinic located in Erie, Pennsylvania. Dr. Meera Narasimhan serves as the Associate Provost for Health Sciences at the University of South Carolina, as well as the Professor and Chair in the Department of Neuropsychiatry and Behavioral Sciences at the University Of South Carolina School Of Medicine. The presenters were paid consultants of Otsuka Pharmaceutical Development & Commercialization, Inc.

Their presentation covered the following main objectives:

  • Discuss current barriers in mental health care and the goals of telepsychiatry
  • Consider the potential benefits of telepsychiatry
  • Discuss settings and patient populations for which telepsychiatry may be appropriate/useful
  • Review factors for consideration when implementing telepsychiatry

The first polling question of the presentation asked the audience about barriers to receiving mental health care:

What barrier in mental health care do you feel to be most relevant in your clinical experience?

  1. Cost of therapy/insurance coverage (31%)
  2. Time constraints (11%)
  3. Stigmas (7%)
  4. Patients who have difficulty visiting the office (15%)
  5. Access to available care (37%)

Dr. Narasimhan continued by discussing six barriers to care for people with serious mental illness (SMI): shortage of mental health professionals, transportation difficulties, cost of therapy/insurance, time constraints, stigma, and limited English proficiency. She reviewed the timeline progress in mental health care starting with psychoanalysis and ending with digital psychiatry, which includes telepsychiatry; she noted telepsychiatry is the fourth wave of evolution in psychiatric treatment and care.

Mr. Evans discussed the similarities between telemedicine and telepsychiatry; pointing out they both rely on technology to bring clinical medicine to patients in the form of video conferencing through various platforms. He noted telepsychiatric services are increasing which increases access to care particularly for individuals in remote areas where there are fewer psychiatrists. In his experience there really is no difference between traditional psychiatric treatment and telepsychiatry other than the method of delivery, and discussed studies that indicated similar outcomes and significant improvement in access to care between traditional psychiatry and telepsychiatry. Mr. Evans mentioned there was a better retention of mental health professionals within their organization by using telepsychiatry.

The second polling question asked about providers’ inclination to use telepsychiatry for certain groups of patients:

For which patient population would you be most inclined to utilize telepsychiatry?

  1. Patients in emergency mental health care situations (14%)
  2. Patients who live in rural settings (66%)
  3. Patients who are veterans (1%)
  4. Patients in correctional facilities (3%)
  5. Patients in primary care settings (17%)

Dr. Narasimhan discussed the role telepsychiatry can play in emergency mental health care. It may be used to assess psychiatric patients in the emergency department (ED) and she presented results of a study showing telepsychiatric and face-to-face assessments showed agreement in disposition recommendation and diagnosis. Also, in a retrospective analysis (N=14,522) of a state-wide, ED-based telepsychiatry program, compared to a matched control group, the recipients of telepsychiatry were: less likely to be admitted, likely to have a shorter length of stay, if admitted; more likely to receive 30-day and 90-day outpatient follow-up; and had lower total health care charges in 30-day follow-up period.

Mr. Evans discussed the use of telepsychiatry in correctional facilities, and noted these facilities have become the largest mental health treatment facilities in the U.S. He pointed out the American Psychiatric Association is considering amending its treatment recommendations to include telepsychiatry for correctional facilities as a supplement to on-site services for the following reasons:

  • Prisons and jails are often located in rural communities with limited access to psychiatric services
  • Use of telepsychiatry avoids the need to transport inmates to an off-site location for psychiatric consultation, which enhances the safety of the community
  • Telepsychiatry may also allow for the observation of patients during an after-hours crisis or for monitoring of suspected medication side effects

There are key elements needed for successful implementation of telepsychiatry such as a high level of technical competence of staff and clients, licensing, and other legal considerations, confidentiality and security concerns, data storage, reimbursement, therapeutic relationship, and provider skepticism and acceptance. Both presenters agreed that once established the system is very easy to use by providers and clients, with infrequent technical problems.

Currently 48 states reimburse for telehealth. State policies for telemental-health vary in specificity and scope, and Medicaid reimbursement for telehealth varies from state to state.

The question and answer session included these questions from the audience. The presenters’ responses are summarized below.

  • What are the trends and issues involved with reimbursement of telepsychiatry?
    Mr. Evans stated that twenty states have formal legislation for telepsychiatry. Private payers are starting to come onboard due to mental health parity legislation.
  • How is a suicidal patient handled in a telepsychiatry setting?
    Dr. Narasimhan stated there has to be a solid communication line between the provider site and the client site in case of emergencies. If a patient becomes agitated during the session, local provider staff must be available to address problems at the end user site.
  • How do you address technical issues during a telepsychiatry session?
    Mr. Evans stated there should be identified technical staff at each end with duplicative equipment.
  • Is licensure in one state accepted throughout the U.S.?
    Dr. Narasimhan stated that currently there are hurdles to making this happen. However, nine states are working on state compacts to allow this to occur.
  • How do you address security concerns?
    Mr. Evans stated there are many security concerns with telepsychiatry but most prominent is ensuring the system is HIPAA compliant with the proper level of encryption.
  • Please discuss what connection problems you have encountered using telepsychiatry?
    Mr. Evans stated that they have experienced very few problems, and said in one of his clinics the power went out due to a storm. Dr. Narasimhan agreed and added that there should be test protocols in place before each session where microphones are tested and computer resolution is verified.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/stigma-mental-health-breaking-barriers-uncovering-opportunities/.

Two experts in the field of mental health advocacy came together on October 24, 2016 to present a lively discussion called, “Stigma In Mental Health: Breaking Down Barriers & Uncovering Opportunities.” Allen Doederlein, President of the Depression and Bipolar Support Alliance (DBSA) and Paul Gionfriddo, President and Chief Executive Officer of Mental Health America (MHA) shared their extensive experience in combatting discrimination in mental illness. The speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the virtual forum were to:

  • Discuss the current state of stigma within mental health care and the appropriate terminology for addressing the topic
  • Consider how to target stigma to reduce barriers to care for individuals with mental health conditions
  • Review some available resources and tools that may aid in breaking down stigma in clinical practice.

Mr. Doederlein started the presentation by explaining the exclusionary nature individuals with mental illness being labeled differently, treated differently, and ultimately feeling differently than the rest of the population. He indicated this negativity is a hard cycle to break. Mr. Gionfriddo wondered why stigma persists when, given the prevalence of mental illness, society should be more understanding. Mr. Doederlein described the nature of internal and external stereotypes, and how they are reinforced by society while Mr. Gionfriddo added that, often, behavioral health disorders are defined as “bad behavior”; disorders are only addressed when someone is a danger to self or others.

Stigma leads to discrimination in housing and the workplace, human rights violations, and is a barrier to receiving adequate health services in several ways: it can impact the frequency and thoroughness of behavioral health visits.

Results of the first polling question indicate the high level of stigma:

What percentage of mental health care providers think that their patients feel shame about a mental health condition that they are living with?

  1. 0% to 20% (1%)
  2. 20% to 40% (14%)
  3. 40% to 60% (40%)
  4. >60% (45%)

It was noted that stigma in society can include stigma perpetuated by mental health care professionals. Mr. Doederlein explained how pessimistic views held by mental health care providers can be the result of seeing patients when the patients are acutely distressed, such as patients with enduring mental illness or those receiving inpatient services.

The next polling question focused on types of stigma:

Which form of stigma do you feel most commonly affects the individuals living with mental health conditions that you have worked with?

  1. The use of negative phrases historically associated with mental health or language that “distances” (13%)
  2. Defining the individual based on their illness (64%)
  3. Others having lowered expectations of the individual’s capabilities (15%)
  4. Having diagnosis presented with expectations of poor outcomes (8%)

Mr. Gionfriddo continued the presentation by explaining the mental health patient’s perspective on stigma. Examples like receiving “standard services” instead of being offered options or being diagnosed in a negative way that conveys recovery is not possible may make a person with mental illness feel stigmatized; but Mr. Gionfriddo pointed out this is the same for anyone with a chronic illness. The dignity and rights of all people, but especially people with mental health disorders, are counterpoint to the stigma and shame felt by people with mental illness.

Perspectives on combatting discrimination with compassionate language were discussed by Mr. Doederlein based on his own personal experience. He noted that asking others to consider using positive language to discuss mental illness can be a way to combat discrimination. He offered ten ways to combat language discrimination, particularly highlighting two of them:

  • Avoid sensationalizing – The media often portrays the most shocking and tragic aspects of a situation, and those headlines create fear, which he recommended be avoided to help combat stigma
  • Don’t assume mental health is a factor in violent crime – People with mental illness are much more likely to be victims of crime rather than the one committing the crime.

Another polling question was asked of the audience, this time on tools that can be used to reduce stigma:

Which of the following do you think is the most important tool to use in initiatives to reduce stigma?

  1. Rating scales (paper or electronic, for example, the Opening Minds Scale for Health Care Providers (OMS-HC) (1%)
  2. Social media awareness campaigns (58%)
  3. Education tools (34%)
  4. Awareness paraphernalia (for example, flyers, billboards) (6%)

Each presenter talked about what their organizations are doing to combat stigma. Mr. Gionfriddo talked about the social media campaign #B4Stage4 program at MHA which raises awareness that mental health conditions are generally the only chronic conditions that, as a matter of public policy, the health care system waits until Stage 4 to treat, resulting too often in incarceration. They noted that creating hope for recovery, even in the early stages of illness, is important in reducing stigma. The goal of the program is to change mental illness from a public safety issue to one of public health concern. Through #B4Stage4 and MHA, individuals can complete mental health screening online to help them understand if they should potentially seek help for depression, anxiety, mood disorders and post-traumatic stress disorder (PTSD). Mr. Gionfriddo reported that so far two million people have done so and 66 percent were identified with moderate to severe symptoms. Of those, over 60% had never been diagnosed for a mental health disorder. MHA intends to launch a new initiative in 2017 called Screening-to-Supports (S2S) which will enable consumers to ask for help in the way that works best for them: information and education, referral to care and services, engagement with peers, or self-help tools.

Mr. Doederlein introduced the “Target Zero to Thrive Campaign” offered by the DBSA; its importance lies in the fact that high expectations for recovery combat stigma, and the way to achieve wellness is different for each patient. He cautioned the consequences of residual symptoms are too costly for consumers with mental illness, including:

  • Significantly greater risk of relapse
  • More likely to experience significant functional impairment
  • More likely to have life-threatening co-occurring chronic physical conditions
  • A higher risk of suicide

He raised some striking points regarding treatments that make people “better” instead of “well”: each person with mental illness has different needs so treatments may work well, moderately well, or not at all. However, all treatments should have a goal of remission. Patients that wait too long to seek treatment receive services designed to stabilize them and the follow-up care is often inadequate. One approach providers can consider is a whole health/integrative health approach to treat the mind and body together. Finally Mr. Doederlein indicated that research into mental disorders often focuses on acutely ill individuals, but this doesn’t give a full picture of the diversity of mental illnesses.

The question and answer session included these two questions from the audience. The presenters’ responses are summarized below.

  • What can be done to reach the media on stigma?
    Mr. Doederlein said we all have an opportunity and a duty to speak up when the media engages in stigmatizing mental illness. Using social media and writing letters to editors are two things that we all can do. Mr. Gionfriddo mentioned that he would like the media to stop leading with mental illness headlines. He offered an example of the media’s coverage of a plane that crashed into a mountain – much of the discussion centered on the pilot’s past medical history, including that of a mental illness. The pilot’s medical history might not have been relevant to the plane crash.
  • How does stigma and mental health affect kids?
    Mr. Gionfriddo had two comments: he warned parents about labels their kids might get due to mental health disorders; and talked about teachers who are afraid to label kids with mental illness because it might cost the school district to help the kids. In spite of that, he suggests regular screening for mental health should be as natural for children as hearing, dental, and eye exams. Mr. Doederlein agreed with the need for routine screenings for children. He also mentioned that since mental illness and depression in particular are so prevalent in children, the education system should incorporate compassionate language to prevent negative attitudes against mental illness.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/impact-integrated-health-homes-mental-health-service-delivery/.

During a live PsychU Virtual Forum on June 16, 2016, Katie Arjes, MS, LBSW, CADC, and Carole Matyas, MSW provided insight on the impact of integrated health homes on mental health service delivery. Katie Arjes is Director for UnityPoint Black Hawk-Grundy Mental Health Center’s Integrated Health Home (IHH) program in Waterloo, Iowa. Since her tenure began at IHH in 2013, she has helped implement a team-based patient-centered approach to empowering members to reach their whole health and wellness goals.

Carole Matyas is Vice President of Behavioral Health Operations, WellCare Health Plan, in Tampa, Florida. Ms. Matyas oversees enterprise-wide behavioral health operations for the company, to assure that WellCare develops a fully integrated medical/behavioral program centered in whole person attention and care. WellCare calls its program a Behavioral Health Home (BHH). The speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the virtual forum were to:

  • Understand the Medicaid integrated health home model
  • Explore what payers are looking for in IHH and BHH arrangements
  • Discuss how providers are meeting the expectations of payers and consumers under IHH and BHH arrangements.

Ms. Arjes began the discussion by describing the operations of UnityPoint’s IHH; implemented in July 2014, it is comprised of a team of professionals working together to provide care coordination for the patient’s medical, behavioral health, and social needs using a patient-centered, team-based approach focused on improving the client’s overall well-being.

Care Coordination Tasks Provided By The IHH Program

  • Conducting Comprehensive whole-person assessments
  • Scheduling appointments
  • Making referrals
  • Tracking referrals and appointments
  • Follow-up monitoring
  • Communicating with providers on interventions and goals
  • Conducting joint treatment by staff members
  • Supporting coordination of care with primary care providers and specialists

The team members include a:

  • Nurse Care Manager (1:400 member ratio)
  • Care Coordinator (1:250 member ratio)
  • Peer Support Specialist (1:250 member ratio)
  • Family Support Specialist (1:200 member ratio)

In order to be eligible for UnityPoint’s IHH program, clients must be:

  • Enrolled in Medicaid
  • Diagnosed with one of the seven designated serious mental illness (SMI) diagnoses accepted by the state of Iowa (adults only)
  • Diagnosed with a serious emotional disorder (SED) which causes functional impairment in the member (children and adolescents only)

Ms. Arjes described many benefits of IHH, including a shared care plan which allows IHH to treat the whole client (mind, body, and spirit), reduced red tape, and better communication among health care professionals; and easier access to care, assistance navigating the health care system, referrals to community resources and support services, and access to emergency care for consumers.

She also discussed a number of challenges encountered during implementation of the program, as well as measures taken to meet those challenges. For example, the IHH experienced a decrease in its startup funding (based on enrollment) due to competition for clients with medical health homes and the Iowa Wellness Plan. The entities collaborated to ensure enrollees were served in the arrangement that best met their needs. Other challenges involved meeting quarterly quality metrics, dealing with the new
reimbursement and authorization processes brought about by Medicaid modernization, and informing providers about how an IHH works to encourage them to refer clients to the IHH.

Ms. Matyas, discussed WellCare’s Enterprise Core model for its BHH program from a payer’s perspective. The program conforms to the Institute for Healthcare Improvement’s Triple Aim: improving member experience, improving health of populations, and reducing per capita health care expenditures. WellCare’s roles include assessing readiness of providers to become a WellCare BHH, assisting potential BHH providers with information regarding resources to develop capabilities, contracting for BHH providers, providing quality and performance reports to BHH providers, and monitoring and reporting quality measures and care gaps.

She described member eligibility requirements which included individuals who:

  • Are covered under Medicaid, or are dually-eligible for Medicaid and Medicare
  • Have at least $5,000 in claims within the past 12 months, including one or more visits to a community mental health center (CMHC)
  • Have a diagnosis of:
    • SMI
    • SED
    • Substance use disorder (SUD) with an accompanying chronic medical condition (e.g., diabetes or asthma).

Ms. Matyas highlighted that individuals with SMI are prone to many different physical health problems which adds complexities and costs to treatment, and while these diseases are also prevalent in the general population, their impact on individuals with SMI is significantly greater. If the member meets the eligibility requirements, they are then assigned to the last CMHC they visited. WellCare reviews claims for members with a behavioral health diagnosis and at least $5,000 in costs in prior 12 months who have not received outpatient BH services to make sure they get assigned to a CMHC. The CMHC has three months to outreach and engage their assigned members or the member gets reassigned to another CMHC.

WellCare recommends that BHHs have the following staffing, which includes a:

  • BHH Administrator
  • Clerical Administrator For Data Management
  • Nurse Care Supervisor (1:5 care manager ratio)
  • Care Managers (1:200/250 member ratio)
  • Readily Available Or On-site Primary Care Clinician (1 hour/year/enrolled member)

Care management at WellCare includes behavioral pharmacy management, medication adherence, and disease management. In addition, WellCare providers participate in discharge planning of members from psychiatric institutions, ensure members have annual visits with a primary care physician, and ensure members have appropriate lab studies for their conditions.

Ms. Matyas expressed that payers also experience challenges, for example, finding CMHCs that have an adequate number of appropriate staff to make the program successful. Additional challenges Ms. Matyas mentioned were that models are new and still forming, and that care coordination across entities to ensure effective care management can be difficult as well. As part of the WellCare Enterprise Model Behavioral Health Program, payments to providers are to be based on achieving specific performance levels or benchmarks including Healthcare effectiveness Data and Information Set (HEDIS®), and WellCare’s internally-developed measures.

The question and answer session included these four questions from the audience. The presenters’ responses are summarized below.

  • Where did the startup funding for your program come from?
    Ms. Arjes stated that the IHH Program’s startup funding came from both federal and state dollars.
  • For individuals looking to start an integrated health home, where should they start? What is the best resource out there?
    Ms. Matyas explained that the Centers For Medicare & Medicaid Services (CMS), the Substance Abuse & Mental Health Services Administration (SAMHSA), the Milliman Report referenced in the slides, and National Council of Community Mental Health (NatCon), have an accumulation of information and resource documentation on their websites that could be useful.
  • Does WellCare contract for integrated health homes with CMHCs even in states that do not have a state plan for health homes?
    Ms. Matyas’ short answer was yes. WellCare is attempting to implement health homes in the entirety of the market with approval from the state to move forward, but independent of whether the state has a formal state plan amendment (SPA) for health homes. She mentioned that this provides a challenge, particularly in states where funding supports other types of programs instead of a health home.
  • How is the performance meeting expectations in the BHH? Are lives being changed?
    Ms. Matyas stated that they don’t have a full picture or published data yet, as they are still in infancy stage building BHHs in different markets. She is anticipating being able to speak to this in the future. In the integrated BHH programs where there are outcomes measures, they’re seeing an improvement on some HEDIS measures, Gold Star Measures (readmission rates, 7-day follow up, closing care gaps related to diabetes).

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/suboptimal-response-in-psychotic-mood-disorders-causes-consequences-management-strategies/.

Psychiatrists Henry A. Nasrallah, MD and Peter J. Weiden, MD joined together in a live PsychU virtual forum on March 17, 2016 to discuss their insight into the problem of suboptimal response in people with serious mental illness (SMI), and how to manage their recovery. The presenters were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the virtual forum were to:

  • Explore the negative impact and potential causes of suboptimal response in serious mental illness
  • Discuss the various definitions of remission and recovery in major depressive disorder, bipolar disorder, and schizophrenia
  • Understand pharmacological approaches to suboptimal response

Drs. Nasrallah and Weiden began their presentation by discussing the continuum of treatment response in SMI, from optimal to treatment resistant. They noted that suboptimal response is a reliable predictor of relapse so health care professionals must focus on patients who do not respond adequately. In trying to uncover why someone with SMI does not respond fully to treatment, they suggested looking first at possible non-pharmacologic causes such as incorrect diagnosis, substance use and other comorbidities, problems with adherence to medication, and inability to access treatment.

At this time the first polling question was asked and described participants experience with psychotic/mood disorders and suboptimal response:

In your experience with psychotic and/or mood disorders, what is the most common cause of suboptimal response in patients?

  1. Incorrect diagnosis (15%)
  2. Substance use comorbidities (31%)
  3. Adherence problems (46%)
  4. Treatment access barriers (8%)
  5. Other (0%)

Dr. Weiden pointed out that the answer would differ depending on an individual practitioner’s practice characteristics and the population they treat. The presenters then discussed the definition of remission and recovery for people with major depressive disorder (MDD), bipolar disorder, and schizophrenia, pointing out that in general the definitions are a work-in-progress because treatment goals for people with SMI can vary. Drs. Nasrallah and Weiden described that individuals with schizophrenia have suboptimal outcomes when they experience persistent symptoms or functional impairment between acute episodes. Such complex patients may go many years without treatment if symptoms aren’t severe (e.g. during prodromal stage of adolescence to early adulthood) but repeated episodes of psychosis may build to worsening outcomes; therefore early intervention is essential to potentially avoid relapse at a later age.

The presenters stated that most clinicians focus on the positive (psychotic) symptoms of the disorder by using antipsychotic medications; though the negative and cognitive symptoms are not as easily treated they are just as important for clinical and functional outcomes. Suboptimal response for individuals with SMI can be affected by many different factors such as inaccurate diagnosis, poor adherence to treatment, inadequate medications, side effects, comorbidities or psychosocial factors.

The next polling question was presented and focused around participant’s personal professional preferences for next steps with patients with suboptimal response:

Assuming that you did not identify any secondary reason for suboptimal response in a patient with Major Depressive Disorder who has been on an adequate therapeutic dose of an approved first-line monotherapy, your preferred next step for a partial but suboptimal responder after 6 weeks of treatment is:

  1. Continue with “watchful waiting” without any changes (25%)
  2. Raise the dose higher than your usual target dose (50%)
  3. Suggest adding a psychotherapy targeting remaining symptoms (0%)
  4. Change to your next antidepressant choice (25%)
  5. Add an adjunctive therapy (0%)

Dr. Nasrallah agreed with the audience selection of raising the dose of the current medication followed by watchful waiting. He noted that many patients treated in real world settings experience more complications and challenges than those patients in drug trials, and thus may require higher doses of medications or longer periods to reach remission than are commonly indicated in guidelines. Dr. Weiden noted the importance that these choices be made actively and be based on clinical decisions with patients about how best to address suboptimal response under the circumstances faced by each patient.

The presenters then offered their thoughts on pharmacologic approaches including no changes to medications, changing the dose or primary medication all together, adding another medication, or discontinuing a medication. They also pointed out that clinicians need to keep track of outcomes experienced by their patients with SMI to help with optimal recovery.

Dr. Nasrallah offered a parting thought: that all three of the conditions discussed during the virtual forum (MDD, bipolar disorder, and schizophrenia) are syndromes with multiple subtypes, making the conditions difficult to treat. Additionally, he observed that patients’ brains are different at various stages of illness so clinicians need to constantly evaluate the needs of their patients. Dr. Weiden mentioned that he always tells his patients “the treatment failed you; you didn’t fail the treatment”. He also cautioned that some patients are not always inclined to talk about their symptoms, so clinicians may need to be creative in getting full information on patients’ status.

The question and answer session included these two questions from the audience. The presenters’ responses are summarized below.

  • Dr. Weiden, you spoke about distressing positive symptoms. Is the absence of distressing symptoms on the continuum of recovery? Those with mental illness often define recovery in terms of being able to live a meaningful life.
    Dr. Weiden stated that he’s dealt with patients who have heard voices but they didn’t interfere with their lives. In this case, he stated, he would not call this a suboptimal response. Rather he tends to look for distress or disability. Dr. Nasrallah agreed and stated that the patient and doctor need to determine in advance what outcomes are desired. Taking patients’ perspective into account is very important as outcomes are also determined by what patients hope to achieve.
  • Are there specific considerations when serving the older adult population?
    Dr. Nasrallah stated that the aging patient is very important as a category. This population may have experienced progressive brain changes throughout their lifetime due to multiple treatments and relapses – so treatment can become complex. Dr. Nasrallah stated that some aging patients have their first episodes of depression, mania or psychosis after age 65, which can cause diagnostic issues because etiologies and treatment approaches are different. Furthermore, according to the speaker, late onset depression, mania, or psychosis can be attributed to vascular reasons, not neurotransmitter reasons; and there are degenerative disorders that cause psychotic symptoms, such as Alzheimer’s. Dr. Weiden agreed and stated that there are more drug interactions in the elderly population as well.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or presentation slides at https://www.psychu.org/ncqa-hedis-measures-mental-health-current-landscape-future-developments/.

Two experts from the National Committee for Quality Assurance (NCQA) provided information on the organization’s efforts to measure quality of care for behavioral health and substance use care during a PsychU Virtual Forum held live on March 31, 2016. Junqing Liu, PhD, MSW, a Research Scientist; and Emily Morden, MSW, Senior Research Associate gave an overview of the organization’s goals and described current measures as well as those under development. Babette S. Edgar, Pharm.D. MBA, BCPS FAMCP was moderator for the forum. Dr. Edgar is a principal at BluePeak Advisors and President-Elect for the Academy of Managed Care Pharmacy. Dr. Edgar laid the foundation for the virtual forum by discussing the cost of behavioral health disorders to the individual and society in general, including the high prevalence of physical illness in the behavioral health population and associated costs.

The NCQA presenters focused on HEDIS® (Healthcare Effectiveness Data and Information Set) measures for serious mental illness (SMI). HEDIS measures are used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service; there are 12 measures currently in use related to behavioral health; eight related to effectiveness of care, two for access and availability of care, one measuring mental health utilization, and one for utilization of the Patient Health Questionnaire-9 (PHQ-9) under the NCQA electronic clinical data system (ECDS) domain.

Ms. Morden began the presentation by sharing a list of HEDIS measures related to behavioral health currently in use, under development, or proposed for the future. She followed up by providing examples of how health plans are doing over time with initiation of substance use treatment, and follow-up after hospitalization for mental illness; both measures showed a decline from 2011 to 2014, indicating a need for improvement. Next Ms. Morden discussed the high prevalence of SMI, details of four measures that address schizophrenia and bipolar disorder, and health plan performance on the measures:

Table 1: NCQA© HEDIS ® Measures Addressing Schizophrenia, Bipolar
Disorder, & Health Plan Performance
Measure Percent Of Health Plans Completing Measure
Adherence to Antipsychotic Medications For Individuals With Schizophrenia 60%
Diabetes Screening For People With Schizophrenia Or Bipolar Disorder Who Are Using Antipsychotic Medications 80%
Diabetes Monitoring For People With Diabetes & Schizophrenia 69%
Cardiovascular Monitoring For People With Cardiovascular Disease & Schizophrenia 76%

Dr. Liu unveiled new measures currently being developed, and then gave an in-depth explanation of the approach to identification and treatment of the disorders:

  1. A suite of substance use measures to cover alcohol screening and treatment, opioid overuse, and follow-up care
  2. Depression screening, monitoring and outcome measures
  3. Evaluating telehealth for HEDIS behavioral health measures

At this point, audience members participated in two polling questions surrounding alcohol screening:

What would be the most relevant setting of care for alcohol screening and brief intervention measures?

  1. Primary care (39%)
  2. Behavioral health care (30%)
  3. Emergency department for everyone (15%)
  4. Emergency department for patients who had alcohol use related complications (e.g. injury from a car accident, intoxication) (17%)

What do you see as the biggest challenge in introducing a Screening Brief Intervention & Referral For Treatment (SBIRT) alcohol screening?

  1. Lack of use of claims codes on alcohol screening brief interventions that are available (19%)
  2. Lack of providers who are trained to provide SBIRT services (45%)
  3. Variation of the quality of SBIRT services (7%)
  4. Defining what counts as brief intervention (11%)
  5. Lack of documentation of alcohol screening and brief intervention in structured fields in an electronic health record (EHR) (17%)

Following a discussion of HEDIS measures for opioid overuse and balancing pain management, audience members participated in a polling question addressing opioid overuse monitoring:

What is the most important pain management measure concept to develop in order to minimize the unintended consequences of opioid overuse monitoring?

