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Interacting with First Responders Webinar: Follow-Up Q&A Podcast

Dr. Heather Davidson sits down with Kathy Day to respond to unanswered questions from PsychU’s Interacting with First Responders webinar. Their conversation covers discussions among patients, family members, and law enforcement before and during a mental health crisis.

PsychU · Interacting with First Responders Webinar: Follow-Up Q&A Podcast

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.

Heather Davidson, PhD, is a Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc. Dr. Davidson earned her PhD in physiology and neuroscience from the Medical University of South Carolina in Charleston, SC.

 

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

Heather Davidson is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

 

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

Prior to the coronavirus disease 2019 (COVID-19) pandemic, the average primary care physician compensation rose by 2.5%, from $237,000 in 2019 to $243,000 in 2020. Between October 4, 2019 and February 10, 2020, average specialist salaries rose by 1.5%, from $341,000 in 2019 to $346,000 in 2020. The highest average annual compensation was for orthopedics at $511,000; the lowest was for pediatrics at $232,000. Average annual compensation for psychiatrists was $268,000.

For the time period reviewed, about 58% of primary care physician practices, and 55% of specialist practices offered an incentive bonus. Examples of incentive bonuses are collections bonuses (monies collected from consumers, resulting in a net profit) and work relative value unit (productivity measure) bonuses. The average incentive bonus for all health care workers is about $26,000; however, the average incentive bonuses for specialty physicians ranges from $31,000 to $96,000. PCP physicians usually earn 64% of an incentive bonus, while specialists usually earn 69% of an incentive bonus.

These statistics were released on May 14, 2020, in the Medscape “Physician Compensation Report 2020” by Leslie Kane, MA. The findings are based on analysis of survey responses collected between October 4, 2019 and February 10, 2020, from more than 17,000 physicians working in 30 specialties. The survey examined salary, incentive bonus, and denied claims, and their attitudes about the field of medicine.

The full text of the Medscape “Physician Compensation Report 2020,” was released on May 14, 2020. A copy is available online at https://www.medscape.com/slideshow/2020-compensation-overview-6012684.

For more information, contact: 

  • Leslie Kane, MA, Business of Medicine, Medscape, 825 8thAvenue, New York, New York 10019; 212-301-6700; Email: LKane@webmd.net; Website: https://www.medscape.com/author/leslie-kane

On May 21, 2020, Texas Governor Greg Abbott directed the Texas Health and Human Services Commission (HHSC) to expand testing for coronavirus disease of 2019 (COVID-19) to the approximately 4,700 residents, and about 18,000 staff at 23 state-operated inpatient psychiatric hospitals and state-supported living centers (SSLC). This testing is part of the state’s continued effort to reduce the chances of the spread of COVID-19 at these facilities and protect these vulnerable populations.

Previously, residents at both types of facilities were tested if they displayed symptoms of COVID-19 or had possible exposure to the virus. The new round of testing will cover those who have shown no signs of COVID-19 or have not been tested within the last 30 days. Testing began May 26 and is currently ongoing. Once the results are in, HHSC will evaluate the need for further testing with the Texas Department of State Health Services.

The governor’s announcement noted that since March 13, 2020, and as of May 20, 161 residents of SSLCs and inpatient psychiatric facilities have tested positive for COVID-19 and 107 had recovered. As of June 3, 2020, across the 23 facilities there have been 178 positive cases. Currently, eight facilities have at least one positive resident. Of those 178 positive cases, 139 have recovered. Since the emergency began, there have been fewer than 10 deaths among SSLC and inpatient psychiatric facility residents.

HHSC operates 13 state supported living centers that provide 24-hour residential care, medical services, and vocational training for people with intellectual and developmental disabilities. The agency also operates 10 state hospitals that provide acute inpatient psychiatric care for adults, children, and adolescents.

For more information, contact: 

  • Scott Schalchin, Associate Commissioner, State Supported Living Centers, Texas Health and Human Services Commission, 4900 North Lamar Boulevard, Austin, Texas 78751-2316; Email: scott.schalchlin@hhsc.state.tx.us; Website: https://gov.texas.gov/news/post/governor-abbott-directs-hhsc-to-expand-covid-19-testing-to-all-state-hospitals-state-supported-living-centers

On May 29, 2020, the Kentucky Cabinet for Health and Family Services (CHFS) awarded five Medicaid managed care contracts with an aggregate value of about $8 billion. The five companies are Aetna, Humana, Molina Healthcare, UnitedHealthcare, and WellCare. Aetna will also serve children in Kentucky SKY, the Medicaid risk-based managed care delivery program for the state foster care program and the Department for Juvenile Justice. The plans are at-risk for all Medicaid physical health, behavioral health, and pharmacy services. The contracts are slated to go live on January 1, 2021 and will run through December 31, 2024. The contracts may be extended by six additional two-year periods.

The state’s current managed care contracts are with Aetna (via Coventry Cares), Anthem, Humana (via CareSource), Passport Health Plan, and WellCare. These contracts have been extended through December 31, 2020. About 1.3 million beneficiaries are enrolled in one of the five current Medicaid managed care plans.

The state issued the request for proposals (RFP 2000000202) on January 10, 2020. This was a rebid after the state cancelled contracts awarded on November 26, 2019, due to concerns about how the award process was handled. Proposals were due by February 7, 2020. Responses were also submitted by Anthem Kentucky Managed Care Plan, Inc.; and Passport Health Plan, Inc.

The proposals received the following scores:

  • Aetna received 1,653 points.
  • WellCare received 1,662 points.
  • Humana received 1,605 points.
  • UnitedHealthcare received 1,520.5 points.
  • Molina received 1,507 points.
  • Anthem received 1,491 points.
  • Passport received 1,409.5 points.

The proposals for Kentucky SKY received the following scores:

  • Aetna received 1,126.3 points.
  • WellCare received 1,120.6 points.
  • Humana received 1,066.6 points.
  • UnitedHealthcare received 1,044.2 points.
  • Molina received 1,017.4 points.

PsychU last reported on this topic in “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published on January 5, 2020. The article is available at https://www.psychu.org/kentucky-announces-cancellation-of-medicaid-managed-care-contracts-to-be-rebid-in-january/.

For more information, contact: 

  • Susan Dunlap, Executive Director of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-564-7042; Email: Susan.Dunlap@ky.gov; Website: https://chfs.ky.gov/
  • Kate Marx, Corporate Communications, Humana, 500 West Main Street, Louisville, Kentucky 40202; 502-271-9288; Email: kmarx1@humana.com; Website: https://www.humana.com/
  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802; 562-951-1588; Email: Caroline.Zubieta@molinahealthcare.com; Website: https://www.molinahealthcare.com/members/common/en-US/abtmolina/compinfo/newsmed/Pages/newsmed.aspx
  • Charles N. Talbert, Manager, External Communications, WellCare Health Plans, Inc., 211 Perimeter Center, Suite 800, Atlanta, Georgia 30346; 770-913-2181; Email: charles.talbert@wellcare.com; Website: https://www.wellcare.com/
  • Will Shanley, Director of Public Relations, United Healthcare, 5901 Lincoln Drive, Minneapolis, Minnesota 55436; 612-486-4361; Email: will.shanley@uhc.com; Website: https://www.uhc.com/
  • Leigh M. Woodward, Senior Communications Partner, Aetna Medicaid, 4630 Woodland Corporate Boulevard, Tampa, Florida 33614; 860-900-6058; Email: WoodwardL1@aetna.com; Website: https://www.aetna.com/

The Centers for Medicare & Medicaid Services (CMS) will require hospitals to adopt the Medicare Hybrid Hospital-Wide 30-Day Readmission (HWR) measure by 2023, and will begin a mandatory measurement period running from July 1, 2023 to June 30, 2024. In July 2025, the results will be posted to Medicare Hospital Compare. The HWR is based on electronic health record data and claims data for Medicare beneficiaries. CMS believes that the proliferation of EHR systems and standardization of extraction and reporting of clinical data for quality measurement provide an opportunity to integrate these data into measures of hospital performance. The HWR will replace the current Claims-Based Hospital-Wide All-Cause Readmission measure.

The new HWR measure was included in the Medicare 2020 Hospital Inpatient Prospective Payment System Final Rule, released on August 16, 2019. During 2019, 150 hospitals participated in a voluntary HWR pilot program. In preparation for the mandatory HWR reporting period that starts July 1, 2023, CMS will implement two voluntary year-long measurement periods, with the first starting on July 1, 2021 and running through June 30, 2022. The second period will start July 1, 2022, and run through June 30, 2023.

The HWR measure will be required as a part of each hospital’s inpatient quality reporting (IQR) program requirements. The Medicare Hospital IQR Program is a pay-for-reporting quality program which reduces payment to hospitals that fail to meet program requirements.

For the HWR measure, the numerator is unplanned all cause 30-day readmission. Readmission is defined as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an earlier, eligible index admission. The denominator is admissions for Medicare fee-for-service (FFS) beneficiaries age 65 and older enrolled in Part A for the 12 months prior to admission who are matched in EHR and claims data and who are discharged alive, and not transferred to an acute care facility. The measure excludes the following populations:

  • Admitted to Prospective Payment System-exempt cancer hospitals
  • Without at least 30 days post-discharge enrollment in FFS Medicare
  • Discharged against medical advice
  • Admitted for primary psychiatric diagnoses
  • Admitted for rehabilitation
  • Admitted for medical treatment of cancer

The HWR measure uses clinical data elements from the EHR for risk adjustment in addition to claims data. The goal is to use clinical data, such as laboratory test values and vital signs, to risk adjust for consumer-level factors that influence readmission to adjust for severity of illness in hospital outcome measures.

Under the current Claims-Based Hospital-Wide All-Cause Readmission measure, CMS reports risk-standardized readmission rates for several conditions, including acute myocardial infarction, heart failure, pneumonia, and hip and knee arthroplasty. CMS has also developed hospital readmission measures for stroke and chronic obstructive pulmonary disease. In 2013, CMS began publicly reporting a hospital-wide, all-condition readmission measure that captures 92% of readmissions following eligible admissions.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

During March 2020, among 305 people in Atlanta, Georgia who were hospitalized with laboratory-confirmed coronavirus disease 2019 (COVID-19), about 83% were African American, a higher than expected share based on overall hospital admissions. At a group of four affiliated hospitals, which accounted for 67% of those in the cohort, 80% of the group were African American compared with 47% of hospitalized people overall during March 2020. The hospitalized African Americans were not more likely than other races to receive invasive mechanical ventilation or to die during hospitalization.

About 61.6% of the 305 people hospitalized with COVID-19 were over age 65, and 50.5% were female. The median age was 60 years, with a range between 23 to 95 years. Data on race/ethnicity were available for 297 (97.4%), among whom, 247 (83.2%) were African American, 32 (10.8%) were non-Hispanic white, eight (2.7%) were non-Hispanic Asian or Pacific Islander, and 10 (3.4%) were Hispanic.

About 26% of those hospitalized with COVID-19 had none of the conditions associated with higher risk for severe disease, including being 65 years or older. About 6.6% of the group resided in long-term care facilities before hospitalization.

About 40.1% of the hospitalized people had private insurance; 33.4% were Medicare beneficiaries; 10.9% were Medicaid beneficiaries; and 14.9% were uninsured. The hospitalized African Americans were more likely than those of other races/ethnicity to be Medicaid beneficiaries, at 13.5% compared to 0.0%. However, those in the African American group were not more likely to be uninsured than the other groups.

These findings were reported in “Characteristics And Clinical Outcomes Of Adult Patients Hospitalized With COVID-19 — Georgia, March 2020” by Jeremy A. W. Gold, M.D.; Karen K. Wong, M.D.; Christine M. Szablewski, DVM; Priti R. Patel, M.D.; et al. They analyzed data from a convenience sample of hospitalized adults in metropolitan Atlanta and southern Georgia. The data included individuals admitted between March 1 and 30, 2020 to one of eight hospitals.

PsychU last reported on this topic in “National COVID-19 Death Statistics Show Racial Impact Disparity,” which published on May 25, 2020. The article is available at https://www.psychu.org/national-covid-19-death-statistics-show-racial-impact-disparity/.

For more information, contact:

  • Brendan Jackson, M.D., MPH, Medical Epidemiologist, U.S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, Georgia 30333; 404-639-0536; Email: brjackson1@cdc.gov; Website: www.cdc.gov/;
  • U.S. Centers for Disease Control and Prevention, 3311 Toledo Road, #2403, Hyattsville, Maryland 20782; 800-232-4636; Email: media@cdc.gov; Website: www.cdc.gov/.

Symptom reduction for people with health anxiety who were treated with internet-delivered, text-based cognitive behavior therapy (CBT) was similar to outcomes for people who received face-to-face CBT. Health anxiety, sometimes called somatic symptom disorder or hypocondriasis, is a common mental health problem associated with distress, substantial costs, and frequent health care utilization. The internet CBT and face-to-face CBT were delivered over 12 weeks. After completing treatment, both groups had a similar reduction in their health anxiety symptoms. The internet CBT group generated lower net social costs. The researchers concluded that the online treatment format should be considered as a first-line intervention for health anxiety. The net social cost for the internet CBT treatment was $3,854 lower than face-to-face CBT.

The internet CBT program is a text-based online treatment in which the individual works with conventional CBT strategies and communicates regularly with a therapist through an email-like system. The internet CBT program could be accessed at any time of day. Therapists spent 10.0 minutes per participant per week in the online CBT versus 45.6 minutes for face-to-face CBT.

These findings were reported in “Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial” by Erland Axelsson, Ph.D.; Erik Andersson, Ph.D.; Brjánn Ljótsson, Ph.D.; et al. The researchers conducted a randomized non-inferiority clinical trial in a primary care setting with 204 Swedish adults diagnosed with health anxiety. They compared the effects of internet-delivered CBT to conventional face-to-face CBT. Follow-up data was collected for 12 months after treatment was completed. The analysis of net social cost included costs of therapies and medications (including the cost of internet CBT or face-to-face CBT), costs of non-medical help and services, and indirect costs such as those of unemployment.

The full text of “Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial” was published May 13, 2020 by JAMA Psychiatry. An abstract is available online at https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2765960?guestAccessKey=818cdc24-4487-4f9b-b8a9-2c4a47b571d4&utm_source.

More information about the study is posted online at https://clinicaltrials.gov/ct2/show/NCT02314065.

For more information, contact: 

  • Erik Hedman-Lagerlöf, Ph.D., Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Nobels Väg 9, SE-171 65, Stockholm, Sweden; Email: kire.hedman@ki.se; Website: https://staff.ki.se/people/erihed

Between March 13 and April 30, 2020, 1.4 million health care workers had been laid off due to the coronavirus disease 2019 (COVID-19) pandemic, and about 17% (243,000 workers) had been employed by physician practices. The physician practice layoffs represented about 1% of the total 23.1 million job losses in April 2020.

Of the 1.4 million health care layoffs, in addition to the physician practice layoffs, about 36% (503,000) of the health care job losses were from dentist offices, and another 15% (205,000) were from offices of other health care professionals. The remaining 34% of health care jobs lost were from other health care sectors.

The 1.4 million jobs lost in the health care industry represented 6% of the total 23.1 million job losses in April 2020. The national unemployment rate in April was 14.7%. According to data tracked by the Bureau of Labor Statistics (BLS), employment fell in all major industry sectors, with the heaviest losses in leisure and hospitality.

Across all employment sectors, the number of unemployed persons who reported being on temporary layoff increased about ten-fold in April 2020, from 1.8 million to 18.1 million. The number of permanent job losses increased by 544,000 to 2.0 million. The number of people who were jobless for less than five weeks increased by 33.6%, from 10.7 million to 14.3 million,

The BLS released the April 2020 employment statistics on May 8, 2020. The statistics are from two monthly surveys. The household survey measures labor force status, including unemployment, by demographic characteristics. The establishment survey measures nonfarm employment, hours, and earnings by industry.

For more information, contact:

  • Bureau of Labor Statistics, 2 Massachusetts Avenue Northeast, Washington, District of Columbia 20212; 202-691-5200; Email: PressOffice@bls.gov; Website: https://www.bls.gov/news.release/empsit.nr0.htm

Facebook, Inc. will pay $52 million to settle a class action lawsuit filed by more than 10,000 current and former social media content moderators who allege that their task of reviewing user posts that included images of extreme and graphic violence created significant psychological trauma. As moderators, the plaintiffs reviewed posted images to ensure that they did not violate the company’s policies on “harmful content.” On May 5, 2020, the class filed a preliminary approval motion of settlement. If the court grants the motion, the class intends to file a motion for final approval. The preliminary settlement covers moderators working in California, Arizona, Texas, and Florida from 2015 going forward.

In the settlement, Facebook agreed to establish a fund to maintain a testing and treatment program for content moderators to receive ongoing medical testing and monitoring, and any necessary medical and psychiatric treatment, until determination is made that their psychological trauma is no longer a threat to their health. Additionally, moderators will be able to mute audio by default and change videos to black and white. They will be able to access on-site counseling and a 24-hour hotline staffed by mental health professionals. Facebook will conduct emotional resiliency screenings during the hiring process and will post information about psychological support.

The original complaint, Scola, et al., v. Facebook, Inc., was filed in September 2018. It became a class action to include content moderators who reviewed content for Facebook via various third-party vendors and contractors, such as Pro Unlimited, Inc., Accenture LLP, Accenture Flex LLC, and U.S. Tech Solutions, Inc.

The plaintiffs noted that in 2015, Facebook helped draft workplace safety standards to protect content moderators from this type of workplace trauma. The safeguards included providing moderators with robust and mandatory counseling and mental health supports; altering the resolution, audio, size, and color of trauma-inducing images; and training moderators to recognize the physical and psychological symptoms of post-traumatic stress disorder. However, the plaintiffs alleged that Facebook ignored the workplace safety standards.

For more information, contact:

  • For the Plaintiffs: Joseph Saveri Law Firm, 601 California Street, Suite 100, San Francisco, California 94108; 415-500-6800; Fax: 415-395-9940; Website: https://saverilawfirm.com/
  • For Facebook: Press Office, Facebook, 1 Hacker Way, Menlo Park, California 94025; Email: press@fb.com; Website: https://newsroom.fb.com/

About 14% of internal medicine physician members of the American College of Physicians (ACP) used telemedicine technologies every week to conduct video visits with consumers, according to a survey in January 2020. Video visits were more common in rural areas, and were used by 40% of rural physicians compared to 31% of those in non-rural areas.

About one-quarter of ACP members used telemedicine weekly to conduct physician-to-physician e-consultations (24%) and asynchronous evaluation (25%) of data submitted through a consumer portal or other secure system. About 30% of physicians used remote monitoring (29%) and remote care management (31%) weekly. Rural physicians used remote monitoring and remote care management (when the technology was available) significantly more than non-rural physicians.

The survey differentiated among different types of telemedicine and digital health applications, collecting usage data in the following categories:

  • Video visit.
  • Physician-to-physician electronic consultations via virtual communication tools or portals in real-time or via store-and-forward.
  • Asynchronous evaluation by a physician or other clinical professional of a consumer’s information or images provided by the consumer through a secure portal.
  • Monitoring of physiological data points. Providing remote care management and coaching via phone, text, or video technologies to discuss health status ​and lifestyle behaviors.
  • Integrated data about fitness, sleep quality, or basic heart rate from consumer-grade wearables into a consumer’s medical record.

The share of ACP members who said they had the technology available varied with the type of technology. Weekly usage among those with the technology ranged between 40% and 65%, depending on the type of technology.