  1. Pain assessment and follow up (19%)
  2. Use of non-pharmacologic therapy (i.e. multidisciplinary approach) and non-opioid pharmacologic therapy as a first-line
    treatment for chronic pain (41%)
  3. Avoid the prescription of opioids for acute pain at high dosage or for a long period of time (16%)
  4. Use of psychotherapy and multidisciplinary approach for chronic lower back pain (9%)
  5. New users of opioids: patients signing a consent form for receiving opioid treatment, screening for risk of substance abuse
    (9%)
  6. Chronic users of opioids: patients receiving a urine drug test in the past 6 or 12 months, monitoring of functional status (4%)
  7. Other (2%)

Dr. Liu introduced a measure proposed for 2017 that will use administrative claims data as a method to collect information for HEDIS: “follow up after emergency visit for mental health or substance use.” The method is known as ECDS and is expected to “…stimulate better data sharing and interoperability of health care systems, and ensure that information needed to provide high-quality health care services reaches the right people when it is most useful. Adding the ECDS domain to HEDIS is an attempt to bridge existing gaps in communication and interoperability such that electronic clinical data can be effectively used for quality improvement”. NCQA has developed a learning collaborative to support ECDS with the goal of honing the process by which administrative data can be used for HEDIS measures. The collaborative consists of 13 volunteer health plans who will study three depression measures of care.

Finally, Dr. Liu touched on using telehealth coding for services associated with HEDIS measures. She explained the same current procedural terminology (CPT) codes are used for providing services via telehealth as for in-person except a modifier (GT) must be used to designate telehealth.

The last polling question focused on telehealth inclusion in HEDIS measures:

What do you see as the biggest challenge of including telehealth in HEDIS measures?

  1. Lack of available coding to identify telehealth visits (9%)
  2. Lack of use of telehealth claims codes that are available (5%)
  3. Ensuring quality care is being delivered by trained providers (17%)
  4. Defining what type(s) of telehealth visits that should count (13%)
  5. Variability of use and quality of telehealth across different health systems and plans (45%)
  6. Lack of incentives to document telehealth in claims or medical records (7%)
  7. Other (4%)

The question and answer session included these six questions from the audience. The presenters’ responses are summarized below.

  • How do we identify which of the HEDIS measures are best to focus on in the changing health care environment?
    Dr. Edgar mentioned that it would depend upon the health plan and what types of members and the prevalence of disease covered in the population – this would drive where and what measures to focus upon. Dr. Liu agreed and added that there is a desire for additional outcome measures to be developed.
  • How can our agency benchmark with other mental health organizations on population health metrics?
    Dr. Lui stated that there are measures included in provider reporting programs, for instance, depression or alcohol screening is included in some provider reporting programs and there are national benchmarks for these items. For NCQA’s product, they use these measures in HEDIS as well as with mental health home programs for benchmarks for reference.
  • Major depression is a common mental health disorder among adolescents, is NCQA working towards specific measures for this population and disease state?
    Ms. Morden stated that NCQA is including the adolescent population within some measures for depressive symptoms. She affirmed that the organization definitely recognizes the importance of having measures that address this specific population.
  • What are the biggest changes or additions from previous versions of the HEDIS measures as they relate to behavioral health systems?
    Dr. Lui explained that HEDIS publishes a measure volume annually, and during the process there may be updates to measures if necessary. These could be situation where new clinical practice guidelines are developed or new codes which measures are asked for. Dr. Lui added that she didn’t believe there were significant changes from the previous years’ volume, more like minor updates. The biggest changes were the new measures being introduced to HEDIS 2017.
  • Is there a standard set of outcome measures agreed upon for majority of behavioral health services by payers?
    Dr. Lui stated that outcome measures are really in their infancy. She added that, as such, there is not a consensus among payers or other stakeholders about outcome measures, though there is a strong desire for this. There is still a need to explore outcome measures outside of depression, using depression outcome measures as an example to build off of.
  • Dr. Edgar, in your efforts with the Academy of Managed Care Pharmacy, how do you see mental health impacting managed care organizations, particularly from a quality of overall management perspective?
    Dr. Edgar referenced her opening comments in her response, from a managed care perspective, the prevalence of mental health conditions is increasing. This is a growing concern around managed care pharmacy from both a quality and cost perspective, as individuals with behavioral health and chronic care conditions are more expensive; mental health drugs are expensive.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/understanding-role-social-determinants-population-health-management/.

On November 17, 2016 during a live PsychU Virtual Forum, Arthur C. Evans, Jr., PhD, the Commissioner of Philadelphia’s Department of Behavioral Health & Intellectual disAbility Services (DBHIDS), and Paul Block, PhD, the Vice President of Consulting for OPEN MINDS, presented their insights into the importance of social determinants of population health.

The objectives of the virtual forum were to:

  • Explore the connection between social determinants of health and the well-being of a population
  • Understand why social determinants of health should be addressed, especially for people with behavioral health needs
  • Understand what can be done to lessen the impact of adverse social conditions on a population’s health from the public health perspective

The overall presentation focused on why income, housing, and employment are important to an individual’s well-being, the challenges that social determinants present to population health management, insights into what health care providers can do to address social determinants in their service delivery strategy, and the successful interventions that the City of Philadelphia, Pennsylvania has put into place to address these challenges in order to improve the health status of individuals in their care.

The presenters began the conversation by discussing the challenges to keeping populations healthy that the U.S. health system currently faces. Dr. Evans began by saying the current system of care is focused more on illness as opposed to preventive health, which tends to be intensified in the behavioral health setting by the fact that resources are often allocated towards serving individuals in a reactive way. He went on to cite the dual-natured challenge for health care providers, namely, to continue to address behavioral health crises when they occur but to also proactively focus resources toward behavioral and physical health prevention and wellness efforts. Drs. Evans and Block both discussed financing models as a perpetuating factor in the lack of early intervention and prevention efforts, as payers are not always responsible for financing interventions for these determinants and available funding does not typically allow providers the flexibility to provide care in more proactive ways.

Dr. Evans continued by explaining the connection between social determinants of health and the well-being of a population. He began with a discussion of the factors that influence health status, and then compared a traditional treatment model with a recovery-oriented system of care. Dr. Evans stated that the current model is characterized by the mentality that outcomes are measured by “fixing” individuals as they come in for treatment, and can be problematic because it: constrains provider thinking about why individuals may be coming for care; develops treatment options that only address issues conventionally related to health care; and limits treatment to only individuals who actively seek help. In contrast, the recovery-oriented system views an individual within the context of their lives and environment, in order to develop treatment that addresses all factors that may be influencing an individual’s well-being.

The first polling question of the presentation was focused on respondents’ perception of the most important social determinants:

What do you think is the most important social determinant of health in the area where you live and work?

  1. Economic stability (33%)
  2. Education (3%)
  3. Social and community acceptance (6%)
  4. Access to health care and health literacy (17%)
  5. Safe community, access to health foods, and sufficient housing (41%)

Drs. Evans and Block expounded that all answers were valid, and that the goal is to expand providers’ ways of thinking to include a discussion of social determinants and their impacts on health outcomes. Dr. Evans mentioned, in particular, that stabilizing housing can have a large impact on outcomes.

Dr. Evans continued by discussing health disparities with significant economic impacts on the health care system. He mentioned that even though aggregate data may show positive outcomes, health care providers need to investigate their disaggregated data for additional trends and insights. He provided an example from his own work in Philadelphia: when investigating aggregate data for penetration (service access) Philadelphia’s outcomes appeared quite good, but when looking at disaggregated data they could tell that these positive outcomes did not hold true for Asians and African Americans. Dr. Evans mentioned that for Philadelphia the service access measure has sweeping consequences, not only for individuals’ access, but for the health care system as a whole, as individuals with untreated mental health and substance use issues cause significant cost to the system.

Dr. Block discussed the difference that better management of social factors can have on health outcomes. He stated that the behavioral health population is particularly impacted by social determinants of health, and due to this, tend to demonstrate poorer health outcomes, are less likely to receive adequate care, and may face stigma when they seek care. He continued by stating that individuals with mental health issues tend to cost the health care system more than individuals without mental health issues, and this may lead to a hesitancy to move more funding toward preventative measures outside of mental health care treatment. Dr. Evans agreed and added that untreated behavioral health conditions also contribute to increased spending on physical health care.

Dr. Block demonstrated that only 5% of Medicaid enrollees account for more than 50% of total expenditures, raising a critical question for the health care system – why are these individuals so expensive to care for? He pointed to behavioral health conditions and social determinants as key answers to this question. He discussed the idea that social determinants are more complicated than just focusing on poverty, and presented the Graham Center’s Social Deprivation Index (SDI) as one way to predict health outcomes for individuals based on a more comprehensive set of social determinants.

The second polling question of the presentation attempted to assess respondents understanding of U.S. spend on social services, which a majority of participants answered correctly:

In the United States, for every $1.00 spent on health care, how much is spent on social services?

  1. $2.00 (10%)
  2. $1.50 (4%)
  3. $1.00 (1%)
  4. $0.75 (4%)
  5. $0.50 (81%)

Dr. Block discussed that according to a World Health Organization study, even though the United States spends more than all other countries on health care alone, the United States is only 13th in ranking when you consider health care with social services, indicating a potential mistaken priority in spending.

Dr. Evans then presented the change that the City of Philadelphia, Pennsylvania, has been implementing in order to address population health, keys to the transition included:

  • Moving from a traditional model to a recovery-based model
  • Providing public education and training
  • Focusing on prevention and early intervention
  • Involving and engaging the community
  • Developing cross-system collaboration
  • Providing evidence-based services
  • Developing innovative ways to provide treatment
  • Integrating behavioral health care and intellectual disability services into a comprehensive system

Dr. Evans discussed looking at broad interventions that they can implement or improve in order to affect public health. A few examples of social determinants being leveraged to improve the health of Philadelphia’s population were discussed, including: tackling stigma and social understanding of mental health issues; employment; housing; and community capacity. He walked through a specific example, improving permanent supportive housing for individuals with serious mental illness: Philadelphia takes a systems approach to addressing homelessness, where the City provides targeted outreach for individuals with the longest histories of homelessness, places qualifying individuals with specialized residential substance abuse treatment programs for individuals experiencing long-term homelessness, and referring individuals with chronic street homelessness to safe havens or shelters (serving 554 individuals in 2015 alone). Dr. Evans presented compelling cost outcomes experienced by the City of Philadelphia after homelessness interventions were implemented. For individuals involved in the Safe Haven program alone, this resulted in an average cost reduction from the $112 average cost per day experienced during the implementation of the program to $18 average cost per day one year after lease-up.

Dr. Evans described the evidence that provider organizations should look for to know that their population management approach is working, including looking at both high-level macro data and subset data on specific measures.

Dr. Evans concluded his case study by discussing the “rethinking” needed to address population health management. He focused on 7 competencies:

  • Working At The Community- & Group-Level: Most practitioners are trained to work with specific individuals. However in population health management, interventions need to be more group-, neighborhood-, or community-wide.
  • Working Upstream: Right now practitioners serve a more passive role, where they wait for individuals to come to them. When thinking about population health management, practitioners need to work on intervening at the earliest moment.
  • Trying A Broad Set Of Strategies: The primary way that most practitioners deal with behavioral health treatment is through psychotherapy, medication, and possibly case management. When thinking about population health management, practitioners need to address additional factors (social determinants) with new strategies outside of a traditional health care realm.
  • Working With Non-Diagnosed Populations: Going beyond only those who have been diagnosed to address health for all populations – even those who are currently healthy.
  • Delivering Health Promotion Interventions: Health is not just the absence of illness, it’s more than this. If practitioners can help individuals who are healthy stay healthy, and to work on wellness, they can help reduce the likelihood they develop a condition needing treatment.
  • Working In Community & Other Non-Clinical Settings: Getting out of the treatment black box – working in various and creative community settings to provide the community with information to help them be healthy and well, and to get services when needed.
  • Developing Health Activation Approaches & Empowering Others: Educating in order for individuals to take more ownership of their health and wellness.

The question and answer session included these two questions from the audience. The presenters’ responses are summarized below.

  • What experiences have you had in moving funds, or in other words, how are these services being paid for?
    Dr. Evans explained that Philadelphia has created a single-payer behavioral health care system where all of the public sector dollars (including Medicaid) flow through his office. This has allowed them to redistribute funding that is saved (with state approval) to other programs. In addition, the ACA has reduced the reliance on grant dollars for the uninsured population – which could be reutilized for upstream public health strategies.
  • Vocational support for behavioral health clients is perceived in many settings as a paraprofessional activity, instead of a clinical one, what are your experiences in framing these supports as clinical supports?
    Dr. Block indicated that integration may increase collaboration to make sure that these activities are supported not just by paraprofessionals, but also by all the stakeholders in a population’s overall health.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/patient-engagement-mental-health-strategies-improve-care/.

Rebecca Roma, MD, MBA and Heather Fair, RN, offered their perspectives on patient engagement in mental health during a live PsychU Virtual Forum on May 25, 2016. Dr. Roma is the Medical Director of the Community Treatment Team at Mercy Behavioral Health in Pittsburgh PA; and Ms. Fair is a Registered Nurse / Case Manager for the Community Treatment Team at Mercy Behavioral Health in Pittsburgh. The presenters were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc. Their presentation covered the following main objectives:

  • Discuss patient engagement from the patient and clinician perspective
  • Detail the outcomes and economics of patient engagement
  • Address current challenges in patient engagement by analyzing specific engagement model

Results of the first polling question of the presentation concerned the percent of patients that do not continue treatment:

In your experience, what percentage of patients drop out of treatment within one year of initiation due to disengagement?

  1. < 10% (3%)
  2. 11% to 25% (20%)
  3. 26% to 50% (35%)
  4. > 50% (40%)

A definition of patient engagement from the Agency for Healthcare Research and Quality was discussed and Dr. Roma emphasized that engagement is not just for the patient, the team treating the patient must also be engaged. Patients should feel they are being heard and understood by the team, and that positive outcomes are possible. Even so, not all patients want to be involved and there are many factors that may influence patient engagement – these were discussed during the presentation.

Lack of patient activation and engagement can result in economic consequences to the patient, society, payers, and tax payers. Readmissions, medical errors and other negative health consequences such as low functional status that result from non-engagement all contribute to the economic burden. The presenters shared studies that indicated patients who are highly-engaged had lower rates of hospitalization and emergency department visits; and statistics of patient disengagement in serious mental illness, e.g. 17% of patients drop out of treatment during their first year, 24% do not attend appointments as scheduled.

A profile of patients who disengage in treatment was presented (more likely if younger, male, ethnic minority, poor alliance with therapist, co-occurring serious mental illness); as well as common reasons for low engagement, e.g. the patient believed they no longer need services, they cannot benefit from services, and treatment is not helpful to them. The presenters also stated that the health care system should take some responsibility for lack of patient engagement: services offered might not fit the patient’s needs and the attitude of the staff, clinic setting, and facilities might influence patients’ engagement levels.

So how can patient engagement be improved? The presenters offered a list of dos and don’ts for providers such as: determine the needs of the patient, don’t use fear as a tactic; help the patient to plan his or her treatment, then support the patient’s plan, don’t build the plan for them; acknowledge the patients’ barriers and difficulties as well as their successes.

The next polling question was offered as a way to introduce the next section on the use of electronic and technology tools to improve patient engagement:

In your experience, how many of your patients use the internet to inform themselves about their illness?

  1. < 10% (20%)
  2. 11% to 25% (32%)
  3. 26% to 50% (35%)
  4. > 50% (12%)

The presenters offered their insight on this topic: the use of technology is increasing but it is being used mainly by younger patients. The discussion that followed included how patients use technology, e.g. to gather information about their illness, as a gateway to mental health services because they fear the stigma of reaching out, and telepsychiatry, especially in rural or underserved areas.

The final polling question asked the audience to look into the future and the role technology may play:

If you think 5 years into the future, how much of a role do you think technology will play in patient engagement?

  1. < 10% (0%)
  2. 11% to 25% (1%)
  3. 26% to 50% (44%)
  4. > 50% (50%)

Dr. Roma pointed out that health care providers must also embrace technology in order for it to be more widely used.

The question and answer session included these four questions from the audience. The presenters’ responses are summarized below.

  • What is the most important aspect of that first contact to schedule an appointment with the client to ensure attendance?
    Ms. Fair said when first meeting with people, it is important to treat them as an individual, listen to what they’re saying, and realize that their treatment goals are different from other people. Some people want to take their meds and be involved in group therapy, others want no part of either. She believes meeting the person where they’re at and being able to build a therapeutic relationship with them will help on a therapeutic level. Dr. Roma gave an example of an older woman under her care; when the woman heard she was going to receive a daily visit to help with daily medications she didn’t think it was necessary; she didn’t want to think of herself as a mental health patient.
  • How can resistance to taking medication be overcome?
    Dr. Roma offered that engagement is not the “be all, end all” to resistance, because resistance oftentimes comes from a lack of insight. Even if you try to explain to somebody what their disease is and what the medication is for, they’re not going to be convinced. However, having a good therapeutic alliance, engaging with somebody, and respecting their opinion (and sometimes agreeing to disagree), if they trust you enough, they might take the medication, and they might have less resistance, even if they don’t believe what it’s for, and they don’t believe they have a disease. Ms. Fair gave an example of a patient seen by Dr. Roma and herself, who had resistance to medications. Ms. Fair said Dr. Roma did a great job giving the patient options and saying “this is your recovery”, not saying that she had to take her medicine. The key was giving the patient options, being able to take part in her own recovery, and not having someone else dictate it for her. Dr. Roma ended with this thought: “Getting to know a person on the level that’s more than just their symptoms. Getting to find something that you have in common with them or that you like about them really, really, helps with the engagement piece.”
  • How much does office- based versus community-based play a role or a factor in patient engagement?
    Dr. Roma thinks it depends upon the patient, she personally favors community-based approaches and knows not everyone does. She has patients who think it’s not appropriate for practitioners to see them at their home, they would rather see practitioners in the office, because that’s how they define the doctor/patient relationship. She thinks sometimes people are worried about boundary issues but also thinks professionals are moving away from the model where practitioners are only observers of the symptoms – to a model where they can show personality and have a relationship with their patients.
  • What’s the proper wording to use for clients other than “I understand”? I feel that some clients feel I don’t understand, and I don’t want them to feel disengaged from the beginning.
    Ms. Fair suggested rewording the question in a way that proves understanding, without saying to patients “I understand”, because that’s probably something they hear often. Dr. Roma thinks it might be helpful to reframe the issue: one of the techniques in motivational interviewing is whatever the person is saying to you, say it back to them; such as “let me see if I am understanding this”, and try to define the problem. You’re saying “let me ask you, am I understanding this correctly?” Dr. Roma said she can empathize, but can’t really understand what her patients are going through.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/achieving-triple-aim-innovations-care-management-improving-value-care-mental-health/.

Joseph Parks, MD, and Stephen Christian-Michaels provided their insight during a live PsychU Virtual Forum on October 4, 2016 entitled “Achieving The Triple Aim Through Innovations In Care Management: Improving The Value Of Care In Mental Health.” Dr. Parks currently serves as the Director of Missouri MO HealthNet Division (Missouri Medicaid) in the Missouri Department of Social Services. He is a Distinguished Research Professor of Science at Missouri Institute of Mental Health with the University of Missouri, St. Louis. He is the Senior Medical Advisor for the National Council For Behavioral Health and national behavioral health representative at large for The Joint Commission. Mr. Christian-Michaels, a social worker and family therapist, is the President and Chief Executive Officer at Family Services of Western Pennsylvania. He started working collaboratively in primary care in 2003, embedding as a therapist in a primary care family practice. The speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the virtual forum were to:

  • Recognize the complex needs of people with mental illness
  • Understand the Triple Aim and how it helps guide population health management
  • Demonstrate the effectiveness of care management in providing value in mental health services

The presentation discussed improving the value of care for individuals with serious mental illness (SMI).

Results from the first polling question focused demonstrated a large percentage of participants were treating patients with comorbidities:

What percentage of your clients that receive health care services at your organization have co-morbid mental/physical health care needs?

  1. Up to 10% (1%)
  2. 11% to 25% (4%)
  3. 26% to 40% (24%)
  4. Greater than 40% (60%)
  5. Not applicable (11%)

Dr. Parks stated that providers treating individuals with SMI would have greater than 40% of clients with SMI having co-morbid conditions; if the providers treated more of the general population, then 26% to 40% of clients with SMI will have co-morbid conditions. Mr. Christian-Michaels agreed.

Dr. Parks continued the presentation by discussing the life expectancy of all-cause deaths in the general population (78.0 years of age) compared with the life expectancy for individuals with SMI (51.8 years of age) in the public sector. Surprisingly, Dr. Parks stated, over 80% of lives lost for people with SMI were due to chronic medical disorders (diabetes, hypertension, and stroke) and not due to accidents or suicides, as would be expected. He then opened a discussion of metabolic syndrome by comparing the results of the 2005-2006 Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study which, among other things, measured blood laboratory values and chronic medical illness in people with schizophrenia, and the National Health and Nutrition Examination Survey (NHANES) study of the general population. Approximately 36% of males and 52% of females with schizophrenia in the CATIE study had metabolic syndrome compared to 20% of males and 25% of females in the general U.S. population which was measured in the NHANES study.

Dr. Parks discussed the importance of addressing these disparities, as they contribute to health care costs. Generally, people with SMI are high utilizers of health care leading to higher cost of care; Dr. Parks showed 2012 data from a national actuarial firm that demonstrated that individuals with no mental disorders had annual per member per month (PMPM) health care costs between $340 and $582 while individuals with SMI had PMPM health care costs between $1,197 and $1,436. Dr. Parks then presented New York Medicaid data compared the annual medical costs of individuals with no mental disorders to those with mental disorders, which was shown to be $16,000 versus $21,000 respectively.

Mr. Christian-Michaels began addressing the difficulty in effectively treating individuals with SMI by saying that one main problem is stigma; some individuals with SMI avoid seeking services due to potential stigma or discrimination. Dr. Parks added that treatment for people with SMIs can also become complicated due to multiple mental disorders or medical illnesses.

Mr. Christian-Michaels spoke about the Triple Aim, an approach created by the Institute for Healthcare Improvement (IHI), and how it guides population health management. He stated the goals of the Triple Aim: to simultaneously improve care, improve population health, and reduce costs per capita.

Dr. Parks provided a definition to guide the discussion on population health: that it is a conceptual framework for thinking about why some populations are healthier than others, and includes the policy development and resource agenda and allocation that flow from policy. He stated that population health is measured by indicators, and is influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services. He went on to say the volume and acuity of behavioral health patients in primary care offices and emergency departments confirms the need for timely access to behavioral health resources.

Continuing, Dr. Parks discussed the key principles of population health:

  • Population-Based Care: Focus on the whole population not just the individuals actively seeking care
  • Data Driven Care: Use data to make informed decisions to serve those in your population who most need care
  • Evidence-Based Care: Best available evidence to guide treatment decisions and delivery of care
  • Care Management: Identify and correct care gaps, coordinate care across multiple providers

According to Dr. Parks, the federal Patient Protection and Affordable Care Act (PPACA) of 2010 provided a framework for population health management through innovative programs which include: community health needs assessment requirements, expansion of prevention and wellness services, hospital readmissions reduction programs, community-based care transitions programs, and health
homes.

Results from the second polling question demonstrated a vast majority of responders worked in a setting with partial integration:

What level of behavioral health integration is present in the organization where you work?

  1. Complete financial / clinical integration; 100% screening (15%)
  2. Partial integration; screening of high risk patients (45%)
  3. No integration, some behavioral health available, no screening (10%)
  4. Not applicable (30%)

According to Mr. Christian-Michaels, the current fractured health care system cannot produce effective treatment for people with SMI and co-morbid medical conditions. He began the next presentation section with an additional polling question:

In your professional experience which of the following effects of a fractured health care system do you encounter most often?

  1. Primary Care Physicians (PCPs) not prepared to deal with behavioral health (53%)
  2. Community Mental Health Centers (CMHCs) not prepared to deal with routine medical care (11%)
  3. Differential confidential rules (10%)
  4. Depression not diagnosed early enough (2%)
  5. Medications not managed effectively (23%)

Dr. Parks commented that part of the problem resides in primary care physicians’ (PCPs) attitudes concerning people with mental illness, and relayed that in his own experience he’d encountered challenges to creating a collaborative environment where all practitioners are focused on all patients being treated, regardless of their behavioral health needs. In addition, both presenters mentioned the need for health care professionals to take full advantage of available technology to treat their patients with SMI, including tablets to collect data, using outcomes data from electronic health records, and making use of registries, as data can help repair the “grand canyon” division between behavioral health and primary care.

Mr. Christian-Michaels then discussed the requirements necessary to perform and implement data-driven, population health management. Providers must be competent in care coordination, including care management and clinical integration. The characteristics required by providers include being: patient-centered, outcomes-oriented, enabled by technology, able to use data and analytics, transparent on performance, and able to partner across organizations where PCPs and behavioral health specialists are colocated.

The moderator asked another discussion question: “You mentioned the importance of staffing in implementing changes for efficient provision of behavioral health services. What types of training should staff receive in order to adapt to the new models of care?”

Mr. Christian-Michaels stated that staffing was important when implementing changes, and that helping staff understand the importance of regular training was a step in the right direction. He said professionals cannot be trained once and feel that is enough; recovery oriented-practices must have continuous training. Dr. Parks added that training goes both ways; CMHC staff has to be trained in primary care principles and PCPs must be trained in behavioral health conditions.

The question and answer session included these four questions from the audience. The presenters’ responses are summarized below.

  • How do you get different EHR vendors together?
    Dr. Parks said that it is really hard to find behavioral health and primary care EHRs that integrate well, but they had the best luck by linking to statewide health information exchanges.
  • How can a specialty behavioral health provider partner with hospitals?
    Mr. Christian-Michaels recommended that providers build relationships first with medical directors and CEOs of hospitals and explain how they can help to reduce important measures, like hospital readmissions.
  • How can an organization start a population health program?
    Dr. Parks stated that building a disease registry is the best way to start. He advised choosing one condition to start, like depression or diabetes, and then to progress from there. He also mentioned that a leader is an important key to the transition.
  • What possible challenges do the aging baby boomers have on population health management?
    Mr. Christian-Michaels and Dr. Parks said that baby boomers may actually help the push toward population health management; as this generation has come to expect a certain degree of care which is akin to many of the processes used for population health management.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing or polling results, please access the recording at https://www.psychu.org/future-psychopharmacology-new-treatment-innovation-still-alive/.

A dynamic presentation on the future of psychopharmacology was presented by Stephen M. Stahl, MD, PhD during a PsychU virtualforum on November 1, 2016. Dr. Stahl is a Professor of Psychiatry at University of California-San Diego, an Honorary Fellow at University of Cambridge, and Director of Psychopharmacology for the California Department of State Hospitals. Dr. Stahl was a paid consultant for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of this virtual forum were to:

  • Discuss reasons for the slowdown of innovative treatments for psychopharmacology
  • Show that future advances in psychopharmacology may rely more on symptoms than distinct psychiatric disorders
  • Propose that new treatments will be defined for subpopulations of people with similar symptoms, genetics, and imaging biomarkers.

Although Dr. Stahl’s presentation was highly-technical, his presentation style was crisp, entertaining, and to the point, at times using everyday analogies to explain a concept. He began with his views on the current state of psychopharmacology: he sees pharmaceutical companies shifting away from a focus on the central nervous system towards diseases such as cancer; he believes clinical trials in psychopharmacology may be flawed due to high placebo response rates; and he believes the domain of medical science includes validating new targets – which leads to revolutionary medication development.

Through a series of animated slides, Dr. Stahl identified the current difficulties experienced thus far in developing new therapies based on current treatment options and their underlying mechanisms. He began a discussion of the importance of understanding psychiatric disorders as collections of symptoms; that symptoms originate from different circuitry and anatomy of the brain; and that similar symptoms are seen in many different psychiatric disorders. He pointed out that there are around 155 psychiatric disorders in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) but only 79 psychiatric symptoms, alluding to the significant crossover of symptoms among disorders.

In answer to a question about the classification of disease versus disorder in psychiatry, Dr. Stahl explained that anxiety, depression, schizophrenia and psychoses are not diseases, they are disorders – a collection of symptoms. Disorders may be descriptive and reliable, but they do not predict treatment response nor are they linked to neurobiology. He attributed psychiatric symptoms with malfunctioning brain circuits in various parts of the brain and provided several animated and detailed slides describing this in major depressive disorder, anxiety disorder, schizophrenia, and attention-deficit hyperactivity disorder (ADHD), as well as a tutorial on basic neurotransmission within the synapse, and the interaction of circuitry within a neuronal network of the brain. Dr. Stahl stated that he believes the best way to identify unmet needs in psychiatry is to identify the symptom and find the related “sick” circuit for treatment.

Dr. Stahl postulated that early recognition and pre-symptomatic treatments may be possible in the future and will be especially important for disease prevention and addressing treatment resistance. He suggested that pharmaceutical development should target treatments where limited or none currently exist: cognitive symptoms of schizophrenia and depression, cognitive and behavioral symptoms of dementia, and substance abuse. Dr. Stahl highlighted the future prospect of treatment for substance abuse, because he believes the next revolution in treatments will be in this area largely due to a huge unmet need, and the fact that animal testing in this area provides a translational foundation for humans. Additionally, he stated that science is making rapid neurobiological progress in treatments for substance abuse, and discarded drugs for other treatments may be recirculated for the benefit of substance abuse disorders. He also presented information on stress-induced activation of inflammatory response and immune dysregulation as they relate to psychoses.

He concluded with a wrap-up: innovation in psychopharmacology is stalled and awaiting solutions to problems with clinical trial methodology and the lack of new targets; new approaches will most likely target symptoms that cross numerous psychiatric conditions by focusing on malfunctioning neuro-circuits; and ultimately biomarkers from genetics and neuroimaging may be able to subtype psychiatric symptoms along a neurological basis – this is all still a work in progress.

The question and answer session included these five questions from the audience. Dr. Stahl’s responses are summarized below.

  • How will neuromodulation affect the development of drugs, and will one overtake the other?
    Dr. Stahl assumed the questioner was referring to deep brain stimulation or transcranial magnetic stimulation (TMS). Dr. Stahl believes there is lots of promise with these treatments but it is still primitive.
  • How can you avoid polypharmacy if you treat symptoms and circuits?
    Dr. Stahl questioned whether or not polypharmacy should be avoided, and suggested a “rational combination therapy” can be used, the same as treatments for acquired immunodeficiency syndrome (AIDS) or cancer.
  • How helpful is genome typing for psychiatry?
    Dr. Stahl doesn’t believe it’s very helpful yet, but might be in the future, although he stated that individuals should not expect a blood test to diagnose major depressive disorder (MDD). He indicated pharmacogenomics may tell us which drugs to use and that treatment will be based on a balance of evidence, some of which will come from genes. He relayed that most genes contribute only 1% of variance in evidence, but 6-8 genes may weigh in favor of (or against) something. Genomics may help in identifying drug metabolism to modulate dosing paradigms or identify possible treatment resistance. He suggested listeners track pharmacogenetics closely, as reimbursement is just starting for this field.
  • What are the most promising neurotransmitter systems of modulating agents for addiction disorders?
    While Dr. Stahl acknowledged no one knows for sure, he speculated that glutamate may be a likely candidate.
  • What would the DSM look like based on neuro-circuitry? Can you publish a mock DSM and gain support for this line of thinking?
    Dr. Stahl indicated a book in mind to be written, which has 79 psychiatric symptoms (not 155 disorders) which can be attributed to a hypothesized gene, neurotransmitter, and which includes what drugs can cause the symptom and what drugs can stimulate or block specific neurocircuits.

This summary was developed utilizing the full recorded presentation of this virtual forum, which is available on PsychU for all members free of charge. For full sourcing and polling results, please access the recording or the presentation slides at https://www.psychu.org/achieving-triple-aim-innovations-care-management-improving-value-care-mental-health/.

Joseph Parks, MD, and Stephen Christian-Michaels provided their insight during a live PsychU Virtual Forum on October 4, 2016 entitled “Achieving The Triple Aim Through Innovations In Care Management: Improving The Value Of Care In Mental Health.” Dr. Parks currently serves as the Director of Missouri MO HealthNet Division (Missouri Medicaid) in the Missouri Department of Social Services. He is a Distinguished Research Professor of Science at Missouri Institute of Mental Health with the University of Missouri, St. Louis. He is the Senior Medical Advisor for the National Council For Behavioral Health and national behavioral health representative at large for The Joint Commission. Mr. Christian-Michaels, a social worker and family therapist, is the President and Chief Executive Officer at Family Services of Western Pennsylvania. He started working collaboratively in primary care in 2003, embedding as a therapist in a primary care family practice. The speakers were paid consultants for Otsuka Pharmaceutical Development & Commercialization, Inc.

The objectives of the virtual forum were to:

  • Recognize the complex needs of people with mental illness
  • Understand the Triple Aim and how it helps guide population health management
  • Demonstrate the effectiveness of care management in providing value in mental health services

The presentation discussed improving the value of care for individuals with serious mental illness (SMI).

Results from the first polling question focused demonstrated a large percentage of participants were treating patients with comorbidities:

What percentage of your clients that receive health care services at your organization have co-morbid mental/physical health care needs?

  1. Up to 10% (1%)
  2. 11% to 25% (4%)
  3. 26% to 40% (24%)
  4. Greater than 40% (60%)
  5. Not applicable (11%)

Dr. Parks stated that providers treating individuals with SMI would have greater than 40% of clients with SMI having co-morbid conditions; if the providers treated more of the general population, then 26% to 40% of clients with SMI will have co-morbid conditions. Mr. Christian-Michaels agreed.

Dr. Parks continued the presentation by discussing the life expectancy of all-cause deaths in the general population (78.0 years of age) compared with the life expectancy for individuals with SMI (51.8 years of age) in the public sector. Surprisingly, Dr. Parks stated, over 80% of lives lost for people with SMI were due to chronic medical disorders (diabetes, hypertension, and stroke) and not due to accidents or suicides, as would be expected. He then opened a discussion of metabolic syndrome by comparing the results of the 2005-2006 Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study which, among other things, measured blood laboratory values and chronic medical illness in people with schizophrenia, and the National Health and Nutrition Examination Survey (NHANES) study of the general population. Approximately 36% of males and 52% of females with schizophrenia in the CATIE study had metabolic syndrome compared to 20% of males and 25% of females in the general U.S. population which was measured in the NHANES study.

Dr. Parks discussed the importance of addressing these disparities, as they contribute to health care costs. Generally, people with SMI are high utilizers of health care leading to higher cost of care; Dr. Parks showed 2012 data from a national actuarial firm that demonstrated that individuals with no mental disorders had annual per member per month (PMPM) health care costs between $340 and $582 while individuals with SMI had PMPM health care costs between $1,197 and $1,436. Dr. Parks then presented New York Medicaid data compared the annual medical costs of individuals with no mental disorders to those with mental disorders, which was shown to be $16,000 versus $21,000 respectively.

Mr. Christian-Michaels began addressing the difficulty in effectively treating individuals with SMI by saying that one main problem is stigma; some individuals with SMI avoid seeking services due to potential stigma or discrimination. Dr. Parks added that treatment for people with SMIs can also become complicated due to multiple mental disorders or medical illnesses.

Mr. Christian-Michaels spoke about the Triple Aim, an approach created by the Institute for Healthcare Improvement (IHI), and how it guides population health management. He stated the goals of the Triple Aim: to simultaneously improve care, improve population health, and reduce costs per capita.

Dr. Parks provided a definition to guide the discussion on population health: that it is a conceptual framework for thinking about why some populations are healthier than others, and includes the policy development and resource agenda and allocation that flow from policy. He stated that population health is measured by indicators, and is influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services. He went on to say the volume and acuity of behavioral health patients in primary care offices and emergency departments confirms the need for timely access to behavioral health resources.

Continuing, Dr. Parks discussed the key principles of population health:

  • Population-Based Care: Focus on the whole population not just the individuals actively seeking care
  • Data Driven Care: Use data to make informed decisions to serve those in your population who most need care
  • Evidence-Based Care: Best available evidence to guide treatment decisions and delivery of care
  • Care Management: Identify and correct care gaps, coordinate care across multiple providers

According to Dr. Parks, the federal Patient Protection and Affordable Care Act (PPACA) of 2010 provided a framework for population health management through innovative programs which include: community health needs assessment requirements, expansion of prevention and wellness services, hospital readmissions reduction programs, community-based care transitions programs, and health
homes.

Results from the second polling question demonstrated a vast majority of responders worked in a setting with partial integration:

What level of behavioral health integration is present in the organization where you work?

  1. Complete financial / clinical integration; 100% screening (15%)
  2. Partial integration; screening of high risk patients (45%)
  3. No integration, some behavioral health available, no screening (10%)
  4. Not applicable (30%)

According to Mr. Christian-Michaels, the current fractured health care system cannot produce effective treatment for people with SMI and co-morbid medical conditions. He began the next presentation section with an additional polling question:

In your professional experience which of the following effects of a fractured health care system do you encounter most often?

  1. Primary Care Physicians (PCPs) not prepared to deal with behavioral health (53%)
  2. Community Mental Health Centers (CMHCs) not prepared to deal with routine medical care (11%)
  3. Differential confidential rules (10%)
  4. Depression not diagnosed early enough (2%)
  5. Medications not managed effectively (23%)

Dr. Parks commented that part of the problem resides in primary care physicians’ (PCPs) attitudes concerning people with mental illness, and relayed that in his own experience he’d encountered challenges to creating a collaborative environment where all practitioners are focused on all patients being treated, regardless of their behavioral health needs. In addition, both presenters mentioned the need for health care professionals to take full advantage of available technology to treat their patients with SMI, including tablets to collect data, using outcomes data from electronic health records, and making use of registries, as data can help repair the “grand canyon” division between behavioral health and primary care.

Mr. Christian-Michaels then discussed the requirements necessary to perform and implement data-driven, population health management. Providers must be competent in care coordination, including care management and clinical integration. The characteristics required by providers include being: patient-centered, outcomes-oriented, enabled by technology, able to use data and analytics, transparent on performance, and able to partner across organizations where PCPs and behavioral health specialists are colocated.

The moderator asked another discussion question: “You mentioned the importance of staffing in implementing changes for efficient provision of behavioral health services. What types of training should staff receive in order to adapt to the new models of care?”

Mr. Christian-Michaels stated that staffing was important when implementing changes, and that helping staff understand the importance of regular training was a step in the right direction. He said professionals cannot be trained once and feel that is enough; recovery oriented-practices must have continuous training. Dr. Parks added that training goes both ways; CMHC staff has to be trained in primary care principles and PCPs must be trained in behavioral health conditions.

The question and answer session included these four questions from the audience. The presenters’ responses are summarized below.

  • How do you get different EHR vendors together?
    Dr. Parks said that it is really hard to find behavioral health and primary care EHRs that integrate well, but they had the best luck by linking to statewide health information exchanges.
  • How can a specialty behavioral health provider partner with hospitals?
    Mr. Christian-Michaels recommended that providers build relationships first with medical directors and CEOs of hospitals and explain how they can help to reduce important measures, like hospital readmissions.
  • How can an organization start a population health program?
    Dr. Parks stated that building a disease registry is the best way to start. He advised choosing one condition to start, like depression or diabetes, and then to progress from there. He also mentioned that a leader is an important key to the transition.
  • What possible challenges do the aging baby boomers have on population health management?
    Mr. Christian-Michaels and Dr. Parks said that baby boomers may actually help the push toward population health management; as this generation has come to expect a certain degree of care which is akin to many of the processes used for population health management.

This video is part 2 of a series on Basic & Advanced Concepts In Psychopharmacology, from the Psychopharmacology Collection. This video reviews neurotransmitter receptor subtypes, provides an overview of neurotransmitter circuitry and biosynthesis, and speaks to the functional connectivity of monoaminergic neurotransmitters. The video concludes with an overview of the morphology and function of neuroglia and the various types of neuroglial cells in the nervous system.

This video is part 1 of a series on Bipolar Disorder, from the Psychopharmacology Collection. This video briefly reviews the proposed anatomical location of manic and depressive symptoms before discussing the potential roles of gamma-aminobutyric acid (GABA), glutamate, serotonin, norepinephrine, and dopamine in Bipolar Disorder and the hypothesized interactions of these neurotransmitters, and concludes with a brief discussion of the proposed mechanisms of action of pharmacologic treatments of Bipolar Disorder.

In February 2015, the American Psychiatric Association (APA) published an educational paper providing psychiatrists with recommendations on navigating the ethical and legal landscape of involving caregivers in treatment for individuals with mental disorders. The resource document details a variety of reasons why caregiver involvement in psychiatric care is important and complex, which are summarized in Table 1.

Table 1: The Importance & Complexity Surrounding Caregiver Involvement In The Treatment Of Mental Disorders
Importance Of Caregiver Involvement Complexity Of Caregiver Involvement
  • To combat potential cognitive barriers to understanding which may affect individuals with mental disorders from making informed decisions about their care in the event that they do not understand their diagnosis, treatment options, or symptoms
  • To provide financial, housing, food, and emotional supports to individuals with mental disorders when needed
  • To ensure, possibly across the entire lifespan, that those additional supports are secured
  • The episodic nature of mental disorders changes the needs for caregiver involvement over the lifespan of the diagnoses
  • In the case of early-onset of mental illness, it may be necessary for a practitioner to facilitate change in caregiver from a parent to sibling, spouse, etc.
  • Planning for needs will be different for each individual with a mental disorder
  • Initiating the development of therapeutic relationships that survive the test of conflict
Table 1 developed by PsychU. Data Source: American Psychiatric Association (APA). (2015, February). Resource document on interacting with caregivers. Retrieved from https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/resource-2015-interacting-with-caregiver.pdf

In addition, the article discusses a variety of legal and ethical considerations (e.g. right to privacy and confidentiality of medical records) that may arise from sharing information with caregivers, or involving them in treatment planning and management. Finally, a comprehensive set of recommendations is provided to psychiatrists for effectively engaging in obtaining a history of caregiver participation, planning for caregiver participation, and responding to a crisis in the presence, or potential absence, of a formal caregiver plan.

The full text of “Resource Document On Interacting With Caregivers” was published online in February 2015 by the American Psychiatric Association; a copy was accessed February 22, 2017.

The Quality Payment Program (QPP) was developed by the Centers for Medicare and Medicaid Services (CMS) as part of the far reaching Medicare Access and CHIP Reauthorization Act of 2015 (MACRA); one of its provisions begins in 2019 when CMS will pay participating providers based on the quality and effectiveness of care they provide to beneficiaries. During this webinar, hear from Paul Cotton, BA, Director of Federal Affairs at the National Committee for Quality Assurance (NCQA); and Elizabeth Arend, MPH, Quality Improvement Advisor at the National Council for Behavioral Health, two experts in initiatives that improve health care quality. They discuss the importance of this new program to the behavioral health field.

Hear more from Paul Cotton, BA, and Elizabeth Arend, MPH, as they respond to additional questions from attendees in this follow-up Q&A:

Key Messages

  • Most patients with bipolar disorder (BD) initially present in the primary care setting.
  • With a high clinical index of suspicion, and awareness of the key differentiating features of depressive symptoms in BD versus major depressive disorder (MDD), primary care physicians (PCPs) can help ensure accurate, early diagnosis, and help to optimize patient outcomes.
  • Key clinical decision-making steps include an in-depth patient interview detailing personal, family, and social history; the use of case-based finding tools; clinical confirmation of BD diagnosis via Diagnostic and Statistical Manual of Mental Disorders criteria; evaluation of risk to self or others; and referral when necessary.
  • Pharmacological and psychosocial treatments, patient education, and ongoing monitoring of symptoms, functioning, and treatment safety are important in the long-term management of BD.

After the Department of Veterans Affairs (VA) hospitals began using the Mental Health Environment of Care Checklist (MHEOCC) to identify facility-specific hazards in its mental health units, the number of inpatient suicides decreased by 82%. Between 2000 and 2007, before the VA hospitals began using the MHEOCC, the inpatient suicide rate was 4.2 per 100,000 admissions. After implementing the MHEOCC, from 2008 to 2015, the inpatient suicide rate was 0.74 per 100,000 admissions.

The MHEOCC was developed with the hope that removal of hazards would decrease the number of suicides that occur on inpatient mental health units. It focuses on architectural and other physical-environment changes, such as hooks or anchor points, non-shatterproof glass, and non-tamper-resistant electrical outlets

These findings were reported in “Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide” by Bradley V. Watts, M.D., M.P.H.; Brian Shiner, M.D., M.P.H.; Yinong Young-Xu, Sc.D.; and Peter D. Mills, Ph.D., M.S. The researchers analyzed VA data from 2000 to 2015. The data included root cause analysis reports, which provided a count of suicides occurring on mental health units from 2000 to 2015, and the number of mental health admissions and bed days of care for the same period. The researchers sought to determine if the lower inpatient suicide rate after implementing the MHEOCC in 2008 was sustained over an extended period. Additional findings were as follows:

  • The inpatient suicide rate from 2000 through 2007 implementation ranged from a high of 6.1 per 100,000 admissions to a low of 2.4 per 100,000 admissions. Across the entire period, the rate was 4.2 per 100,000 admissions.
  • During the implementation phase from 2008 through 2010, the inpatient suicide rate was 3.6 per 100,000 admissions in 2008; 0 in 2009, and 1.2 per 100,000 admissions in 2010.
  • During the continuation period from 2011 through 2015, the inpatient suicide rate was 0, except for in 2012 when it was 1.1 per 100,000 admissions.

The researchers found that the inpatient suicide rate during the continuation period was equal to or lower than the rate during the implementation period. The researchers concluded that the MHEOCC was associated with a sustained reduction in suicides occurring on inpatient mental health units because removing the facility-based suicide hazards, allowed staff to focus on care delivery, rather than monitoring access to the hazards.

The checklist has been used in all VA mental health units since October 2007. In 2014, the VA National Center for Patient Safety released “Veterans Affairs Environmental Programs Service Mental Health Guide,” which includes the tenets of the checklist and a discussion about each point. The guide recommends solutions and products to ensure that veterans are cared for in a safe, and therapeutically enriching environment.

The full text of “Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide” was published in November 2016 by Psychiatric Services.

For more information, contact:

  • Bradley V. Watts, M.D., Assistant Professor of Psychiatry, Psychiatry, Dartmouth Medical School, 1 Rope Ferry Road, Hanover, New Hampshire 03755-1404; 603-650-1200; Fax: 603-650-1202; Email: Bradley.v.watts@dartmouth.edu; Website: http://geiselmed.dartmouth.edu
  • Peter Mills, Ph.D., M.S., Director, NCPS Field Office, National Center for Patient Safety, Department of Veterans Affairs, White River Junction Veterans Medical Center 163 Veterans Drive, White River Junction, Vermont 05009; Email: Peter.Mills@va.gov; Website: http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp

During this question and answer session, Drs. Manning and Correll respond to unanswered questions from their Webinar entitled “Managing Metabolic Wellness In The Mentally Ill: Perspectives From Both A Primary Care Provider (PCP) & A Psychiatrist”.

Finding the best predictor of patients’ health care utilization and costs is becoming more important as reimbursement continues to move toward value-based designs. In order to improve and maintain quality of care, it’s essential for payers and providers to identify high-risk individuals who may benefit from interventions such as care coordination, medication management, and patient self-management. Traditionally, claims-based data have been used to examine diagnoses, utilization, and costs of care to better identify, serve, and plan interventions for high-cost patients.

An article published in the 2016 March Edition of Health Affairs, “Adding A Measure Of Patient Self-Management Capability To Risk Assessment Can Improve Prediction Of High Costs,” describes a retrospective analysis to explore whether knowing a high-risk individual’s ability to self-manage his or her condition(s) provides actionable information for health care professionals to effectively improve the individual’s health; and to determine if a patient’s measured activation level is useful over time in predicting health care costs and utilization. Past studies have shown individuals who are less activated in health self-management are also more difficult to assist with care coordination, are less adherent to treatments including medications, less likely to follow good nutrition, or to get regular exercise than individuals with high activation.

The study population was comprised of 98,142 adults who received health care services at Fairview pam2Health Services (a Pioneer Accountable Care Organization) in Minnesota between 2011 and 2014; completed a Patient Activation Measure (PAM); did not have a diagnosis of dementia; and opted into the study. Focusing on high-risk patients (n=14,721), researchers combined a commercial risk assessment product (based on demographic data, episodes of care, diagnoses, and pharmacy use) with data from the PAM to see if they could accurately predict hospitalization, emergency department visits, and costs of care. As a first step, researchers compared high-risk patients to low-risk patients on measures of demographics (age, sex, income, geographic location) and health (patient activation, risk score, chronic conditions, costly utilization). Next, researchers examined the relationship between patient activation level and cost data (from hospitalization and emergency department visits) for years 2012 through 2014.
Finally, researchers performed predictive analysis using the 2011 score derived from PAM to see if they could project patients’ utilization over the same three years. Results were controlled for demographics, the 2011 commercial perspective risk score, outside utilization (services not received at Fairview facilities), and by a primary care provider.

Chart 1 shows the conditions observed in the study group by risk level.clinicalcharacteristicsResults showed PAM scores accurately predicted costly utilization up to three years from the time
the score was initially established. The study indicates that knowing the activation level of individuals with chronic conditions may help to determine how much, and what types of care coordination is needed – including coaching for self-management – to improve individuals’ health.

Additional findings included:

  • High-risk patients were older (60+ years) and had lower incomes than low-risk patients
  • High-risk patients were twice as likely to be depressed than low-risk patients, and to be at the lowest activation level
  • High-risk patients were three times more likely to visit the emergency department and 14 times more likely to be hospitalized (2011 data)
  • Hospitalization costs were 38% lower for individuals with high activation levels than individuals with low activation levels (2012)
  • Emergency department costs were 37% lower for individuals with high activation levels than individuals with low activation levels (2012)

Discussion

The authors recommend future models of care take into account an individual’s behavior and social profile to make better use of health care resources, and suggest that health care professionals focus their efforts on patients whose risk is modifiable, e.g. patients who are at higher levels of activation.

The full text of “Adding A Measure Of Patient Self-Management Capability To Risk Assessment Can Improve Prediction Of High Costs” was published in the March 2016 issue of Health Affairs.

The Veterans Health Administration (VHA) has long been concerned with traumatic brain injury (TBI) experienced by individuals seeking its services. At least one report cites 45% of veterans seeking mental health care have a lifetime history of TBI, defined as a positive response to a question on the Traumatic Brain Injury 4 (TBI-4) assessment “Have you ever been knocked out or unconscious following an accident or injury?” In a recent study “Responses to Traumatic Brain Injury Screening Questions and Suicide Attempts among Those Seeking Veterans Health Administration Mental Health Services” authors Alexandra L. Schneider, et al report on an attempt to determine if a positive screen on the TBI-4 was associated with increased risk for suicide attempt within one-year post screening, citing a lack of information on the connection between TBI and suicide attempts.

Results of the study indicate that significantly more veterans who screened positive on the TBI-4 at mental health intake had a documented suicide attempt one year after the assessment than veterans who screened negative on the assessment.

In addition, of people who screened positive on the TBI-4, most were male (94.4%), and most were Caucasian (76.9%) compared to other races. The period of service for people who screened positive were 41.2% Vietnam Era, 21.4% Post-Vietnam Era, 32.7% Persian Gulf War, and 4.7% other.

Study Details

The study was conducted on data obtained from 1,097 veterans who received mental health intake services at the VHA’s Eastern Colorado Health Care System (ECHCS) between December 2006 and February 2010. Veterans were selected for the study if they did not seek care at any other VHA facility during the one-year period following assessment. Demographic information on included veterans came from the VHA Corporate Data Warehouse (CDW), a national repository of clinical and administrative data.

The TBI-4 is a four-question assessment tool used by the VHA to identify individuals who had probable lifetime history of TBI. Its four questions are:

  1. Have you ever been hospitalized or treated in an emergency room following a head or neck injury?
  2. Have you ever been knocked out or unconscious following an accident or injury?
  3. Have you ever injured your head or neck in a car accident or from some other moving vehicle accident?
  4. Have you ever injured your head or neck in a fight or fall?

As noted above, question 2 covers key criteria needed to diagnose TBI: an injury event which resulted in unconsciousness. The results of TBI-4 were tested against Ohio State University’s TBI-ID, a three- to five-question interview conducted to determine lifetime TBI. The comparison revealed the TBI-4 to be a reliable measure, producing a sensitivity of 0.58 and specificity 0.77.

The VHA mandates that veterans’ suicide behaviors and ideations be tracked by VHA clinical staff members by completing a suicide behavior report (SBR), which is then entered into a patient’s electronic medical record (EMR). According to the study, this information includes “behavior that is self-directed and deliberately results in injury or the potential for injury to oneself with evidence, either implicit or explicit, that the individual wishes to die, means to kill himself, and understands the probable consequences of his actions or potential actions.” For the current study, information on suicide came from two sources: 1) the Suicide Prevention Application Network (SPAN) database which contains information on suicide events beginning on October 1, 2008; and 2) the CDW which was searched for SBR documentation for events as early as December 2006 using the text strings “Suicide Behavior Report” and the key phrase from the SBR “Description of event”.

Of veterans who screened positive for Question 2 of the TBI-4 (n=468), 1.5% (n=7) attempted suicide within one year of the assessment, and none who screened negative to Question 2 of the TBI-4 attempted suicide within one year of the assessment. The results are statistically significant, however because the number of attempted suicides was low, there is a possibility the screen may overestimate risk of suicide.

The authors suggest that in line with the VHA’s increasing efforts to identify people at risk of suicide, researchers should consider examining national VHA SBR data, and study people with TBI over a longer period of time.

The full text of “Responses to Traumatic Brain Injury Screening Questions and Suicide Attempts among Those Seeking Veterans Health Administration Mental Health Services” was published online by Frontiers in Psychiatry on April 16, 2016.

Researchers in England embarked on a five-year study beginning 2011 to improve the cardiovascular health of people with serious mental illness (SMI), focusing on how to detect and manage cardiovascular disease (CVD) of this vulnerable population in a primary care setting. It is a well-known fact that people with both SMI (e.g. schizophrenia and bipolar disorder) and CVD die earlier than people with CVD and no SMI.

The program is called PRIMROSE (Prediction and Management of Cardiovascular Risk in People with Severe Mental Illnesses); it is funded by National Institute for Health Research, and led by Dr. David Osborn and researchers at University College London. The project has three distinct components (shown below) which, when completed, will provide the evidence needed to design, implement and assess the effectiveness of a new model of care for CVD in people with SMI. The first two components have been completed and the results of the third component were not published at the time of this report.

  1. Developed A Risk Score Tool – Researchers conducted a prospective study to develop a 10-year risk score for predicting newly recorded cardiovascular events in people with SMI. Using data from The Health Improvement Network (THIN) primary care database, which contains service utilization on 10 million patients from over 500 contributing general practices as well as diagnoses and basic socio-demographic information, researchers developed two predictive models: 1) one using body mass index (BMI) and 2) another relying on lipid measures.  The PRIMROSE BMI and lipid CVD risk prediction models performed better in people with SMI than with people having CVD risk factors and no SMI.
  2. Developed An Intervention And Training Program – Under this program practicing nurses:
    1. Studied inequalities in CVD reduction in people with SMI.
    2. Conducted a focus group, consisting of various health care professionals and users of services, to identify effective strategies and barriers for nurses in providing CVD risk management in a primary care setting to people with SMI.
    3. Conducted a systematic review of behavioral and pharmacological interventions that have been effective in reducing CVD in people with SMI.

A total of 75 health care professionals participated in 14 focus groups and the proceedings were audio-recorded, transcribed, and analyzed. As a result, five barriers were identified which hindered delivery of primary care-based interventions to people with SMI and risk of CVD:

  1. Negative perceptions of people with SMI (e.g. stigma)
  2. Difficulties managing a healthy lifestyle due to side effects of antipsychotic medications and symptoms of mental illness
  3. Difficulties accessing services
  4. Non-attendance at appointments
  5. Lack of awareness around working with increased CVD risk and SMI

The focus groups also identified ways to improve receipt of interventions by people with SMI and/or CVD including: involving supportive others, improving patient engagement with services, continuity
of care, providing positive feedback in consultations, and goal setting.