Compared to the penetration rate in 2019, use of video visits, remote monitoring, and remote management increased, as measured with comparable audiences year-over-year. Use of video visits increased from 3% to 10%. Use of remote monitoring increased from 5% to 11%. Use of remote care management increased from 12% to 18%. Use of e-consultations remained flat at 21% in both 2019 and 2020. Use of wearables also remained flat at 3% in both years.

The primary barriers to telemedicine adoption were financial and structural concerns, not a lack of physician interest. Only 6% said they were not interested in offering virtual care. Only 7% doubt the need for virtual care in their practices. Variation in telehealth use by specialists reflected the institutional resources available and the nature of the various medical specialties.

These findings were reported in “2020 ACP Member Survey about Telehealth Implementation” by the ACP. The survey was conducted in December 2019 through January 2020 to explore the use of telehealth among internal medicine physicians and subspecialists who are members of ACP. This is the second year that ACP has conducted this survey. For the current survey, ACP sent surveys to 1,972 members age 65 and younger; the response rate was 11.7%. Of those who responded, 49% were in general internal medicine, 24% in hospital medicine, and 26% were subspecialists. The survey questions evaluated the availability of technology, as well as frequency of use, for six different categories of telehealth services.

The researchers identified two short-term opportunities to increase adoption of telemedicine and digital health. The first is to increase implementation of remote monitoring and remote care management technology. The second is to increase the use of video visit technology where it is already implemented.

In a press release, ACP President Robert M. McLean, M.D., MACP, noted that “The survey was conducted before the COVID-19 pandemic, which resulted in the lifting of some regulatory barriers.” He said, “At the time of this survey, telephone call visits were not covered by any insurance payers, so no physicians were formally calling them ‘visits,’ so we did not even ask the question.”

The full text of “2020 ACP Member Survey about Telehealth Implementation” was released in April 2020. An abstract is available online at https://www.acponline.org/system/files/documents/practice-resources/health-information-technology/telehealth/acp-telehealth-survey-results-2020-march.pdf.

For more information, contact:

  • Laura Baldwin, Director, Public Relations, American College of Physicians, 190 North Independence Mall West, Philadelphia, Pennsylvania 19106; 215-351-2668; Email: lbaldwin@acponline.org; Website: https://www.acponline.org/.

About 90% of physicians in nine countries, including the United States, said that they or a colleague are participating in video or telephone visits with consumers. About 47% of physicians using telemedicine for consultation during the coronavirus disease 2019 (COVID-19) outbreak are using telemedicine for the first time. About 20% of physicians using video conferencing and telemedicine tools expect to use them significantly more than before.

In the United States, 63% of physicians said they used telemedicine tools for remote treatment during the COVID-19 outbreak. About 81% reported a decline in consumer volume, with 62% reporting a significant drop and 19% reporting a mild drop. About 11% reported a significant increase in consumer volume, and 3% reported a mild increase. The remaining 4% reported no change. About 32% of calls and time were related to COVID-19, and 68% were for non-COVID-19 concerns. Additional details about their use of telemedicine were as follows:

  • About half (47%) used a consumer-facing video conferencing platform such as Skype or Zoom.
  • About one-third (32%) reported using telemedicine for mental health consultation.
  • Less than half reported using telemedicine platforms for remote learning for their nurses and practice staff (21%) or themselves (34%).
  • Few used clinical decision support tools (7%) or remote monitoring wearables and sensors (8%).

The survey respondents’ practice in eight medical specialties: general practice or internal medicine, cardiology, oncology, neurology, psychiatry, rheumatology, and dermatology. Their reported use of telemedicine before, during, and their projected use after the COVID-19 pandemic public health emergency (in their countries) varied by specialty.

These findings were reported in “COVID-19 HCP Sentiment Surveys Part 1: Physician Engagement with Patients and Remote/Telehealth Experiences” by Sermo. The poll was conducted from March 23 to 30, 2020, among a convenience sample of 1,392 Sermo members in nine countries: China (111),France (167), Germany (137), Great Britain (135), Italy (323), Japan (110), Spain (181), Switzerland (7), and the United States (221). The participants were in eight specialties: general practice or internal medicine, cardiology, oncology, hematology, neurology, psychiatry, rheumatology, and dermatology. About half specialized in general practice or internal medicine. The survey topics related to the participants’ experiences with health care consumers and remote/telemedicine.

Sermo also leveraged its social platform to conduct a poll among 1,300+ international physician members. Results revealed that about 85% said they were providing remote services, and 90% said a colleague is providing services via telehealth. About 68% believe the shift to telehealth will have a lasting impact, and 28% said office-based face-to-face visits will remain more important than telemedicine. About 77% said that given the right circumstances, they support the shift toward telemedicine.

The full results of “COVID-19 HCP Sentiment Surveys Part 1: Physician Engagement with Patients and Remote/Telehealth Experiences” were published April 2020, by Sermo. A copy is available for download at https://www.sermo.com/COVID19-HCPSentimentStudy-Part2.

The topline results of “HCP INSIGHTS: Telemedicine Explodes In These Uncertain Times” were published April 16, 2020, by Sermo. A copy is available online at https://www.sermo.com/telemedicine-explodes-in-these-uncertain-times/.

For more information, contact:

  • Joanna Molke, Marketing Director, Sermo, Inc., 200 Park Avenue South, Suite 1310, New York, New York 10003; Email: joanna.molke@SERMO.com; Website: https://www.sermo.com/.

In this presentation, Dr. Mona Sobhani, PhD, Director of Research and Operations
USC Center for Body Computing, Los Angeles, California, addresses privacy and security considerations during the Covid-19 pandemic. Dr. Sobhani gives real word considerations for clinicians to consider during this challenging time.

Mona Sobhani, PhD, is Director of Research and Operations at the USC Center for Body Computing (CBC), a digital health research and innovation center.  By training, she is a cognitive neuroscientist with behavioral, physiological, and neuroimaging research experience in psychopathic traits, mirror neurons, emotion regulation, fear conditioning, and sensory-motor feedback.  Dr. Sobhani holds a Ph.D. in Neuroscience from the University of Southern California. She also holds a B.S. in Animal Physiology and Neuroscience from the University of California, San Diego.

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

Mona Sobhani, PhD is a paid consultant of Otsuka Pharmaceutical Development & Commercialization, Inc.

Fatima Sadat, PharmD, is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

The U.S. Food and Drug Administration (FDA) has posted initial validation results of 12 antibody tests for coronavirus disease 2019 (COVID-19), or SARS-CoV-2. During March and April 2020, the FDA granted the tests an Emergency Use Authorization (EUA). The validation analysis is based on information submitted by the test developers, which the FDA reviewed before granting the EUA.

The FDA summarized the expected performance of the tests, and assumed a COVID-19 population prevalence of 5% for the positive and negative predictive value (PPV and NPV) calculations. The PPV and NPV help those who are interpreting the tests understand how likely it is that a person who receives a positive result truly does have antibodies, and how likely it is that a person who receives a negative result truly does not have antibodies. PPV and NPV are calculated using a test’s sensitivity, its specificity, and a prevalence assumption.

The FDA noted that the summary results are an incomplete representation of the performance of these tests. The FDA is providing a calculator that will allow users to see the estimated performance of a single test or two independent tests based on their performance characteristics and the estimated prevalence of SARS-CoV-2 antibodies in the target population.

In addition to the 12 antibody tests authorized under an individual EUA, over 200 more antibody tests are being evaluated in a pre-EUA or EUA review. The FDA worked with National Institutes of Health, the Centers for Disease Controls and Prevention, and the Biomedical Advanced Research and Development Authority to help establish a capability at the National Cancer Institute (NCI) to independently validate certain antibody tests, including antibody tests that were not the subject of an EUA or pre-EUA, as well as those that were under FDA review. The main goal of this effort is to determine whether available antibody tests are accurate.

To validate the antibody tests, the NCI team runs a “validation panel” with a set of 110 blood samples from 30 people who had a confirmed SARS-CoV-2 infection and 80 samples taken from people before the COVID-19 pandemic started. Each sample in the validation panel was tested by at least two separate labs.

The FDA intends to use the NCI data to inform future decision making about whether to authorize the test or take other action regarding tests that fail to perform adequately. NCI has shared validation data from 13 test kits so far with the FDA. The FDA posted the results at https://www.fda.gov/medical-devices/emergency-situations-medical-devices/eua-authorized-serology-test-performance.

For more information, contact:

  • Office of Media Affairs, U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Building 32, Room 5245, Silver Spring, Maryland 20993; 301-348-1956; Email: FDAOMA@fda.hhs.gov; Website: https://www.fda.gov/medical-devices/emergency-situations-medical-devices/eua-authorized-serology-test-performance

All New York long-term care facilities must communicate coronavirus disease 2019 (COVID-19) test results and deaths to residents’ families, according to an executive order issued by New York Governor Andrew M. Cuomo. The order includes adult home and other assisted living facilities. Additionally, the Governor also announced a new directive requiring nursing homes to immediately report to the Department of Health (DOH) the actions they have taken to comply with all laws, regulations, directives, and guidance issued by the DOH based on guidance from the federal Centers for Disease Control and Prevention (CDC).

The state guidance requires nursing homes to do the following:

  • Provide personal protective equipment (PPE) and temperature checks for staff. New York State will provide PPE to nursing facilities on an emergency basis.
  • Isolate COVID residents in quarantine.
  • Separate staff and transfer COVID-positive residents within a facility to another long-term care facility or to another non-certified location.
  • Notify all residents and their family members within 24 hours if any resident tests positive for COVID or if any resident suffers a COVID-related death.
  • Readmit COVID positive residents only if they have the ability to provide adequate level of care under DOH and CDC guidelines.

The executive order, 202.18, requires any skilled nursing facility, nursing home, or adult care facility licensed and regulated by the DOH to notify a family member or next of kin within 24 hours if any resident tests positive for COVID-19, or suffers a COVID-19 related death. A related order, 202.19, sets a penalty for non-compliance at $2,000 per violation per day. On April 23, 2020, Governor Cuomo said the state DOH partnered with the state’s attorney general to investigate nursing homes that violate the executive order.

For more information, contact:

  • Jonah Bruno, Director of Communications, New York State Department of Health, Empire State Plaza, Corning Tower, Albany, New York 12237; Email: dohweb@health.ny.gov; Website: https://www.health.ny.gov/
  • New York Office of the Attorney General, The Capitol, Albany, New York 12224-0341; Website: https://ag.ny.gov/

Nurses are incredibly resilient, but the COVID-19 pandemic has imposed significant challenges to those in the profession. Alan “Tony” Amberg, MS, MSN, APRN, PMHNP-BC, PsychU’s Nurses Corner Section Advisor, proposes Psychological First Aid as a means to offer emotional and practical support to nurses exposed to severe stress. It is designed to create a sense of safety and comfort, encourage contact and engagement, and connect the individual to helpful social support resources. Moderated by Rachel Self, PhD, Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialize, Inc., this webcast illuminates how the coronavirus crisis may enhance nurses’ compassion, increase their courage, and strengthen their determination to bring every patient back to health.

Featuring:

  • Alan “Tony” Amberg, MS, MSN, APRN, PMHNP-BC
    Nurses Corner Section Advisor; Psychiatric Consult Liaison Psychiatric Nurse Practitioner at Northwestern Memorial Hospital
  • Rachel Self, PhD
    Senior Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

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 and also does outpatient clinical work at 7 Hills Healthcare Center, also in Chicago. He is also an Emeritus Board Member and Former President of the Illinois Chapter of the American Psychiatric Nurses Association (APNA).

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

During 2017, the total costs for outpatient prescription opioid expenses for adults were $7.7 billion for 110.4 million prescription fills. Of the $7.7 billion for prescription opioid expenses, Medicare paid 40.9%. Private insurance (including TRICARE) paid 28.6%. Individuals and family members paid 15.5% out-of-pocket. Medicaid paid 10.5%, and other sources paid 4.5%. The other sources include the Department of Veterans Affairs (but not TRICARE); the Indian Health Service; military treatment facilities; state or locally funded community and neighborhood clinics or health departments; workers’ compensation, and liability insurance.

The average annual total per-person expense was $3,693 for all outpatient prescriptions among adults with one or more prescription opioid fills in 2017. The average per-person out-of-pocket expense was $385.

These findings were reported in “Total Expenses, Total Utilization, and Sources of Payment for Outpatient Prescription Opioids in the U.S. Adult Civilian Noninstitutionalized Population, 2017” by Yao Ding, Ph.D.; and G. Edward Miller, Ph.D. The researchers analyzed the Medical Expenditure Panel Survey (MEPS) Household Component to estimate total expenses and prescription fills for all outpatient prescription opioids that are commonly used to treat pain. They ranked the top five opioid by total expenses in 2017. They also estimated annual total and out-of-pocket expense per person for all outpatient prescriptions among adults with at least one outpatient opioid fill and at least one fill of the top five opioid products in 2017.

A link to the full text of “Total Expenses, Total Utilization, and Sources of Payment for Outpatient Prescription Opioids in the U.S. Adult Civilian Noninstitutionalized Population, 2017” may be found at www.openminds.com/market-intelligence/resources/040720mepsopioidscrips.htm.

For more information, contact:

  • Bruce Seeman, Agency for Healthcare Research and Quality, 5600 Fishers Lane, Floor 7, Rockville, Maryland 20857; 301-427-1998; Fax: 202-960-6343; Email: bruce.seeman@ahrq.hhs.gov; Website: https://www.ahrq.gov/.

About 51% of adults in North Carolina are at higher risk for severe illness from coronavirus disease 2019 (COVID-19) because they are age 65 or older and/or have an underlying health condition associated with higher risk. The estimate is based on data from the NC State Center for Health Statistics Behavioral Risk Factors Surveillance System (BRFSS) for 2018.

The underlying health conditions are based on those identified by the Centers for Disease Control and Prevention (CDC) as being associated with higher risk: chronic lung disease, cardiovascular disease, severe obesity, diabetes, kidney disease, liver disease, and immunosuppressive conditions, including cancer treatment, smoking, and other immune disorders. During 2018, the most recent year for which full data are available, about 42% of North Carolina residents had one of the high-risk underlying health conditions.

The prevalence of those with one or more health conditions increased by age. The infection rate by age group fluctuated. COVID-19 deaths were concentrated among the older age groups.

The confirmed COVID-19 case rate for specific underlying conditions and death rates varied by condition. The highest death rate was among those with pre-existing cardiovascular disease; about half died. About one-third of those with diabetes or chronic lung disease died after contracting COVID-19. About one-fifth of those with kidney disease died due to COVID-19.

The North Carolina Department of Health and Human Services reported its findings in “Risk Factors For Severe Illness From COVID-19.” The goal was to identify the share of state residents at higher risk for a serious outcome if they contracted COVID-19. The data sources do not contain every underlying health condition identified by the CDC.

For more information, contact:

  • Mandy Cohen, Secretary, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina 27699-2001; 919-855-4840; Email: news@dhhs.nc.gov; Website: https://covid19.ncdhhs.gov/dashboard#by-age.

Many mental health conditions are diagnosed in primary care settings, but a significant percentage of individuals referred to mental health care may not receive recommended treatment. One aim of the shift to care integration, where collaborative primary care, mental health care and care management services are located in the same setting, is to narrow the gap between diagnosis and appropriate treatment. In “Veterans Health Administration Investments in Primary Care and Mental Health Integration Improved Care Access,” published in Health Affairs (August 2019), Lucinda B. Leung and colleagues provide a systematic review that broadly examines the national Primary Care–Mental Health Integration (PC-MHI) initiative of the Veterans Health Administration (VHA)

Primary Care: Mental Health Integration Overview

Integrating care services is thought to be optimal–but it is easier said than done. Since 2007, the Veterans Health Administration (VHA) has invested in an initiative called Primary Care–Mental Health Integration (PC-MHI) in their clinics nationwide.  The VHA’s objective in launching PC-MHI was to improve veterans’ access to mental health services in a primary care setting by offering specialists and case managers, in addition to primary care physicians. Designated specialized mental health services are made available for veterans diagnosed with serious mental illnesses. The idea behind this methodology is that by siting all professionals in a centralized location, veterans would feel more at ease when seeking help and receiving collaborative care, personalized to their specific needs. To drive home the importance of collaborative care models in veterans’ treatments, the VHA required clinics caring for 5,000 or more patients annually to implement PC-MHI. PC-MHI serves as the first line of treatment that the VHA offers for mental health services. Specialty-based mental health care and inpatient treatment services are provided as needed to the veterans.

The VHA facilitated the clinics’ provision of PC-MHI care by blending two evidence-based models: embedding mental health specialists within primary care teams to provide centralized, collaborative care; and offering mental health–trained care managers to deliver evidence-based services over the telephone.

  • Specialists, often psychologists, conduct a timely assessment with the primary care patient, provide treatment options for mental and behavioral issues, and offer consultants to primary care physicians to continue managing challenging patient behaviors.
  • Care managers, often registered nurses, also work collaboratively with primary care providers to systemically monitor symptoms and treatment adherence, provide decision support, and assist in specialty-based mental health referrals.

Design and Methods

In comparing clinics that fully implemented PC-MHI programs in the first year, with those that did not, one study found zero differences in rates of mental health visits and diagnoses between the two clinic groups. Separate analyses of veterans who received PC-MHI services compared with veterans who did not found that those who did receive PC-MHI services had a higher likelihood of completed referrals to specialty mental health care, greater odds of obtaining psychiatric diagnoses and treatment, and a lower likelihood of emergency visits.

In this particular national study, the objective was to examine whether increasing PC-MHI services in primary care settings had any effect on health care use and total costs. This specific study focused on VHA primary care patients who received primary care services from any of the 396 VHA clinics mandated to provide PC-MHI services from October 2013 through September 2016. Of the 396 mandated clinics, 153 were hospital based, whereas 243 were community based.

Outpatient and inpatient VHA visits were categorized and measured. The categories for visits are as follows:

  • All mental health care visits
  • Specialty-based mental health visits
  • Primary care visits
  • Other non-mental health specialty visits
  • Telephone visits
  • Emergency visits
  • Hospitalizations

Unit cost estimates were pulled from the VHA’s decision support files. Total VHA health care costs were calculated by multiplying health care use by unit cost estimates.  This particular activity-based costing method does not include fee-based care from VHA providers who are paid for by the VHA.

Primary outcomes were reported as relative measurements of the effect of each percentage-point increase in clinic PC-MHI penetration on average numbers of health care visits and costs per person per year.

The primary predictor for this study was the PC-MHI penetration rate, indicating the proportion of assigned primary care patients who saw a PC-MHI provider in each clinic annually. Clinics were dichotomized into either having a high penetration rate, meaning the clinic fell above the median PC-MHI penetration rate of 6.3%, or having a low penetration rate, meaning the clinic fell below the median PC-MHI penetration rate of 6.3%.

Through a multilevel analysis, the study estimated the effect of the clinical PC-MHI penetration rate on patients’ health care utilization outcomes, after adjusting for year and clinic fixed effects. Then, two separate analyses were conducted to see if the PC-MHI targeted patient conditions for collaborative care experienced more significant impacts: depression, anxiety, or both; and bipolar disorder, schizophrenia or both.

Implications and Limitations

While this study was conducted on a wide-sweeping, national level, there are several limitations to consider when reviewing the findings:

  • The study did not include medical care received outside the VHA system.
  • The study did not control for factors related to PC-MHI, such as mental health care staffing, which could have affected health care use and costs.
  • The VHA administrative data sources may be subject to coding inaccuracies due to the transition from ICD-9 to ICD-10 diagnostic codes.