  1. Test The Cost Effectiveness Of The Intervention – Researchers are conducting a cluster randomized controlled trial to test the cost effectiveness of a practice-nurse led intervention in primary care to reduce CVD risk in people with SMI over a 12-month period. Seventy general practices are taking part in the trial to study approximately 350 people with SMI, age 30-75 years, with elevated risk of CVD. The cohort will be followed at six and 12 months after receiving interventions that aim to lower total cholesterol in participants as compared to usual care. Other outcomes include improved blood pressure, BMI, waist circumference, smoking status, and quality of life; adherence to treatments and services; health eating, physical activity, and use of alcohol. The results will undergo an economic evaluation to determine the intervention’s cost effectiveness versus standard care.

For more information on PRIMROSE see:

  • National Institutes for Health Research. PGfAR – RP-PG-0609-10156: Prediction and management of cardiovascular risk for people with severe mental illnesses. A research programme and trial in primary care (PRIMROSE). Retrieved November 2016 from National Institutes for Health Research: https://www.journalslibrary.nihr.ac.uk/programmes/pgfar/RP-PG-0609-10156/#/
  • Osborn, D. PJ. (2015, February 1). The PRIMROSE cardiovascular risk prediction models for people with severe mental illness: Results from the PRIMROSE Research Programme: Prediction and Management of cardiovascular Risk in People with Severe Mental Illnesses. Retrieved from JAMA Psychiatry:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353842/pdf/emss-62216.pdf
  • Burton, A. (2015, August 28). Lowering Cardiovascular Disease Risk for People with Severe Mental Illnesses in Primary Care: A Focus Group Study. Retrieved from PLOS.org: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0136603
  • Osborn, D. (2016). Evaluating the clinical and cost effectiveness of a behaviour change intervention for lowering cardiovascular disease risk for people with severe mental illnesses in primary care (PRIMROSE study): study protocol for a cluster randomised controlled trial. Retrieved from www.ncbi.nlm.nih.gov: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4751703/pdf/13063_2016_Article_1176.pdf

“All politics is local”, or so the saying goes in American politics. The same can be said for providing health care services, including for behavioral health. Different geographic regions in the country have their own strengths and weaknesses when it comes to preventing, identifying, and treating behavioral health disorders. A new report from Mental Health America (MHA), “The State of Mental Health in America, 2017,” provides state-level data and rankings on 15 important measures that, when analyzed, provide an understanding of the prevalence of behavioral health disorders among youth and adults in each state, as well as the level of access state residents have to adequate care. MHA is the United States’ leading community-based nonprofit dedicated to addressing the needs of those living with mental illness and to promoting the overall mental health of all Americans.

Measures reported included mental health workforce availability (the ratio of the county population to the number of mental health providers) as well as the following targeted metrics surrounding mental health statistics of adults and youth:

Adult Measures Youth Measures
  • Adults with any mental illness (AMI)
  • Adults with dependence or abuse of illicit drugs or alcohol
  • Adults with serious thoughts of suicide
  • Adults with AMI who did not receive treatment
  • Adults with AMI reporting unmet need
  • Adults with AMI who are uninsured
  • Adults with disability who could not see a doctor due to costs
  • Youth with at least one major depressive episode (MDE) in the past year
  • Youth with dependence or abuse of illicit drugs or alcohol
  • Youth with severe MDE
  • Youth with MDE who did not receive mental health services
  • Youth with severe MDE who received some consistent treatment
  • Children with private insurance that did not cover mental or emotional problems
  • Students identified with emotional disturbance for an individualized education program (IEP)

Information in the report can be used by policymakers and other stakeholders to more fully understand the needs of people with mental illness in America, in order to ensure and advocate that adequate resources be available to them long before they reach the most critical points in the disease process.

Data included in the report came from public sources that met MHA’s guidelines for inclusion. The downloadable resource contains state and national data, state rankings, and infographics reflecting results of analyses, and is complemented by an interactive online resource.

The report, “The State Of Mental Health In America, 2017” was accessed in November 2016.

The companion interactive online resource was also accessed in November 2016 and is available at http://www.mentalhealthamerica.net/issues/state-mental-health-america.

The National Technical Assistance Network For Children’s Behavioral Health (TA Network), funded by the Substance Abuse & Mental Health Services Administration (SAMHSA) has announced the launch of a three‐year Quality Collaborative on Improving the Use of Psychotropic Medications in Residential Treatment Facilities (RTFs). This initiative will collaboratively review current practices and develop and implement strategies to improve psychotropic medications prescribing for children and youth in care.

Nine RTFs from across the nation have been selected to participate and will be supported through a learning collaborative model and use of a Continuous Quality Improvement tool, to identify objectives and strategies, and track process and outcome indicators using a continuous quality improvement structure, adapted from the Quality Improvement Framework developed by the Center For Health Care Strategies, Inc., a core partner in the TA Network.

This was reported by TA Network on October 25, 2016.

Contact Information: Center for Health Care Strategies, Inc., 200 American Metro Boulevard., Suite 119, Hamilton, New Jersey 08619; 609-528-8400; Email: media@chcs.org; Website: www.chcs.org

We know that suicide risk is a major concern in those suffering from mental illnesses such as major depression. Can you discuss the risk of suicide in regard to those individuals with bipolar disorder?

Bipolar disorder is the psychiatric condition with the highest prevalence of attempted or completed suicides.1 In fact, the risk of suicide in patients with bipolar disorder is higher than in patients with schizophrenia and, maybe surprisingly, slightly higher than in patients with major depression.1 A suicide-risk assessment should be conducted any time patients with bipolar disorder present with mood symptoms. The assessment should review both risk and protective demographic and illness factors, including past course of illness, family history, and presence of comorbid conditions.2

References

  1. Baldessarini, RJ. Reducing suicide risk in psychiatric disorders. Curr Psychiatr. 2003;2(9):14–24.
  2. Hirschfeld RMA, Bowden CL, Gitlin MJ, et al for the Work Group on Bipolar Disorder. Practice guideline for the treatment of patients with bipolar disorder. Second edition. 2002. Available at: https://www.psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf. Accessed October 24, 2016.

Can you describe some of the pros and cons of treatment guidelines?

Treatment guidelines are useful in that they can identify evidence-based interventions and highlight their value over less proven remedies across short- and long-term phases of treatment.1 They usually offer replicable, systematic recommendations and also often helpfully point out what not to do (e.g., avoiding antidepressant medications during bipolar mixed states).1,2 On the other hand, while treatment guidelines may offer broad recommendations, they must be tailored to the circumstances of an individual patient by taking into account several factors including, but not limited to, idiosyncratic comorbidities, risk-benefit ratios, concerns about treatment adherence, outcomes for patients with versus without rapid cycling, and/or past suicide attempts.1 Further, treatment guidelines, unfortunately, can also become quickly outdated if they are not regularly revised to keep pace with the expanding literature.3

References

  1. Goodwin GM, Haddad PM, Ferrier IN, et al. Evidence-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016;30(6):495–553.
  2. Pacchiarotti I, Bond DJ, Baldessarini RJ, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. Am J Psychiatry. 2013;170(11):1249–1262.
  3. Fountoulakis KN, Vieta E, Sanchez-Moreno J, et al. Treatment guidelines for bipolar disorder: a critical review. J Affect Disord. 2005;86:1–10.

What role do unresolved symptoms play in the risk of relapse for patients with bipolar disorder?

Residual affective symptoms are, unfortunately, common in patients with bipolar disorder and can greatly hasten and increase the overall risk for future relapses and recurrences of either polarity.1 In the National Institute Of Mental Health (NIMH) Collaborative Depression Study, residual symptoms were the strongest predictor of relapse, followed by a history of rapid cycling.1 These residual and/or subsyndromal symptoms can impinge on work and social functioning,2 quality of life,2 and, at times, may become confused with medication side effects (as in the case of lethargy, sedation, or cognitive complaints).

References

  1. Judd LL, Schettler PJ, Akiskal HS, et al. Residual symptom recovery from major affective episodes in bipolar disorders and rapid episode relapse/recurrence. Arch Gen Psychiatry. 2008;65(4):386–394.
  2. Samalin L, de Chazeron I, Vieta E et al. Residual symptoms and specific functional impairments in euthymic patients with bipolar disorder. Bipolar Disord. 2016;18(2):164–173.

Can you discuss the risk of suicide in regard to those individuals with bipolar disorder?

Individuals with bipolar disorder have a 20- to 30-fold increased risk of suicide compared with the general population.1 Suicide attempts or completions in individuals with bipolar disorder are more prevalent than in those with unipolar depression, and these suicide attempts/completions are most often associated with bipolar depressive episodes—especially those with mixed features.2–4 Known clinical risk factors within bipolar disorder include a history of previous attempts, rapid cycling, comorbid anxiety or substance use disorders, trait impulsivity-aggression, and a history of childhood trauma or abuse.3,4 Several candidate genes have also been preliminarily linked with an increased risk for suicidal behavior.5

References

  1. Pompili M, Innamorati M, Raja M, et al. Suicide risk in depression and bipolar disorder: do impulsiveness-aggressiveness and pharmacotherapy predict suicidal intent? Neuropsychiatr Dis Treat. 2008; 4(1):247–255.
  2. Isometsä E. Suicidal behavior in mood disorders—who, when, and why. Can J Psychiatry. 2014;59(3):120–130.
  3. Baldessarini RJ. Reducing risk in psychiatric disorders. Curr Psychiatr. 2003;2(9):14–24.
  4. Goodwin GM, Haddad PM, Ferrier IN, et al. Evidence-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016;30(6):495–553.
  5. Perlis RH, Huan J, Purcell S, et al. Genome-wide association study of suicide attempts in mood disorder patients. Am J Psychiatry. 2010;167(12):1499–1507.

What constitutes recovery from serious mental illness, and how is it measured? Although there are many definitions for recovery they all contain components of hope, self-efficacy and self-help, and empowerment. Some experts view recovery as a process, a stage, or an outcome of treatment. In the world of person-centered care, being able to measure recovery – however it is defined – is essential to providing quality health care. There are several measures of recovery being developed but their implementation is just beginning so further studying is warranted.

A new report entitled “The reliability and validity of the Maryland Assessment of Recovery in Serious Mental Illness Scale,” published online March 22, 2016 for Psychiatry Research, details a study that closely examined the efficacy of the Maryland Assessment Of Recovery In Serious Mental Illness Scale (MARS), a new 25-item self-report instrument to measure personal recovery of people with serious mental illness (SMI). Two preliminary examinations of MARS have already been done with satisfactory reports about the psychometric aspects of the measure; however researchers wanted to further test its validity.

For the current study, researchers established baseline information from 250 participants with serious mental illness recruited from three Veterans Administration centers and one community mental health program where they received outpatient mental health treatment. Data from participants were collected by self-report tools or via interviews by researchers on clinical outcomes, social and community functioning, health status, and other recovery-related constructs such as hope, empowerment, and self-efficiency. Data were collected with various measurement instruments¹ including the MARS, then researchers compared the results from MARS to results from the other instruments.

The MARS was determined to be a psychometrically sound instrument to measure recovery in individuals with SMI; it showed good internal consistency and test-retest reliability as well as good construct validity (e.g. it can measure what it claims to measure). It demonstrated a strong positive relationship with recovery-related tools (hope, empowerment, personal self-efficacy); a strong negative relationship with measures of self-stigma. It demonstrated moderately positive relationships with empowerment, interpersonal agency, quality of life and the perceived recovery oriented nature of the service system (e.g. does the facility offer recovery-oriented treatment, and measures of customer satisfaction). Weaker relationships were seen with measures of cognitive and social functioning.

The researchers concluded that the MARS may play an important role in gaining a better understanding of the recovery process in individuals with serious mental illness and in evaluating programs designed to promote recovery. The study provided evidence that as an assessment tool MARS is reliable, consistent, psychometrically sound, and able to measure hope, empowerment, self-efficacy, and personal agency of people with SMI.

The full text of “The reliability and validity of the Maryland Assessment of Recovery in Serious Mental Illness Scale,” was published in March 2016 in Psychiatry Research.

¹In addition to the MARS, researchers named the following scales: Herth Hope Index, Rogers Empowerment Scale, Personal & Interpersonal Agency Scale/Subscale, Internalized Stigma Of Mental Illness Inventory, The Positive & Negative Syndrome Scale, the Brief Symptom Inventory, Global Severity Ind3x, Positive Symptom Distress Index, Repeatable Battery For The Assessment Of Neuropsychological Status, SF-12 Health Survey, Substance Use Event Survey For Severe Mental Illness, Social Functioning Scale, Social Support Questionnaire-Brief Version, Social Support Questionnaire, Recovery Oriented System Indicators Measure, Client Satisfaction Questionnaire.

The final rule implementing the Medicare Access & CHIP Reauthorization Act (MACRA) contains provisions that change how physicians and provider organizations will use and report their use of certified electronic health record technology (CEHRT). In key changes, physicians will attest that they are not engaged in “information blocking” and that they provide consumers with timely access to their personal health data.

Further, the Centers For Medicare & Medicaid Services (CMS) will revise the current Meaningful Use measurement, which requires the physician to meet the measurement standard completely to receive credit. Instead, under the new reporting structure, CMS plans to give physicians a base score of 50% for reporting the required measures regarding their use of EHR technology. They also can earn a bonus for reporting on optional measures.

Calendar year 2017 will be the MACRA transition period to advanced alternative payment models (APMs) and the Merit-Based Incentive Payment System (MIPS) for those not participating in an APM. MIPS consolidates components of the Meaningful Use program, the Physician Quality Reporting System, and the physician value-based payment modifier. MIPS requires eligible professionals to report their use of CEHRT in terms of “advancing care information.”

CMS has dubbed the 2017 transition year as the “Pick Your Pace” performance period because MIPS-eligible professionals can choose from participation options, that will each prevent a negative MIPS payment adjustment. Clinical professionals can choose to report one measure in the quality performance category; one activity in the improvement activities performance category; or report the required measures of the advancing care information performance category and avoid a negative MIPS payment adjustment.

  • Clinical professionals can choose to report to MIPS for a full 90-day period or, ideally, the full year, and maximize the MIPS eligible clinician’s chances to qualify for a positive adjustment.
  • Failure to report on any activity will result in the full negative adjustment of 4%.
  • MIPS eligible clinicians can participate in Advanced APMs, and if they receive a sufficient portion of their Medicare payments or see a sufficient portion of their Medicare patients through the Advanced APM, they will qualify for a 5% bonus incentive payment in 2019.

A fact sheet released by the Office Of The National Coordinator Of Health Information Technology, “FACT SHEET: Quality Payment Program and Health Information Technology,” explains the MACRA Advancing Care Information performance category under the Quality Payment Program. The goal of the Advancing Care Information category is to modernize, streamline, and replace the Medicare EHR Meaningful Use Incentive Program for eligible professionals. The fact sheet notes that CEHRT certified to the 2014 Edition EHR criteria can be used during the “Pick Your Pace” performance period of 2017. However, the 2015 edition CEHRT is required for use in 2018.

The 2015 edition requires vendors to publish application programming interfaces (API), which make it easier for software programs such as smartphone apps to access information from other programs, for certified health IT. The rule also promotes transparency in that developers are required to disclose any additional types of costs that a customer might incur to implement or use CEHRT, as well as any limitations, including contractual and technical impediments that could prevent users from successfully implementing and using CEHRT.

PsychU summarized the impact of MACRA in “MACRA: The Big Picture,” which published on November 7, 2016.

For more information, contact: Quality Payment Program, Centers For Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; Website: https://qpp.cms.gov/; or media can send questions to Centers For Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: www.cms.gov.

The Joint Commission issued new standards for eating disorder programs that went into effect on July 1, 2016. The new standards apply to provider organizations accredited by The Joint Commission under its Behavioral Health Care Accreditation Program that offer eating disorders care, treatment, or services in residential or outpatient programs. The new standards raise the total number of Joint Commission standards for eating disorder programs from four to 33.

The previous standards required provider organizations to assess and monitor the individual’s food-related behaviors and weight. The new standards address 11 aspects of care, including assessments, data collection and analysis, transitions of care, roles of key staff and other clinicians, supervision of individuals served, and family involvement.  The key changes can be summarized as follows:

  • Assessment should take place from admission to discharge so that the provider organization can measure the effectiveness of the individual’s treatment, as well as the organization’s overall effectiveness. The assessments should include a complete history and physical examination to include blood tests (including thyroid function) and an electrocardiogram, as well as physical condition and psychological assessments. Organizations that provide 24-hour care should assess the risk of falling, and develop a prevention plan.
  • Treatment should cover the specific care, treatment, and services to be delivered by the organization, including psychosocial, medical, nutritional, and psychiatric components. The provider organization should maintain a line of communication with other medical facilities that may be providing care to a shared consumer in rehabilitation for an eating disorder.
  • The treatment services should be delivered by a multidisciplinary care team with experience and/or training in treating eating disorders to include a physician or pediatrician (for individuals under age 13) either on staff or on call 24-hours a day every day; if the physician is not on-staff, an advanced practice nurse who can prescribe; a psychiatrist or clinical psychologist on staff or on call 24-hours a day every day; a registered dietitian; and a registered nurse, unless there is an advanced practice nurse on staff.
  • Family involvement efforts should seek to engage the individual’s family in care, treatment, or services, but in accordance with the individual’s needs and preferences.
  • Organizational practices should ensure that the provider organization gives individuals and their families information about insurance coverage and financial assistance, and residential facilities should ensure that they have specific policies regarding the individual’s ability to leave the facility, have visitors, and access the Internet.

About 10% of the United States population, 20 million women and 10 million men, will have clinical symptoms of an eating disorder such as anorexia or bulimia, at some point in their lives. About 95% of people with active eating disorders are between ages 12 and 25. About 25% of college-age women engage in bingeing and purging.

According to Peggy Lavin, LCSW, interim executive director of The Joint Commission’s Behavioral Health Care Accreditation Program, “Eating disorders can cause very complex emotional and physical problems, resulting in severe medical consequences, including heart disease, bone loss, muscle weakness and depression. This is why The Joint Commission decided it was so important to develop and implement new standards to improve patient safety and quality of care for eating disorder patients and their families.”  The new requirements are added to The Joint Commission’s Comprehensive Accreditation Manual For Behavioral Health Care Organizations (CAMBHC).

The full text of “The Joint Commission: New Requirements For Residential and Outpatient Eating Disorders Programs” was released in January 2016 by The Joint Commission.

For more information, contact: Elizabeth Eaken Zhani, Relations Manager, The Joint Commission, 1 Renaissance Boulevard, Oakbrook Terrace, Illinois 60181; 630-792-5914; Email: ezhani@jointcommission.org; Website: www.jointcommission.org; or Katie Looze Bronk, Media Relations Specialist, The Joint Commission, 1 Renaissance Boulevard, Oakbrook Terrace, Illinois 60181; 630-792-5175; Email: kbronk@jointcommission.org; Website: www.jointcommission.org.

The federal Department Of Health & Human Services (HHS) should develop a standardized core set of quality measures for home- and community-based services (HCBS) and long-term services and supports (LTSS), according to a recommendation from the National Quality Forum (NQF). Currently, measures and reporting requirements vary across numerous federal, state, local, and privately funded programs. States and provider organizations have flexibility to establish their own quality measures, and NQF recently endorsed 19 measures in the Experience Of Care survey, which are standardized measures for HCBS.

The NQF recommended standardized measure development in the following 11 domains:

  1. Service Delivery & Effectiveness
  2. Person-Centered Planning & Coordination
  3. Choice & Control
  4. Community Inclusion
  5. Caregiver Support
  6. Workforce
  7. Human & Legal Rights
  8. Equity
  9. Holistic Health & Functioning
  10. System Performance & Accountability
  11. Consumer Leadership in System Development

The overall recommendation is that the HCBS core measures should include supplemental measures that can be tailored to specific populations, settings, and programs. For each domain, the NQF split out the recommendations in to short-term, intermediate, and long-term horizons. In the short-term, HHS should support the development of a standardized core set of HCBS quality measures; and then use existing program data to develop quality measures related to transparency, equity, and accurate reporting of HCBS wait lists. Over the long-term HHS should leverage technology innovations to develop systems that monitor multiple indicators of health and service disparities in caregiver support, workforce adequacy, consumer privacy ability to exercise rights, and holistic health and functioning; as well as to assess system performance.

The NQF recommendations were released in “Quality in Home and Community-Based Services to Support Community Living: Addressing Gaps in Performance Measurement.” The report presents the results of an environmental scan to assess the current state of HCBS quality measurement, and makes recommendations to HHS about opportunities for closing gaps. The recommendations were developed by a multistakeholder committee formed by NQF under a contract with HHS. For the environmental scan, NQF staff used the following definitions to categorize HCBS measures, measure concepts, and instruments:

  • Measure: a metric that has a specific numerator and denominator and has undergone scientific testing
  • Measure concept: as a metric that has a specific numerator and denominator, but has not undergone testing
  • Instrument: a psychometrically tested and validated survey, scale, or other measurement tool

The committee identified 14 characteristics of a high quality HCBS system, and conducted an initial search that found 261 measures, 394 measure concepts, and 75 instruments. To identify the highest priority measure gap areas, the committee considered the impact that measurement in each domain would have on HCBS quality. The committee distinguished between different types of measurement gaps. In some domains, measures appear to be limited to only one population of HCBS users; in other domains, few or no measures exist to assess aspects described within a domain or a subdomain. The committee evaluated gaps in terms of the following:

  • Costs of poor quality to consumers, caregivers, natural supports, workers, communities, and the nation
  • Extent of the performance gap between current practice and the committee’s characteristics of high-quality HCBS
  • Likelihood that measurement in the domain would close the gap
  • Extent to which measurement in the domain could benefit all populations across the spectrum of HCBS

The committee highlighted 11 areas for HCBS measurement development. They include service delivery, person-centered planning, choice, community inclusion, caregiver support, workforce issues, protection of human rights, equity, holistic health and functioning, system performance and accountability, and consumer leadership in system development. The 11 areas cover 40 measurement topics. Within each area, the committee recommended short-term, intermediate, and long-term action, and identified promising measure concepts.

  • The short-term recommendations are focused on measures and measure concepts currently used by HCBS programs to capture differences in service delivery, utilization, and outcomes across sociodemographic characteristics. The committee identified existing measure concepts addressing housing, homelessness, and transportation.
  • The intermediate recommendations are focused on investments in methods for enabling further development that would enhance the construct of the measure within the domains and subdomains. Examples include access to existing program data, and then using the data to develop quality measures related to transparency and accurate reporting of HCBS wait lists. The recommendations examine the use of administrative data for obtaining information about sociodemographic characteristics to assess equity.
  • The long-term recommendations focus on areas where more research is needed, and includes the leveraging of technology innovations to develop systems that monitor multiple indicators of health and service disparities.
NQF HCBS Quality Measure Recommendations, By Domain
Domain Short-Term Intermediate Long-Term
Service Delivery & Effectiveness
  • Expand implementation of process measure concepts related to the person’s needs met and goals realized subdomain
  • Support development of quality measures for the delivery subdomain, and focus on identifying aspects of service delivery important to consumers; invest in developing person-centered outcome measures.
  • None
Person-Centered Planning & Coordination
  • Review existing measure concepts in the assessment subdomain to evaluate whether changes can be made to make them more generalizable.
  • Expand implementation of process measure concepts related to person-centered planning and coordination subdomains.
  • Develop structure, process, and outcome measures for the coordination subdomain that address coordination of services across all aspects of health care and social service delivery.
  • Structure measures should focus on system-level requirements and infrastructure to support effective coordination at the individual level.
  • Promote a balanced approach to development and use of system and individual-level measures for each subdomain.
  • None
Choice & Control
  • Validate and expand the use of process and structure measure concepts related to the personal choices and goals, choice of services and supports, and self-direction subdomains.
  • Assess the evidence for and scientific acceptability of measure concepts and instruments that are currently in use.
  • Develop structure quality measures to assess program practices and designs that promote choice and control.
  • Provide technical assistance to program officials to help operationalize and measure the subdomains of choice and control.
  • None
Community Inclusion
  • Test validity and reliability, and expand the use of process and structure measure concepts related to the meaningful activity subdomain.
  • Support efforts to further examine how to operationalize the construct of community inclusion and develop outcome quality measures for this domain.
  • None
Caregiver Support
  • Ensure that medical records and care plans include identification of family caregivers/natural supports, with consent of the consumer as appropriate.
  • Identify or develop measures of family caregiver/natural support involvement in service planning, assessment of family caregiver/natural support needs, impact of caregiving including employment, and availability of resources and training for family caregivers/natural supports.
  • Further develop and disseminate family caregiver/natural support assessments.
  • Develop benchmarks for outcomes related to family caregiver/natural support well-being.
  • Support the development of the infrastructure needed for the collection and management of data related to the well-being, training, and involvement of the family caregiver/natural support and the availability and utilization of resources to support them.
Workforce
  • Identify or develop measures of worker retention and turnover, worker wages and benefits, worker satisfaction, worker training and skill competency.
  • Improve collection and use of administrative data for structure and process measures related to the workforce.
  • Support the development of worker-focused outcome measures, such as worker satisfaction, satisfaction with preparation, quality of relationships with consumers and supervisors, level of support and engagement, opportunities for skill development and career advancement.
  • CMS should collaborate with HRSA and the Department Of Labor to identify means of improving and expanding data collection on the HCBS workforce.
  • Establish the processes and infrastructure needed for collecting the above data related to the workforce.
Human & Legal Rights
  • Identify measures of human and legal rights currently in use in HCBS programs, assess their validity and reliability, and expand their use.
  • Identify, validate, and expand the use of the most promising measures from among the process measure concepts currently in use to assess critical incident reporting and management.
  • Develop outcome quality measures related to all of the subdomains of human and legal rights.
  • Examine the use of administrative data in developing measures for the privacy subdomain.
  • Develop the evidence base for the processes that the HCBS system can implement to optimize HCBS consumers’ privacy, preservation of their human and legal rights, and ability to exercise their rights.
Equity
  • Identify equity measures currently in use in HCBS programs that examine differences in service delivery, utilization, and outcomes across age, gender, race/ethnicity, disability type, and other sociodemographic characteristics.
  • Identify existing measures of housing, homelessness, and transportation and assess their validity and reliability and expand their use.
  • Invest in methods for enabling access to existing program data and developing those data into quality measures related to transparency.
  • Improve standardization and reporting of waiting list data for HCBS in order to improve accuracy and develop quality measures.
  • Examine the use of administrative data for obtaining information on race/ethnicity, age, gender, languages spoken, and other information for examining equity.
  • Leverage technological innovations to develop systems for monitoring various indicators of health and service disparities.
Holistic Health & Functioning
  • Identify reliable and valid health and functional assessment tools commonly used in community settings from which standardized quality measures could be developed.
  • Identify existing outcome measures across all dimensions of holistic health, with particular focus on the dimensions of behavioral and social health and functioning.
  • Expand the use of validated quality measures related to falls, medications, immunizations, and other quality measures focused on health promotion and prevention.
  • Identify and develop standardized quality measures derived from health and functional assessment tools routinely used in community settings.
  • Develop outcome measures across all dimensions of holistic health, with particular focus on the dimensions of behavioral and social health and functioning.
  • Develop, test, and disseminate a universal assessment tool for assessing and monitoring all dimensions of holistic health and functioning and generating a global health and functioning profile.
System Performance & Accountability
  • Expand the use of measures and measure concepts related to rebalancing, waiting lists, and unmet need.
  • Conduct research on, validate, and standardize available structure and process measure concepts related to: (1) financing and service delivery, and (2) data management and use.
  • Build upon current measure development projects (e.g., Medicaid’s Testing Experience & Functional Tools [TEFT] grant), and continue developing states’ data infrastructures to enable efficient and effective data management and use.
  • Develop a uniform measure of HCBS waiting lists.
  • Evaluate promising practices in HCBS delivery through the lens of the Committee’s HCBS quality framework.
  • Require timely, periodic, standardized public reporting of HCBS participation, consumer outcomes, waiting lists, unmet needs, costs, and other elements related to system performance.
  • Support the continued development and dissemination of evidence-based/research validated practices and policies throughout HCBS and quality measures that assess the extent to which these practices are used across HCBS.
Consumer Leadership In System Development
  • Allocate resources necessary for developing consumer leadership reporting.
  • Evaluate existing quality review teams with substantial participation of HCBS consumers who are effectively engaged in reviewing and making recommendations to improve HCBS programs.
  • Develop structure, process, and outcome measures to assess the subdomains of consumer leadership in system development.
  • Devote resources to research how the system can support meaningful consumer involvement in the design, implementation, and evaluation of the HCBS system and how to capture such involvement via quality measures.

NQF released the full text of “Quality in Home and Community-Based Services to Support Community Living: Addressing Gaps in Performance Measurement” in October 2016.

For more information, contact: Sofia Kosmetatos, Director, Media Relations & Online Communications, National Quality Forum, 601 13th Street NW, Suite 500 North, Washington, District Of Columbia 20005; 202-478-9326; Email: press@qualityforum.org; Website: http://www.qualityforum.org/HCBS.aspx.

Most patient-centered medical homes (PCMHs) serving Medicaid beneficiaries will not count as advanced alternative payment models (APMS) under the new Medicare Access & CHIP Reauthorization Act Of 2015 (MACRA) rules for fee-for-service physician payment. Under MACRA, Medicare physicians must participate in the CMS Quality Payment Program (QPP). The program has two value-based options: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs). Professionals can pick one of the two options. MIPS does not apply to hospitals or facilities.

MIPS requires eligible professionals to submit quality of care reports to avoid a negative payment adjustment linked to failure to report. Those who hit benchmarks for high performance could earn a payment rate increase.

Advanced APMs are risk-based arrangements that provide added incentives to deliver high-quality and cost efficient care. The structure of APMs can vary widely, to apply to a specific clinical condition, a care episode, or a population. Current APMs include the Medicare Shared Savings Program accountable care organizations (ACOs), medical home models, and episode payment models for cardiac and joint care.

Advanced APMs meet three criteria. Participants are required to use CEHRT. Secondly, payment for professional services is provided based on quality measures similar to those in the MIPS quality performance category. Lastly, the APM entities are at risk of loss for more than a nominal amount or the entities must be a medical home model.

Because the PCMH structure used by most state Medicaid programs lack an element of financial risk for the provider organizations, these programs are not considered Advanced APMs. Physicians participating only in a Medicaid PCMH without an element of risk must report to MIPS.

PsychU summarized the impact of MACRA in “MACRA: The Big Picture,” which published on November 7, 2016.

For more information, contact: Quality Payment Program, Centers For Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; Website: https://qpp.cms.gov/; or media can send questions to Centers For Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: www.cms.gov.

The Centers for Disease Control and Prevention define social determinants of health as economic and social conditions that influence the health of people and communities. Why are income, housing, and employment important to people’s well-being? This webinar answers that question, and provides insight into what health care providers must do to address social determinants in their service delivery strategies. Dr. Arthur Evans, Commissioner of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Service (DBHIDS) shares his experience in improving the health status of Philadelphians in need of behavioral health and/or intellectual disability services.

Key Messages

  • In light of the elevated rates of medical conditions in patients with bipolar disorder (BD), this study sought to identify clinical and demographic features associated with increased risk of comorbidities using baseline data from a clinical trial that evaluated 482 patients aged 18–68 years with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis of BD I or II.
  • Of these patients, 96.3% had ≥1 comorbidity, 71.2% had ≥1 cardiometabolic disturbance, 56.2% had ≥1 non-cardiovascular comorbidity, and 80.5% met criteria for substance use.
  • In multivariate analyses, older age and less severe manic symptoms were independent predictors of cardiometabolic disturbances; female sex, a lifetime substance use disorder, younger age of illness onset, and longer illness duration were independent predictors of non-cardiovascular conditions; and lower household income and higher manic severity were independent predictors of substance use.
  • This study highlighted the substantial medical burden in BD and shed light on some specific associations among these comorbidities with specific demographic and clinical variables.

People in psychiatric crisis who visited an emergency department (ED) for mental health care had visits lasting 18% to 60% longer than other people visiting the emergency department for a non-psychiatric problem. The variance in the ED visit length depended on the circumstance. If the person with a psychiatric problem was admitted to the hospital, the median ED visit length was similar at 264 minutes for those needing psychiatric care versus 269 minutes for those needing general medical or surgical care. However, the median length of stay was longer for those needing psychiatric care who were admitted for observation (27% longer), transferred (60% longer), or discharged (31% longer). Emergency department visitors needing psychiatric care were transferred six times more frequently than nonpsychiatric emergency department visitors.

These findings were reported in “Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002–11” Jane M. Zhu, M.D., MPP; Astha Singhal, DMD, Ph.D.; and Renee Y. Hsia, M.D., MSc. The researchers conducted a retrospective analysis using a national database of emergency department visits from 2002 through 2011. The data set came from the National Hospital Ambulatory Medical Care Survey (NHAMCS), an annual survey by the Centers for Disease Control and Prevention that derives national estimates of various measures of health care provision based on visits to sample hospital. They described trends in median and 90th percentile length of stay for more than 200,000 psychiatric and non-psychiatric emergency department visits with one of four possible outcomes: hospital admission, transfer, outpatient observation, or discharge.

During the period under review, the number of annual emergency department visits increased by 30%, from 82.2 million to 106.8 million. However, the number of psychiatric visits increased by 55%, from 4.4 million to 6.8 million. A large proportion of the increase in psychiatric visits was due to alcohol-related disorders. Additional findings were as follows:

  • Over time, the differences in psychiatric and non-psychiatric median length-of-stay (LOS) did not narrow, except for observation admissions.
  • Emergency department visits later hospitalized—The psychiatric visit LOS was 264 minutes compared to 269 minutes for a non-psychiatric visit. About 18% of psychiatric visits and 15% of non-psychiatric visits resulted in hospitalization.
  • Emergency department visits later admitted for observation—The psychiatric visit LOS was 355 minutes compared to 279 minutes for a non-psychiatric visit. About 2% of psychiatric visits and 2% of non-psychiatric visits resulted in observation.
  • Emergency department visits later transferred—The psychiatric visit LOS was 312 minutes compared to 195 minutes for a non-psychiatric visit. About 10% of psychiatric visits and 2% of non-psychiatric visits resulted in transfer.
  • Emergency department visits later discharged—The psychiatric visit LOS was 189 minutes compared to 144 minutes for a non-psychiatric visit. About 67% of psychiatric visits and 82% of non-psychiatric visits resulted in discharge.

The researchers concluded that emergency departments lack capacity for psychiatric care, and the prolonged LOS for discharged psychiatric emergency department visits could be partially due to a shortage of outpatient mental health facilities and substance abuse treatment programs.

The full text of “Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002–11” was published in the September 2016 issue of Health Affairs.

For more information, contact: Jane M. Zhu, M.D., National Clinician Scholar, Division of General Internal Medicine, Perelman School of Medicine, 3641 Locust Walk, Colonial Penn Center, Philadelphia, Pennsylvania 19104-6218; Email: zhuja@upenn.edu; Website: http://ldi.upenn.edu/expert/jane-m-zhu-md-mpp; or Katie Delach, Senior Medical Communications Officer, Department of Communications, Perelman School of Medicine at the University of Pennsylvania, 3535 Market Street, Mezzanine Suite 60, Philadelphia, Pennsylvania 19104; 215-349-5964; Fax: 215-349-8312; Email: katie.delach@uphs.upenn.edu; Website: www.uphs.upenn.edu/news/meet_us.

Between 2004 and 2012, racial/ethnic disparities in access to mental health care increased. White consumers had the highest levels of access in 2004 and in 2012 compared to Black, Hispanic, or Asian consumers. During the period, the percentage of White consumers using mental health services or psychotropic medications increased more than for consumers in other racial/ethnic groups. The disparity was largely due to greater use of psychotropic medications among Whites, which increased by 3.3 percentage points – from 13.8% to 17.1%. Among Black consumers medication use increased by 1.1 percentage points, from 6.2% to 7.1%; among Hispanic consumers medication use increased by 0.3%, from 6.5% to 6.8%. Among Asian consumers medication use increased by 3.9 percentage points, rising from 3.5% to 7.4%.

These findings were reported in “Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004–2012” by Benjamin Lê Cook, Ph.D., MPH, Nhi-Ha Trinh, Ph.D., Zhihui Li, M.S., Sherry Shu-Yeu Hou, MPH, and Ana M. Progovac, Ph.D. The researchers analyzed data from a nationally representative sample of 214,597 adults from the 2004–2012 Medical Expenditure Panel Surveys. The goal was to compare trends in racial-ethnic disparities in mental health care access among whites, blacks, Hispanics, and Asians. The researchers used the Institute of Medicine definition of disparities: “all differences except those due to clinical appropriateness, clinical need, and patient preferences.” Their comparison focused on past-year use of any mental health care, receipt of any outpatient mental health care, or use of any psychotropic medication.

Past-Year Use Of Mental Health Care Reported In 2004–2005 & 2011–2012, By Racial-Ethnic Group
Race/Ethnicity White Black Hispanic Asian
Data Year 2004 – 2005 2011 – 2012 2004 – 2005  2011 – 2012  2004 – 2005  2011 – 2012 2004 – 2005 2011 – 2012
Number Of Survey Responses 25,864 22,938 7,006 10,614  11,440 14,388 2,125 4,177
Percent Reporting “Any Mental Health Care” 16.3%  19.5%  7.7%  9.2%  7.9%  8.7%  3.7% 4.9%
Percent Reporting ‘Outpatient Mental Health Care” 8.8% 9.4% 5.2% 4.5% 4.7% 4.7% 4.1% 5.2%
Percent Reporting Use Of Psychotropic Medication 13.8% 17.1% 6.2% 7.1% 6.5% 6.8% 3.5% 7.4%

Between 2004 and 2012, the data indicated that the percentage point gap widened for Black-White disparities and for Hispanic White disparities. The disparity was mixed between Asian-White disparities. Additional trend findings were as follows:

  • For Blacks, in 2004, the gap in the percentage reporting any mental health care was 8.2 percentage points, at 16.3% for Whites and 7.7% for Blacks. By 2012, the gap had widened to 10.3 percentage points. The gap for use of psychotropic medication widened from 7.6 percentage points to 10 percentage points.
  • For Hispanics in 2004, the gap in the percentage reporting any mental health care was 8.4 percentage points, at 16.3% for Whites and 7.9% for Hispanics. By 2012, the gap had widened to 10.9 percentage points. The gap for use of psychotropic medication widened from 7.3 percentage points to 10.3 percentage points.
  • For Asians, in 2004, the gap in the percentage reporting any mental health care was 12.6 percentage points, at 16.3% for Whites and 3.7% for Asians. By 2012, the gap had increased to 14.6 percentage points. However, the gap for use of psychotropic medication lessened from 10.3 percentage points to 9.7 percentage points.

The researchers concluded that for Blacks and Hispanics, disparities were exacerbated over the 2004 to 2012 period, and that progress was limited among Asians. They proposed that the disparities could be reduced by clinical interventions to improve identification of mental illness, expansion of health insurance, or other policy approaches to remove financial barriers to access. Compared to White and Asian consumers in this study, a greater percentage of Black and Hispanic consumers were enrolled in Medicaid or were uninsured.

The full text of “Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004–2012” on August 1, 2016 in Psychiatric Services.

PsychU reported on this topic in “Mental Health Diagnoses & Treatment Rates Vary Significantly With Race & Ethnicity,” which published on May 23, 2016.

For more information, contact: Benjamin Lê Cook, Ph.D., Assistant Professor, Department of Psychiatry, Harvard Medical School, and Center for Multicultural Mental Health Research, Cambridge Health Alliance, 120 Beacon Street, Somerville, Massachusetts 02143; 617-503-8449; Email: bcook@cha.harvard.edu; Website: https://connects.catalyst.harvard.edu/Profiles/display/Person/81080.

This video is part 1 of the 3-part series from the Psychopharmacology Collection. The video starts with an introduction to the organization and anatomy of the nervous system, provides an overview of the processes of neurotransmission and introduce some of the receptor types involved, and concludes with a review of some basic principles of receptor pharmacology.

Key Messages

  • The increasing prevalence and comorbidity of metabolic syndrome (MetS) and mental health disorders (MHDs) has raised interest in potential underlying mechanisms.
  • The relationship between MetS and MHDs is thought to be bidirectional. In addition to environmental and lifestyle factors, shared mechanisms such as chronic inflammation, disruption of neuroregulatory pathways, and hypothalamic−pituitary−adrenal (HPA) axis dysregulation may underlie these syndromes. Further, inflammation caused by maternal obesity/MetS may ultimately increase the risk of MHDs and MetS in offspring.
  • The authors recommended treating individuals with comorbid MetS and MHD using an integrated approach to target aspects of both conditions. The need to develop strategies to prevent maternal transfer of increased risk for these syndromes was also emphasized.

On August 1, 2016, the federal Centers for Medicare & Medicaid Services (CMS) updated the Nursing Home Compare Five-Star quality ratings to include five of six new measures announced in March 2016. The new measures address rates for successful discharges, emergency visits, and re-hospitalizations.

CMS has not yet incorporated the sixth new quality measure for the percentage of residents receiving anti-anxiety/hypnotic medications. In the update announcement, CMS noted that it has been difficult to determine appropriate nursing home benchmarks for the acceptable use of these medications. The five new measures, the data source, and a definition for each are as follows:

  1. Percentage of short-stay residents who were successfully discharged to the community, based on Medicare claims and the Minimum Data Set (MDS). This measure reports the percentage of all new admissions to a nursing home from a hospital where the resident was discharged to the community within 100 calendar days of entry and for 30 subsequent days, did not die, was not admitted to a hospital for an unplanned inpatient stay, and was not readmitted to a nursing home.
  2. Percentage of short-stay residents who have had an outpatient emergency department visit, based on Medicare claims and the MDS. This measure reports the percentage of all new admissions or readmissions to a nursing home from a hospital where the resident had an outpatient emergency department visit (i.e., an emergency department visit not resulting in an inpatient hospital admission) within 30 days of entry or reentry.
  3. Percentage of short-stay residents who were re-hospitalized after a nursing home admission, based on Medicare claims and the MDS. This measure reports the percentage of all new admissions or readmissions to a nursing home from a hospital where the resident was re-admitted to a hospital for an inpatient or observation stay within 30 days of entry or reentry.
  4. Percentage of short-stay residents who made improvements in function, based on the MDS. This measure assesses the percentage of whose physical function short-stay residents whose independence in three mobility functions (i.e., transfer, improves from admission to locomotion, and walking) increases over the course of the nursing home care discharge episode.
  5. Percentage of long-stay residents whose ability to move independently worsened, based on the MDS. This measure is a change measure that reports the percent of long-stay residents whose ability to move who have demonstrated a decline in independence of locomotion when comparing independently worsened the target assessment to a prior assessment. Residents who lose mobility may also lose the ability to perform other activities of daily living, like eating, dressing, or getting to the bathroom.

The Nursing Home Compare quality ratings are based on health inspections, staffing, and quality measures. The three ratings are combined to calculate an overall rating. Nearly all nursing homes have a rating; the exception is for facilities with fewer than two inspections. The five new quality measures will be phased into the star rating system gradually, beginning in July. At that time the new measures will only be counted at half of their full value. In January 2017, CMS will fully count the new measures. Nursing homes will be given a three-month preview of the data before it is incorporated into the Five-Star Quality Rating System.

For more information, contact: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: www.cms.gov.

“If you worked for me, you’d be fired this afternoon.”

That was a quote from Representative Chris Collins (R-N.Y.), speaking to Dr. Shantanu Agrawal, deputy administrator and director of the Centers for Medicare & Medicaid Services (CMS) Center for Program Integrity, at the House Energy and Commerce Committee’s Subcommittee on Oversight and Investigations hearing on combating improper payments and ineligible provider organization reimbursements in both the Medicaid and Medicare programs. The hearing took place a few months ago and brought to the forefront the seriousness of the problems with fraud in the health care industry.

The hearing was in response to what has been deemed the failure of CMS to curb “misspent” Medicaid and Medicare payments (which totaled and estimated $80 billion in 2014) – these misspent funds include everything from improper coding, to payments made to ineligible provider organizations, to reimbursements for people ineligible for services, to fraud (see “CMS Lambasted for Failing To Curb Medicaid, Medicare Fraud And Abuse” from Modern Healthcare).

One topic that received attention at the hearing was the CMS requirement that all state Medicaid programs implement criminal background checks for health care clinical professionals and suppliers determined to pose increased financial risk of fraud, waste, or abuse by August 1, 2015 (see State Medicaid Programs Must Run Criminal Background Checks On All Clinical Professionals & Suppliers Deemed High Risk). Now a year later, new reports from the Office of Inspector General (OIG) find that most states have not completed this task. The OIG reports that 37 of the 47 states included in the report had not implemented fingerprint-based criminal background checks for new and existing professionals and provider organizations to be enrolled in the federal health care program (see “Medicaid Enhanced Provider Enrollment Screenings Have Not Been Fully Implemented” from The Department of Health and Human Services); and that between 2011 and 2014, 27,000 high-risk professionals were allowed to enroll without completing the background checks. Fourteen states reported that they will not meet the September 2016 deadline for all Medicaid enrollments to be revalidated for professionals.

Part of the problem with Medicaid fraud is related to the Medicaid enrollment data system, called the Provider Enrollment, Chain and Ownership System (PECOS). According to a recent OIG report, PECOS has professional names that do not match the names filed with state Medicaid agencies and the majority of state Medicaid provider organizations are not reporting the proper ownership information (see “Medicaid Vulnerabilities Related To Provider Enrollment And Ownership Disclosure” from The Department of Health and Human Services). This includes 14 State Medicaid programs that did not verify the completeness or accuracy of provider organization ownership information. Also missing – a comprehensive database for identifying provider organizations that have been terminated for cause, leading to 12% of professionals and provider organizations that were terminated for cause in 2011 by one state’s Medicaid agency, still participating in another state’s Medicaid program in 2012.

The OIG has issued many recommendations to CMS to help “fix” these issues – including assisting states with background checks and developing a central system where states can share data about Medicaid provider organizations and professionals. What does this focus on Medicaid fraud mean for provider organizations?

Provider organizations need to be prepared for increased scrutiny of Medicaid reimbursements. We’re all familiar with stories of fraud and abuse – just a couple months ago, federal authorities reported the largest ever bust for health care fraud, leading to 300 arrests (including 60 licensed medical professionals, 30 of which were physicians) for $900 million in false billings to Medicare and Medicaid (see “Feds Charge 300 In Nation’s Largest Health Care Fraud Bust” from NBC News). Stories like these often tempt executives to be ambivalent about Medicaid billing – thinking that there is nothing criminal taking place in their organization, so they don’t need to be concerned. But there are just as many examples of “unintentional” fraud. Sloppy billing, improper coding and documentation, and lack of eligibility documentation for clinicians and consumers can all lead to trouble.

Provider organizations need to have their own internal compliance systems in place to root out the “red flags” before they draw attention from CMS auditors. In an era of increased scrutiny, organizations need to have an internal compliance or risk-management group that is proactively reviewing billing data for irregularities or suspicious billing.

Second, organizations need to pay close attention to their employees. While many states have been slow to implement background checks, CMS is continuing the push this requirement. If you have clinicians on staff that are part of a “high-risk provider category” (including newly enrolling home health provider organizations, any clinical professional or provider organization who has an existing overpayment, etc.), ensure that you have all the necessary documentation in place and your employees are properly credentialed to participate in Medicaid.

If the spring congressional hearing was any indication, we’re only going to see continued scrutiny of the Medicaid billing. We know that Congress and CMS are taking Medicaid fraud seriously  – be sure that your organization is too.

hedisqualityimprovementprojectmeasurementandinterventiondevelopment

This document  outlines potential opportunities for health care quality improvement that may be derived from HEDIS®.  Two particular HEDIS® measures of interest to stakeholders managing the quality of services rendered to schizophrenic patients include Adherence to Antipsychotic Medications for individuals with schizophrenia and Follow-Up After Hospitalization for mental illness.

payerqualitymeasures

This document outlines potential opportunities for health care quality improvement that may be derived from HEDIS® and NQF-endorsed measures.

Our team at OPEN MINDS spends a lot of time tracking what you – our members – want to read. As I reviewed the “most read” articles of this year, I would say that “the new rules” are getting the most attention. From the new competition via telehealth and court rulings about autism coverage, to new legislation and regulations around IMDs, parity, and more – the most read coverage was on the market intelligence that shapes strategy. These are the “top 10” most-read news stories so far this year.

Walgreens To Offer Behavioral Health Services Nationwide Through MDLIVE Collaboration
On May 10, 2016, behavioral health services were available to consumers through Walgreens pharmacy locations. The services will be provided through a telehealth collaboration with MDLIVE’s subsidiary Breakthrough Behavioral. Behavioral health services through Breakthrough’s network of more than 1,000 licensed behavioral health professionals nationwide, including psychiatrists, therapists, and psychologists, will be available by appointment as secure video sessions.

Medicaid Finalizes Managed Care Rules, Including Qualified End To IMD Exclusion
On April 25, 2016, the federal Centers for Medicare & Medicaid Services (CMS) released the final rules for Medicaid managed care plans. The new rule includes plans to end the exclusion of any payment for care provided to adults between age 21 and 64 in an institution of mental disease (IMD). The rule means that the capitated rate paid to Medicaid managed care plans can be used to reimburse for mental health or addiction treatment services provided for up to 15 days in a given month to adults in a residential treatment setting with 17 or more beds. Historically, Medicaid has excluded coverage of any services provided to adults in an IMD.

Michigan Governor Proposes To End Medicaid Behavioral Health Carve-Out
Michigan Governor Rick Snyder’s proposed budget for fiscal year 2017 includes a proposal to end the Medicaid behavioral health carve-out by September 30, 2017 (the end of fiscal year 2017). Currently, Michigan Medicaid behavioral health services are provided by regional behavioral health authorities that operate prepaid inpatient health plans (PIHPs) to manage Medicaid and non-Medicaid mental health specialty services, addiction treatment, and home- and community-based waiver services for people with developmental disabilities.

CMS To Provide Federal Match To State Medicaid Programs To Support EHR Adoption By Behavioral Health & Long-Term Care Provider Organizations
On February 29, 2016, the federal Centers for Medicare & Medicaid Services (CMS) issued a guidance memo to state Medicaid directors advising them that they could use federal funding to help behavioral health, addiction treatment, and long-term care provider organizations adopt electronic health record (EHR) technology. The funding is intended to help professionals and hospitals eligible for Medicaid EHR incentive payments connect to other Medicaid provider organizations that were not eligible under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act.

CMS Final Medicaid Parity Rule Released: All Plan Types Included
On March 29, 2016, the federal Centers for Medicare & Medicaid Services (CMS) released its final rule on mental health and addiction/substance use disorder treatment parity for state Medicaid programs and Children’s Health Insurance Program (CHIP) plans. The rule affects over 23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP plans; and applies to carve-in and carve-out arrangements. State Medicaid programs, including those that contract with a managed care entity, must comply with the requirements no later than October 2, 2017. ABP coverage offered by states must also comply with the requirements of this section no later than October 2, 2017. Medicaid fee-for-service plans are exempted only for beneficiaries who receive all services via fee-for-service.

Beacon Health Options Wins Washington State Behavioral Administrative Services Organization Contract
On February 23, 2016, Beacon Health Options announced that it was awarded the Washington State Health Care Authority (HCA) contract to administer public behavioral health services. The behavioral health administrative service organization (BH-ASO) contract is a complement to the state’s new integrated physical and behavioral health Medicaid managed care model and will start in the first two “early adopter” counties (Clark and Skamania). Beacon will administer behavioral health crisis services for all individuals in this regional service area (RSA) regardless of their insurance status or income level, as well as managing access to additional non-crisis services for eligible individuals who lack insurance coverage.

24 States Awarded Planning Funds For Federal Certified Community Behavioral Health Center Demonstration
On October 19, 2015, the federal Substance Abuse and Mental Health Administration (SAMHSA) awarded 24 states funding to develop plans for a Certified Community Behavioral Health Centers (CCBHCs) and prepare applications to participate in a two-year demonstration program. Each state was awarded between about $800,000 to $900,000. At the end of the planning period, SAMHSA will select eight of the 24 states to participate in the demonstration program, which will begin in January 2017. The 24 states will use the funding to ensure that community behavioral health clinics that apply to become “certified” meet the criteria for the CCBHC staffing mix; service access and availability; coordination of services; the scope of services, quality improvement and reporting requirements; and organizational, authority, governance, and accreditation.

Pennsylvania Court Rules Insurers Must Cover School-Based Applied Behavioral Analysis Under Autism Treatment Mandate
On November 13, 2015, the Pennsylvania Superior Court ruled that Independence Blue Cross (IBC) was required to provide coverage for school-based applied behavioral analysis (ABA). The lawsuit, Burke v. IBC, was filed by the Pennsylvania Health Law Project on behalf of the family of a six-year-old boy after IBC denied the family’s request for coverage of services provided at the boy’s elementary school. IBC not only claimed that the services were excluded because they were being delivered in a school-based setting, but challenged the authority of Pennsylvania’s autism insurance mandate as well. The Superior Court ruled that insurers must cover treatment or services for children with autism spectrum disorder in school, as well as at home.

Fourteen Organizations Bid On Pennsylvania’s First Medicaid Managed Long-Term Services & Supports Procurement
On May 6, 2016, the Pennsylvania Department of Human Services (DHS) announced that it received 14 bids from managed care organizations (MCOs) in response to the state’s recent request for proposal (RFP) issued for the Community Health Choices (CHC) program that will provide Medicaid managed long-term services and supports (MLTSS). The CHC MCOs will coordinate physical health care and LTSS for older persons, persons with physical disabilities, and individuals who are dually eligible for Medicare and Medicaid (dual eligible). The goal of this program is to allow DHS and the Department of Aging to serve more Pennsylvanians in their communities and allow consumers to have an active voice in the services they receive.

On June 21, 2016, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) released a new set of 32 quality measures for Certified Community Behavioral Health Clinics (CCBHCs) and other community behavioral health clinic (BHC) provider organizations to help them gauge the progress a BHC is achieving in important behavioral health objectives. Although many of the measures were originally developed to monitor care in large health plan systems, the manual is designed to allow uniform monitoring and assessment across states and a variety of BHCs at the BHC level. There are 14 BHC-lead measures and 18 state-lead measures that require data collection by the state. Of these quality measures, 11 will or may be used by the states selected to participate in the CCBHC demonstration program to make quality bonus payments (QBPs) to the participating CCBHCs.

The measures were released in “Metrics & Quality Measures For Behavioral Health Clinics Technical Specifications & Resource Manual.” It provides detailed guidance on each of the measures to help states and BHCs identify practices that are successful or that need improvement. These materials were developed in partnership with the Centers for Medicare & Medicaid Services (CMS) and the Office of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services. Some of the measures have been endorsed by the National Quality Forum. The Data Reporting Templates for Behavioral Health Quality Measures complement the technical specifications manual.  These templates are designed to provide a simple mechanism for BHCs to collect, record and report data related to these performance measures. Some of these quality measures are re-specifications of existing measures that are now designed to be used at the clinic level. Other measures are new and are designed to address aspects of care important for BHCs in general and the CCBHCs specifically.