Despite the study’s limitations, there were several findings that can further improve the VHA’s experience with providing integrated, collaborative care to veterans. For example, for every percentage-point increase in PC-MHI penetration, a VHA clinic patient had an 11% increase in average total mental health visits and a 9% increase in average total costs.

While each percentage-point increase in PC-MHI was accompanied by a rise in total mental health visits, there also was a reduction in specialty-based mental health visits. Additionally, an increase in PC-MHI penetration was associated with higher average primary care and telephone visits per patient per year. Among patients with serious mental illness, an increased PC-MHI penetration reflected greater numbers of specialty-based mental health visits.

Overall Findings

Overall, the general findings of the study reflect that veterans treated in clinics with a higher PC-MHI penetration rate received more mental health care overall—with a higher total cost to the VHA—than those treated in clinics with lower PC-MHI penetration. Patients with mild-to-moderate mental health conditions who were seen in clinics with higher penetration rates received more integrated mental health care and primary care than those who visited clinics with lower penetration rates. The VHA’s primary objective when implementing PC-MHI was to increase mental health access for primary care patients. In essence, the study’s findings indicate that greater PC-MHI penetration rates are associated with improved access, demonstrated by the patients’ use of available services.

An increase in patient services can result in an increase in health care costs. The VHA incurred greater total costs for veterans seen at higher-penetration clinics, compared with total costs associated with individuals seen at clinics with lower penetration rates. Costs aside, the study did demonstrate that implementing the PC-MHI program revealed unmet needs among veterans, untreated mental health problems, requests for assistance with behavior change, and a strong need for other preventative services.

As intended, this study supports that PC-MHI allows veterans with targeted conditions of depression and anxiety to receive mental health services within a primary care setting, preserving access to traditional mental health services for veterans with serious mental illnesses.

On April 10, 2020, a new online addiction treatment platform, Tech Together, was launched. The platform is a partnership between Google, Facebook, and Twitter, along with the Center for Safe Internet Pharmacies (CSIP). The platform addresses two key issues—treatment access and recovery support—to help consumers seeking information about addiction treatment or those in recovery find help online during the COVID-19 public health crisis.

The site provides a treatment locator that links to state behavioral health departments to help consumers find information and resources about local treatment options. It also links to the national Behavioral Health Treatment Services Locator, hosted by the Substance Abuse and Mental Health Services Administration.

To help consumers assess their need for addiction treatment, the Tech Together website provides a link to a free federal government online addiction disorder screening and assessment called the “Tobacco, Alcohol, Prescription medication, and other Substance use” (TAPS) tool. The tool consists of a combined screening component followed by a brief assessment for those who screen positive.

To help consumers in recovery access critical recovery support groups online for the duration of social distancing recommended by the Centers for Disease Control during COVID-19, the Tech Together site offers a list of online recovery support groups or virtual meetings. The list was compiled by Google through work with various non-profit addiction treatment provider organizations.

The site hosts videos featuring stories of recovery from drug addiction. The site also describes how the other Tech Together partners are supporting recovery on their platforms, as follows:

  • Facebook allows its members to offer crisis support over Facebook Messenger, host Facebook Live support sessions, and connect through Facebook Groups. In 2019, Facebook partnered with Partnership for Drug-Free Kids and the Center on Addiction, to launch the Stop Opioid Silence (SOS) campaign to reduce stigma associated with opioid use disorders.
  • Twitter provides real-time engagement for its members to share their stories of recovery, and online community building. Twitter offers hashtags for people in recovery, such as #RecoveryMovement, #OpenRecovery, and #RecoveryWorks.

Tech Together was originally launched in November 2018 with the goal of leveraging its partners’ platforms, products, and tools to help address the opioid crisis. The goal is to raise public awareness and education about addiction disorder and recovery and make it easier for people to find help and support.

CSIP is a non-profit organization chartered in 2011. The organization allows Internet industry leaders to address the problem of consumer access to illegitimate pharmaceutical products on the Internet. Its members include representatives from the Internet ecosystem and each point in the online advertising and purchase/delivery cycle, including domain name registries, registrars, shipping companies, payment processors, and advertising service provider organizations. More information is available at https://techtogether.co/.

For more information, contact:

  • Ashley Schlosser, Media Contact, Center for Safe Internet Pharmacies, 466 Cortona Cove, West Lake Hills, Texas 78746; 512-968-0562; Email: aschlosser@safemedsonline.org; Website: https://safemedsonline.org/contact-us/.

On May 12, 2020, the Virginia Attorney General’s office, the American Civil Liberties Union, and a Charlottesville attorney reached a pre-hearing stipulated settlement agreement with the Virginia Department of Corrections (DOC) about DOC’s plans to review the case for early release for eligible inmates during the coronavirus disease 2019 (COVID-19) public health emergency. DOC will ensure that inmates who are not released receive prompt medical treatment, and that facilities take all necessary precautions to prevent the spread of COVID-19.

As of May 16, 2020, the DOC had released 182 prison inmates in order to slow the spread of COVID-19. As of May 18, 2020, DOC reported that 900 offenders and 73 staff members have tested positive for the virus. Five inmates died of COVID-19.

The complaint, Whorley v. Northam, was filed on April 8, 2020, on behalf of 27 incarcerated people. The plaintiffs alleged that overcrowded prisons failed to keep them safe from contracting COVID-19. A DOC spokesperson said that after the plaintiffs reviewed DOC’s plans for addressing the COVID-19 emergency, they found little to pursue. As a result, the complaint will be dismissed.

On March 12, 2020, Virginia Governor Ralph Northam issued a state of emergency with an end date of June 10, 2020. On March 13, 2020, the Governor ordered the DOC to evaluate early release for some inmates. On April 22, 2020, the DOC released its plan for COVID-19 early release. The plan provides for the early release of eligible inmates who have a viable home plan and a low or medium risk of recidivism. Offenders convicted of a Class 1 felony or a sexually violent offense are not eligible for consideration. DOC began early releases after the General Assembly approved the Governor’s budget amendment on April 22.

Under the stipulated agreement in Whorley v. Northam, the DOC agreed to amend or otherwise clarify the release provisions in its existing Early Release Plan as follows:

  • Amend the plan to provide reference to the home plan criteria to specify that any address provided may be verified by a local probation and parole officer, rather than the re-entry counselor normally used. Suspend the requirement that home plans not be verified more than six months before the individual’s anticipated release date. The individual must still have a viable home plan, and must be able to provide an address where the individual will be able to live without violating any conditions of a court order. The individual must be able to adhere to any lease restrictions in terms of the individuals allowed to live in that residence.
  • Give priority consideration for approval of release to those individuals who have a health condition enumerated by the Centers for Disease Control and Prevention as being at higher risk of health complications if that individual were to contract COVID-19.
  • Review eligible individuals prior to the expiration of the declaration of emergency. If the DOC elects not to release an inmate potentially eligible for release under the Early Release Plan, DOC will notify the inmate of the decision.
  • Consider the review and release of eligible individuals on a rolling basis during the period of the emergency declaration.
  • Update the COVID-19 webpage to report, on a daily basis, the number of individuals who have been released. As of May 16, 2020, the DOC had released 182 offenders with a year or less left on their sentences.

For more information, contact:

  • Lisa E. Kinney, Media Contact, Virginia Department of Corrections, Post Office Box 26963, Richmond, Virginia 23261; 804-674-3275; Email: COVID19Inquiries@vadoc.virginia.gov; Website: https://vadoc.virginia.gov/
  • American Civil Liberties Union of Virginia, 701 East Franklin Street, Suite 1412, Richmond, Virginia 23219; 804-644-8022; Fax: 804-649-2733; Email: acluva@acluva.org; Website: https://acluva.org/
  • Interfaith Action For Human Rights, Post Office Box 55802, Washington, District of Columbia 20040; 240-324-9160; Email: Info@interfaithactionhr.org; Website: https://www.interfaithactionhr.org/

New York behavioral health provider organizations are delivering 82% of programs via telehealth during the COVID-19 public health emergency, according to a member survey conducted by the Coalition for Behavioral Health. About 40% of organizations reported an increase in overall demand for behavioral health services from new consumers, and 73% reported increased demand from existing consumers. About 21% of provider organizations reported that the overall current demand for services exceeds current program capacity.

Despite increased demand, individual provider organizations have lost between $45,000 and $2.4 million in revenue since the state of emergency was declared. Based on those who responded, the Coalition estimated total losses to the sector in New York of over $63 million.

Behavioral health provider organizations have had significant increased costs due to purchasing technology for staff and consumers, buying personal protective equipment (PPE), and adding additional cleanings at face-to-face sites. The additional costs averaged $311,000 per organization. The Coalition estimated a total additional cost of over $32.8 million for the survey respondents. About 21% of the organizations have furloughed or laid off staff.

These findings were reported by the Coalition for Behavioral Health. It conducted an online survey from April 15 to April 24 with chief executive officers (CEO) of its member organizations. Responses were completed by one-third of the organizations. Each of the respondents’ programs have a median of three sites open for face-to-face services, including residential and congregate care programs. The programs are also providing long-acting injectable medications and other in-person care.

The Coalition offers policy, advocacy, training, and technical assistance to more than 100 community-based behavioral health provider organizations in New York. The member organizations provide mental health and addiction prevention, treatment, and recovery services for more than 600,000 consumers annually.

For more information, contact:

  • Nadia Chait, Associate Director of Policy & Advocacy, The Coalition for Behavioral Health, 123 William Street, Suite 1901, New York, New York 10038; 212-742-1600; Email: nchait@coalitionny.org; Website: https://www.coalitionny.org/

About 87% of Medicare inpatient psychiatric facility (IPF) claims with outlier payments during 2014 and 2015 failed to meet the medical necessity or documentation requirements set by Medicare. During fiscal years (FYs) 2014 and 2015, the number of IPF claims with outlier payments increased by 28%. Total Medicare payments for the IPF claims with outlier payments rose by 19%, from $450 million to $534 million. The Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS) estimates that Medicare overpaid IPFs by $93 million for stays that resulted in outlier payments, but were non-covered or partially non-covered because inpatient treatment was not medically necessary for all or part of the stay.

An audit of a random sample of 160 claims found that 142 had missing or inadequate medical record elements. Most were missing physician certifications. Of the 142 medical records, 12 did not clearly support that the IPF had protected the individual’s right to make informed decisions regarding care. Oversight by the Centers for Medicare & Medicaid Services was not adequate to prevent or detect the IPFs’ errors.

These findings were reported in “An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements” by the OIG. The audit covered 36,120 inpatient claims with nearly $1 billion in total Medicare payments. The goal was to determine whether IPFs complied with Medicare coverage, payment, and participation requirements for services provided in FYs 2014 and 2015 that resulted in outlier payments.

A link to the full text of “An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements” may be found at www.openminds.com/market-intelligence/resources/040820oigiptpsychoutliers.htm.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: Donald.white@oig.hhs.gov; Website: https://oig.hhs.gov/

One-third of primary care physicians (PCPs) doubt that medication assisted treatment (MAT) for opioid use disorder (OUD) is more effective than non-medication-based treatment; they also doubt that MAT is safe for long-term maintenance treatment. Two-thirds of PCPs believe MAT is more effective for treatment and that MAT is safe for long-term use. According to a survey of PCPs, about one-fifth (20.2%) are interested in treating consumers with OUD.

Federal efforts to expand treatment with medication have focused on PCPs who can prescribe injectable, extended-release naltrexone and, after obtaining a waiver from the Drug Enforcement Administration, buprenorphine for OUD in the office setting. Methadone for OUD can only be dispensed by specialty Opioid Treatment Programs, and cannot be dispensed by office-based outpatient physicians.

Most PCPs (81.8%) supported increasing insurance coverage of OUD medication. A majority (76.4%) supported increasing government investment in OUD medication. About 47.7% supported allowing physicians to prescribe methadone for OUD in primary care settings. Few (38.0%) supported eliminating the federal requirement that office-based physicians obtain a waiver to prescribe buprenorphine.

The researchers concluded that federal policy changes to increase the caseload limits for physicians with a buprenorphine waiver and to expand the types of health care professionals who can prescribe buprenorphine are “unlikely to lead to widespread availability of primary care-based medication treatment of OUD.” They noted that to increase medication assisted OUD treatment rates, it may be necessary to incorporate addiction medicine into physician training, and delivery system reforms, or embed addiction medicine professionals in primary care practices.

These findings were reported in “Medication for Opioid Use Disorder: A National Survey of Primary Care Physicians” by Emma E. McGinty, Ph.D., MS; Elizabeth M. Stone, MS; Alene Kennedy-Hendricks, Ph.D.; Marcus A. Bachhuber, M.D.; and Colleen L. Barry, Ph.D., MPP. The researchers conducted a national survey in February 2019 with a random sample of 1,000 primary care physicians to examine their beliefs and attitudes about the effectiveness of OUD medication treatment and policies. The survey was completed by 361 PCPs.

The full text of “Medication for Opioid Use Disorder: A National Survey of Primary Care Physicians” was published April 21, 2020 by Annals of Internal Medicine. A copy abstract is available online at https://annals.org/aim/article-abstract/2764855/medication-opioid-use-disorder-national-survey-primary-care-physicians.

For more information, contact:

  • Emma Beth McGinty, Ph.D., Associate Professor, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Hampton House 359, Baltimore, Maryland 21205; 410-614-4018; Email: bmcginty@jhu.edu; Website: https://www.jhsph.edu/faculty/directory/profile/2908/emma-beth-mcginty

In this interview, Dr. Steven Chen, PharmD, FASHP, FCSHP, FNAP discusses how community pharmacists can play a major role in COVID-19 testing administration with the recent guidance from US Health and Human Services that under the Public Readiness and Emergency Preparedness Act, licensed pharmacists may order and administer COVID-19 tests that the U.S. Food and Drug Administration has authorized. He addresses how pharmacists are well positioned to broadly perform testing that will provide vital data as public health professionals strategize how best to slow the coronavirus’ spread.

Dr. Steven Chen, PharmD, FASHP, FCSHP, FNAP, is an Associate Professor and Associate Dean for Clinical Affairs at the USC School of Pharmacy and the William A. Heeres and Josephine A. Heeres Chair in Community Pharmacy. He has received honorary fellowships from the California Society of Health-System Pharmacists, the American Society of Health-System Pharmacists, and the National Association of Practitioners. Dr. Chen was recognized by the Center for Medicare and Medicaid Services in 2016 for his collaboration with The Partnership for Public Service that contributed to 87,000 lives saved, 2.1 million fewer patient harms, and $19.8 billion in cost savings. He is founder of the California Right Meds Collaborative (CRMC), which engages health plans, pharmacists, health systems, and pharmacy schools in California in the initiation and spread of sustainable Comprehensive Medication Management services.

Dr. Steven Chen, PharmD, FASHP, FCSHP, FNAP volunteered his time to Otsuka Pharmaceutical Development & Commercialization, Inc.

According to a recent analysis, few managed long-term services and supports (MLTSS) program contracts assess or reassess the well-being of their members’ family caregivers. Of the 31 programs evaluated, seven (22.6%) specify such an assessment, as well as what an assessment should address (i.e., health, welfare, stress, burnout). These programs include those in Hawaii, New Mexico, Pennsylvania, South Carolina, Tennessee, Wisconsin Family Care, and the Wisconsin Family Care Partnership. The member is defined as the Medicaid beneficiary who is receiving the services through the managed care delivery system.

Additional findings include:

  1. The two elements most commonly found in MLTSS contracts are inclusion of the family caregiver in service planning and care coordination, and services and supports for caregivers.
  2. Contracts for all but one MLTSS program include a reference to family caregivers as part of the care team, upon the member’s consent.
  3. Contracts for all but two MLTSS programs reference coverage of services such as respite care and caregiver training.
  4. Twelve MLTSS programs in 11 states now support a program where a spouse or other family member may be paid to provide care to the member, at the member’s choice.

The researchers conclude that states have made progress in support for family caregivers in MLTSS. However, states still have opportunity to continue improving support for family caregivers in their MLTSS programs. A potential solution for this is to ensure that MLTSS contracts between states and health plans include clearly defined requirements to identify and support family caregivers.

These findings were presented in “Recognition of Family Caregivers in Managed Long-Term Services and Supports,” by AARP Public Policy Institute. Researchers for AARP studied 31 MLTSS programs in 23 states. These include the MLTSS program(s) in Arizona, California, Delaware, Florida, Hawaii, Idaho (2 programs), Illinois (2 programs), Iowa, Kansas, Massachusetts, Michigan (2 programs), Minnesota (2 programs), New Jersey, New Mexico, New York (2 programs), Ohio (2 programs), Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas (2 programs), Virginia, and Wisconsin (2 programs). The goal was to examine support for family caregivers in MLTSS.

The full text of “Recognition of Family Caregivers in Managed Long-Term Services and Supports” was published by AARP. A copy is available online at https://www.aarp.org/ppi/info-2020/recognition-of-family-caregivers-in-managed-long-term-services-supports.html.

For more information, contact:

  • Media Office, AARP Public Policy Institute, 601 E Street Northwest, Washington, District of Columbia 20049; Email: media@aarp.org; Website: https://www.aarp.org/

As of mid-April 2020, about 43% of community-based addiction treatment provider organizations in North Carolina lacked sufficient cash on hand to remain in business for the next 30 days due to financial constraints created by the coronavirus disease 2019 (COVID-19) outbreak and public health emergency. According to survey responses provided by 70 community-based addiction treatment provider organizations, in addition to the 43% that reported having no more than 30 days cash on hand to fund operations without receiving reimbursements, 10% reported having 31 to 45 days cash on hand, 13% reported having 46 to 60 days cash on hand, and 16% reported having 61 to 90 days cash on hand. The remaining 18% reported having more than 90 days cash on hand.

Across the state, addiction treatment provider organizations lost revenue as demand for treatment dropped during the public health emergency, while new expenses to acquire personal protective equipment (PPE) and to implement telehealth treatment increased. To respond to the financial stress, about 27% of the organizations have laid off staff or cut positions, and another 40% were considering staff cuts. About 33% were staffing as normal. More than half, 57%, have closed at least one program. About 10% of programs cannot admit new consumers. About 19% of the organizations said they were operating as normal without service disruptions.

These statistics are the result of a survey conducted by Addiction Professionals of North Carolina (APNC). From April 13 to 20, APNC surveyed 70 of its member addiction treatment provider organizations. APNC is a network of more than 650 provider organizations and professionals. The survey was sent to executives at its member organizations statewide. The respondents are representative of provider organizations across all regions of North Carolina in terms of revenue mix and consumer volume.

For more information, contact:

  • Sarah Potter, Executive Director, Addiction Professionals of North Carolina, 3373 National Drive, Suite 225, Raleigh, North Carolina 27612; 919-630-8134; Email: spotter@apnc.org; Website: http://www.apnc.org/.

On April 14, 2020, the U.S. Food and Drug Administration (FDA) issued guidance that temporarily expands availability of digital health devices intended to aid treatment for metal heath disorders. The FDA reduced regulatory barriers on devices it believes pose low risk of harm to users. The goal is to expand the availability of these devices while reducing user and health care professional contact and potential exposure to COVID-19 during the pandemic.

The FDA defines software functions as “devices” when the functions are intended to aid diagnosis, cure, mitigation, prevention, or treatment of a disease or condition. Software intended to maintain or encourage a healthy lifestyle unrelated to diagnosis, cure, mitigation, prevention, or treatment of a disease or condition is not considered a device.

The temporary expansion policies affect two categories of digital devices:

  • Computerized behavioral therapy and other digital health therapeutic devices for psychiatric disorders; and
  • Low-risk general wellness and digital health products for mental health or psychiatric conditions.