14 Behavioral Health Clinic, Clinic-Lead Measures
Measure Name Measure Steward NQF # CCBHC Demonstration Measure CMS Medicaid Core Set CCBHC QBM
Routine Care Needs (ROUT) SAMHSA NA No NA NA
Time to Initial Evaluation (I-EVAL) SAMHSA NA Yes NA NA
Time to Comprehensive Person and Family-Centered Diagnostic and Treatment Planning Evaluation (TX-EVAL) SAMHSA NA No NA NA
Deaths by Suicide (SUIC) SAMHSA NA No NA NA
Documentation of Current Medications in the Medical Records (DOC) CMS 0419 No NA NA
Preventive Care and Screening: Adult Body Mass Index (BMI) Screening and Follow-Up (BMI-SF) CMS 0421 Yes NA NA
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC-BH) NCQA 0024 Yes Child Core NA
Controlling High Blood Pressure (CBP-BH) NCQA 0018 No Adult Core NA
Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (TSC) AMA-PCPI 0028 Yes NA NA
Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling (ASC) AMA-PCPI 2152 Yes NA NA
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-BH-C) AMA-PCPI 1365 Yes Child Core R
Major Depressive Disorder: Suicide Risk Assessment (SRA-A) AMA-PCPI 0104 Yes NA R
Screening for Clinical Depression and Follow-Up Plan (CDF-BH) CMS 0418 Yes Adult Core NR
Depression Remission at Twelve Months (DEP-REM-12) Minnesota Community Measurement 0710 Yes NA NR

 

18 Behavioral Health Clinic State-Lead Measures          
Measure Name Measure Steward NQF # CCBHC Demonstration Measure CMS Medicaid Core Set CCBHC QBM
Housing Status (HOU) SAMHSA NA Yes NA NA
Suicide Attempts (SU-A) SAMHSA NA No NA NA
Patient Experience of Care Survey (PEC) SAMHSA NA Yes NA NA
Youth/Family Experience of Care Survey (Y/FEC) SAMHSA NA Yes NA NA
Follow-Up After Emergency Department Visit for Mental Illness (FUM) NCQA NA Yes NA NA
Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA) NCQA NA Yes NA NA
Plan All-Cause Readmission Rate (PCR-BH) NCQA 1768 Yes Adult Core NR
Diabetes Screening for People with Schizophrenia or Bipolar Disorder who Are Using Antipsychotic Medications (SSD) NCQA 1932 Yes NA NA
Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (SMI-PC) NCQA 2607 No NA NA
Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) NCQA NA No NA NA
Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC) NCQA 1933 No NA NA
Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (AMS-BD) CMS 1880 No NA NA
Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA-BH) CMS NA Yes Adult Core R
Follow-Up After Hospitalization for Mental Illness, ages 21+ (adult) (FUH-BH-A) NCQA 0576 Yes Adult Core R
Follow-Up After Hospitalization for Mental Illness, ages 6 to 21 (child/adolescent) (FUH-BH-C) NCQA 0576 Yes Child Core R
Follow-up care for children prescribed ADHD medication (ADD-BH) NCQA 0108 Yes Child Core NR
Antidepressant Medication Management (AMM-BH) NCQA 0105 Yes Adult Core NR
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET-BH) NCQA 0004 Yes Adult Core R

On October 19, 2015, SAMHSA awarded 24 states funding to develop plans for CCBHCs and prepare applications to participate in a two-year demonstration program. Each state was awarded between about $800,000 to $900,000. At the end of the planning period, SAMHSA will select eight of the 24 states to participate in the demonstration program, which will begin in January 2017. The 24 states will use the funding to ensure that community behavioral health clinics that apply to become “certified” meet the criteria for the CCBHC staffing mix; service access and availability; coordination of services; the scope of services, quality improvement and reporting requirements; and organizational, authority, governance, and accreditation.

PsychU reported on this topic in “24 States Awarded Planning Funds For Federal Certified Community Behavioral Health Center Demonstration,” which published on February 5, 2016.

For more information, contact: Brad W. Stone, Director, Office of Communications, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Room 8-1029, Rockville, Maryland 20857; 240-276-2130; Fax: 240-276-2135; Email: Bradford.Stone@SAMHSA.hhs.gov; Website: www.samhsa.gov.

Signed on April 16, 2015 by President Obama, the Medicare Access and CHIP Reauthorization Act (MACRA) provides funding for the Children’s Health Insurance Program (CHIP) through 2017 and makes sweeping reforms to Medicare physician reimbursement (see Congress Reauthorizes CHIP Through September 2017). Additionally, MACRA:

  • Extends certain special payment add-ons for Medicare provider organizations, such as the ambulance add-ons and increased inpatient hospital payment adjustment for certain low-volume hospitals
  • Extends funding for abstinence education, the personal responsibility education program, the health care work force demonstration program, and other programs
  • Disallows Medigap plans, which cover 100% of out-of-pocket costs beginning with the first dollar
  • Increases Medicare premiums for beneficiaries with higher income beginning in 2018

The largest provision of MACRA, and the one that is getting all the attention, is the Quality Payment Program, which replaces the use of the sustainable growth rate to adjust physician payments. The Quality Payment Program applies to physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists participating in Medicare Part B. Within the program, there are two components eligible clinical professionals can participate in: the Merit-Based Payment System (MIPS) and the Alternate Payment Model (APM). Both components focus on moving from payment for services to payment for quality and value.

MIPS: The MIPs model applies to individual clinical professionals or group practices and will make positive, negative, or neutral adjustments to Medicare payments. Payment adjustments will be calculated using a weighted composite score compared to the MIPS performance threshold. The composite score consists of four categories: quality, resource use, clinical practice improvement activities, and advancing health care information. Payment adjustments will start at four percent in 2019 and eventually rise to nine percent in 2022. In 2026, in addition to the MIPS payment adjustment, the fee schedule will be increased .25% each year.

Quality is worth 50% of the composite score under MIPS, and as such, is one of the most important categories clinical professionals and group practices will report. Scoring on quality performance will be based on six measures that each clinician or group chooses from a list of proposed measures. At least one measure must be cross-cutting and one measure must be an outcome or high-value measure. Examples of measures clinical professionals and group practices can select include Diabetes: Hemoglobin Ale (HbAlc) Poor Control; Anti-Depressant Medication Management; Screening for Osteoporosis for Women Aged 65- National Clinical Registry 85 Years of Age; etc. Additionally, clinical professionals or groups can report on specialty measure sets, such as behavioral and mental health.

APM: The APM applies to individual clinical professionals or group practices participating in advanced alternative payment initiatives with nominal financial risk. This would include the following programs – Track 2 and 3 of the Shared Savings Program, the Next Generation ACO Model, Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus (CPC+), and Oncology Care Model. Clinical professionals or group practices who meet the Medicare beneficiary or payment thresholds set by the rule will automatically qualify to receive a five percent lump sum bonus on their Medicare Part B payments. The bonus will be available from 2019-2024. Beginning in 2026, APMs will receive a .75% fee schedule increase each year.

The long and the short of it is even those clinical professionals and provider organizations that have been trying to avoid value-based payment will be forced—through their compensation—to address the issue of relative cost and quality. MACRA is essentially assuming that every clinical professional and every provider organization participating in the Medicare program is, in fact, not paid just for volume.

So who are the likely winners and losers in new world of MACRA? MACRA will benefit:

Organizations already participating in alternative payment models who have made investments in metrics-based performance improvement will be at an advantage, as the new rule offers the opportunity for an additional bonus payment and a fee schedule increase.

Clinical professionals who have embraced the medical home concept in their practices will benefit from better performance that results in rate increases. CMS has made clear that they are in full support of patient centered medical homes – clinical professionals participating in this model receive full credit in the clinical practice improvement activities category. CMS also intends for the expanded medical home initiative under the Center for Medicare and Medicaid Innovation to be included as an advanced payment model whether or not provider organizations take on nominal financial risk.

Electronic health record (EHR) and analytics companies – MACRA will drive demand for EHR systems and systems with reporting capabilities that can be used to improve clinical practice and provider organization performance. And, time is short – there is about seven months to get ready for the first reporting year, which begins January 1, 2017.

Digital health solutions that can prove a return-on-investment in terms of achieving bonuses – Clinical professional practices and provider organizations will look at ways to optimize performance using technology, assuming that the bonuses exceed the cost of the technology.

There are also stakeholders that are going to be at a disadvantage in the new world of MACRA:

Clinical professionals in solo practices will struggle. In their impact study of the rule, CMS has estimated that 87% of clinicians in solo practice will face negative payment adjustments under the MIPS model. And CMS’ estimates show that the more clinical professionals in a group, the less likely they are to face negative payment adjustments. For groups with 10 to 24 clinical professionals, 59.4% are expected to face negative payment adjustments while only 18.3% of groups of a 100 or more are expected to receive negative payments.

Provider organizations in limited-risk APMs without real-time performance management systems will also be at a disadvantage. Those organizations will be less likely to achieve bonus payments – and will suffer from relatively flat payment rates.

The Track One Shared Savings ACOs won’t get an opportunity for enhanced payments. ACOs participating in track one of the Shared Shavings Program have been excluded from the advanced payment model because they do not have an opportunity to share risk. Clinical professionals under this model will participate in MIPs and eventually receive less favorable incentives as they are excluded from the bonuses in the APM.

Hospitals with higher than average operating margins in 2008 did not have consistently better outcomes on Medicare mortality rate measures from 2008 through 2011 for acute myocardial infarction (AMI) or pneumonia. Hospitals with higher than average operating margins had a modest increase in their mortality rates for congestive heart failure (CHF).

These findings were reported in “Relationship Between Hospital Financial Performance And Publicly Reported Outcomes” by Oanh Kieu Nguyen M.D., MAS; Ethan A. Halm M.D., MPH; and Anil N. Makam M.D., MAS. The researchers sought to assess the relationship between hospital financial performance and publicly reported outcomes of care, and to assess whether improved outcome metrics affect subsequent hospital financial performance. They conducted an observational study using audited financial data from the 2008 and 2012 Hospital Annual Financial Data Files from the California Office of Statewide Health Planning and Development (OSHPD). That data from OSHPD was merged with data on outcome measures publicly reported by the federal Centers for Medicare & Medicaid Services (CMS) via the Hospital Compare website for July 1, 2008 to June 30, 2011.

The analysis included all general acute care hospitals (279 participating hospitals) with available OSHPD data in 2008 and at least one publicly reported outcome from 2008 to 2011. Hospital financial performance was measured in three ways: net revenue by operations, operating margin, and total margin. Outcomes were 30-day risk-standardized mortality and readmission rates for AMI, CHF, and pneumonia. Additional findings were as follows:

The researchers concluded that robust financial performance for a given hospital is not associated with improved publicly reported outcomes for AMI, CHF, and pneumonia. They noted that financial incentives in addition to public reporting, such as readmissions penalties, may help motivate hospitals with robust financial performance to further improve on the publicly reported outcomes.

The full text of “Relationship Between Hospital Financial Performance And Publicly Reported Outcomes” was published online on February 29, 2016, by Journal of Hospital Medicine.

For more information, contact: Russel Rian, Assistant Director of Public Relations, Communications, Marketing, and Public Affairs, UT Southwest Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-8519; 214-648-3404; Email: Russell.Rian@utsouthwestern.edu; Website: www.utswmedicine.org; or Oanh Kieu Nguyen, M.D., Southwest Medical Center, University of Texas, 5323 Harry Hines Boulevard, Dallas, Texas 75390-9169; 214-648-3135; Fax: 214-648-3232; E-mail: oanhk.nguyen@utsouthwestern.edu.

Poor patient engagement is a well-known obstacle in the pursuit of better health care outcomes – an obstacle with mounting costs in our value-based market. The consumers who are actively involved in their health care experiences (i.e., engaged) show better outcomes and lower costs, while the consumers who are the least engaged have health costs averaging between eight percent and 21% higher than the highly engaged consumers (see Consumer Engagement Is The Missing Piece In Population Health). And we have covered this challenge before.

The transition to a new model of value-based financing and service delivery means that provider organizations need to consider a new way of thinking about consumer relationships as our system evolves. A big part of consumer engagement is about getting consumers to be part of their own “care team” – to be involved in the decisions about their care, to understand their provider options, and to be actively involved in their treatment planning. Efforts to increase engagement are about efforts to affect the probability of an individual making a preferred choice. This means engaging consumers is a big part of population health. Guiding the consumer to make the “preferred” choice within this value-based system has four key elements:

  1. Relevance – The marketing process needs to convince a health care consumer that the preferred choice is important, despite any possible stigma.
  2. Convenience – The preferred choice needs to be as easy to make as possible, including easy to use tech functionality.
  3. Reinforcement – The preferred choice needs to be acutely rewarding, through incentives that reward incremental progress.
  4. Support – Consumers will need help making the preferred choice, through health coaching and integration into clinical treatment.

solving for engagement

For every patient engagement strategy, there is some tech tool that can affect the value equation. Where does computerized cognitive behavioral therapy (cCBT)  fit into a long list of many “preferred tech choices” of consumers (see Consumer-Directed Therapies – Where Consumer Use Has Outpaced Science), as well as payers (see Digital Medicine From The Payer Perspective)? This was the topic of the session, “Treatment Technology From The Payer Perspective: How UPMC Is Using Computerized Cognitive Behavioral Therapy For Population Health”, given by Ellen Beckjord, Ph.D., MPH, Director, Population Health Program Design & Engagement Optimization, UPMC Health Plan last week at The 2016 OPEN MINDS Strategy & Innovation Institute. Dr. Beckjord discussed the importance of patient engagement and how tech-based treatment systems, like cCBT program Beating the Blues are coping with the engagement challenge.

The question – how do executive teams leverage the power of those options, and where is it appropriate to do that? The first thing to recognize is that the “all health care is local” paradigm is shifting and that technology is what is shifting it. And when consumers are no longer local (whether that means they are no longer “in the building” or they are spread out over wide and multiple geographic areas), that means there will be more competition for those consumers.

It turns out that despite the mounting evidence for its efficacy, cCBT is not (yet) for everyone – with a completion rate of less than 10%, as the steadily declining continuation rates shared by Dr. Beckjord show. Dr. Beckjord also noted, “Even though we see positive outcomes for those completing the program, the vast majority of consumers are still dropping out of the program. This is an example of, if you build it, there is no way these people will come.” But when treatment happens, it is successful – so far, Beating the Blues is seeing large decreases in both depression and anxiety.

results 2014

Solving the problem of patient engagement is especially pertinent for provider organizations – even those that have not taken the step to adopt that next big tech tool. If you can’t keep people engaged in your services, you are going to fail to achieve either the outcomes or the cost savings needed to maintain the necessary payer relationships (see ‘Winning The Game’), or anywhere else that health participation is important, including care coordination.

Looking forward, keep your eye on two issues. One issue is how are the new tech-enabled services integrated into “best practice” clinical services? The second, how the “data” from tech-enabled service transactions is integrated into consumer health records in electronic health recordkeeping systems.

What is the likely impact of pay-for-value on mental health treatment? What are the effects of these changes on the organizations serving consumers with mental health disorders? How do we assure quality mental health service delivery in a changing health and human service financing landscape?

Those three questions were the focus of today’s web briefing, “Quality Mental Health Care In A Value-Based Environment: Keeping The Vision Beyond Mental Health Month”, that I co-presented with Askesis’ Vice President of Technology and Business Development, Robert Teitt. The quality issue is critical. But health plan managers and clinical professionals alike agree that the measures of what is “quality” mental health are far from settled (see A Few More Drops In The Performance Measurement Bucket).

Our team sees three drivers of the measurement of quality (and value) in the current environment. First, what consumers think matters more than ever before. Consumer expectations are changing and ushering the era of “consumer sovereignty” (see Consumer Sovereignty As Success Strategy and Another Look At Consumer Sovereignty). Consumers of all kinds of health services have come to expect “more” – not only “best practice” treatment but also personalization, convenience, and great experience.

Then, there is the “trickle down” effect of health plan ratings. With the majority of the U.S. population getting their health services through health plans, the health plan ratings are more important than ever. Consumers rely more than ever on ratings to select a health plan – and health plan managers are focused on the services and provider organizations that can improve those ratings. Whether the ratings are based on the “right” measures of quality is another story. (For more on the effect of The National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) and the Centers for Medicare & Medicaid Services (CMS) STARS rating systems, check out Are You Suffering From Measurement Fatigue? ).

Finally, there is the new era of transparency brought to us by an ubiquitous internet. Whether curated like the CMS STARS site, which rates health plans, hospitals, nursing home, or more (to see for yourself, check out Hospital Compare from Medicare.gov), or the open source sites that crowdsource ratings like Yelp – the ratings are available for all to see – and that gets attention. This is a new context for the “quality” issue.

But beyond the issue of how the measurement of quality is changing, there are other factors to consider in forecasting what is “to come” in mental health treatment. So what are the proverbial “tea leaves” of the future treatment system? First there is the continued move of services to community-based settings. The use of “residential” levels of care as a health care intervention continue to decline as technology and flexible funding make more service delivery possible in consumers’ homes. But, we will see more consideration of “residence” (as in housing) as a factor in health care (see Is Housing Health Care? and Residential Care ‘Repackaged’).

Another factor is that technology is creating the era of “mental health care everywhere” with screening kiosks in grocery stores (see Crowdfunding Campaign Funds More Behavioral Health Screening Kiosks In Philadelphia), the proliferation of tech-enabled clinical services (see The Telehealth Market – Now, Soon & Future), mental health care management on mobile platforms (see Primary Care Goes Virtual & On-Demand), and tech-enabled mental health in retail locations (see What To Make Of The Popular Press Romance With Tech-Delivered Therapy and Walgreens To Offer Behavioral Health Services Nationwide Through MDLIVE Collaboration). Whether tech-enabled services are viewed as “good” or “bad,” they are here to stay.

This very technology is remaking the traditional model of case management for supports for consumers with complex needs. The focus on a model that is primarily face-to-face services will likely morph into a hybrid model using tech-enabled platforms that allow consumer self-direction and leverage analytics to determine the type and frequency of care coordination supports. And, this technology will likely change the preferred model for primary care/behavioral health integration. The “one-stop shop” with co-located services will become, for some consumers, the one-stop experience – with disparate health care professionals collaborating in real time on a consumer’s care using virtual tools.

The Medicaid health home option was established under the Patient Protection and Affordable Care Act of 2010 and implementation began in 2011. In this webinar hear from two experts – one representing a payer and one from a provider—about how these programs are working to coordinate the physical and behavioral needs of vulnerable consumers. Presenters Carole Matyas, Vice President of Behavioral Health Operations, WellCare Health Plan; and Katie Arjes, Director, Integrated Health Home Program, Unity Point Health – Blackhawk Grundy Mental Health Center, provide on-the-ground information on what may work and what barriers can arise.

Nursing homes are getting more attention these days for a few reasons. First, the costs – in 2014, spending on freestanding nursing care facilities and continuing care retirement communities reached $155.6 billion, or an increase of 3.6% from 2013. In 2015, the median annual cost for a private room in a nursing home was $91,250 (with a median daily cost of $250), and the median annual cost of a semi-private room was $80,300 (with a median daily cost of $220). And of all health care costs for the population over the age 85, nursing home care ranked as the highest expense, with an average annual cost of $24,185.

Second, nursing homes are the “residence” for a high number of individuals with mental illnesses. Over 500,000 persons with mental illness (excluding dementia) reside in U.S. nursing homes on a given day, significantly exceeding the number in all other health care institutions combined (see “Mental Illness In Nursing Homes: Variations Across States” from the National Center for Biotechnology Information). And, the Pre-admission Screening and Resident Review (PASRR) programs identified that in 2013, 17.5% of new admissions to nursing homes were assigned ICD codes for anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, or post-traumatic stress disorder (see “2014 PASRR National Report A Review of Preadmission Screening and Resident Review (PASRR) Programs” from Medicaid.gov).

Finally, as policies about long-term services and supports are shifting, there is more focus on the consumers “living” in nursing homes and how to facilitate their return to the community. In 2013, we saw the majority of Medicaid long-term services and supports (LTSS) funding shift from institutional care to home- and community-based services (HCBS) for the first time. In 2013, 51.3% of the $146 billion in total federal and state Medicaid expenditures for LTSS were HCBS – compared to 2008, when only 25% of Medicaid LTSS spending was for HCBS and the remaining 75% was for institutional care in nursing homes (see Where Are We With Managed Long-Term Services & Supports?).

Which brings us to the question of nursing home performance. The Centers for Medicare & Medicaid Services (CMS) launched its Nursing Home Compare website in 1998 for the 17,000 nursing homes that participate in Medicare or Medicaid, and began its 5-star rating system for nursing homes in 2008 (see “Medicare Nursing Home Compare” from Medicare.gov). Currently, the core indicators for nursing home performance include information from health inspections, staffing ratios, and five short-stay measures (residents in an episode whose cumulative days in the facility is 100 days or less in the quality reporting period) and 13 long-stay measures (residents in an episode whose cumulative days in the facility is 101 days or more in the quality reporting period) (see “Nursing Home Quality Initiative Quality Measures” from the Centers for Medicare & Medicaid Services).  Examples of those measures include:

Short Stay Quality Measures:

  • Percent of residents who self-report moderate to severe pain (short stay)
  • Percent of residents with pressure ulcers that are new or worsened (short stay)
  • Percent of short-stay residents who newly received an antipsychotic medication

Long Stay Quality Measures:

  • Percent of residents who were physically restrained (long stay)
  • Percent of residents who have depressive symptoms (long stay)
  • Percent of long-stay residents who received an antipsychotic medication

In April 2016 (see “Further Improvements to the Nursing Home Compare Five-Star Quality Rating System” from the Centers for Medicare & Medicaid Services), CMS will begin posting data for six new quality measures (QMs) on Nursing Home Compare:

  1. Percentage of short-stay residents who were successfully discharged to the community
  2. Percentage of short-stay residents who have had an outpatient emergency department visit
  3. Percentage of short-stay residents who were re-hospitalized after a nursing home admission
  4. Percentage of short-stay residents who made improvements in function
  5. Percentage of long-stay residents whose ability to move independently worsened
  6. Percentage of long-stay residents who received an ant-anxiety or hypnotic medication

How has this CMS initiative improved nursing home performance? That has become a tricky question to answer. Over the last few years, the program has met with criticism that too many nursing homes – including many with poor performance – were gaining four and five stars (see “Medicare Star Ratings Allow Nursing Homes To Game The System” from The New York Times). In response, CMS is changing the star ratings – where previously 78% of nursing homes scored 4 or 5 stars in the Quality Measures category and 54% had either 4 or 5 stars overall, now the star ratings are curved and “five stars” are reserved for only the 10% of nursing homes with the highest scores in the state health inspections, and “one star” is reserved for the 20% of those SNFs that score the lowest. The rest of the nursing homes are then evenly assigned between 2, 3, and 4 stars (see “Reading The Stars: Nursing Home Quality Star Ratings, Nationally and By State” from The Henry J. Kaiser Family Foundation).

Nursing Home Ratings

Example of Nursing Home Star Ratings For Three Facilities In The Gettysburg, Pennsylvania Area

What is the practical effect of these star ratings? What immediately jumps to mind is consumer choice. For consumers and family members who are in need of skilled nursing care, the star rating is a helpful tool in sorting through the many options – and means that many nursing homes who aren’t performing will see increased competition in their market.

And recently, CMS has upped the ante, so to speak. The new Medicare bundled payment program for joint replacement, the Comprehensive Care for Joint Replacement (CJR) program, is going to make the stars program more important than ever for nursing homes. Under the new bundled payment model, hospitals are responsible for the costs from the time of the surgery through 90 days after hospital discharge – and CMS has waived the three-day stay rule allowing consumers to be discharged from a hospital to a SNF. The caveat is the nursing home must have a rating of three or more stars for at least seven of the previous 12 months. Data shows that currently, one in three SNFs are ineligible for the waiver (see “1 in 3 SNFs In Bundled Payment Test Areas Won’t Qualify For Three-Day Stay Waiver” from McKnight’s Long-Term Care News). The analysis estimates that in some test areas, up to 80% of facilities would be barred from the waiver due to their low star rating (see “What CMS’ New Comprehensive Care for Joint Replacement (CJR) Model Means for Long-Term Care Providers” from On Shift).

Last week, I took a look at how hospitals are stacking up when it comes to meeting the Centers for Medicare and Medicaid Services (CMS) 5-Star Rating System definition of performance (see Consumer Star Ratings For Hospitals – It’s Only Going To Get Harder To Earn Those 5 Stars). But it is one thing to report on the performance of provider organizations in the interests of consumer transparency – it’s another to see if those performance measures are actually changing provider organization performance. With regard to the performance measures in the Medicare Hospital Value-Based Purchasing (HVBP) program and Hospital Readmissions Reduction Program, the simple answer is “no” and “no,” respectively.

Medicare Hospital Value-Based Purchasing Program

On October 1, 2012, CMS launched its Hospital Value-Based Purchasing (HVBP), which adjusts what CMS pays hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of care they give patients. Hospitals not paid through this system, such as critical access hospitals, are not subject to payment adjustments by the HVBP program.

The financial model of the program is that Medicare withholds a percentage of acute-care hospital payments and puts the money into a value-based purchasing pool. Hospitals submit quality data for the prior performance year, which determines whether the next year’s payment rate is increased or decreased. In fiscal year (FY) 2016, Medicare will withhold 1.75% of each hospital’s Medicare base operating Diagnosis Related Group payments for contribution to the value-based purchasing pool – an increase from FY 2015, when the withhold was 1.5% (see “Hospital Value-Based Purchasing” from Medicare.gov). CMS estimate that the total amount available for value-based incentive payments in FY 2016 will be approximately $1.5 billion (see “Fiscal Year (FY) 2016 Results for the CMS Hospital Value-Based Purchasing Program” from The Centers for Medicare & Medicaid Services).

The performance measures for the program fall in four quality domains that make up a Total Performance Score (TPS):

  • 10% – Clinical process of care
  • 25% – Patient experience of care (Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score)
  • 40% – Outcomes (hospital mortality measures for acute myocardial infarction, heart failure, and pneumonia, the central line-associated bloodstream infection measure, the catheter associated urinary tract infection measure, the surgical site infection strata, and the AHRQ PSI-90 Composite)
  • 25% – Efficiency (Medicare spending per beneficiary)

What kind of improvements has this program brought to hospital quality and performance? The answer is, not much. In October 2015, The U.S. Government and Accountability Office (GAO) issued a report that concluded that the initial results of the program showed “no apparent shift” in hospitals’ performance trends on the quality measures included in the HVBP. After analyzing the first three years of the HVBP program (2013 – 2015), the GAO found that “officials from selected hospitals reported that the HVBP program reinforced their ongoing quality improvement programs without leading to major changes.”

Number and amount of hospital value-based purchasing bonuses

However, there is still hope for the future. Overall, the GAO determined that while the HVBP program hasn’t resulted in major changes in quality yet, improvements may be seen in the future as the program continues to evolve (see “Initial Results Show Modest Effects on Medicare Payments and No Apparent Change in Quality-of-Care Trends” from the U.S. Government Accountability Office).

Hospital Readmissions Reduction Program

The Medicare Hospital Readmissions Reduction Program also began on October 1, 2012 and is designed to reduce Medicare payments to IPPS hospitals with excess readmissions. CMS defines readmission as an admission to a hospital within 30 days of a discharge from the same or another hospital. Excess readmissions are measured by dividing a hospital’s number of “predicted” 30-day readmissions for heart attack, heart failure, pneumonia, hip/knee replacement, and chronic obstructive pulmonary disease (COPD) by the number that would be “expected,” based on an average hospital with similar patients – ratio greater than one indicate excess readmissions (see “Hospital Readmissions Reduction Program” from Medicare.gov). In FY 2016, the maximum penalty for excess readmissions was three percent – an increase from the maximum penalty of one percent in 2013 and two percent in 2014.

What kind of improvements has this program brought to hospital quality and performance? The answer seems to be that hospitals are going in the wrong direction. According to a compilation of the statistics by the American Hospital Association (see “Rethinking the Hospital Readmissions Reduction Program” from The American Hospital Association), the percent of hospitals incurring a HRRP penalty has increased between 2013-2015, and the percent of hospitals not incurring a penalty has shrunk:

  • 2013 – 63% of hospitals penalized, and 37% not penalized
  • 2014 – 64% of hospitals penalized, and 36% not penalized
  • 2015 – 76% of hospitals penalized, and 24% not penalized

The results for 2016 don’t look to be any better, as only 23.5% (799) of the 3,400 hospitals subject to the HRRP program will face no penalty in the coming year – and thirty-eight hospitals will be subject to the maximum three percent reduction (see “Most Hospitals Face 30-day Readmissions Penalty In Fiscal 2016” from Modern Healthcare).