The FDA does not intend to enforce its current requirements for the following software functions that may meet the definition of a device related to psychiatric conditions and the COVID-19 pandemic. Based on its current understanding, the FDA believes these software functions pose low risk to consumers:

  1. General wellness software functions to promote, track, and/or encourage choices, which, as part of a healthy lifestyle, have a well-established link between helping a person live well with or reduce the person’s risk of certain chronic psychiatric diseases or conditions. Chronic psychiatric conditions may include (but are not limited to): depression, anxiety, obsessive compulsive disorder, autism, and attention deficit/hyperactive disorder. The software functions could include claims that “daily motivational reminders to perform physical activity may help people with depression live well,” or that “mindfulness and medication activities may help people with chronic anxiety live well.”
  2. Software functions that help people with diagnosed psychiatric conditions maintain their behavioral coping skills by providing a “Skill of the Day” behavioral technique or audio messages that the user can access when experiencing increased anxiety related to the COVID-19 public health emergency.
  3. Software functions that help teach users to “just notice,” accept, and embrace difficult or previously unwanted thoughts and feelings during the COVID-19 public health emergency, so that the users open up to these unpleasant feelings and learn not to overreact to them or avoid situations where they are invoked.
  4. Software functions that display, at opportune times, images or other messages for a person who wants to stop addictive behavior due to increased anxiety during the COVID-19 public health emergency.
  5. Software functions that help users self-manage their disease or conditions without providing specific treatment or treatment suggestions.
  6. Software functions that use a checklist or a questionnaire of common signs and symptoms for a psychiatric disorder (e.g., anxiety due to stay-in-place orders) and to provide a list of possible medical conditions and advice on when to consult a health care professional.
  7. Software functions that guide a user through a questionnaire of signs and symptoms for a psychiatric disorder (e.g., anxiety or stress due to stay-in-place orders) and to provide a recommendation for the type of health care facility most appropriate to their needs.

In general, the FDA does not intend to object to the distribution and use of computerized behavioral therapy devices and other digital health therapeutic devices for psychiatric disorders where such devices do not create an undue risk in light of the public health emergency. The FDA believes such devices will not create such an undue risk when the following four criteria are met:

  • Software verification, validation, and hazard analysis has been performed and demonstrates that the device implements the therapy model as intended.
  • Appropriate cybersecurity protections are in place consistent with FDA pre- and post-market recommendations.
  • The labeling, including user instructions, specifically instruct the user to contact a physician before using the device, even if the device is marketed directly to the consumer.
  • The user is prompted to acknowledge the recommendation to contact a physician before use, such as by providing a standalone check-box that is separate from any end user license agreement.

The FDA emphasized that the guidance does not apply to higher risk digital health devices that include software functions for the treatment of a specific psychiatric condition, for example to support abstinence during addiction treatment. The guidance will not apply to digital health devices intended to replace face-to-face or telehealth treatment sessions or to those devices intended to treat specific psychiatric conditions where the condition may require an urgent or immediate clinical intervention, and delay may pose significant harm.

The relaxed guidance policies do not affect general wellness software functions that are not considered devices. Such functions can be unrelated to a specific disease or condition, related to sleep, related to mental health or psychiatric conditions, or provide reminders, as follows:

  1. Functions unrelated to a specific disease or condition include promoting relaxation, mindfulness, or meditation; and reducing stress, fatigue, or feelings of isolation due to the COVID-19 public health emergency.
  2. Functions related to sleep include promoting good sleep to include improving the sleep experience; having more relaxing or restful sleep; and sleeping through the night or sleeping all night.
  3. Functions related to mental health or psychiatric conditions include providing motivational tips via text and other messages intended to reduce stress related to COVID-19 or promote a positive mental outlook.
  4. Functions that provide reminders could include reminding the user to adhere to recommended physical distances from others during the current public health emergency.

The guidance was released in “Enforcement Policy for Digital Health Devices For Treating Psychiatric Disorders During the COVID-19 Public Health Emergency.” The policy will remain in effect “only for the duration of the public health emergency related to COVID-19.” The guidance does not apply to digital health devices that are intended to be solely or primarily relied upon by the health care professional or consumer to make a clinical diagnosis or treatment decision. In the document, the FDA clarified how two FDA Guidance Documents, “General Wellness: Policy for Low Risk Devices” and “Policy for Device Software Functions and Mobile Medical Applications,” apply to products that may be beneficial to individuals experiencing psychiatric conditions or have mental health concerns during this public health emergency.

Comments on the guidance can be submitted to:

  • Docket number FDA-2020-D-1138, Dockets Management, U.S. Food and Drug Administration, 5630 Fishers Lane, Room 1061, Rockville, Maryland 20852; 888-463-6332; Email: CDRH-COVID19-DigitalHealthForPsychiatricDisorders@fda.hhs.gov; Website: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-digital-health-devices-treating-psychiatric-disorders-during-coronavirus-disease.

On April 29, 2020, officials at the Montgomery County, Pennsylvania Correctional Facility (MCCF) reported that 18.7% of the facility inmates (177 of the total 948 tested) tested positive for coronavirus disease 2019 (COVID-19). Before conducting the testing, MCCF had been aware of six cases.

Of the 177 who tested positive, 3.4% were showing COVID-19 symptoms and 96.6% had no symptoms. No updated information as to the current number of the facility inmates affected by COVID-19 is available. However as of May 12, 2020, no new cases of COVID-19 were reported at the MCCF.

About 75.8% of the MCCF inmates are being held in isolation (175 individuals) or quarantine (544 individuals), depending on whether they tested positive, or came into contact with someone who did. If a prisoner or inmate tests positive, MCCF will not release the individual until after treatment and during recovery. However, if that individual is due to be released from maximum time served, that individual would be referred to a physician in the community. All released individuals are asked to follow up with an outside medical professional if they have influenza-like symptoms.

MCCF employees who test positive are directed to remain off work until they are cleared by a medical professional to return to work. Employees awaiting results are directed to self-quarantine in their homes. Employees who test negative may return to work once cleared by a medical professional.

The decision to test personnel was made solely by officials at MCCF; the Pennsylvania Department of Corrections (DOC) does not operate or have any jurisdiction over county jails. According to a spokesperson from the DOC, the DOC tests any inmate whose release is anticipated and only will be released if the test is negative.

Current information regarding COVID-19 in Montgomery County can be found at https://data-montcopa.opendata.arcgis.com/pages/covid-19.

Current information regarding COVID-19 in the Pennsylvania Department of Corrections facilities can be found at https://www.cor.pa.gov/Pages/COVID-19.aspx.

For more information, contact:

  • Teresa Harris, Public Affairs Manager, Montgomery County, Pennsylvania, Post Office Box 311, Norristown, Pennsylvania 19404-0311; 610-278-3000; Email: tharris@montcopa.org; Website: https://www.montcopa.org/
  • Maria A. Finn, Press Secretary, Pennsylvania Department of Corrections, 1920 Technology Parkway, Mechanicsburg, Pennsylvania 17050; 717-728-2573; Email: ra-contactdoc@pa.gov; Website: https://www.cor.pa.gov/

On April 27, 2020, the White House announced a plan to expand testing for coronavirus disease 2019 (COVID-19) that would increase aid to states with the goal of expanding nationwide testing capacity to about 2 million tests per week. The federal goal is to ensure that the states are able to test 2% of their populations monthly, and monitor populations at higher risk of infection and poor outcomes. Testing plans and rapid response programs will be federally supported, state managed, and locally executed.

The plan includes eight steps focused on three core elements: adequate supplies to collect samples, timely monitoring to identify new cases or clusters, and rapid contact tracing. The eight steps are as follows:

  1. Build the foundation for diagnostic testing
  2. Mobilize the private sector to develop tests
  3. Issue U.S. Food and Drug Administration (FDA) Emergency Use Authorizations (EUAs) for tests, which will allow the developers to release the tests without submitting extended validation for FDA approval
  4. Galvanize commercial and research laboratories and professional associations to ramp up testing capacity
  5. Facilitate state efforts to access and utilize all available testing capacity
  6. Identify and expand public and private sector testing infrastructure
  7. Strengthen the testing supply chain
  8. Coordinate with governors to support testing plans and rapid response programs

The administration describes the federal role as facilitating a partnership between federal, state, local, and tribal governments, along with the private sector and professional institutions. The responsibility of each sector was outlined in the “White House Opening Up America Again: Blueprint For Testing Plans & Rapid-Response Programs.” The “Blueprint” is intended to facilitate state development and implementation of robust testing plans and rapid response programs to prevent and contain local COVID-19 outbreaks.

The federal government is responsible for the following:

  1. Publish guidelines for Opening Up America Again and provide a blueprint for the testing plans and rapid response programs.
  2. Provide strategic direction and technical assistance regarding the best use of available testing technologies.
  3. In partnership with states, strategically align laboratory testing supplies and capacity with existing and anticipated laboratory needs.
  4. Provide expedited regulatory authorizations for tests and testing equipment.
  5. Publish and update procedural guidance for administering diagnostic tests (i.e., prioritization algorithms and protocols).
  6. In partnership with the private sector, accelerate research and development of innovative diagnostic tests (e.g., rapid, non-invasive Point-of-Care (POC) tests).
  7. Identify and share best practices and provide technical assistance to state, local, and tribal governments to improve their testing, surveillance, and contact tracing programs.
  8. Act as supplier of last resort.

State, local, and tribal governments are responsible for the following:

  1. Develop testing plans and rapid response programs, as called for by the President’s Guidelines.
  2. Maximize the use of all available testing platforms and venues (e.g., private, public, hospital, clinic-based laboratories).
  3. Identify and overcome barriers to efficient testing (e.g., underutilization of deployed assets, misallocation of supplies, logistical failures).
  4. Develop and implement sentinel monitoring and rapid response programs.

The role of the private sector and professional associations includes the following:

  1. Develop new technologies.
  2. Seek EUA for new technologies, as appropriate.
  3. Accelerate production of tests and materials, such as swabs.
  4. Share data and information from clinical trials with other stakeholders.
  5. Expand testing partnerships with state, local, and tribal governments.

In a press briefing on May 12, 2020, White House Press Secretary Kayleigh McEnany said that about 300,000 diagnostic tests per week are being conducted. She said that by the end of the week the administration estimates that 10 million diagnostic tests will have been conducted since the pandemic began in the United States. About 2.7% of the population has received a COVID-19 diagnostic test.

For more information, contact:

  • The White House, 1600 Pennsylvania Avenue Northwest, Washington, District of Columbia 20500; 202-456-1414; Website: https://www.whitehouse.gov/

As payers move toward population-based payment models, the National Qualify Forum (NQF) and Humana believe that the models should evaluate both social risk and clinical risk to acknowledge the interdependence of social, behavioral, and environmental factors on health outcomes. The payment models should provide incentives for addressing health-related social needs such as food access, environmental safety, and social support. Current risk-adjustment models assume that these factors exist in isolation; they include some factors while excluding others, and fail to capture social context explicitly and intentionally.

These recommendations were issued in “Clinical and Social Risk Adjustment — Reconsidering Distinctions” by William Shrank, M.D., chief medical officer of Humana, and Shantanu Agrawal, M.D., MPhil, president and chief executive officer of National Quality Forum. Their analysis builds on a recent NQF and Humana collaboration, “Food Insecurity and Health: Overcoming Food Insecurity Through Healthcare-Based Interventions” released on March 2, 2020. The guide highlights that social needs such as food insecurity and social isolation can lead to or worsen serious chronic conditions.

They said that accumulating evidence suggests that clinical and social risk factors overlap more than has been previously realized. Age is usually included in clinical risk adjustment method, and of 193 current performance measures endorsed by NQF, 89% had models that used age as a variable. However, the authors wrote that age may affect health outcomes by various biologic and non-biologic mechanisms, which among older people include higher rates of poverty, social isolation, and food insecurity. Current risk adjustment approaches may oversimplify disease processes and burden and an insufficient understanding of how social context affects disease burden.

Additionally, they said that the coronavirus disease 2019 (COVID-19) outbreak has revealed the inter-relatedness of social context and physical health. Humana’s outreach to its COVID-19-positive and highest risk members found high rates of social isolation and considerable barriers to accessing healthy food. Dr. Agrawal said, “Growing evidence indicates that socially disadvantaged people have comparatively worse health outcomes suggesting that clinical and social risk are related. To improve the health outcomes of all people, including the disadvantaged, we must consider this growing body of evidence as part of a comprehensive, 21st century approach to risk adjustment.”

The NQF and Humana collaboration, “Food Insecurity and Health: Overcoming Food Insecurity Through Healthcare-Based Interventions,” focuses on practical implementation recommendations and challenges including addressing routine screening for food insecurity, identifying appropriate clinical actions (medical and non medical), and measuring changes in rates of food insecurity in populations. It details strategies that can be tailored for organizational context, resources, and need, to facilitate and enhance food insecurity interventions and ultimately improve health outcomes.

The full text of “Clinical and Social Risk Adjustment — Reconsidering Distinctions,” was published April 23, 2020 by New England Journal of Medicine. An abstract is available online at https://www.nejm.org/doi/full/10.1056/NEJMp1913993.

The full text of “Food Insecurity and Health: Overcoming Food Insecurity Through Healthcare-Based Interventions” was released on March 2, 2020. A copy is available online at https://store.qualityforum.org/products/food-insecurity-and-health-overcoming-food-insecurity-through-healthcare-based-interventions.

For more information, contact:

  • Information Office, National Quality Forum, 1099 14th Street Northwest, Suite 500, Washington, District of Columbia 20005; 202-783-1300; Fax: 202-783-3434; Email: info@qualityforum.org; Website: http://www.qualityforum.org/

About 4.1% of the population in Los Angeles County, California, had already had coronavirus disease 2019 (COVID-19) as of April 20, 2020, based on the preliminary results of a study that tested 863 adults for antibodies to COVID-19. These results are from the first round of an ongoing study by researchers at the University of Southern California and county public health officials.

As of early April 2020, 7,994 confirmed cases of COVID-19 had been reported to the county, with more than 600 COVID-19-related deaths. However, based on the rate of positive tests within the representative sample of adults included in the antibody testing, from 221,000 to 442,000 adults in the county have had the infection. The estimated infection prevalence was 28 to 55 times higher than the rate of confirmed cases.

The testing took place on April 10 and 11 at six drive-through sites. Participants were recruited via a proprietary database that is representative of the county population. The database is maintained by LRW Group, a market research firm. The researchers used a rapid antibody test for the study. The test’s accuracy was further assessed at a lab at Stanford University using blood samples that were positive and negative for COVID-19. The researchers intend to continue conducting antibody testing over time on a series of representative samples of adults to determine the scope and spread of the pandemic across the county.

As of May 12, 2020, 33,180 confirmed COVID-19 cases have been reported to the county, with 31,670 in the county plus 953 in Long Beach and 557 in Pasadena. These confirmed cases represent 0.3% of the county’s 10.9 million residents. Two-thirds (23,833) of those with confirmed COVID-19 are adults between the ages of 18 and 65. Among the confirmed cases, 1,613 people have died representing a 4.8% death rate in the county, Long Beach, and Pasadena.

The Los Angeles Department of Public Health reported hospitalization rates only for the county. Among the 31,670 confirmed cases in Los Angeles County only, 5,508 (17.4%) were hospitalized. Of those with confirmed COVID-19, 1,503 died, representing 4.7% of all those with a confirmed case, and 27.3% of those who were hospitalized.

The USC and county study results have not yet been peer reviewed. The researchers plan to test new groups of participants every few weeks in coming months to gauge the pandemic’s trajectory in the region.

The Los Angeles County infection statistics are posted online at http://publichealth.lacounty.gov/media/Coronavirus/locations.htm.

For more information, contact:
•Paul Simon, Director of the Division of Assessment, Planning, and Quality, Los Angeles County Department of Public Health, 313 North Figueroa Street, Room 806, Los Angeles, California 90012; 213-240-8144; Email: psimon@ph.lacounty.gov; Website: http://ph.lacounty.gov/
•Communications & Public Affairs, Los Angeles County Department Of Public Health, 313 North Figueroa Street, Room 806, Los Angeles, California 90012; 213-240-8144; Fax: 213-481-1406; Email: media@ph.lacounty.gov; Website: http://publichealth.lacounty.gov/media/

On April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) issued regulatory changes to further expand beneficiary access to telehealth services in their homes for the duration of the coronavirus disease 2019 (COVID-19) public health emergency. CMS is waiving limitations on the types of clinical practitioners and provider organizations that can furnish Medicare telehealth services, and is raising reimbursement rates for audio-only telephone services. CMS will reimburse for Medicare telehealth services provided by rural health clinics and federally qualified health clinics.

Prior to this change, only physicians, nurse practitioners, physician assistants, and certain others could deliver telehealth services. CMS will now allow physical therapists, occupational therapists, and speech language pathologists to provide telehealth services.

CMS will also allow hospitals to bill as the originating site for providing telehealth services to beneficiaries registered as hospital outpatients but who are staying at home. The beneficiary’s home can serve as a temporary “department of the hospital” where the beneficiary can receive counseling and educational service as well as therapy services via telehealth technology.

Reimbursement for audio-only telehealth services is increased to match the outpatient office rate, from a range of about $14 to $41 to about $46 to $110. The payments are retroactive to March 1, 2020.

In addition to raising reimbursement rates for audio-only telephone services, CMS also expanded the list of eligible audio-only telephone services to include many behavioral health and consumer education services. CMS is waiving the video requirement for certain telephone evaluation and management services, and adding them to the list of Medicare telehealth services because some Medicare beneficiaries may lack access to interactive audio-visual technology required for telehealth services. CMS also recognizes that some beneficiaries would choose not to use audio-visual telehealth services offered by their health care professionals.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

At the end of March 2020, administrators from 323 hospitals and health systems responding to a federal survey about their challenges addressing the coronavirus 2019 (COVID-19) pandemic said limited testing supplies to confirm COVID-19 and delayed results led to difficulties in staffing and in discharging to post-acute care. Of the 323 hospitals and health systems that responded to the survey, 117 were treating one or more people with confirmed COVID-19, and 130 were treating one or more people with suspected COVID-19. Of the remaining 76 hospitals, 32 said they were not treating anyone with COVID-19, and 44 did not report this information. The administrators reported shortages of testing, staffing, supplies, personal protective equipment (PPE), and durable equipment.

Impact Of Testing Supply Shortages

The hospitals reported severe shortages of testing supplies. They lacked complete kits and/or the individual components and supplies needed to complete tests, such as nasal swabs, viral transfer media, and reagents used to detect the virus. As a result, the hospitals were not able to effectively test staff, people seeking care, and others in the community concerned about possible exposure.

The shortage of diagnostic testing contributed to substantial difficulties in maintaining or expanding facility capacity to care for people with suspected or diagnosed COVID-19. The hospitals reported that test results often took seven days or longer to receive. Those that relied on external laboratories reported delays due to infrequent specimen pickups, mailing delays, and labs’ restrictive business hours. Some hospitals experienced inconsistent turnaround times and were unable to predict when results would arrive, and so could not advise staff (or the community) on how long they should self-quarantine while waiting for results.

In addition to interfering with timely discharges, hospitals reported that the lack of timely test results affected staffing because staff presumed to be COVID-19 positive could resume work only after receiving the negative test results.

Impact Of Difficulties Discharging To Post-Acute Care

Many hospitals reported that post-acute facilities were requiring negative COVID-19 tests before accepting individuals discharged from hospitals. As a result, people who no longer required acute care were required to remain hospitalized while waiting for their test results.