What does this data from CMS tell us about the move towards performance? Progress is slow – but I would argue that we’re still at the beginning of the process. It has been less than four years since CMS implemented these value-based programs for hospitals – with growing financial penalties each year. But change doesn’t happen overnight – even with financial incentives, it takes time to cultivate a performance-driven culture. As Monica Oss has discussed before, the move to value-based contracting is “really, really easy to say and really, really hard to do” (Moving To Value – Easy To Say & Hard To Do).  I think what we are witnessing now is the period of transition where hospitals and other provider organizations are creating the metrics-based management tools they need and building a culture that is focused on performance management.

According to Shirley Repta, Ph.D., Chief Executive Officer, The Pavilion at Williamsburg Place, flaws in developing this culture often include poor care continuation – she writes:

I do believe that a big part of the problem with satisfaction scores are – in our attempt to cut costs and improve efficiencies, we made the experience for patients much like being on an assembly line. The continuity of care between providers is poor. The advent of hospital programs provided efficiencies and reduced length of stays, while often leaving patients confused and feeling that no one is actually managing their care. In fact I have seen many instances in the hospital setting where things really were not followed up on – a patient was not moved forward effectively because one doctor was handing things off to another, and no one had a good overview of the patient’s entire needs. 

OPEN MINDS Senior Associate, George Braunstein identifies two major issues that make it difficult for hospitals to make the necessary cultural transition to performance focused operations – he writes:

First of all, hospitals are designed and run as episodic care organizations. Some have moved to change that culture, but just as the community system struggles to move away from their old models, there are few hospital systems that have been fully able to make the changes necessary. Secondly, hospitals struggle to engage physicians in these new models. Because the system, especially hospital-based care, is designed around the medical model, they are trying to engage a group that does not change practice models and culture easily. My hypothesis is that the system will stumble but eventually find a way to work with this. However, it will not be easily done and it won’t help that they will have a growing population of demanding and educated baby boomers who want value, but also want some parts of the old model.

As hospitals work to make this transition, there are also new business opportunities for community-based provider organizations – reducing readmissions and improving consumer experience requires more in-depth care coordination and engagement with organizations and professionals in the community. Community-based organizations have the opportunity to position their organization to be a partner to hospitals in performance improvement with new service lines and programs designed to better serve consumers in the community.

Specialty mental health service use by commercially insured consumers diagnosed with serious mental illnesses (SMI), such as depression, bipolar disorder, or schizophrenia changed very little after the Mental Health Parity and Addiction Equity Act (MHPAEA) went into effect for plan years starting July 1, 2010. During the year after the MHPAEA went into effect, the average consumer with one of the three mental health conditions had 0.339 fewer visits to a psychiatrist compared to the year before. There were no significant changes in the number of visits to a psychologist or to another type of mental health professional.

These findings were reported in “Mental Health Parity’s Limited Impact on Utilization and Access for Health Plan Beneficiaries” by Benjamin F. Miller, PsyD; Molly A. Nowels, MA; Lynn M. VanderWielen, Ph.D., MPH; and R. Mark Gritz, Ph.D. The researchers were awarded a grant through the Health Care Cost Institute’s (HCCI) State Health Policy Grant Program. The grants were awarded to six projects analyzing how states are implementing the provisions of the federal Patient Protection & Affordable Care Act of 2010 (PPACA) and other reforms to improve their health care systems. The research projects were done by independent researchers using HCCI’s repository of commercial claims data for over 50 million insured Americans.

For this project, the researchers focused utilization changes for commercially insured consumers diagnosed with three conditions that are often seen in mental health settings. They compared the utilization patterns of beneficiaries in states with minimal parity laws prior to MHPAEA to utilization patterns of beneficiaries in states with comprehensive parity laws. For this analysis, the researches included commercially insured consumers enrolled in the same plan and living in the same state from July 1, 2009 through December 31, 2011. Consumers were identified as having one of the three mental health conditions if they had either two outpatient claims or one inpatient claim with the diagnosis codes for depression, bipolar disorder, or schizophrenia. The number of annual visits to a psychiatrist, psychologist, or other mental health professional from July 1, 2009 to June 30, 2010 was compared to the number of annual visits from January 1, 2011 to December 31, 2011. The report does not present the raw data outcomes of the comparisons; it reports only the researchers conclusions.

The researchers said the number of visits to mental health professionals in states that had minimal parity laws prior to implementation of the MHPAEA did not increase later as would be expected if parity had increased access to care. In states that had better parity laws before the MHPAEA, the data indicated a decrease in number of visits to a psychiatrist and visits to other mental health professionals. The researchers noted that previous studies had found similar effects. They concluded that parity laws may not have had their intended effect of increasing access and utilization of mental health services. They recommended that additional policy efforts focus on strengthening enforcement of the MHPAEA and supporting alternative access points, such as primary care, for mental health care beyond specialty mental health settings. Further, they recommended that the adequacy of the mental health workforce be assessed to ensure that enough professionals are located to address community need.

For more information, contact: Health Care Cost Institute, 1100 G Street NW, Suite 600, Washington, District of Columbia 20005; 202-803-5200

The online rating platform Yelp may complement the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The domains included in Yelp reviews correspond to the majority of HCAHPS domains. Plus, Yelp reviews covered an additional twelve domains related to patient- and caregiver-centered experiences not found in HCAHPS. However, the majority of Yelp topics that most strongly correlate with positive or negative reviews are not measured or reported by HCAHPS.

These findings were reported in “Yelp Reviews Of Hospital Care Can Supplement And Inform Traditional Surveys Of The Patient Experience Of Care” by Benjamin L. Ranard, Rachel M. Werner, Tadas Antanavicius, H. Andrew Schwartz, Robert J. Smith, Zachary F. Meisel, David A. Asch, Lyle H. Ungar, and Raina M. Merchant. The researchers analyzed data from the June 2012 to June 2013 HCAHPS survey from the Hospital Compare data set. They identified hospitals on the list in the data set, removed those that lacked American Hospital Association (AHA) annual survey data,and then checked Yelp reviews for each of the hospitals that were posted as of July 15, 2014. The researchers excluded reviews that Yelp flagged as possibly fake. To identify the topics of the Yelp reviews, the researchers used natural language processing methods to identify co-occurrences of words in text. The topics were assigned to HCAHPS domains. Only 1,352 hospitals had Yelp reviews.

The researchers used data from the AHA annual survey to describe hospitals by number of beds, region, teaching status, and ownership. These characteristics have previously been linked to HCAHPS scores. Then they correlated the mean Yelp review rating of each hospital with the HCAHPS survey’s overall hospital rating for each hospital. There were 4,681 hospitals in the Hospital Compare data set, and 1,451 of these hospitals had Yelp reviews (with a total of 18,058 Yelp reviews). Of the 4,681 hospitals in Hospital Compare, 4,360 hospitals had AHA data, and of these hospitals, 1,352 (31 percent) had Yelp reviews. In aggregate, the final cohort of 1,352 hospitals had 16,862 Yelp reviews, with a median of four Yelp reviews per hospital.

The researchers found that Yelp measures and analysis can also provide actionable feedback for hospitals. While the domains included in Yelp reviews covered the majority of HCAHPS domains, Yelp reviews covered an additional twelve domains not found in HCAHPS. The researchers concluded that by analyzing Yelp postings with natural language processing methods, it is also possible to identify for policy makers the measures of hospital quality that matter most to patients and caregivers. The 12 domains in Yelp hospital reviews not found in HCAHPS are as follows:

  1. Cost of hospital visit
  2. Insurance and billing
  3. Ancillary testing
  4. Facilities
  5. Amenities
  6. Scheduling
  7. Compassion of staff
  8. Family member care
  9. Quality of nursing
  10. Quality of staff
  11. Quality of technical aspects of care
  12. Specific type of medical care

To see Yelp hospital reviews for Philadelphia – http://www.yelp.com/search?find_loc=Philadelphia,+PA&cflt=hospitals (accessed May 2, 2016).

The full text of “Yelp Reviews Of Hospital Care Can Supplement And Inform Traditional Surveys Of The Patient Experience Of Care” was published April 2016 issue of Health Affairs.

For more information, contact: Raina M. Merchant, M.D., Department of Emergency Medicine Leadership & Faculty, Penn Medicine, 423 Guardian Drive, 13 Blockley Hall, Philadelphia, Pennsylvania 19104; 215-662-4000; Email: Raina.merchant@uphs.upenn.edu; Website: www.med.upenn.edu/apps/faculty/index.php/g321/p8145916.

Will value-based reimbursement really happen? And, if it does, will it be sustainable for our organization? This was the “big theme” in my many discussions with executives at this year’s 2016 OPEN MINDS Performance Management Institute.

The question of whether value-based reimbursement “will really happen” is in the context of provider organization executives who say they are “prepared” but can’t get health plans to pull the trigger on their new and innovative program ideas. That is in contrast to my many conversations with health plan executives who are planning to move ahead with value-based reimbursement – but express doubts that they can find provider organizations with the management competencies and infrastructure they need to proceed. For more, see What Do You Need To Demonstrate & Manage Your Value?.

For the specialty provider organizations serving complex consumers, the use of value-based reimbursement is just in the early stages – our recent OPEN MINDS survey found that 15% of behavioral health and social service organizations are in some type of value-based payment arrangement. For most organizations in the survey, this represents less than 20% of their overall organizational revenue. This is a contrast to primary care and acute care where the use of pay-for-performance is higher.

The question of sustainability of value-based reimbursement for service provider organizations is a separate issue. There is the issue of readiness for managing “risk” contracts – If Capitated Contracts Are In Your Future, Then What? and Three Competencies For Risk-Based Contracting: Advice From An Executive Who Is There. And, the issue of capitalizing the development of this infrastructure – The Business Model Transition To Value-Based Care. But even with the capital and the competencies, managing for “value” requires a change in organizational culture – Performance Management Needs Performance-Driven Leaders.

I asked my colleague Jamie Stewart, Chief Administrative Officer of Grafton Integrated Health Network and chair of the OPEN MINDS Performance Management Institute, about the readiness and sustainability of organizations in the field – he noted that the field is not as ready for value-based reimbursement as its executives would like to believe.

I think the most surprising thing to me from this year’s institute was not as much from the provider side, as from the payer side. I thought – and many others I have spoken with also thought – that the payers were further along in readiness (and willingness) to accept value-based and risk-based contracting and had a clearer understanding of what risk they would be sharing or asking us, as providers, to take on.

A lot of comments I’ve heard showed providers’ disdain for the payers. Behavioral health providers think they are terminally unique, that they are unequivocally better at doing what they do than their competitors, and that they are further along than them. But I see that whole set of perceptions as a major weakness for our industry. Many executives think their organization is more prepared than they really are. When it comes down to actually operating in a value-based system, you have to ask: Have these organizations truly developed a system that allows them to capture data that can prove the desired result of the contract? Is the culture of their organizations truly understanding of a “do-less, make-more” model that focuses on quality outcomes vs. quantity of services? In many circumstances, the answer to those questions is no.

I think a lot of provider organizations in behavioral health “drink their own Kool-Aid,” and therefore perceive they are at a different place than they really are. And that is a problem because if they do try and fail, especially large systems, I can see the payers going a different direction. At the Healthcare Financial Management Association (HFMA) conference, I was struck by how the major health system executives have a professional relationship with payers that goes beyond just payer/provider. They have negotiated contracts and in that process, the payer knows the provider beyond just “someone who submits claims.” I do not think we have that in behavioral health, due to our lack of “material” size in the eyes of payers.

Jamie Stewart’s observation shows the need for a shift in strategic positioning for specialty provider organizations from “vendor” to “partner” of health plans (see The Business Model Transition To Value-Based Care). But to have a significant relationship with health plans, management teams of specialty organizations need to look beyond a narrow set of services and think broadly in terms of the consumer populations they serve. This means being willing to “own” all the services and supports needed for a specific group of consumers – to create a “value-added” service experience for consumers that is the basis for a “value-added” relationship with health plans.

Key Messages

  • The majority of patients with depression are seen in a primary care setting, where a visit-based, problem-centered approach is often taken toward diagnosis and management of anxiety and depression.
  • In this study, implementation of a collaborative care program for the management of primary care patients with depression and anxiety improved achievement of care plan goals, including ≥2 contacts per month with the clinic, 5-point improvements in Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder 7-item scale (GAD-7) scores, and improvement in depression and anxiety symptoms.

Earlier this month at The 2016 OPEN MINDS Performance Management Institute, we heard a lot from both payers and provider organizations about the system-wide move to value-based care. My takeaway from these sessions? To prepare, executives of provider organizations need to be able to both manage financial risk and demonstrate their “value” to payers in terms of both performance and cost. To do that, they need to act now to find a way to combine fiscal data systems with clinical performance management to produce the data they need to manage payer-mandated performance requirements and value-based contracts.

But the question many provider organizations are asking themselves is, how? There are two phases to preparing your system:

First, they need the ability to “integrate” that data in some form of data warehouse. Second, they need to understand what information they need for performance management and the ability to use that data warehouse to produce real-time actionable performance reports.

Value-based Data Dash 3-2-16

The data warehouse concept is about creating a system that pulls together all of your organization’s data into an integrated system. This includes your fiscal data, data from your electronic health record (EHR) system, payroll data, and clinical outcomes and wellness data. Many organizations have this data – but not in a way that allows it to be combined and analyzed together.

The data in your payroll and fiscal systems provide the raw data needed to track costs over time. But linking that cost data to the “outcomes” that your organization is achieving is more difficult. It is combining these two elements that allows the creation of a multidimensional array of data that lets you answer important questions that get to the heart of improving your organization’s performance: How do we run our business at the lowest possible cost? How do we achieve the highest possible outcomes? And how do we analyze the best practices that combines both?

So what are the actionable information that your team needs to manage value-based contracts?

  • Longitudinal Consumer Progress Reports – All of your consumers should have clear, meaningful, and replicable goals for their treatment. A goal progress report allows providers and stakeholders to see, at a glance, the progress an individual consumer, or group of consumers, are making (or not making). This report should include the consumer’s baseline rating and standard daily/weekly ratings, and direct comparison to expected trajectory to assess status.
  • Case Prioritization – Professionals, case managers, and supervisors should be able to identify cases with the greatest need and apply resources and support accordingly (as well as be held accountable to reducing risk and managing caseload effectively). Risk can be identified and sorted by various factors, such as individual risk (self-injury, suicidality, housing needs, etc.) and value-based risk (progress/outcomes lower than expected in relation to cost and service utilization).
  • Workforce management – Clinical supervisors and business managers should be able to make sure that cost is managed by ensuring that each service is provided by the most appropriate person. This means not having high-paid/degreed professionals providing basic services, unless the case warrants it due to risk. You can do this type of workforce management by examining staff roles, degrees, direct and indirect cost, services volume by type and cost, etc.
  • Risk Evaluation – Professionals and clinical directors should be able to evaluate weighted risk based on various variables, as well as how future changes to the numbers will affect cost and service needs based on advanced algorithms and/or predictive modeling.
  • Cap Rate/Case Rate Monitoring – Clinical directors, program directors, and other internal stakeholders should be able to see value in real time (progress/outcomes vs. cost) and use that information to make critical financial decisions and monitor specific contracts.

Of course, I would be remiss if I didn’t mention that having the reporting to track clinical, financial, and operational key performance indicators is not enough – but clinical and business managers need training in how to use data to analyze performance and develop and implement solutions.

Having the ability to use your financial and clinical data will allow you to “steer your own ship” – creating an organization that can demonstrate value and position your organization to compete.

It’s coming. Over the past couple of months, we’ve covered how all payers are introducing many variants of value-based reimbursement – Moving To Value – Easy To Say & Hard To Do and Pay-For-Value In Action. One of the big stories in the next 24 months will be the shift in payment methodology in the Medicare program – with $123 billion in spending moving to pay-for-value by 2018.

4-1-16 Target Percentage

While the payers are moving ahead with the speed and inevitability of glaciers, the bigger question is how ready is the service delivery system for these changes? The answer is, not as prepared as they should be. Here is a summary of a few of the recent surveys:

According to a 2015 survey of 165 health care providers by KPMG LLP, Alternative Payment Arrangements – Implications for the Finance Function, 85% of finance departments lack the “very sophisticated” capabilities needed to support capitation, bundled payments, and quality-based payments. Of respondents, 13% feel their financing department is “undeveloped” for risk management and accounting for innovate payment mechanisms (see “Healthcare Provider Finance Trailing New Demands Tied To Value-Based Contracts: KPMG Survey” from KPMG).

The 2015 HFMA’s Executive Survey: Value-Based Payment Readiness, surveyed 146 senior financial executives, comprising CFOs, vice presidents of finance, and finance directors, about where their organizations’ readiness is for value-based mechanisms and found that only 12% currently incorporate these payments and 40% don’t believe their organizations have the capabilities to succeed at value-based payments within the next three years (see “HFMA’s Executive Survey: Value-Based Payment Readiness” from The Healthcare Financial Management Association).

The 2014 Survey of U.S. Physicians from The Deloitte Center for Health Solutions surveyed 561 physicians to examine current levels of value-based care participation and found that 52% report having 10% or less of their compensation from value-based sources in the previous 12 months and expected this to stay the same for the next 12 months. While the survey didn’t gauge “readiness”, it found that 78% reported “contentment” with traditional salary and fee-for-service (FFS) payment arrangements (see “Perspectives From The Deloitte 2014 Survey Of U.S. Physicians” from Deloitte).

This situation is both a challenge and an opportunity. The challenge for payer and health plan executives is finding provider organizations that are ready for this shift to value-based reimbursement. The challenge for provider organization executives is building the required competencies. The opportunity is being able to create a sustainable system with value-based payments – and surviving what will be a very turbulent period in the market. The value-based payment models are moving ahead, with or without all of the provider organizations being either “ready” or “content” with the old reimbursement models.

For more on preparing your organization, check out these resources from the PsychU Resource Library:

  1. The Business Model Transition To Value-Based Care
  2. Pay-For-Value In Action
  3. Finding The New Opportunities With Health Plans
  4. Moving To Value – Easy To Say & Hard To Do

Over the years, I have seen some creative executive titles – “Director of First Impressions,” “Creator of Opportunities,” “Chief Amazement Officer,” and “Happiness Advocate” spring to mind. But a new title has cropped up on the health and human service market over the past decade: “Chief Experience Officer.” What does this position do? The short answer is, “improve the customer experience.”

But according to the recent Forbes article, “Does Your Brand Need a Chief Experience Officer?”, there is a lot more behind that simple answer – Steve Olenski writes:

The “Chief Experience Officer,” or CXO, is an increasingly prominent position in businesses today, due to an increasing disconnect customers often feel from the companies that they work with….The defined purpose of the CXO is to improve the customer experience (both internal as well as external), and if you’re finding a lack of engagement from your base, there might be a reason. Does your client experience need tweaking? It may well have a need, and having a CXO in modern business helps ensure that employees and clients feel good about the company they work with…

Over the past few months, our team has written a lot about the importance of the “customer experience” to organizational success. With increased competition from other provider organizations and health plans, more transparency in performance ratings and rankings, and a shift to value-based reimbursements, providing a positive customer experience for both your payers and consumers is paramount. This requires not only understanding who your customers are and what they want, but also aligning your business practices with what they value (see Consumer Sovereignty As Success Strategy and Another Look At Consumer Sovereignty).

So how to do this? Better customer service and a better customer experience. This involves understanding the current customer experience – and developing and managing a plan to improve it. And many health care organizations are finding that to give the customer experience its due, it’s necessary to designate an executive to be responsible for this function – the chief experience officer. As consultant Ingrid C. Lindberg said in “Chief Experience Officers Push Patients To Forefront” from Managed Care, “[health plans] put people in charge of costs and they put people in charge of care, but they don’t put anyone in charge of meeting the needs of patients or customers.” Sometimes the act of hiring a CXO can be symbolic in itself – having an executive designated as a CXO sends the message to consumers that their experience is important to the organization (see “New Seat in the Hospital C-Suite: The Rise of the Chief Experience Officer” from Becker’s Hospital Review). However, contrarians argue that the CXO is merely for show — and the consumer experience should be part of the organization’s entire strategy and the responsibility of all business units.

So if you have a CXO, what is their focus? According to a recent survey of CXOs working in the health care market, “CXO Responsibilities & Strategic Priorities: 11 Things To Know” from Becker’s Hospital Review, the following are the top five strategic priorities for CXOs:

  1. Relationship-based culture (including staff and physician awareness, engagement and communication)
  2. Experience improvement initiatives (including programs focused on access, rounding and physician communication)
  3. Strategy, leadership, and governance (including alignment and strategy)
  4. Measurement and analytics (including improving data sources and transparency)
  5. Patient and family voice (including patient and family engagement and advisory councils)

You may ask, what is the “return” on investing in the CXO position? It is amazingly simple to measure. Customer retention and customer volume can be measured – and the impact of good (or bad) customer experience on those metrics can also be measured. Putting it together creates your “customer experience ROI.” (For more, see “Customer Experience Competency #4 – Prove the ROI Connection between Experience and Growth” from Customer Bliss, by Jean Bliss.)

So who has a customer experience officer? I thought it was rare in health and human services, but a quick web search found lots of executives in these new positions:

  1. Beacon Health System (Lori Turner, Chief Marketing, Innovation & Customer Experience Officer)
  2. Cleveland Clinic (Adrienne Boissy, M.D., Chief Experience Officer)
  3. Maxim Healthcare Services, Inc. (Julie Judge, Chief Experience Officer)
  4. Capella Healthcare (Rita Croom, Senior Vice President & Chief Experience Officer)
  5. UC San Diego Health System (Thomas Savides, M.D., Chief Experience Officer)
  6. Johns Hopkins Medicine (Lisa Allen, Chief Patient Experience Officer)
  7. Adventist Health System ( Pam Guler, Vice President, Patient Experience)

And the list could go on…

Whether your organization has the size or the structure to support a “chief experience officer” position, managing your customer experience is not optional. Great consumer engagement and great customer service are increasingly critical to organizational sustainability. For more on building your organization’s consumer service, check out these resources from the PsychU Resource Library:

  1. Consumer Focused? Think Mass Customization
  2. The Business Model Transition To Value-Based Care
  3. How Can We Deliver A Seamless Primary Care/Behavioral Health Consumer Experience?

A few weeks ago, we covered a report issued by the Idaho Office of Performance Evaluations which found that in the two years since the Idaho Medicaid program moved mental health services to managed care, the program reduced spending on an annualized basis by approximately $28 million, or approximately 20%. The bulk of the savings came from reductions in psychosocial rehabilitation services (PSR) (see Idaho Medicaid Managed Behavioral Health Carve-Out Reduced Community-Based Costs).

The report noted that since the program’s implementation, total spending dropped from $22.3 million in July to August 2013, to $17.7 million in February to March 2015, with PSR spending dropping nearly by half. In August 2013, PSR costs were $6.95 million and other outpatient service costs were $4.11 million. In March 2015, PSR costs were down to $3.79 million and costs for other outpatient services were $5.39 million.

This data highlights some big successes for this type of managed care model, but it also leads to some questions – particularly about the reduction of PSR services. We know that the reduction in the utilization of more intensive, inpatient services saves money, but does it improve the quality of care for consumers?

After the Idaho story was released, I had a great conversation about this topic with Linda Hall, Executive Director of the Wisconsin Association of Family & Children’s Agencies. Ms. Hall discussed her experience with managed care in Wisconsin:

While I agree that managed care offers some care coordination that is helpful and in some areas provides access where there were few if any individual providers serving Medicaid enrollees, I see Wisconsin still suffering in terms of community-based mental health capacity due to the conversion to Medicaid managed care 20+ years ago and managed care companies’ approval/non-approval of services and limiting of provider panels. We lost important outpatient and residential care (for substance abuse) that has never been replaced. 

Hopefully managed care in 2016 will be done right and not result in further decreases in access to care. I keep up a drumbeat with our members on the importance of being managed care/health system friendly (provide what they need, have a well-functioning electronic health record, know your costs), but I still worry that the health systems will proceed with mental health care in ways that dismiss what we have learned about effective community support. More data on effective care would be good.

Ms. Hall makes some great points – and it all comes back to the idea that lowering costs is only one part of the equation when it comes to improving the health care system. The much-discussed goals of the “triple aim” are to improve overall health of the population, improve the quality and experience of care for consumers, and lower overall costs.

What I see is that the payers (like Medicaid plans) and health plans are moving away from traditional volume-oriented contracts to value-based care arrangements, and are trying to tie the cost reductions to improved outcomes and consumer experience. These value-based models come in many forms – accountable care organizations (see The Top 10 Medicaid ACO Performance Measures), bundled payment models (see The Latest Telehealth Example: Pay-For-Value), population-based payment models, and a variety of other capitated performance-based models (see If Capitated Contracts Are In Your Future, Then What?). And I believe these models are here to stay – which means that executives of provider organizations must find a way to work within this new financing system while developing a host of competencies that position them to work closely with managed care companies.

How? By finding ways to demonstrate your organization’s value. To do this, you first need to develop a relationship with the payers in your market. Consider what metrics they are tied to through Medicaid and Medicare and how you can help them to meet their performance requirements. Next consider your own programs and services. Look at your organization from a population-perspective, rather than just at a consumer level. Ask – How can you improve overall health for the community you serve? How can you align programs and services with the goals of the payers and health plans in your market?

The strategic implication is that you may need to modify your existing services lines – or consider new services to better serve your market. Finally, you need data that “proves” that your service lines can achieve both high quality outcomes and cut costs. For more on building these value-based relationships with managed care organizations to improve outcomes and lower costs, check out some of our resources:

In Idaho and across the country, managed care organizations are successfully delivering treatment services to large populations and doing it in a way that saves states significant sums of money. These demonstrated savings show that value-based reimbursement and managed care arrangements aren’t going anywhere, so your best bet is to make your organization, as Ms. Hall termed it, “managed care friendly.”

The shift from fee-for-service (FFS) reimbursement to value-based contracting is certainly a work in progress. Some markets, some payers, and some services are more in progress than others. But one place where the shift has gone from concept to reality is Arizona – in the Maricopa County, Arizona system. Arizona’s Regional Behavioral Health Authority (RBHA), Arizona (GSA 6), is managed by Mercy Maricopa, which is sponsored by Mercy Care Plan and Maricopa Integrated Health System (MIHS). Mercy Care Plan is an Arizona Medicaid Plan sponsored by Dignity Health and Carondelet Health Network, and managed by Aetna. In 2014, RBHA moved ahead with a master plan that reshapes how providers are reimbursed for services.

We got an up-close look at this plan at The 2016 OPEN MINDS Performance Management Institute, where Don Fowls, M.D., President of Don Fowls & Associates discussed the framework for contracting in Maricopa County and the challenges of value-based purchasing when developing integrated models of care, in his session, “Moving To Value-Based Purchasing In An Era Of Integration – A Guide For Managing High Cost Members”. For its delivery system model, Mercy Maricopa Integrated Care (MMIC) is launching several integrated behavioral health and primary care options for consumers, and is pushing for having 50% or more of their total spend in value-based arrangement by 2017-2018 (for a breakdown of this system and a look at the integrated care options, check out Maricopa County’s Emerging Integrated Care Management Model).

Their model to move to value-based arrangements is taking place in three-phases – with a “possible” fourth phase:

  1. Phase 1: Value-based contracts for permanent supportive housing and ACT and scheduled implementation for person-centered health care homes (integrated health homes)
  2. Phase 2: Clinically integrated organizations (CIOs) and accountable care organizations (ACOs)
  3. Phase 3: Bundled payments/episodes of care (aggregate the total costs for providing care into one bundle that reimburses all providers for all services during a period of time or care cycle)
  4. “Possible” Phase 4: Capitation (A set amount of money paid per member per month (PMPM) for each member assigned; Provides all reimbursement for services, administration and margin from the PMPM. The provider is at risk if costs exceed revenue and can gain if revenue exceeds cost.)

The results from their initial implementation of value-based contracting has been positive. In 2014 and 2015, Mercy Maricopa implemented their initial value-based contracts with five provider organizations for assertive community treatment (ACT) services. Under these initial arrangements, a portion of potential payment is tied to performance on defined measures centering on access, quality, satisfaction, and utilization/cost. This creates a system where bonuses may be paid for meeting performance goals – what Dr. Fowls termed using “the carrot, not the stick.” These provider organizations were given the following performance metrics:

  1. 10% reduction in inappropriate emergency room use for assigned members
  2. 10% reduction in readmission rates
  3. 10% increase in employment
  4. 10% increase in housing rates
  5. 10% increase in primary care practice (PCP) visits

Mercy Maricopa is now moving ahead and contracting with additional providers, including community-based behavioral health providers and primary care and specialty medical providers. Performance measures are tied to specific, mutually agreed upon goals. Initially they include process measures but the trend is to move more to measures focused on member outcomes, including those that impact psychosocial determinants. The big challenge according to Dr. Fowls? “It is the culture shift of moving from a traditional block payment to value-based payment. You get used to getting paid a set amount at the beginning at each month, and it really takes a shift in mindset and perspective about the way to do things.”

The successes – and challenges – of these early pay-for-value models is going to do much to inform executives of payers, health plans, and provider organizations about the most successful models and the appropriate rates. For more on Maricopa County, check out Mercy Maricopa Offers Medicaid Beneficiaries With SMI Four Integrated Care Options.

On February 16, 2016, the Core Quality Measures Collaborative, which includes the federal Centers for Medicare & Medicaid Services (CMS) and America’s Health Insurance Plans (AHIP), announced the release of seven core sets of cross-payer quality measures. One set is intended to measure the quality of primary care delivered by accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). The other six are condition-specific, targeting cardiology, gastroenterology, HIV and hepatitis C, medical oncology, obstetrics and gynecology, and orthopedics. The core measures in each set are reported at the clinician level, the facility level, or health plan level.

The Collaborative believes that the core measures, aligned across payers, will support quality improvement and reporting across the health system. Aligning the measures is also expected to reduce reporting burden on physicians. CMS is already using some measures from each of the core sets, and plans to implement new core measures across applicable Medicare quality programs as appropriate, while eliminating redundant measures that are not part of the core set. CMS will use a notice and public rule-making process to update the Medicare quality program reporting requirements. Commercial health plans are rolling out the core measures as part of their contract cycle.

The Collaborative used a consensus process to develop the core measure sets. Initially, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. Workgroups reviewed measures currently being used by CMS and health plans, as well as measures endorsed by the National Quality Forum (NQF) for the individual measure sets.

For more information, contact:

  • Courtney Jay, Media Contact, America’s Health Insurance Plans, 601 Pennsylvania Avenue, NW, South Building, Suite 500, Washington, District of Columbia 20004; Email: cjay@ahip.org; Website: ahip.org
  • Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: cms.gov

One key to creating a performance-driven culture in any organization is making sure that how we reward our staff is aligned with our performance goals. While “rewards” come in many forms, this obviously raises the question, how are you going to pay your staff?

Performance-based compensation, while common in many fields, is a rarity in health and human services. Moving to performance-based compensation is a big task – with implications for financial operations, recruiting, and supervisors. Yesterday, at The 2016 OPEN MINDS Performance Management Institute, I looked at a few fundamentals you need to take into account beyond “making more money” in my pre-institute seminar – “Implementing Performance-Based Compensation – Current Models, Issues & An Approach To Successful Implementation”. The first is how to build a compensation strategy that aligns with your overall strategic goals and the second is to decide how to measure clinical productivity.

Decide how to develop a compensation strategy that works for your organization – Adopting a performance-based compensation model is essential to ensuring that you get the best return-on-investment (ROI) from your human capital. But, this is only is effective if you align your organizational compensation strategy with your strategic goals. To do this, there are a few best practice tips to keep in mind when developing a model:

  • Establish specific goals for your comp model – Start by establishing objectives that align with your overall organizational strategy. If you create a plan that is incentivizing behavior that is incongruent with your organization’s core mission, it will ultimately create confusion for your staff. Then, work out the details – make the goals as clear as possible, determine the measurement methodology, and determine what incentives will be used.
  • Determine what incentive compensation you can afford. Will that be bonuses, profit sharing, percentage of billed services, percentage of collected bills, or something else?
  • Determine when incentives will be paid – This means knowing who will provide oversight of the program; who will measure the program; and what the process will be for determining the payouts.
  • Develop and implement a pilot program – After running this test of the new plan, modify your plan based on findings from the pilot, and be completely transparent about why changes are being made.
  • Develop the full roll-out plan – When this is done, make sure that there is a strong focus on education and training for staff. Make a commitment to adjust the plan as needed.

Decide how to measure clinical staff productivity – This is a big and controversial issue in health and human services. You need to consider things like the number of clinical encounters, gross billing, net collections, and quality (re: clinical satisfaction, peer review, committee work, administrative work, etc.). In addition, we need to determine what non-quantitative items should be included in the model, e.g., indirect service time, telephone based services, etc. In one example, a health system is looking for a total productivity contribution per clinical team member of 31 hours per week – with each billable hour of service worth 1.0 and each non-billable your of service (for example, telephone care coordination, documentation, and supervision) worth 0.25.

What does this look like in practice? This afternoon as a follow-up to my seminar, OPEN MINDS Senior Associate Joseph Naughton-Travers and Carrie Nelson, M.D., Senior Medical Director, Advocate Physician Partners in his session, “Models For Physician Compensation & Productivity Management: How Provider Organizations Are Negotiating Clinical Staff Contracts”. In the session, Dr. Nelson gave an example of a model for physicians at Advocate Physician Partners, a care management collaboration that works with Advocate Health Care system. Within Advocate, employed physicians have a 95% of physician salary as base and a five percent withhold based on performance. Physicians are also eligible for an additional bonus based on performance. The performance is based on a combination of factors – including clinical health outcomes, such as patient safety, care coordination, and clinical integration; and patient experience ratings.

In the future, I expect we’ll see more organizations working to align staff compensation with overall organizational performance goals. For more on staff compensation modes, see When It Comes To Compensation, Proceed With Caution.

The federal Centers for Medicare & Medicaid Services (CMS) is examining the feasibility of requiring states and integrated care organizations participating in the dual eligible Financial Alignment Demonstration to report on the extent to which individualized care plans are being developed for beneficiaries. The goal would be to ensure that CMS has adequate information to assess the extent to which care coordination is occurring in the demonstration. Currently, the organizations and states participating in the demonstration report on core measures, but the measures are different for the capitated model and the managed fee-for-service (MFFS) model. Two of the 10 core capitated model measures provide information on the extent to which care coordination is occurring, but none of the core measures for the MFFS model provide similar information. CMS also collects information about the extent to which care coordination is occurring through state-specific measures in some states, but these measures are not comparable across these states or both the capitated and MFFS demonstration models. CMS has also added comparable demonstration-specific questions to the Consumer Assessment of Healthcare Providers and Systems, which must be completed annually by all organizations participating in the capitated model and all states using the MFFS model.

The key focus of the Financial Alignment Demonstration is integrating Medicare and Medicaid services and financing, and improving care coordination for dual eligible beneficiaries. In 2010, Medicare and Medicaid costs for dual eligibles were estimated at $300 billion. For the demonstrations, states were granted flexibility in designing their Financial Alignment Demonstrations. As of August 2015, CMS had approved 13 states to participate in the three-year demonstration. Approximately 441,000 beneficiaries are enrolled in the demonstrations.

These findings were reported in “Additional Oversight Needed of CMS’s Demonstration to Coordinate the Care of Dual-Eligible Beneficiaries” by the U.S. Government Accountability Office (GAO). The GAO was asked to examine care coordination for dual eligible Medicare-Medicaid beneficiaries in the states participating in the Financial Alignment Demonstration, which began in 2013. In this report, the GAO reviewed provision of and CMS oversight of the four care coordination requirements for the demonstrations, which are, care coordinators, health risk assessments, individualized care plans (ICPs), and interdisciplinary care teams (ICTs). For the demonstrations, the ICOs include health plans or other qualified entities. A care coordinator is the person responsible for facilitating the coordination of services for the beneficiary. A health risk assessment examines a beneficiary’s needs, and is used to help develop an ICP that includes the beneficiary’s goals and strategies toward meeting those goals. The ICT is a team of health care professionals that includes the care coordinator who as a team work closely with the beneficiary to implement and maintain the ICP.

For this analysis, the GAO focused on the first five states to implement their demonstrations: California, Illinois, Massachusetts, Virginia, and Washington. Of these states, only Washington was using the MFFS model; the remaining states were using the capitated model. For this non-generalizable sample of states, from June 2013 to December 2015, the GAO examined how the integrated care organizations are implementing care coordination, their challenges, and the extent to which CMS oversees these care coordination activities. The GAO interviewed 11 integrated care organizations within the five states, with 3 ICOs in California and 2 ICOs in each of Illinois, Massachusetts, Virginia, and Washington.

The GAO reviewed CMS guidance outlining the measures used to monitor the demonstration and the CMs oversight role to determine whether the existing measures assessed the extent to which care coordination is occurring in the demonstration. The GAO sought to determine if the measures assessed whether care coordinators were meeting with beneficiaries, whether health risk assessments were being completed and ICPs developed, and whether ICT meetings were taking place. In a key difference, the GAO noted that, according to CMS officials, the agency primarily oversees the organizations under the capitated model while it oversees the states under the MFFS model. Additional details about the variation in care coordination activities were as follows:

  • Assignment of care coordinators—The ICOs used a variety of approaches to assign care coordinators to beneficiaries. These approaches included assigning them by geographic proximity to the beneficiary or to the beneficiary’s primary care provider. Others assigned care coordinators a mix of low-, moderate-, and high-risk beneficiaries, or assigned care coordinators based on the coordinator’s qualifications and areas of expertise. Care coordinators varied in their qualifications and backgrounds, and the type of care they coordinated. Their degrees and licensures included nursing, social work, or behavioral health. Some ICOs had separate care coordinators assigned to handle medical needs versus behavioral health needs, but others had care coordinators who were responsible for coordinating care across medical, behavioral, and social services.
  • Care coordination activities—Care coordinators also used a range of interactions with beneficiaries in order to coordinate care, including by mail, e-mail, telephone, or in person. Some interacted by telephone regardless of the beneficiary’s risk level; others used a mix of telephone and in-person methods depending on the beneficiary’s risk level and needs. Locations of in-person visits; often they took place in the beneficiary’s home, but some care coordinators met beneficiaries in other settings, such as parks, libraries, homeless shelters, or the office of a health care professional.
  • Conducting the health risk assessment—The ICOs differed in how they conducted the health risk assessments, particularly in how they identified high- and low-risk beneficiaries. The identification usually took place at enrollment, but before the health risk assessment was conducted. Some of the states assigned an initial risk category. In those states, the ICOs confirmed or adjusted the risk level during the health assessment. In states that did not pre-assign a risk level, the ICOs conducted an initial health screening and then administered the health risk assessment. The assessment tools varied by state. . The Illinois demonstration required an assessment of medical, psychosical, functional, and cognitive needs, as well as medical and behavioral health needs. The Massachusetts demonstration assessed the same domains as Illinois, but also assessed needs related to housing, employment status, and food security.
  • Development of ICPs—The ICP templates varied by organization in the five states, and they differed in length, complexity, and focus. Some ICOs used an ICP template developed by the state; others developed their own templates. The ICPs varied in length, from shorter plans containing three to five goals to longer plans containing many goals, some included short and long-term goals. Some ICOs tailored the ICP to the beneficiary risk level, such that ICPs for low-risk beneficiaries focused on health education, and ICPs for high-risk beneficiaries focused on identifying gaps in care. The ICPs were not necessarily clinical plans, and one ICO included home-and community-based services such as referral to transportation services.
  • Frequency and format of ICTs—The ICT process varied by organization across the five states, with the needs of the beneficiary as the key driver of the frequency and format of ICT meetings. Communication and meetings among ICT members took place in different ways. ICT meetings can include the beneficiary. Some ICOs set the frequency of ICT meetings depending on the beneficiary’s needs; meetings could be triggered by hospitalizations or other acute events; for some beneficiaries, ICT meetings took place on a regular basis for on-going health needs.

The GAO reported that the ICOs interviewed described challenges that affected their ability to coordinate care for beneficiaries. These challenges included difficulty locating beneficiaries and some organizations noted that locating beneficiaries enrolled via passive enrollment was challenging. The ICOs also reported challenges engaging beneficiaries and primary care provider organizations, and communicating with beneficiaries about the demonstration. The GAO said its interviews with beneficiary advocacy groups and provider organizations raised questions about the extent to which care coordination is actually occurring.

In its recommendations, the GAO said that CMS should develop comparable core data measures across both the capitated and MFFS models that measure the extent to which ICT team meetings are occurring, and for MFFS states, CMS should develop measures that examine the extent to which health risk assessments are completed. Further, CMS should align the existing state-specific measures regarding the extent to which ICPs are being developed across the capitated and MFFS states to make them comparable and designate them as a core reporting requirement.

For more information, contact:

  • Kathleen M. King, Director, Health Care, U.S. Government Accountability Office, 441 G Street, NW, Room 7149, Washington, District of Columbia 20548; 202-512-7114; Email: KingK@gao.gov; Website: gao.gov/products/GAO-15-401; or Chuck Young, Managing Director, Public Affairs, U.S. Government Accountability Office, 441 G Street, NW, Room 7149, Washington, District of Columbia 20548; 202-5124800; Email: youngc1@gao.gov; Website: www.gao.gov
  • Financial Alignment Initiative, Medicare-Medicaid Coordination Office, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; Email: MedicareMedicaidCoordination@cms.hhs.gov; Website: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCare Coordination.html; or Press Contact, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: cms.gov

On January 28, 2016, the federal Centers for Medicare & Medicaid Services (CMS) introduced new patient experience of care star ratings for Home Health Compare to augment previously posted information about home health provider organization performance in nine areas. The system now rates home health provider organizations based on consumer responses about their experience of care on the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey. Of the more than 11,000 home health provider organizations with data on Home Health Compare, about 6,000 now have star ratings for the overall patient experience of care for people who completed an episode of home health care between July 2014 and June 2015 and completed the HHCAHPS survey.

The HHCAHPS measures evaluate consumer’s experiences with home health agencies in terms of the quality of care provided overall and for specific care issues, and the quality of communication between the provider organization and the individual and family members. The five HHCAHPS survey topics are given star ratings of one star (poor performance) to five stars (very good performance). Additional details about the methodology were released in September 2014 in “Medicare Technical Notes For HHCAHPS Star Ratings.” The survey questions that contribute to the star ratings are as follows:

  1. Care of Patients—The star ratings are based on responses to questions 9, 16, 19, and 24.
  2. Communication Between Providers and Patients—The star ratings are based on responses to questions 2, 15, 17, 18, 22, and 23.
  3. Specific Care Issues—The star ratings are based on responses to questions 3, 4, 5, 10, 12, 13, and 14.
  4. Overall Rating of Care provided by the Home Health provider organization—The star rating is based on responses to question 20.
  5. Survey Summary star rating—This star rating is an average of the four other star ratings.

To receive HHCAHPS star ratings, home health provider organizations must have at least 40 completed surveys during the reporting period; CMS believes that at this level, the data is sufficient to reliably measure true organization performance and assign star ratings. CMS recognizes that caseloads at some home health provider organizations may vary, and they may meet the threshold of 40 or more surveys for some reporting periods but not for all reporting periods. CMS plans to update Home Health Compare quarterly; those home health provider organizations that do not currently have patient experience star ratings may have star ratings in the future.

The Home Health Compare website can be viewed online at https://www.medicare.gov/homehealthcompare/search.html (accessed February 18, 2016).

PsychU reported on this topic in “2.5% Of Home Health Provider Organizations Receive Top Quality Ranking In Initial Medicare Star Ratings,” which published on September 30, 2015.

For more information, contact: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: www.cms.gov

Key Messages

  • The National Quality Forum (NQF) has identified more than 700 quality metrics, but only 30 are directly related to behavioral health, and fewer still measure patient outcomes.
  • This Open Forum sought to review behavioral health quality measures, describe criteria relevant to assessing measures, and provide a case for encouraging the development, collection, and routine use of functional outcome measures in behavioral health care.

Key Messages

  • In March 2011 the Department of Health and Human Services (DHHS) released the National Quality Strategy, with three aims: 1) improve overall quality of care; 2) improve population health; 3) reduce cost of high-quality healthcare.
  • A number of federal and state agencies have focused on behavioral health quality in recent years, with several new Healthcare Effectiveness Data and Information Set (HEDIS) measures being added that specifically address integration of physical and behavioral healthcare.
  • This study sought to examine behavioral health quality measures that state Medicaid and behavioral health agencies use and identify common themes among states.
  • While the use of behavioral health quality metrics exist, there are opportunities for improvement in assessing care outcomes, substance abuse treatment, crisis services, and standardized experience-of-care surveys.

Interview with Emily Morden, MSW, Senior Healthcare Analyst at the National Committee for Quality Assurance (NCQA©) in Washington, DC.

©2015 National Committee for Quality Assurance. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)

Interview with Babette Edgar, PharmD, MBA, president-elect of the Academy of Managed Care Pharmacy, and the principal of BluePeak Advisors. Dr. Edgar has been in the managed care industry for 23 years, and advises health plans, pharmacy benefits management companies and pharmaceutical companies on Medicare and managed care strategies, operations and compliance issues.

The new National Committee for Quality Assurance (NCQA) health plan accreditation standards for 2016 have an intensified focus on access to medical and behavioral health care, even in the context of narrow networks. NCQA released the new standards on July 28, 2015; the new standards are effective as of July 1, 2016.

A new Network Management section provides a more comprehensive assessment of plan network adequacy. Some of the behavioral health network management standards are previously existing NCQA access measurement standards that are included in the new Network Management section without modification. Others are previous NCQA standards that have been enhanced to clarify how health plans must evaluate access to behavioral health (and other specialists). The new Network Management section includes the following standards related to behavioral health:

  • Plans must measure access to high-volume behavioral health professionals against standards for geographic distribution for each type of behavioral health professional and other measurable standards developed by the plan. This is an existing standard that has been added to the new section without modification.
  • Plans must evaluate access to behavioral health appointments. This standard has been updated. It now clarifies that access to behavioral health care must be evaluated separately for routine appointments for prescribing versus non-prescribing behavioral health professionals; for the percentage of initial visits for routine care that take place within 10 business days; and for the percentage of visits for follow-up routine care that take place within a timeframe pre-defined by the plan itself.
  • Plans must identify opportunities to improve access to behavioral health care services. This standard has been updated to clarify that in addition to considering member experience, plans should use a holistic approach to identify and implement interventions to improve access to behavioral health services by considering the results from their analyses of availability, accessibility, and member experience.
  • Plans must seek to improve members’ experience with behavioral health care and services. This is an existing standard that has been added to the new section without modification. Plans can assess complaints and appeals regarding behavioral health care and services, or plans can assess results from member experience surveys.

New provider network directory standards require health plans to assess the accuracy of online provider organization network directories. The coverage details to be disclosed in the network directory include whether the physician group serving an in-network hospital is also part of the plan’s physician network. New Utilization Management standards strengthen NCQA’s ability to detect systematic issues related to utilization management by adding requirements and modifying NCQA’s file review process.

NCQA Accreditation contains all key elements that federal law and regulations require for State Health Insurance Marketplace plans. Forty states recognize NCQA Accreditation as meeting their requirements for Medicaid commercial plans; more than a dozen states mandate it for Medicaid. Medicare deems plans with NCQA Accreditation for Medicare Advantage, and the Federal Employees Health Benefits Program accepts NCQA Accreditation. NCQA health plan accreditation is also designed to give potential enrollees a way to compare health plan quality.

Before finalizing the new standards, NCQA reviewed public comments on the proposed standards that were submitted from March 11 to April 8, 2015.  The proposed standards noted that “Wait time for mental health services continues to be a concern, particularly visits with psychiatrists.” The new health plan requirement aligns with NCQA’s managed behavioral health organization (MBHO) accreditation standards. NCQA recommended that health plans assess availability for each of the following types of professionals providing behavioral health care: physicians, doctoral level non- physicians, and non-doctoral level non- physicians. The NCQA also recommended that health plans assess availability for inpatient, residential, and ambulatory behavioral health provider organizations.

A copy of the proposed 2016 Health Plan Accreditation Standards (which became obsolete as of April 8, 2015) can be viewed online at http://www.ncqa.org/Portals/0/PublicComment/HPA2016/Health%20Plan%20Accreditation%202016%20and%20Additional%20Accreditation%20&%20Certification%20Product%20Updates%20Overview.pdf (accessed August 13, 2015).

A copy of the “Rationale for Proposed Updates to HPA 2016 Standards and Guidelines” can be viewed online at http://www.ncqa.org/Portals/0/PublicComment/HPA2016/Appendix%202_Rationale%20for%20Proposed%20Updates%20to%20HPA%202016%20Standards%20and%20Guidelines.pdf (accessed August 13, 2015).

For more information, contact:

  • Raena Akin-Deko, Assistant Vice President, Product Development, National Committee for Quality Assurance, 1100 13th Street, NW Suite 1000, Washington, District of Columbia 20005; 202-955-1748; E-mail: akin-deko@ncqa.org; Website: ncqa.org
  • Matt Brock, Director of Communications, National Committee for Quality Assurance, 1100 13th Street, NW Suite 1000, Washington, District of Columbia 20005; 202-955-1739; E-mail: brock@ncqa.org; Website: ncqa.org

On July 31, 2015, the federal Centers for Medicare & Medicaid Services (CMS) finalized a proposal to create a new rate setting structure for the Medicare Inpatient Psychiatric Facilities (IPF) Prospective Payment System (PPS). In this new system, Medicare is creating an IPF-specific market basket that accounts for the goods and labor that contributed to the 2012 costs of operating an IPF as a freestanding facility or as a psychiatric unit of an acute care hospital or critical access hospital. Previously, rates for the 1,617 IPF PPS were set using an aggregated market basket of costs for goods and labor for rehabilitation facilities, IPFs, and long-term care hospitals. The fiscal year (FY) 2016 labor-related share of the new IPF market basket is 75.2%, which is an increase from the FY 2015 rate of 69.3%. Per diem base rates are slated to increase by 1.7% over the 2015 payment rate of $728.31.

The changes were finalized in “Inpatient Psychiatric Facilities Prospective Payment System – Update for Fiscal Year Beginning October 1, 2015 (FY 2016), which published in the Federal Register on August 5, 2015. In the update, CMS reminded IPFs that implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) goes into effect for discharges as of October 1, 2015. Additional proposals finalized included the following:

  • A 17% rural adjustment will be phased out for 37 IPF provider organizations whose status will change from rural to urban as a result of the wage index changes to the Core Based Statistical Areas (CBSA). The provider organizations operating these 37 facilities will receive two-thirds of the rural adjustment in FY 2016 and one-third in FY 2017, and no rural adjustment for FY 2018 and subsequent years.
  • The FY 2016 IPF per diem rate varies depending on whether the IPF reported required quality data for the IPF Quality Reporting (IPFQR) program, at $743.73 for those that reported the data and $729.10 for those that did not. The IPFQR program is a pay-for-reporting program established by the Patient Protection and Affordable Care Act (PPACA). IPFs are subject to a reduction of two percentage points in their annual payment update for failure to meet administrative and data reporting requirements on specified quality measures.

Additionally, two new quality measures and reporting requirements have been added to the IPFQR program. The 2015 IPFQR program measure set includes 14 measures. In the FY 2016 final rule, CMS is increasing the IPFQR Program measure set to 16 measures by adding five measures and removing three measures.

PsychU reported on this topic in “Medicare Proposes Separate Rate Setting For Inpatient Psychiatric Facilities,” which published on June 18, 2015.

For more information, contact: Media Relations, Office of Communication, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/About-CMS/Agency-Information/CMSLeadership/Office_OC.html; or Katherine Lucas or Jana Lindquist, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 410-786-7723; Website: www.cms.gov.

For any executive in the health and human service field, this is a headline you want to avoid – “12 Hospitals You Might Want to Avoid.”

Of course, if you are a health care consumer, that’s the kind of headline that catches your attention (it caught my attention). This story, from Consumer Reports, identified the lowest scoring hospitals for infection prevention using data from the Centers for Disease Control and Prevention. Consumer Reports ranked over 4,000 hospitals in the United States based on the rates for two of the most common and deadly bacterial infections in hospitals: MRSA and C. diff.

Consumer Reports is certainly not the only place where health care organization performance data is “reinterpreted” for the public. A quick Google search reveals a wealth of similar headlines – “Pa. Hospitals Rated First To Worst: Where Does Your Hospital Rate?” from The Newtown Patch, “4 Shore hospitals nailed for injuries, illness” from app., “10 Cities Where You Don’t Want to Get Sick” from 24/7 Wall Street, and “New York’s most dangerous hospitals” from The New York Post.

For better or worse, as the health and human service field moves to value-based reimbursement and pay-for-success contracts, more explicit measurement of “performance” is inevitable. And in the Internet era, there is no data that won’t make its way to the public eye in one form or the other.

So what should an executive team to do in this era of public performance metrics? First, if you’re not familiar with rating systems, now is the time to get a feel for the players and the measures:

  1. CMS Developing Quality Star Ratings For Medicare-Medicaid Plans
  2. Most State Medicaid Agencies Using HEDIS Measures For Behavioral Health Performance
  3. 30 State Medicaid Plans Now Reporting On Some HEDIS Measures For Adults
  4. Medicaid MCO Performance On HEDIS Measures Lower Than Commercial Health Plan Performance
  5. NCQA Proposes New Medicaid Behavioral Health HEDIS Quality Measure For 2016
  6. New Medicaid Quality Measures Focus On Monitoring Opioids, Diabetes, & Antipsychotics
  7. Yelp & ProPublica Collaborate To Give Consumers Health Care Facilities Data

Then, you need to think in terms of a two-prong process – managing your online reputation and management of your actual performance. The first is actively managing the information that gets “top billing” about your organization in the press and online. This involves tracking the online reviews, comments, and articles – and responding to them. For example, in the case of the Consumer Reports  coverage, several of the hospitals did respond with public statements – “Hospital response to CR’s question: St. Petersburg General Hospital” and “Hospital response to CR’s question: Venice Regional Bayfront Health” from The Safe Patient Project. (I would like to point out that this is not “emergency public relations” response – but should be an on-going, day-to-day response to both published articles and public comments on social media.)

The second is actually improving performance on the common performance measures that will become part of the “public image” of your organization. This is parallel to, but somewhat different from, the traditional view of quality improvement. This is a more consumer-centric view of performance measures – think “consumer sovereignty” (see Consumer Sovereignty As Success Strategy) and “strategic quality” (David Garvin’s “Competing On The Eight Dimensions Of Quality”, Harvard Business Review, November-December, 1987). And, shift the role of performance to the strategic. The focus is on the quality attributes that are important to customers and the public. It is an orientation that prevents a common problem with quality improvement data – focused on and investing in performance attributes that are not important to consumers. In the instance of the hospitals in the Consumer Reports story, “How 9 hospitals responded to Consumer Reports ratings as worst in the country” from Becker’s Hospital Review, many noted new infection control initiatives to improve their performance.

If managing your online reputation and managing your consumer-critical metrics is not part of your current marketing plan, here are some resources from the PsychU Resource Library to get you started on framing this challenge:

  1. Succeeding In The Online Ratings Game – First, Know The Score
  2. Succeeding In The Online Ratings Game – Second, You Need A Plan
  3. Yelp Comes To Health Care – One More Reason For Online Reputation Management
  4. The New Google Search Rules For Health Care & What The