Due to the longer stays, and the need to prepare for possible surges, the hospitals reported concerns about potential shortages of intensive care unit beds, negative pressure rooms, and isolation units. They said the limitations to bed availability created challenges in sufficiently separating COVID-19 and non-COVID-19 cases within their facilities.

Impact Of PPE Shortages

The PPE shortages (masks, including N95 masks and surgical masks; face shields; gowns; and gloves) and lack of a robust PPE supply chain contributed to the following problems:

  • Use of PPE was heavier than normal due to the slow turnaround for COVID-19 testing confirmation. People waiting for test results remained in the hospital longer, and staff were obligated to use PPE to avoid contaminating others.
  • Difficulties restocking the PPE needed to protect staff, and availability of PPE from federal and state sources was uncertain. At the time of the survey, some hospital administrators said they had not received supplies from the Strategic National Stockpile, or that the supplies they did receive were not sufficient in quantity or quality.
  • Supply chain for medical equipment was disrupted due to increased demand for PPE from health care provider organizations and others.
  • Costs for PPE increased sharply. One administrator reported that the price for masks that previously cost 50 cents rose to $6.

These statistics were reported in “Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23–27, 2020” by the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS). The survey is intended to be a national snapshot of hospital challenges and needs for responding to the COVID-19 pandemic. The OIG conducted brief telephone interviews with a random sample of administrators from 323 hospitals across 46 states, the District of Columbia, and Puerto Rico. The contact rate was 85%. The hospitals included 10 Special Pathogen Centers, 100 critical access hospitals, 24 major teaching hospitals, and a range of hospitals nationwide of various sizes and characteristics. Most were treating people with confirmed or suspected COVID-19. The interview had three questions:

  • What are your most difficult challenges in responding to COVID-19?
  • What strategies is your hospital using to address or mitigate these challenges?
  • How could government best support hospitals responding to COVID-19?

At the time the survey was conducted, the federal government, states, local, and tribal entities had taken action to help hospitals respond to COVID-19. The Coronavirus Aid, Relief, and Economic Security (CARES) Act signed on March 27, 2020, provided the basis for additional actions.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: Donald.white@oig.hhs.gov; Website: https://oig.hhs.gov/

Between February and March 2020, median hospital operating margins fell from 4% to -8%, about 11 percentage points, in one month. Median operating margins in March were more than 170% below budget, about 15 percentage points. Median operating margins on earnings before interest, taxes, depreciation, and amortization fell 107% below budget expectations in March.

Both revenue and volume declined. Revenue was 13% below budget expectations in March 2020 compared to the previous year. Inpatient revenue was 13% below budget expectations, and outpatient revenue was 17% below budget. At the same time, expenses remained generally the same because hospitals maintained front-line caregivers and incurred added expense to maintain and expand inventories of drugs, supplies, equipment, and capacity in preparation for a surge.

Volume changes between February and March 2020 were reflected in the following data points:

  • The median hospital occupancy rate dropped from 62% to 53%.
  • The median intensive care unit occupancy rate dropped from 68% to 62%.
  • Overall discharges fell by 4% and were 13% below budget expectations.
  • Adjusted consumer days dropped by 10% and were 15% below budget expectations.
  • Operating room minutes dropped by 17% and were 26% below budget.

Year-over-year discharges dropped by 11%, and adjusted discharges fell by 13%. Emergency department visits dropped by 15% year-over-year Bad debt and charity care rose 13% year-over-year. Hospitals with 500 or more beds had a 19% year-over-year increase. At small hospitals with 25 or fewer beds, bad debt and charity care represented 15% of budget. Both bad debt and charity care are likely to continue to rise due to Coronavirus Disease (COVID) 2019-related unemployment and loss of job-based health insurance; consumers will enroll in Medicaid or be uninsured.

These findings were reported in “National Hospital Flash Report for March 2020” by Kauffman Hall. The report is based on March 2020 data reported by about 800 hospitals. Kauffman Hall issues Flash Reports monthly.

The full text of “National Hospital Flash Report” was published in April 2020. A copy is available online at https://flashreports.kaufmanhall.com/national-hospital-report-april-2020.

For more information, contact: 

  • Jim Blake, Managing Director, Kaufman, Hall & Associates, LLC, 5202 Old Orchard Road, Suite N700, Skokie, Illinois 60077; 847-441-8780; Email: flashreports@kaufmanhall.com; Website: https://www.kaufmanhall.com/

About 8.9% of Medicare beneficiaries residing in long-term care facilities during 2011 to 2013 paid for all medications out-of-pocket (OOP). Long-term care Medicare enrollees without drug coverage or with private insurance received significantly fewer prescriptions than if they had been enrolled in Medicare Part D. During 2012, beneficiaries without any drug coverage received 43.6 fewer prescriptions than those with Part D, non-low income subsidy (LIS) coverage. Beneficiaries with only temporary drug payment assistance, for example, through the Medicare hospice benefit, received 43.9 fewer prescriptions, on average. The average number of prescriptions filled among Medicare enrollees was the same whether in Veterans Administration (VA) or in Part D non-LIS.

During 2012, the majority, or 82%, of Medicare long-term care residents were covered by Medicare Part D as the main source of drug coverage, with or without a full or partial LIS. The majority of residents, 67.0% were covered by Medicare Part D and receiving full LIS. About 0.4% were covered by Medicare Part D and received partial LIS, and about 15.0% were covered by Medicare Part D, but not receiving LIS. About 8.5% were enrolled in private insurance, and 0.2% had coverage through the VA. No drug coverage was detected for 8.9%; they paid for all prescriptions OOP (0.9%) or they received only temporary drug payment assistance (8.0%), such as through the Medicare hospice benefit.

The researchers found large differences in medication use that could not be explained by differences in health status. They concluded that Medicare beneficiaries in long-term care settings who lacked reliable drug coverage received less medication than those who had reliable drug coverage. The difference remained after controlling for underlying medical conditions. The researchers said this persistent difference suggested potential underuse of medications and potential economic barriers.

These findings were reported in “Adequacy of Prescription Drug Coverage in Long-term Care” by Becky Briesacher, Ph.D.; Brianne Oliveri-Mui MPH; Bhavika Chhabra, PharmD; and Benjamin Koethe, MPH. The researchers analyzed a nationwide sample of 332,087 Medicare enrollees who spent more than 100 days in a long-term care facility from 2011 to 2013. The sample was from a nationwide long-term care database of prescription-level, resident-level, and facility-level data. The goal was to assess enrollment in prescription drug coverage, OOP payments, and medication use. Inadequate drug coverage was defined as paying OOP for more than half of medication costs. The researchers identified predictors of inadequate drug coverage and total prescription fills.

The full text of “Adequacy of Prescription Drug Coverage in Long-term Care” was published in the May 2020 issue of Medical Care. An abstract is available online at https://journals.lww.com/lww-medicalcare/Abstract/2020/05000/Adequacy_of_Prescription_Drug_Coverage_in.3.aspx.

For more information, contact:

  • Becky Briesacher, Ph.D., Associate Professor, School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, 360 Huntington Avenue, R212 TF, Boston, Massachusetts 02115; Email: b.briesacher@northeastern.edu; Website: https://web.northeastern.edu/chphr/faculty-associates/becky-briesacher/.

About 10% of adult Medicaid beneficiaries ages 18 to 64 with mental health and/or addiction disorders made telehealth visits for behavioral health services in 2017. Telehealth visits were more prevalent among beneficiaries with mental health disorders than those with addiction disorder. About 11.7% of beneficiaries in rural areas and 10.8% of those in non-rural areas made one or more telehealth visits for mental health treatment. About 2.7% of beneficiaries in rural areas and 1.5% in non-rural areas made one or more telehealth visits for addiction treatment.

Between 2012 and 2017, the prevalence of Medicaid telehealth visits for behavioral health disorder treatment increased among rural and non-rural beneficiaries. For both rural and non-rural beneficiaries, the prevalence of telehealth for mental health treatment was higher than for addiction treatment.

Among beneficiaries in rural areas, the prevalence of telehealth visits for mental health treatment rose by 5.9 percentage points, from 5.8% of rural beneficiaries in 2012 to 11.7% in 2017. The prevalence of telehealth visits for addiction treatment rose 1.8 percentage points, from 0.9% in 2012 to 2.7% in 2017.

Among beneficiaries in non-rural areas, the prevalence of telehealth visits for mental health treatment rose by 3.8 percentage points, from 7.0% in 2012 to 10.8%. The prevalence of telehealth visits for addiction treatment rose 0.1 percentage points, from 1.4% in 2012 to 1.5% in 2017.

The mean number of telemedicine visits per person increased over time for rural beneficiaries, from 1.9 visits per person in 2012 to 2.9 visits in 2017. For non-rural beneficiaries, the mean number of telemedicine visits per person decreased from 3.5 visits in 2012 to 2.3 visits in 2017. Telemedicine was associated with receipt of more in-person outpatient services by rural beneficiaries (11.2 more visits for mental disorders and 8.2 more for substance use disorders).

These findings were reported in “Rural-Nonrural Differences in Telemedicine Use for Mental and Substance Use Disorders Among Medicaid Beneficiaries” by Timothy B. Creedon, Ph.D., Kristin E. Schrader, MA, Peggy L. O’Brien, Ph.D., Janice R. Lin, BS, Christopher D. Carroll, MSc, and Norah Mulvaney-Day, Ph.D. The researchers analyzed claims data from the IBM MarketScan Multi-State Medicaid Database between 2012 and 2017 for 1.6 million adult beneficiaries ages 18 to 64 years with mental health and/or addiction disorder diagnoses. The sample was limited to a geographically diverse subset of states that contributed data to MarketScan and had any telemedicine claims during the study period. Within the group of 1.6 million unique beneficiaries, 428,697 lived in rural areas, and 1,174,369 lived in non-rural areas. The goal was to investigate recent rural-non-rural trends in the prevalence and amount of mental and addiction disorder telemedicine received by adult Medicaid beneficiaries. The unit of analysis is a beneficiary year. The 1.6 million unique beneficiaries contributed 2,986,100 beneficiary-years of data over the five-year period of analysis.

The full text of “Rural-Nonrural Differences in Telemedicine Use for Mental and Substance Use Disorders Among Medicaid Beneficiaries” was published April 15, 2020 by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900444.

For more information, contact: 

  • Timothy B. Creedon, Ph.D., Research Scientist, Health Equity Research Lab, 1035 Cambridge Street, #26, Cambridge, Massachusetts 02141; 508-207-3013; Email: tbcreedon@challiance.org; Website: https://www.healthequityresearch.org/

About 35% of primary care professionals believe that a majority of independent primary care practices will have closed by the time the first wave of the coronavirus disease 2019 (COVID-19) pandemic ends, according to a survey conducted in early May 2020 by the Primary Care Collaborative (PCC). About 70% of clinical professionals said their practices have had a significant decrease in consumer volume, which is threatening the practices’ financial viability. However, slight financial improvements emerged: in early May, about 49% reported that over half of visits were reimbursable, compared to 34% the previous week. About 60% believe that policies changed to support primary care during COVID-19 will be reversed once the pandemic lessens.

Just three weeks earlier in a related survey, about 20% of primary care practices predicted that they would close by mid-May. The predictions reflect fears of market consolidation due to financial repercussions of the COVID-19 public health emergency.

Additional findings included the following:

  • Primary care professionals anticipate a rise in behavioral health problems among consumers, and 74% expect to see an increase in the number of consumers with mental health needs. About 30% anticipate that substance abuse will increase. About 24% anticipate that domestic violence will rise.
  • COVID-19 will result in serious delays in care for other illnesses, and 38% anticipate that diverted or avoided care will lead to a rise in non-COVID-19 deaths. About 60% believe consumers will experience avoidable illness due to diverted or avoided care.
  • The majority of primary care practices (54%) lack personal protective equipment (PPE) and COVID-19 testing capabilities.
  • A minority of visits take place via virtual health technologies, and 84% of clinical professionals reported that they have consumers who lack a computer or internet access.
  • About 28% of practices are conducting the majority of visits by video; 28% conduct the majority of visits by telephone; and 14% conduct the majority of visits as e-visits. About 29% of practices report no use of video visits, and 9% report no use of e-visits.

Since mid-March 2020, The Larry A. Green Center has been conducting a weekly Quick COVID-19 Primary Care Survey in partnership with PCC. The goal is to measure the impact of COVID-19 on primary care practices. The week eight survey results reflect responses from 773 primary care physicians, nurse practitioners, and physician assistants working in all states except North Dakota. The majority, 70%, are in family medicine, 11% are in internal medicine, 7% are in pediatrics, 6% are in geriatric, and 7% are in other specialties. About 25% work in rural practices, 18% at a community health center, and 9% at a convenience care setting. For about 58% of the responding primary care professionals, more than 10% of consumers are Medicaid beneficiaries.

The full text of the Primary Care Collaborative’s “Quick COVID-19 Primary Care Survey, Week Eight Executive Summary” was published May 8, 2020. A copy is available online at https://www.pcpcc.org/2020/05/06/primary-care-covid-19-week-8-survey.

The week five survey results were released April 16. They are posted online at https://www.pcpcc.org/sites/default/files/news_files/C19%20Series%205%20National%20Executive%20Summary.pdf.

For more information, contact:

  • Stephen Padre, Senior Communications Manager, Primary Care Collaborative, 601 13thStreet Northwest, #430n, Washington, District of Columbia 20005; Email: spadre@tpcpcc.org; Website: https://www.pcpcc.org/.

Editor’s note: The PCC domain is changing soon to www.thepcc.org, but as of May 11, 2020, the new domain was not live. 

On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) approved a Washington State Medicaid 1115 waiver that will allow the state to pay higher rates to home- and community-based services (HCBS) provider organizations to maintain capacity during the coronavirus disease 2019 (COVID-19) public health emergency. Most of the approved provisions affect long-term services and supports (LTSS). In particular, they extend HCBS flexibilities available under 1915 (c) to beneficiaries receiving LTSS through a state plan amendment.

Additional provisions will allow the Washington State Health Care Authority (HCA) to establish a COVID-19 Disaster Relief Fund. Under these provisions, HCA will be able to use Medicaid funds to stabilize provider organizations as they implement new and expanded care delivery sites while managing economic disruptions. The fund will help provider organizations access needed equipment, broaden access to COVID-19 testing and care, and respond to higher demand.

CMS approved the following additional provisions:

  • HCA can receive federal reimbursement for providing LTSS to beneficiaries, even if they are not timely, updated in the plan of care, or delivered in otherwise-allowable settings.
  • To reduce administrative burden on HCA and beneficiaries, individuals will be permitted to self-attest, or HCA could use an alternative verification of individuals’ income and assets, disability, and level-of-care to qualify for LTSS.
  • Delay initial assessments or annual reassessments for up to one year.
  • HCA can make retainer payments for many habilitation and personal care services provider organizations to maintain capacity during the emergency.
  • HCA can make retainer payments to those organizations that include personal care as a component.

The state had previously been approved for a 1135 Medicaid waiver on March 19, 2020. HCA submitted the 1115 waiver on March 24, 2020, two days after CMS announced the availability of such waivers.

The HCA waiver affects the independent “individual providers” who deliver personal care services but are not employed through a home care provider organization. It also affects an array of residential provider organizations, such as adult family homes, assisted living facilities, home care agencies, adult day health and adult day care programs. HCA also uses the term “provider” to refer to the clinic or hospital billing for the services delivered by an “individual provider.”

Retainer payments were available to be claimed as of May 4, 2020 for residential and adult day providers, along with the rate enhancements. They can claim retainer payments for up to 30 days at 70% of the individual consumer’s rate.

In Washington, payment and rates for residential facilities and individual providers are collectively bargained and ratified by the legislature. Any changes must be approved by SEIU 775 and the residential facility councils. As of May 11, 2020, an agreement had been reached regarding retainer payments for all residential facilities, but rate changes for “individual providers” and home care provider organizations were still pending due to Washington’s parity requirements

CMS was still evaluating HCA’s request for Medicaid expenditure authority to use the Disaster Relief Fund to cover costs associated with treatment for uninsured individuals with COVID-19, housing, nutrition supports, and other COVID related expenditures for states and individuals as well as retainer payments for more than 30 days for provider organizations. Several other requests are also under review. CMS denied HCA’s request to establish a temporary eligibility group for those with incomes 138% to 200% of the federal poverty level.

PsychU last reported on emergency waivers in “34 States Approved For Medicaid 1135 Waivers During COVID-19 Public Health Emergency,” which published on May 11, 2020. The article is available at https://www.psychu.org/34-states-approved-for-medicaid-1135-waivers-during-covid-19-public-health-emergency/ .

For more information, contact:

  • Amy Blondin, Chief Communications Officer, Washington State Health Care Authority, Post Office Box 45502, Olympia, Washington 98504-5502; 360-725-1915; Email: amy.blondin@hca.wa.gov; Website: http://www.hca.wa.gov/.

Editor’s note: this article was updated on May 12 to include clarifications from HCA about the retainer payments and rate enhancements. 

During the coronavirus disease 2019 (COVID-19) national public health emergency, behavioral health provider organizations can accept donations of mobile devices and data plans to facilitate telehealth treatment, according to the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS). Such an arrangement during the public health emergency would not violate federal anti-kickback regulations on providing inducements to beneficiaries. The OIG posted its opinion on April 23, 2020.

The OIG maintains an online document with its feedback on a variety of questions submitted by provider organizations seeking guidance on arrangements to facilitate provision of services during the COVID-19 public health emergency. The feedback explains the application of OIG’s administrative enforcement authorities as applied to arrangements in existence solely during the time period subject to the public health emergency. This feedback is different than an OIG advisory opinion, which is a legally binding decision between the OIG and the requesting organizations.

One or more behavioral health provider organizations asked if they could accept donations of mobile devices, data plans, or both to facilitate telehealth treatment during the COVID-19 disruption for consumers who are financially needy and who do not own their own cell phone. The OIG’s response made the following points:

  • Normally the provision of valuable technology and services to federal health care program beneficiaries for free or at a reduced cost likely implicates the federal anti-kickback statute and beneficiary inducements civil money penalty (CMP).
  • In the context of the COVID-19 outbreak and in light of flexibilities in coverage for various telehealth and other virtual services payable by federal health care programs, the provision of a mobile device, service or data plan, or both by a behavioral health provider organization to a consumer likely presents a sufficiently low risk of fraud and abuse if safeguards are implemented.
  • The safeguards include a good-faith determination that an established consumer is in financial need before the telecommunications technologies are provided and that the consumer needs the technologies to access medically necessary services related to behavioral health treatment. The services must be medically necessary to reduce the risk of overutilization or inappropriate utilization. The third-party funding must be used only for telecommunication technologies.
  • The provider organization must not market the telecommunication technologies or offer/provide free phones to generate business.
  • The devices must be returned and the data plans canceled at the end of the COVID-19 Declaration.

The OIG noted that under certain circumstances, such as the Federal Communications Commission (FCC) distributing grants to certain provider organizations to fund telecommunications technologies, the remuneration from the donor to the provider organization would not trigger federal fraud and abuse laws. However, under other circumstances, arrangements between the donor and the provider organization, or indirect financial relationships between the donor and the consumer, could present risk under the federal fraud and abuse laws. The OIG advised provider organizations to separately assess any fraud and abuse risks that may arise with respect to any direct or indirect financial relationships between the donor and the provider organization, or consumer.

The clarifications were posted at https://oig.hhs.gov/coronavirus/authorities-faq.asp.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: Donald.white@oig.hhs.gov; Website: https://oig.hhs.gov/

In this webcast, Kent Alford discusses an initiative in which a nurse-led primary care clinic located in an underserved urban locale in the Midwest folded in behavioral health care. The initiative highlights the roles nurses can play in improving mental health care delivery by providing culturally sensitive, integrated services. Mr. Alford provides his expert insight into the nurses’ efforts, including their use of the Omaha System taxonomy to document the effects of the integration effort. One result: A 900% increase in psychosocial issues identified among individuals seen at the clinic, comparing calendar year 2018 with calendar year 2016.

Kent Alford is a nurse who serves as Systems Director for Behavioral Health for the University of Maryland Capital Regional Health Systems. Additionally, Mr. Alford serves as Chair of the Behavioral Health Consortium for the State of Maryland and is a member of the Maryland Hospital Association’s Behavioral Health Task Force. He holds the position of Adjunct Professor at Catholic University.

Christina DuVernay, PhD, is a Senior Associate for OPEN MINDS.

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

The New Jersey Medicaid program, NJFamilyCare, is creating Regional Health Hubs (RHHs) to replace its Accountable Care Organization (ACO) Demonstration Project. The four existing ACOs—the Healthy Greater Newark ACO; the Trenton Health Team; the Camden Coalition of Health Care Providers; and the Health Coalition of Passaic County—are designated as RHHs. The state’s fiscal year 2020 budget formally recognized them, and continued a $1.5 million appropriation.

The RHHs differ from the ACOs in that the RHHs will not directly coordinate care for consumers. The ACO Demonstration Project was authorized by a law passed in 2011 that directed the ACOs to coordinate care for Medicaid fee-for-service (FFS) beneficiaries in return for shared savings. Due to implementation delays, the demonstrations finally started in 2016. However, by that time, nearly all New Jersey Medicaid populations were enrolled in managed care, and the managed care organizations (MCOs) were not required to contract with the ACOs. As a result, the ACOs had few MCO contracts, and the FFS population was small. During the demonstration period, the four ACOs evolved into regional collaboratives that integrated, coordinated, and aligned disconnected programs aimed at making communities healthier.

Each RHH serves as a local expert and conduit for state health priorities. They will convene multi-sector partners in their regions to take action on the state’s most urgent health needs, and operate or use a regional health information exchange (HIE) to ensure that health and other data are accessible and useful. The RHHs will provide health care data infrastructure and analysis, support care management, and convene community stakeholders in close coordination with the Department of Human Services (DHS) Office of Medicaid Innovation.

The legislation, New Jersey Senate Bill 4282, to create the regional health hubs and expand to new regions was signed into law on January 21, 2020, and went into effect immediately. Key provisions are as follows:

  • DHS is allowed to expand the RHH model and within six months establish new RHHs in other communities statewide.
  • The RHHs will form health care partnerships to explore innovative structures and practices to integrate, coordinate, and align disconnected programs in order to make communities healthier.
  • Between 10% to 25% of funds appropriated by DHS to each RHH will be based on the hub’s attainment of predetermined goals and performance metrics. The goals and performance metrics will be specified in an annual agreement negotiated between DHS and the RHH entity.

DHS will make NJ FamilyCare claims data available for residents residing in the RHH to facilitate the RHH population health tasks. It may enter into appropriate data sharing agreements for exchange of the data. DHS will share all claims data with the RHH for beneficiaries residing in the hub geographic boundaries. The data catchment area shall include the RHH core region and may overlap with the data catchment areas for other RHHs. Each RHH will maintain a data sharing use and reciprocal support agreement, and any applicable use case agreement, with any statewide health information platform designated by DHS in order to promote interoperability.

A link to the full text of “New Jersey Senate Bill 4282” may be found at www.openminds.com/market-intelligence/resources/120919njbill4282.htm.

For more information, contact:

  • Tom Hester, Director, Office of Communications, New Jersey Department of Human Services, Post Office Box 700, Trenton, New Jersey 08625-0726; 609-292-3717; Email: Tom.Hester@dhs.state.nj.us; Website: http://www.state.nj.us/humanservices/

For centuries, the nursing profession’s overarching mission has been to make patients feel safe, heard, comfortable, and holistically cared for. But in the modern health care system, many nurses aren’t afforded time to fully commit to this mission and are instead limited to tasks driven by cost-management business policies. What’s more, nurses are sometimes siloed in their tasks and unable to work in collaborative team environments that would further benefit patients.

In a two-part position paper, Carole Orchard and colleagues make a two-fold proposal. One, they advocate for a redefinition of roles for nurse leaders; and two, they argue that a systemic shift is needed to allow for interprofessional patient- and family-centered collaborative practice. This article summarizes the key points they make in their two pieces, titled “Collaborative Leadership, Part 1: The Nurse Leader’s Role Within Interprofessional Teams” and “Collaborative Leadership, Part 2: The Role of the Nurse Leader in Interprofessional Team-Based Practice—Shifting from Task- to Collaborative Patient-/Family-Focused Care,” which together make a plea for nurses to return to their roles as person-centered care givers and collaborative leaders.

Background

To maximize their contributions both as managers and as advocates for the nursing profession, say Orchard et al., nurse leaders should be afforded the time to receive leadership training, train other nurses, work with teams of other health professionals to meet patient care goals, and advocate for health care reform.  At the same time, they would also be performing the tasks necessary for quality, comprehensive care of patients. Nurse leaders have received costly educations, which included training on ethics and theory, and they should be able to utilize all the skills in practice that they have studied.

Rising care costs also affect the care nurses can give to their patients in countries with public health care. An ever-growing population of aging and chronic-care patients has had a significant influence on these rising costs, and that has led to the creation of policies to streamline care plans for efficiency. However, these patients’ needs often do not fit perfectly into these predetermined, disease-specific care plans, and they would be better served with more personalized plans developed by their team of health professionals. In reality, since different health professionals involved in these sometimes inadequate care plans are often siloed, they don’t get the opportunity to work with each other to create better plans, and the patient can end up in a cycle of readmissions due to complications that are overlooked or unanticipated by the care plan.

Nurse leaders not only have the skills and expertise to create more tailored care plans for patients with complex conditions, but they possess the knowledge to educate patients and their families/support systems about preventative support measures they can take to minimize complications. If nurse leaders can collaborate with other involved health professionals (physicians, nurses, specialists, etc.) to create and implement these personalized plans, a patient will be better cared for and less likely to need frequent readmissions/visits. This, in turn, will save on costs more effectively than continually treating complications. This proposed model, and solution to better care at lower costs, is called interprofessional patient-centered care practice (IPPCCP).

Evidence and Discussion

The authors of these position papers gathered evidence supporting their argument that nurse leaders have a dual managerial and disciplinary role that would be supported best by interprofessional collaborative teams. They defined IPPCCP as “a partnership between a team of health providers and a patient where the person retains control over his/her care and is provided access to the knowledge and skills of team members to arrive at a realistic team shared plan of care and access to the resources to achieve the plan.” This kind of teamwork tears down silos and gives patients a voice in decision-making.

For health professionals, reports of reduced turnover, increased employee satisfaction, and higher feelings of empowerment result when IPPCCP is implemented. For patients, there have been reports of decreased medical errors, infections, negative events, and length of stays with IPPCCP (Camicia et al. 2013), all of which lead to cost savings. Furthermore, the authors cited evidence found by the World Health Organization that “stresses the importance of integrative collaborative patient-centred care to deal with the increasing population experiencing chronic diseases.”

However, the current state of health care is not necessarily set up to support interprofessional collaboration. The leadership system is hierarchical and siloed, and decisions are not made in a collaborative fashion. Also, nurses are only afforded enough time with their patients to perform necessary tasks, and not the time to collaborate with patients and other health professionals, create comprehensive plans, or educate patients and their families on preventative care. The authors found that many nurses haven’t even been trained on how to effectively collaborate with patients.

In a poll cited by Orchard et al., respondents reported the following measures as impacting the quality of care they received:

  1. Timely access to care.
  2. Respect and caring in delivery of care.
  3. Decisions made in partnership between patients and providers with a basic belief that care should be based on patients’ needs vs. their ability to pay (Montague et al. 2017).

Patients want to have a voice in the decisions being made about their care plans, but they are often not given the chance to offer input or request modifications.

Conclusion

The evidence gathered by the authors support their argument that nurse leaders should be given the opportunity to work in interprofessional, collaborative teams that include other health professionals as well as the patients and their families/communities. This practice requires a dual role in which nurse leaders embody managerial and disciplinary responsibilities. These changes will also require nurses to speak out and persuade policymakers and health care institutions that moving away from health care as a business model and back to a model that is quality-based and person-centered has the potential to not only improve patient care, but to reduce overall spending.

As of April 6, 2020, skilled nursing facilities (SNFs) and assisted living centers caring for people with COVID-19 have experienced an estimated 1,064% increase in costs for required personal protective equipment (PPE). PPE includes gloves, masks, gowns, face shields, hand sanitizer, and soap. Before the COVID-19 national public health emergency was declared on March 13, 2020, SNF and assisted living center PPE included gloves and soap. After the public health emergency went into effect, PPE guidelines were expanded to include the full range of items.

This estimate was developed by the Society for Healthcare Organization Procurement Professionals (SHOPP), an independent non-profit organization. The analysis is based on PPE needs for a 100-bed facility multiplied by 30 days for a total of 3,000 census days per month. The PPE items evaluated were:

  • Gloves: vinyl, latex, and nitryl
  • Masks: 3-ply masks, KN95 masks, N95 masks, and 3M N95 masks
  • Hand sanitizer
  • Isolation gowns
  • Face shields
  • Soap

Prior to the COVID-19 public health emergency, the per resident per day cost for pre-COVID-19 PPE requirements (vinyl gloves and soap) totaled $0.35 per day. For all items required under current COVID-19 guidelines, the total cost per day was $2.36. The cost for COVID-19-required PPE raised SNF and assisted living center costs by 674%.

Since the emergency was declared, pricing for COVID-19-required PPE has been affected by shortages and price volatility. Typical per resident per day costs using gloves and N95 masks totaled $25.10, representing an increase of 1,064% over the pre-COVID-19 cost of $2.36 per day. In the scenario that vinyl gloves would be unavailable, and nitryl gloves would be used as well as N95 masks, per resident per day costs rose to $25.58, representing a 1,084% increase in costs over the pre-COVID-19 cost of $2.36 per day.

During the national COVID-19 public health emergency, nursing homes have been required to adhere to guidelines on admitting people with confirmed and suspected COVID-19. The facilities are required to use appropriate infection control practices, including the use of PPE. The requirements often do not consider availability of staff or their qualifications, or the availability of PPE and its cost.

SHOPP is an independent, non-profit entity created to improve quality and efficiency in post-acute care. The organization represents over 100 procurement professionals representing over 1,500 post-acute care facilities.

For more information, contact:

  • Josh Silverberg, Co-Founder, Society for Healthcare Organization Procurement Professionals, 135 Chestnut Ridge Road, #100, Montvale, New Jersey 07645; 877-267-4677; Email: jsilverberg@shopp.org; Website: https://shopp.org/.

Between January 2013 and December 2016, the Iowa Medicaid program may have failed to adequately document about half of claims paid to health home provider organizations. Iowa’s health home provider organizations did not document core services, integrated health home outreach services, diagnoses, and enrollment with provider organizations. In addition, the health home provider organizations did not maintain documentation to support higher payments for intense integrated health home services and did not ensure that beneficiaries had full Medicaid benefits.

A review conducted by the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS) considered documentation of 130 health home payments selected at random. For each payment, the OIG reviewed the documentation submitted by the health home provider organization and the beneficiaries’ medical records. For 62 of the 130 payments, documentation was inadequate to support the claim. The OIG concluded that Iowa improperly claimed federal Medicaid reimbursement.

During this period, the state paid 795,000 health home claims totaling $107 million, with $92 million as the federal share and the remainder covered by state funds. Based on the improper payment rate in the sample, the OIG recommended that Iowa return $37.1 million. The state disagreed with most of the findings, but did say it was improving its monitoring of the health home program and that it was revising the state Medicaid plan.

These findings were reported in “Iowa Inadequately Monitored Its Medicaid Health Home Providers, Resulting In Tens Of Millions In Improperly Claimed Reimbursement” by the OIG for HHS. The goal was to determine whether Iowa’s claims for Medicaid reimbursement for payments made to health home providers complied with federal and state requirements.

During 2016, Iowa’s health home reimbursements accounted for 3% of the entire federal total nationwide, although Iowa’s population represents only 1% of the national population. For federal fiscal year 2016, nationwide, states claimed federal reimbursement of Medicaid health home services totaling $750 million, with the federal share at $431 million.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7th Street, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: white@oig.hhs.gov; Website: https://oig.hhs.gov/
  • Matt Highland, Public Information Officer, Iowa Department of Human Services, 1305 E Walnut Street, Hoover Building, 1st Floor, Des Moines, Iowa 50319-0114; 515-281-4848; Email: mhighla@dhs.state.ia.us; Website: https://dhs.iowa.gov/ime/providers/integrated-health-home.

The following is a summary of Panchal N., et al. The Implications of COVID-19 for Mental Health and Substance Use. Health Reform Issue Brief – 9440, Kaiser Family Foundation (April 21, 2020), which was developed independently of the article authors.

Key Messages

·The COVID-19 pandemic, associated restrictions and ensuing economic downturn will have mental illness and substance use consequences, as predicted by the self-report of its negative impact on mental health in this Kaiser Family Foundation (KFF) Survey

·The report reveals certain vulnerable demographics (e.g. older adults, families with adolescents, low income, poor physical health) as well as associated factors (e.g. social isolation and income-loss) disproportionately exacerbate the mental health risk

·Scientific research prior to COVID-19 indicates that negative mental health effects in vulnerable social/economic/health features may likely result in increased anxiety, depression, distress, substance use and suicide. Given the pervasiveness of COVID-19, existing and new shortcomings in access to support services essential for the mental health crisis are likely to be exposed

Background

  • Prevalence of any mental illness as well as serious mental illness (associated with functional impairments and poor quality of life) were high in 2017-18. Reports of drug overdose and suicide were also on the rise.
  • Fear, uncertainty and epidemics are stressors that impact overall mental health, and increases risk of developing mental health issues, substance use and suicide

Purpose

  • This brief explored the effects of the COVID-19 pandemic, social distancing policies, and economic crisis on mental health using data from a survey and discussing access to mental health and substance use services.

Methodology

  • Data was collected from a Kaiser Family Foundation survey (KFF Health Tracking Poll) of US adults from March 25-30, 2020. The survey assessed whether worry or stress related to coronavirus had a negative impact (minor and/or major) on the mental health of the responders. Percentage of adults expressing an overall negative impact on their mental health were categorized based on various factors, such as sheltering-in-place, age, gender, presence of children under 18, household income, job status, health status, etc. Sub-analysis differentiated between percentages expressing major versus minor negative impact.

Results

  • Social isolation due to COVID-19 as a mental health risk
    • Social isolation, a factor associated with poor mental and physical health as well as increased risk for suicidal ideation, can be caused by the policies essential for mitigating the spread of COVID-19; e.g. social distancing, self-quarantine, closure of non-essential businesses and schools, and prohibition of large gatherings
    • KFF polling data shows the negative mental health impact was higher in people sheltering-in-place compared to those who were not (overall impact 47% vs 37%; major impact 21% vs 13%). Also, negative mental health impact increased as the perceived level of disruption increased between “a little/not at all”, “some” and “a lot” (overall impact 28%, 44% and 57%, respectively; major impact 10%, 15%, and 28%, respectively)
    • The impact of social isolation differed by demographic group
      • Older adults were less likely to report mental health impact compared to adults between 18-64 years (31% vs 49%); however previous research shows older adults are at a higher baseline risk of poor mental health due to loneliness, and bereavement, contributing to depression and suicide
      • School closures affected all households with children and adolescents. Among parents, negative mental health impact was higher in women (57% vs 32% in men). Among students, those depending on schools for key mental health services were suggested to be greatly impacted, especially given the high rates of mental health issues, substance use and suicide risk among adolescents
    • Income insecurity and job-loss due to COVID-19 as a mental health risk
      • As a historically high number of people file for unemployment benefits during the COVID-19 crisis, previous research discussed herein suggests job-loss is associated with depression, anxiety, higher substance use disorder and increase in suicide rates
      • The KFF poll revealed greater negative mental health impact in those who have “lost job or income” compared to those who have not (overall impact 54% vs 40%; major impact 26% vs 15%). Furthermore, major negative health impact was more in households with lower income (26% for income <$40K; 17% for $40K-89K; 14% for >$90K)
    • Burnout among frontline healthcare workers
      • A combination of an overwhelming number of patients and a shortage of supplies during this pandemic have rapidly increased the demands on healthcare workers
      • A recent publication reported that healthcare workers in China feel an increased psychological burden. But the KFF poll did not find a difference in negative mental health impact between households with and without healthcare workers
    • Poor Physical health during COVID 19 as a mental health risk
      • Centers for Disease Control (CDC) reports that people with chronic physical health conditions (diabetes, serious heart conditions, asthma and chronic lung disease) are at a greater risk for higher severity of COVID-19
      • The KFF poll revealed greater negative mental health impact in people with “only fair or poor health” compared to those with “good, very good or excellent health” (overall impact 53% vs 44%, major impact 29% vs 17%)

Conclusions

The potential negative mental health consequences of the COVID-19 pandemic has been recognized by the World Health Organization as well as national institutions like the CDC and the National Institute of Drug Abuse. The current KFF poll results suggest job-loss, low income and poor physical health, as well as social isolation in older adults and households with adolescents, are of concern with respect to the negative mental health effects during COVID-19. The long- and short-term mental health implications of COVID19 pandemic may reveal existing and new challenges to accessing mental health and substance use services. Some access barriers discussed include loss of insurance coverage, lack of in-network options for those with some coverage, and an overall shortage of mental health professionals.

Clinical Implications

·The article reveals social isolation, higher disruption to life, older age, women in households with children and adolescents, loss of job or income, low household income and poor physical health were factors that disproportionately exert a negative mental health impact during the COVID-19 pandemic.

·COVID-19 associated restrictions and economic downturn are likely to further exacerbate the gaps in mental health access

This summary has been developed independently of the authors. The following disclosures were reported in the original article: “This work was supported in part by Well Being Trust. We value our funders. KFF maintains full editorial control over all of its policy analyses, polling and journalism activities.”

 

This summary was written by Sucharita S. Somkuwar, PhD, BPharm, Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

In this presentation Dr. Timothy Aungst, Associate Professor of Pharmacy at the Massachusetts College of Pharmacy and Health Sciences, discusses the importance of medication optimization and digital technology. Dr. Aungst shares his insights into the cycle of digital medicine and digital endpoints and how these technologies have been used in treating various conditions, including schizophrenia and depression.

Timothy Aungst, PharmD, is an Associate Professor of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences, in Worcester, Massachusetts. During his post-graduate training, he began writing for multiple companies about mHealth and digital health solutions, with a focus on mobile applications. Since then, Dr. Aungst has conducted research on digital health technologies for pharmacy and published multiple peer-reviewed journal articles on the topic.

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

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

Fatima Sadat is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

Nurses are the cornerstone of health care delivery and as such are poised to take a lead role in forwarding the integration of behavioral care into primary care. This is the position taken by the International Society of Psychiatric–Mental Health Nurses (ISPN) and promoted in a recent paper in the Archives of Psychiatric Nursing. In “Quality Improvement and Models of Behavioral Healthcare Integration: Position Paper #2 from the International Society of Psychiatric–Mental Health Nurses” (2019), Lynn P. Shell of the Rutgers University School of Nursing and colleagues focus on nurses’ role in improving and integrating behavioral health care.

Integrating care is a means to improve it, Shell and colleagues write, and indeed a focus on quality is the throughline in their piece. Deficits in care quality in the United States were famously called out in Crossing the Quality Chasm (2001), from the Institute of Medicine. In response, there have been multiple initiatives launched to improve care, which Shell et al. review. One of these was the National Quality Strategy (NQS), which outlined six priorities for defining good care and advancing the Triple Aim, which famously consists of an improved experience of care, better population health, and reduced health care costs.

This table lists the six NQS priorities:

Patient safety Making care safer by reducing harm caused in the delivery of care.
Patient and family engagement Ensuring that each person and family are engaged as partners in their care.
Coordination of care Promoting effective communication and coordination of care.
Dissemination of best practices Promoting the most effective prevention and treatment practices for the leading causes of mortality.
Population health Working with communities to promote wide use of best practices to enable healthy living.
Efficient use of health care resources Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models.

The authors cite the NQS priorities in the service of their argument that nurses’ focus on quality drives improvement in pursuit of the Quadruple Aim. (As discussed, the Triple Aim was conceived a goal for health care delivery. But as provider burnout became a national issue, the Triple Aim was broadened into the Quadruple Aim, with the fourth aim being an improved provider experience.)

Why Integration

Co-occurring behavioral health and substance use disorders are common in primary care settings, particularly among those with chronic medical conditions, highlighting the need for integrated and coordinated care, write Shell and colleagues. They cite a report from the Centers for Medicare and Medicaid Services (CMS) that found that coordinated care, compared with traditional care, lowered costs in a lower-income, high-risk population with medical comorbidity. Coordinated care that includes integrated behavioral health care also has been shown to improve quality and lower costs. A study examining the economic and health benefits of a depression program integrated into diabetes treatment in primary care clinics found better outcomes and cost savings. Compared with usual care, patients in the intervention group averaged 61 additional days without depressive symptoms and had costs averaging $314 less.

The University of Washington IMPACT Study found similar results: With 1801 adults with depressive symptoms in its sample, it found that coordinated, integrated care lowered costs, decreased symptoms of depression and physical pain, and improved patient functioning.

Three Models of Integration

The authors describe several models of integration:

The Four-Quadrant Model. According to the authors, this model assumes competency-based mental health and substance abuse service integration within a primary care setting. Each quadrant considers risk and complexity along with population needs:

Quadrant I      Low to moderate behavioral health and low to moderate physical health complexity/risk

Quadrant II      Moderate to high behavioral health and low to moderate physical health complexity/risk

Quadrant III      Low to moderate behavioral health and moderate to high physical health complexity/risk

Quadrant IV      Moderate to high behavioral health and moderate to high physical health complexity/risk

Factors driving its success include consumer preference, workforce competency, organizational support, and fiscal resources.

Horizontal vs. Vertical Integration Care Models. The authors describe the horizontal model of integration as circular, with equal distribution of responsibility and power shared among providers. Examples of a horizontal integration model include the formation of multi-hospital systems, mergers, and strategic alliances with neighboring hospitals to form local networks.

Vertical models, by contrast, move patients through sequential levels of care; from community-based to acute care, and primary to specialty care. In this model, the physician directs the course of care. Shell et al. write that vertical programs feature intervention, monitoring, and evaluation.

Levels of Integrated Care. Some models feature multiple levels of integrated behavioral care with three notable features: It’s collocated, coordinated, and integrated. In some examples of this, a patient’s behavioral health needs and physical health needs are treated separately. Collaboration happens by referral. Sharing the same location facilitates communication among care providers.

Conclusion

Nursing leaders have proven their leadership in developing each part of the Quadruple Aim, and they continue to contribute to national policy. The authors close their paper by stating the ISPN’s position is that “all nurses be educated on the Quadruple Aim, behavioral health integration, and the importance of both on improving patient care and care outcomes.”

On April 24, 2020, President Trump signed the $484 billion Paycheck Protection Program and Health Care Enhancement Act, (House Resolution 266) to allocate additional funding for programs created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act to provide emergency assistance and health care response for businesses affected by the 2020 coronavirus pandemic. HR 266 provides the following:

  • Approximately $370 billion to the Small Business Administration (SBA) to provide additional funding for the Paycheck Protection Program (PPP) and for emergency small business loans.
  • Approximately $100 billion to the Department of Health and Human Services (HHS) in fiscal year (FY) 2020 supplemental appropriations to HHS for the Public Health and Social Services Emergency Fund.

The SBA provisions are as follows:

  • $310 billion to refill the CARES Act PPP. The PPP can guarantee certain loans made to small businesses during the COVID-19 pandemic. The SBA must guarantee that $30 billion of paycheck protection loans are made by small financial institutions and credit unions. Eligibility for the loans is limited to businesses (including non-profit organizations) with 500 or fewer employees. All hospitals are eligible if less than half their funding, excluding Medicaid payments, is from state or local governments.
  • $60 billion for Economic Injury Disaster Loan (EIDL) loans ($50 billion) and emergency EIDL grants ($10 billion). It expands eligibility for such disaster loans and advances to include agricultural enterprises.

With more funding for the programs, on April 27, 2020, the SBA resumed accepting PPP applications from participating lenders. With the additional funding provided by the new COVID-19 relief package, SBA will resume processing EIDL Loan and Advance applications that are already in the queue on a first come, first-served basis. New applications should be filed through an existing SBA lender as soon as possible. The first round of funding was exhausted within 10 days, and this new round of funding is also expected to be quickly exhausted. There is no guarantee of additional funding through future legislation.

The HHS provisions are as follows:

  • $75 billion to reimburse hospitals and health care provider organizations for health care related expenses or lost revenues that are attributable to the coronavirus outbreak. Within this allocation, $825 million is set aside for community health centers and rural clinics.
  • $25 billion for expenses to research, develop, validate, manufacture, purchase, administer, and expand capacity for COVID-19 tests to effectively monitor and suppress COVID-19. Specified portions of this funding are allocated to states, localities, territories, and tribes; the Centers for Diseases Control and Prevention; the National Institutes of Health; the Biomedical Advanced Research and Development Authority; the Food and Drug Administration; community health centers; rural health clinics; and testing for the uninsured. Additionally, HHS must submit data on COVID-19 cases and a strategic testing plan to Congress.

A link to the full text of “House Resolution 266: Paycheck Protection Program and Health Care Enhancement Act” may be found at www.openminds.com/market-intelligence/resources/042420hr266enr.htm.

As of April 27, 2020, Congress had passed four bills that became law to address aspects of the 2020 coronavirus pandemic. The most recent is H.R. 266 – Paycheck Protection Program and Health Care Enhancement Act, which became law on April 24, 2020. It provides funding of $484 billion. The three earlier bills are as follows:

  • R. 748 – Coronavirus Aid, Relief, and Economic Security Act “CARES Act” became law on March 27, 2020. It provides funding of $2 trillion. The CARES Act provides emergency assistance and health care response for individuals, families, and businesses affected by the 2020 coronavirus pandemic. Key provisions created the Paycheck Protection Program and a Provider Relief Fund. Both are intended to address economic harm due to the COVID-19 public health emergency. A key provision will reimburse provider organizations for COVID-19 diagnosis and treatment provided to uninsured consumers. PsychU reported on the bill on May 4, 2020, in “HHS Begins Releasing $100 Billion CARES Act Funding To Provider Organizations For Relief Assistance & Treating The Uninsured” at https://www.psychu.org/hhs-begins-releasing-100-billion-cares-act-funding-to-provider-organizations-for-relief-assistance-treating-the-uninsured/.
  • R. 6201 – Families First Coronavirus Response Act became law on March 18, 2020. It provides funding of more than $3.4 billion. The bill provides for COVID-19-related paid sick leave, paid family leave tax credits, and free COVID-19 testing during the national public health emergency. It expands unemployment benefits and provides supplemental funding for a variety of food assistance programs. PsychU reported on the bill on March 31, 2020 in “Families First Coronavirus Response Act Signed With $3.47 Billion In Funding & New Mandates” at https://www.psychu.org/families-first-coronavirus-response-act-signed-with-3-47-billion-in-funding-new-mandates/?corner_id=53327.
  • R.6074– Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 became law on March 6, 2020. It provides funding of $8.3 billion. It provided $7.76 billion to federal, state, and local agencies to combat the virus and authorized an additional $500 million to pay for the waivers of Medicare telehealth restrictions. Of the funding to state and local entities, about $2.2 billion is earmarked for activities to prevent virus spread, and another $3 billion is earmarked for vaccine research. PsychU reported on the bill on March 16, 2020, in “New Federal Coronavirus Bill Waives Medicare Telehealth Restrictions” at https://www.psychu.org/new-federal-coronavirus-bill-waives-medicare-telehealth-restrictions/.

For more information, contact:

  • Press Office, Office of Communications and Public Liaison, Small Business Administration, 409 3rd Street, Southwest, Washington District of Columbia 20416; 202-205-7036; Press_Office@sba.gov; Website: https://www.sba.gov/page/coronavirus-covid-19-small-business-guidance-loan-resources and https://www.sba.gov/funding-programs/loans/coronavirus-relief-options/paycheck-protection-program and https://www.sba.gov/funding-programs/loans/coronavirus-relief-options
  • U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, District of Columbia 20201; 202-690-6343; Email: media@hhs.gov; Website: https://www.hhs.gov/provider-relief/index.html.

As of April 23, 2020, about 75% of correctional facilities in the United States report that their staff had adequate personal protective equipment (PPE) for COVID-19, up from 60% on March 30, 2020. Based on self-reports from correctional facilities participating in a survey, about 13% of inmates tested for COVID-19 have tested positive, as have 15% of correctional officers and 12% of health staff. Self-reports come from a convenience sample of a small proportion of U.S. correctional facilities and may not representative of all U.S. correctional facilities.

For this study, of 818 inmates tested, 108 have tested positive; 128 test results are pending. Among correctional officers, 795 have been tested and 122 have tested positive; 93 test results are pending. Among health staff, 156 have been tested and 19 have tested positive; 15 test results are pending.

About 96% of the facilities participating in the study screen new inmates for COVID-19. Current inmate population screening has increased from 46% to 53% between March 25 and April 23. Staff screening has increased from 79% to 90%.

The ongoing study is being conducted by the National Commission on Correctional Health Care in partnership with Marcella Alsan, M.D., Ph.D., and Crystal Yang, JD, Ph.D. of Harvard University. The goal is to gather information on how the COVID-19 pandemic is affecting correctional facilities. The number of participating facilities varies week to week, with the April 23 survey having approximately 185 respondents. The researchers are releasing testing data weekly. Only jails, prisons, and juvenile facilities in the United States are eligible to participate.

The full text of “Study of COVID-19 in Correctional Facilities” is being completed by the National Commission on Correctional Health Care. Copies of the weekly updates are available online at https://www.ncchc.org/study-of-covid-19-in-correctional-facilities.

For more information, contact:

  • National Commission on Correctional Health Care, 1145 West Diversey Parkway, Chicago, Illinois 60614; 773-880-1460; Fax: 773-880-2424; Email: info@ncchc.org; Website: https://www.ncchc.org/.

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. Join Catherine Judd and Darell Smith, along with moderator Otsuka Medical Science Liaison Jason Carter, as they 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 at the University of Texas Southwestern School of Health Professions.
  • Darell A. Smith
    President, Greater Dallas Coalition
  • Jason Carter
    Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

Catherine Judd, MA, PA-C, CAQ-Psy is 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.

On March 17, 2020, the federal Department of Health and Human Services (HHS) Office of Civil Rights (OCR) announced that during the COVID-19 public health emergency, penalties would not be imposed on provider organizations that offer telehealth services using popular video chat applications that may not fully comply with the privacy requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The enforcement discretion will last for the COVID-19 public health emergency. It will extend to telehealth services provided for any reason regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19. A covered health care provider organization can use any non-public facing remote communication product that is available to communicate with consumers.

OCR said health care provider organizations that seek additional privacy protections should provide the services through HIPAA-compliant technology vendors that are willing to enter into HIPAA business associate agreements (BAAs) in connection with the provision of their video communication products. OCR listed the following vendors that represent that they provide HIPAA-compliant video communication products and that they will enter into a HIPAA BAA, including:

  • Skype for Business / Microsoft Teams
  • Updox
  • VSee
  • Zoom for Healthcare
  • me
  • Google G Suite Hangouts Meet
  • Cisco Webex Meetings / Webex Teams
  • Amazon Chime
  • GoToMeeting
  • Spruce Health Care Messenger

Covered health care provider organizations that fail to secure a BAA with video communication vendors will not be subject to a penalty for that or any other noncompliance with the HIPAA Rules that relate to the good faith provision of telehealth services during the COVID-19 nationwide public health emergency. Provider organizations are encouraged to notify consumers that these third-party applications potentially introduce privacy risks, and provider organizations should enable all available encryption and privacy modes when using such applications.

OCR warned that it considers Facebook Live, Twitch, TikTok, and similar video communication applications to be public facing. They should not be used in the provision of telehealth by covered health care provider organizations.

For more information, contact:

  • Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, District of Columbia 20201; 800-368-1019; E-mail: OCRMail@hhs.gov; Web site: www.hhs.gov/ocr/privacy

On February 21, 2020, the federal Department of Health and Human Services (HHS) Office of the National Coordinator for Information Health Technology (ONC) issued its final strategies to reduce the regulatory and administrative burden of using health information technology (IT) and electronic health records (EHRs). The strategies address clinical documentation; ease of using health IT tools and systems; federal health IT and EHR reporting requirements; and public health reporting, including coordination with prescription drug reporting programs and electronic prescribing of controlled substances. The goals are to improve EHR usability and reduce the effort and time required for clinical professionals, hospitals, and health care organizations to record information in EHRs; reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals, and health care organizations; and improve the functionality and intuitiveness (ease of use) of EHRs.

To meet the goal, HHS developed four key strategies, each with multiple components and sub-components. The four strategies are: reduce regulatory burden around clinical documentation requirements for consumer visits, improve health IT usability, improve federal health IT and EHR reporting requirements, and improve public health reporting.

Clinical Documentation Strategies

To improve ease of clinical documentation, the strategy has three components: reducing regulatory burden around documentation requirements for consumer visits; partnering with clinical stakeholders; and leveraging health IT to standardize data and processes around ordering services and related prior authorization processes.

To reduce regulatory burden, the recommendations are as follows:

  1. HHS should continue to reduce overall regulatory burden for documenting encounters
  2. Leverage data already present in the EHR to reduce re-documentation in the clinical note
  3. Obtain ongoing stakeholder input about how to effectively implement documentation policy changes using health IT
  4. Waive documentation requirements as may be necessary for purposes of testing or administering alternative payment methodologies (APMs)

To partner with stakeholders, the recommendations are as follows:

  1. Continue to partner with clinical stakeholders to encourage adoption of best practices related to documentation requirements
  2. Advance best practices for reducing documentation burden through learning curricula included in CMS Technical Assistance and models

To leverage health IT to standardize data and processes around ordering services and related prior authorization processes, the recommendations are as follows:

  1. Evaluate other process and clinical workflow factors that contribute to burden associated with prior authorization
  2. Support automation of ordering and prior authorization processes for medical services and equipment through adoption of standardized templates, data elements, and real-time standards based electronic transactions
  3. Incentivize adoption and/or use of technology that can generate and exchange standardized data supporting documentation needs for ordering and prior authorization
  4. Work with clinical professionals, suppliers, payers, and other intermediary entities to support pilots for standardized electronic ordering of services/items
  5. Coordinate efforts to advance new standards approaches supporting prior authorization

Health IT Usability Strategies

To improve health IT usability, the strategy has four components. The components and sub-strategies address better aligning EHRs with clinical workflows; promoting health IT user interfaces that improve satisfaction, promoting alignment of the clinical content in health IT, and promoting the importance of implementation decisions.

To better align EHRs with clinical workflow; improve decision making and documentation tools, the strategies are as follows:

  1. Better align EHR system design with real-world clinical workflow
  2. Improve clinical decision support usability
  3. Improve clinical documentation functionality
  4. Improve presentation of clinical data within EHRs

To promote user interface optimization in health IT that will improve the efficiency, experience, and end user satisfaction, the strategies are as follows:

  1. Harmonize user actions for basic clinical operations across EHRs
  2. Promote and improve user interface design frameworks specific to health care delivery
  3. Improve internal consistency within health IT products
  4. Promote proper integration of the physical environment with EHR use

To promote harmonization surrounding clinical content contained in health IT to reduce burden, the strategies are as follows:

  1. Standardize medication information within health IT
  2. Standardize order entry content within health IT
  3. Promote best practice and user interface design frameworks for results display within health IT

To improve health IT usability by promoting the importance of implementation decisions for efficiency, satisfaction, and lowered burden for clinical professionals, the strategies are as follows:

  1. Better align EHR system design with real-world clinical workflow
  2. Improve clinical decision support usability
  3. Improve clinical documentation functionality
  4. Improve presentation of clinical data within EHRs

Electronic Health Record Reporting Strategies

To improve federal health IT and EHR reporting requirements, the strategy has three components. The components and sub-strategies focus on easing the burdens caused by program requirements, improving the functionality of health IT, and improving the value of electronic clinical quality measures.

To address program reporting and participation burdens, simplify program requirements, and incentivize new approaches that are both easier and provide better value to clinical professionals, the strategies are as follows:

  1. Simplify the scoring model for the Promoting Interoperability performance category and Medicare Promoting Interoperability Program
  2. Incentivize innovative uses of health IT and interoperability that reduce reporting burdens and provide greater value to physicians
  3. Reduce burden of health IT measurement by continuing to improve current health IT measures and developing new health IT measures that focus on interoperability, relevance of measure to clinical practice and consumer improvement, and electronic data collection that aligns with clinical workflow
  4. To the extent permitted by law, continue to provide states with federal Medicaid funding for health IT systems and promote interoperability among Medicaid health care provider organizations and professionals
  5. Revise program feedback reports to better support the needs of clinical professionals and to improve care

To leverage health IT functionality to reduce administrative and financial burdens associated with quality and EHR reporting programs, the strategies are as follows:

  1. Recognize industry-approved best practices for data mapping to improve data accuracy and reduce administrative and financial burdens associated with health IT reporting
  2. Adopt additional data standards that make access to data, extraction of data from health IT systems, integration of data across multiple health IT systems, and analysis of data easier and less costly for physicians and hospitals
  3. Implement a secure standards-based API approach to HHS electronic administrative systems to promote integration with existing health IT products

To improve the value and usability of electronic clinical quality measures while decreasing health care provider organization burden, the strategies are as follows:

  1. Consider the feasibility of adopting a first-year test reporting approach for the newly developed electronic clinical quality measures
  2. Continue to evaluate the current landscape and future directions of electronic quality measurement and provide a roadmap toward increased electronic reporting through the eCQM Strategy Project
  3. Explore alternate, less burdensome approaches to electronic quality measurement through pilot programs and reporting program incentives

Public Health Reporting Strategies

To improve public health reporting (including coordination with prescription drug reporting programs and electronic prescribing of controlled substances), the strategy has three components. The components and sub-strategies focus on increasing health care professional prescription drug monitoring program (PDMP) queries, increased adoption of electronic prescribing of controlled substances (EPCS), developing a process to address inconsistent data collection, and expanding privacy requirements in Health Insurance Portability and Accountability Act (HIPAA) rules.

To increase health care professional prescription drug monitoring program (PDMP) queries for the retrieval of medication history from a state PDMP, the strategies are as follows:

  1. Federal agencies, in partnership with states, should improve interoperability between health IT and PDMPs through the adoption of common industry standards consistent with ONC and CMS policies and applicable laws including HIPAA rules.
  2. Promote standards-based API emerging technologies to support improved access to and use of opioid prescription histories for opioid use disorder (OUD) prevention and treatment
  3. HHS should increase adoption of EPCS with consideration for preferences specific to health care professionals/provider organization, workflow, and use of available standards.

To develop a process to address the issue of inconsistent data collection by federal, state, and local programs, the strategies are as follows:

  1. HHS should convene key stakeholders, including state and local public health departments and community health centers, to inventory reporting requirements from federally funded public health programs.
  2. HHS should continue to work to harmonize reporting requirements across federally funded programs.

To better facilitate electronic exchange of health information for consumer care by addressing concerns about HIPAA privacy requirements as well as federal confidentiality requirements for addiction disorders, the strategies are as follows:

  1. HHS should continue to work to harmonize reporting requirements across federally funded programs.
  2. HHS should expand upon existing guidance about HIPAA privacy requirements and federal confidentiality requirements governing substance use disorder health information in order to better facilitate electronic exchange of health information for patient care.

The recommendations were presented in “Strategy On Reducing Regulatory And Administrative Burden Relating To The Use Of Health IT & EHRs.” HHS had initially released its proposals in November 2018. The final report reflects input from the more than 200 comments submitted in response to the draft strategy and recommendations.

For more information, contact:

Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, 330 C Street Southwest, Floor 7, Washington, District of Columbia 20201; 202-690-7151; Fax: 202-690-6079; Email: onc.request@hhs.gov; Website: https://www.healthit.gov/.

The COVID-19 pandemic has exerted significant effects on mental health. The prescription of anti-anxiety and antidepressant medications has increased, as have calls to the National Suicide Prevention hotline. In this webinar, Dr. Gaurava Agarwal and Dr. Christine Moutier discuss with Otsuka Senior Medical Liaison Rachel Self the dynamics of mental health and the potential impacts of a pandemic or other extreme stressor, explore a stress continuum model and sources of stress, and highlight strategies for health care professionals to establish and maintain wellness, build resilience, and engage in healthy self-care. Suicide risk and prevention are covered, as are the “Seven C’s” for Stress First Aid.

Featuring:

  • Gaurava Agarwal, MD, is Assistant Professor in the Department of Psychiatry and the Behavioral Sciences, Assistant Professor in the Department of Medical Education, and the Director of Physician Well-Being for Northwestern Medical Group
    Christine Moutier, MD,
    Chief Medical Officer at the American Foundation for Suicide Prevention and a psychiatrist
  • Rachel Self, PhD
    Senior Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

Gaurava Agarwal, MD, is Assistant Professor in the Department of Psychiatry and the Behavioral Sciences, Assistant Professor in the Department of Medical Education, and the Director of Physician Well-Being for Northwestern Medical Group.

Christine Moutier, MD, Chief Medical Officer at the American Foundation for Suicide Prevention and a psychiatrist.

The Food and Drug Administration (FDA) has played a critical role in protecting the United States during the COVID-19 pandemic and has provided numerous guidance documents to support rapid response efforts. One recent guidance document, “Enforcement Policy for Digital Health Devices For Treating Psychiatric Disorders During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency” may help to expand the availability of digital health therapeutic devices for psychiatric disorders during the pandemic. Join Otsuka Medical Science Liaison, Mark Tacelosky, as he discusses the guidance document and how it may ultimately improve mental health during the current crisis.

Speaker is a paid employee for Otsuka Pharmaceutical Development & Commercialization, Inc.

National Quality Forum recently endorsed four behavioral health quality measures. The measures address maximum hours of physical restraint use or seclusion, and separately address timeliness of follow-up after an emergency department visit for an alcohol or other drug abuse or dependence, and timeliness of follow-up after an emergency department visit for mental illness or intentional self-harm. The latter two measures had previously been a single measure.

The endorsed measures are:

  • 0640 HBIPS-2 Hours of Physical Restraint Use:This process measure for facilities was recommended for continued endorsement. It refers to the total number of hours that all individuals admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraints. The data comes from electronic and paper medical records. The measure is reported as the number of times that physical restraints are used for more than two hours divided by the number of psychiatric inpatient days.
  • 0641 HBIPS-3 Hours of Seclusion Use: This process measure for facilities was recommended for continued endorsement. It refers to the total number of hours that all individuals admitted to a hospital-based inpatient psychiatric setting who are held in seclusion. The data comes from electronic and paper medical records. The measure is reported as the number of events divided by the number of psychiatric inpatient days.
  • 3488 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence:This process measure for health plans was recommended for continued endorsement. It is a maintenance measure because it was previously part of an endorsed measure that combined mental health and addiction disorder emergency department follow-up visits. Data for this measure comes from claims for members ages 13 and older who have an emergency department visit with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence and who have a follow-up outpatient visit for AOD. Two rates are reported: the percentage of emergency department visits for which the member receives a follow-up visit within seven days and the percentage of follow-up visits within 30 days of the emergency department visit.
  • 3489 Follow-Up After Emergency Department Visit for Mental Illness:This process measure for health plans was recommended for continued endorsement. It is a maintenance measure because it was previously part of an endorsed measure that combined mental health and addiction disorder emergency department follow-up visits. Data for this measure comes from claims for members ages 13 and older who have an emergency department visit with a principal diagnosis of mental illness or intentional self-harm who have a follow-up visit for mental illness. Two rates are reported: the percentage of emergency department visits for which the member receives a follow-up visit within seven days and the percentage of follow-up visits within 30 days of the emergency department visit.

The recommendations were issued in “Behavioral Health and Substance Use, Spring 2019 Review Cycle: CDP Report” by National Quality Forum (NQF). During the spring 2019 project cycle, the Behavioral Health and Substance Use Standing Committee evaluated six measures. The following two measures were not endorsed during this cycle: NQF  0560 HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification; and NQF 1922 HBIPS-1 Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths Complete. Each Behavioral Health and Substance Use project cycle aims to endorse measures of accountability for improving the delivery of behavioral health care in the United States.

NQF is a consensus-based healthcare organization created in 1999 that works with all members of the healthcare community to drive measurable health improvements. Its mission includes promoting and ensuring consumer protections and healthcare quality through evidence-based measurement and public reporting. NQF-endorsed measures are used by the federal government (Medicare and Medicaid), states, and private-sector organizations to evaluate performance and to share information with consumers. To endorse measures, NQF committees evaluate the evidence-base for measures submitted by measure developers. NQF reconsiders endorsed measures and considers new measures during project cycles. Previously endorsed measures relevant to the project are reconsidered to assess their ongoing importance, validity, reliability, feasibility, and utility.

The full text of “Behavioral Health and Substance Use, Spring 2019 Review Cycle: CDP Report” was published in February 2020 by National Quality Forum. A copy is available online at http://www.qualityforum.org/Publications/2020/02/Behavioral_Health_and_Substance_Use_Final_Technical_Report_-_Spring_2019_Cycle.aspx.

For more information, contact:

  • Information Office, National Quality Forum, 1099 14thStreet Northwest, Suite 500, Washington, District of Columbia 20005; 202-783-1300; Fax: 202-783-3434; Email: info@qualityforum.org; Website: http://www.qualityforum.org/.

Dr. Gaurava Agarwal discusses the effect of social distancing, including loneliness, which he breaks down into three categories. He also shares his thoughts on creating a No-Corona Zone so as to preserve a sense of normalcy in conversations with family and friends. Listen in as this eminent psychiatrist looks at issues that affect everyone during the coronavirus pandemic.

Dr. Gaurava Agarwal has a double appointment at Northwestern University’s Feinberg School of Medicine: He is an Assistant Professor in the Department of Medical Education and in the Department of Psychiatry and Behavioral Sciences at Northwestern University’s Feinberg School of Medicine. He also serves as the Director of Physician Well-Being for Northwestern Medical Group. The recipient of many honors, Dr. Agarwal specializes in occupational and organizational psychiatry with an emphasis on workplace mental health.

Christina DuVernay, PhD, is a Senior Associate at OPEN MINDS. Her twenty years of experience in publishing include Harvard Business School Publishing, Health Affairs, and Johns Hopkins Medicine. She earned her PhD in English at Columbia University.

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

Jim Kenney discusses how managed care organizations are impacted by the COVID-19 pandemic, in both positive and challenging ways. How are payers’ allowances and restrictions changing? What are the pros and cons of using telehealth and telepharmacy to deliver care? What are the opportunities in the midst of crisis? Rick Kegler, Managed Market Liaison for PsychU, asks for Mr. Kenney’s thoughts and projections.

James T. Kenney, RPh, MBA, is the Payer Section Advisor for PsychU. Mr. Kenney is the President of the Academy of Managed Care Pharmacy (ACMP).

Rick Kegler, PharmD, MBA, is a Managed Market Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

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

Rick Kegler, PharmD, MBA, is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

“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.

The South Carolina Department of Mental Health (SCDMH) is updating its qualified provider organization list of community residential care facilities (CRCFs) available for people with mental illness who are at high risk for hospitalization. The list was created in 2011, and resubmitted following expiration in 2018. The SCDMH intends to use the new list to recommend placements for specific individuals currently served by three of its community mental health centers. SCDMH released the solicitation (5400019224) on March 23, 2020, with responses due by April 6, 2020. The initial 12-month contract term is followed by four one-year renewal options. The start date is April 20, 2020.

The state seeks to establish a fixed price contract with a source or sources to provide the services. The established maximum fixed price rate is $30.00 per resident per day.

CRCFs, unlike boarding homes, include not only room and board, but provide a degree of personal care for a period of time in excess of 24 consecutive hours for two or more persons, 18 years old or older. CRCFs are often referred to as “assisted living facilities.” They are licensed and monitored by the South Carolina Department of Health and Environmental Control’s Division of Health Licensing. A CRCF can be a transitional or a permanent placement depending on the preferences of the resident and their support networks/families for independent living settings.

Eligible CRCF residents are those who have had a serious mental illness or other behavioral health disorder and who have had a history of multiple hospitalizations and inpatient psychiatric treatment for 90 or more days, and/or who otherwise may be at significant risk of re-hospitalization. The three centers need the following number of CRCF beds:

  • Columbia Area Mental Health Center (CAMHC) needs 75 CRCF beds in Richland and Fairfield counties
  • Santee Wateree Mental Health Center needs 45 beds in Sumter and Kershaw counties
  • Coastal Empire Mental Health Center needs 45 beds across Beaufort, Hampton, Colleton, Allendale, and Jasper counties.

For more information, contact:

  • Tracy LaPointe, Public Information Director, South Carolina Department of Mental Health, Post Office Box 485, Columbia, South Carolina 29202; 803-898-8581; Email: tracy.lapointe@scdmh.org; Website:https://scdmh.net/dmh-components/community-residential-care-facilities/.

The Department of Veterans Affairs (VA) recently proposed standardizing eligibility criteria for its Program of Comprehensive Assistance for Family Caregivers (PCAFC). Specifically, the VA seeks to expand the definition of serious injury to include any service-connected disability, whether it resulted from an injury, an illness, or a disease. Further, the VA seeks refine the eligibility criteria for personal care services to capture the service needs of veterans and service members with cognitive or neurological impairment or mental health conditions. The VA also proposed changes to the PCAFC stipend payment methodology, definitions for financial planning and legal services, and procedures for revocation and discharge, to include advance notice requirements aimed at improving communication between VA and PFAFC participants. These changes are intended to ensure that the PCAFC regulations reflect changes required by the VA MISSION Act of 2018.

The proposed rule, “Program Of Comprehensive Assistance For Family Caregivers Improvements And Amendments Under The VA MISSION Act Of 2018,” was released on March 6, 2020. Comments will be accepted through May 5, 2020.

The PCAFC, established in 2011, is a component of the VA Caregiver Support Program, which provides services to family caregivers to help veterans with disabilities remain in their homes. It provides caregivers with training, peer mentoring, respite care, a telephone support line and self-care courses. The PCAFC provides additional benefits including a monthly stipend for qualifying family caregivers of eligible veterans who were seriously injured in the line of duty on or after September 11, 2001.

Under the MISSION Act, the VA will expand eligibility for PCAFC to veterans from all eras, starting with those who incurred or aggravated a serious injury in the line of duty on or before May 7, 1975. After that first expansion phase, PCAFC will be extended to eligible veterans who were seriously injured in the line of duty between May 7, 1975 and September 11, 2001. Prior to expanding, VA must fully implement an information technology system required by the MISSION Act.

PsychU last reported on this topic in “VA Expands Private Provider Options For Veterans Under MISSION Act,” which published on July 15, 2019. The article is available at https://www.psychu.org/va-expands-private-provider-options-for-veterans-under-mission-act/.

For more information, contact:

  • Elyse Kaplan, National Deputy Director, Caregiver Support Program, Care Management and Social Work, 10P4C, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Ave. NW, Washington, District of Columbia 20420; 202-461-7337; Website: https://www.caregiver.va.gov/ and https://www.caregiver.va.gov/support/support_benefits.asp

Law enforcement requested consumer electronic health data from a software vendor in 2019 to aid investigations against physicians who had allegedly inappropriately prescribed controlled substances for alleged “pill mills.” Search warrants that have become public were issued to the same vendor, DrChrono, a digital health technology company that provides a software and billing service platform, consisting of web- and cloud-based apps for physicians and consumers.

The search warrants illustrate the tactic:

  • In January 2019, DrChrono complied with a search warrant and provided approximately 9.3 gigabytes of medical records, amounting to 8,316 files from the Gaby Medical Clinic in Fort Smith, Arkansas to the U.S. Drug Enforcement Administration (DEA). For this instance of data-sharing, DEA was investigating two physicians over claims that they were prescribing large quantities of Oxycodone and Xanax. Both physicians pleaded guilty to distributing controlled substances.
  • In July 2019, DrChrono complied with a DEA search warrant and provided records related to a Pennsylvania-based medical practice. A physician was being investigated for giving “goody bags” of drugs to consumers. The bags included analgesics, sedatives, muscle relaxants, and anti-inflammatory drugs. Data obtained from DrChrono included appointment notes that were included in the physician’s files. The physician pleaded “not guilty” to the charges of health care fraud and conspiracy to distribute controlled substances.

In September 2019, the U.S. Office of the Inspector General (OIG) for the Department of Justice released a “Review of the Drug Enforcement Administration’s Regulatory and Enforcement Efforts to Control the Diversion of Opioids.” In this document, the OIG outlined how DEA is trying to compile and use data that is required through Titles II and III of the Controlled Substances Act of 1970 (CSA), in order to combat issues with opioid prescription and abuse. The CSA requires importers, exporters, manufacturers, distributors, dispensers, and health care professionals that handle controlled substances, collectively known as “registrants,” to register with DEA. However, the OIG noted that one of the areas in which DEA’s regulatory and enforcement efforts could have been more effective in combating opioid diversion was that DEA has not taken steps to revise its regulations and require all prescribers to submit prescriptions electronically. This is one reason that the DEA has experienced a lack of information regarding these practices, and may be a reason that DEA has targeted private electronic health record and data storage vendors.

Currently, the DEA cannot access data housed in a state-operated prescription drug monitoring program (PDMP) database or in an electronic health record without a search warrant. However, according to an amicus brief filed in May 2019 by the American Civil Liberties Union (ACLU), the DEA believes that because it is a federal agency it should be able to request individual PDMP records with an administrative subpoena instead of a warrant. The brief was in response to U.S. DOJ v. Jonas. The DEA argued that people should have no reasonable expectation of privacy for their data held in the PDMP because of the “third-party doctrine.” Under that doctrine, people lose the protection from unreasonable search and seizure guaranteed under the Fourth Amendment when they voluntarily share information with a third-party, such as a company they do business with.

DrChrono provides a cloud-based electronic health record; the organization’s software manages data for about 17.8 million consumers, and has processed more than $11 billion in medical bills to date. DrChrono’s privacy policy states that it can share consumer information with partners. DrChrono also claims to not be “responsible for the privacy practices of the others who will view and use the information you disclose to others.”

For more information, contact: 

  • Michael Nusimow, Chief Executive Officer, DrChrono, 328 Gibraltar Drive, Sunnyvale, California 94089; 844-569-8628; Email: michael@drchrono.com; Website: https://www.drchrono.com/
  • Public Affairs, U.S. Drug Enforcement Administration, 8701 Morrissette Drive, Springfield, Virginia 22152; Email: DEA.Public.Affairs@usdoj.gov; Website: https://www.dea.gov/
  • Assistant Inspector General for Audit, Office of the Inspector General, U.S. Department of Justice, 950 Pennsylvania Avenue, NW, Washington, District of Columbia 20530; 202-616-4633; Website: https://oig.justice.gov/
  • American Civil Liberties Union, 125 Broad Street, 18th Floor, New York, New York 10004; 212-549-2500; Website: https://www.aclu.org/blog/privacy-technology/medical-and-genetic-privacy/government-needs-get-warrant-if-it-wants-access

The Medicaid and CHIP Payment and Access Commission (MACPAC) found that most state Medicaid programs use one or more legal authorities to use Medicaid funds to pay for residential or inpatient services provided by an institution of mental diseases (IMD). However, since 1965, the federal Medicaid program has excluded payment for IMD services to ensure that states alone fund inpatient psychiatric services. The goal of this exclusion was to encourage states to build community-based behavioral health capacity.

The federal Medicaid program defines an IMD as “a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.” The term IMD is only relevant to Medicaid; they are not singled out by other payers, state licensure agencies, or accrediting bodies. For licensing purposes, IMDs can provide inpatient or residential mental health and addiction treatment as needed.

Medicaid authorities that states use to pay for services in IMDs include:

  • Demonstration waivers under Section 1115 of the Social Security Act gives the Secretary of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs authorized under the Act, including certain Medicaid requirements, and to allow a state to use federal Medicaid funds in ways that are not otherwise allowed under federal rules. This authority is provided for “experimental, pilot, or demonstration” projects which, in the view of the Secretary, are “likely to assist in promoting the objectives of” the program.
  • In-lieu-of services in managed care are alternative services in a setting that are not included in the state plan or otherwise covered by the contract but are medically appropriate, cost-effective substitutes for state plan services included within a contract.
  • Statutory exceptions to the exclusion for services provided to adults age 65 and older and children and youth under age 21.
  • A new state plan option is in effect from October 1, 2019 to September 30, 2023. This option covers IMD services for up to 30 days in a year for individuals with addiction.

MACPAC also found that state licensure agencies, accrediting bodies, and other payers do not have standards specific to IMDs, given that the designation is unique to Medicaid. Instead, states regulate inpatient and residential treatment facilities separately, and standards vary according to whether a facility provides addiction treatment or mental health care. Federal standards for IMDs are largely determined by whether or not the facilities are Medicare provider organizations; however, there is no federal certification process for these organizations because Medicare does not pay for addiction treatment services in most free-standing facilities.

These findings were presented in “MACPAC Report To Congress: Oversight of Institutions for Mental Diseases.” The report fulfills a statutory requirement in the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act). The requirement is to identify and describe facilities designated as IMDs in selected states and summarize state licensure, certification, or accreditation requirements and Medicaid clinical and quality standards for these facilities. MACPAC estimated the number of IMDs accepting Medicaid in seven selected states (California, Colorado, Florida, Massachusetts, New Jersey, Ohio, and Texas) and determined the types of services these facilities offer. They also determined the roles of federal and state government agencies in the regulation and oversight of IMDs, and selected outpatient behavioral health facilities, including licensure requirements and licensure standard enforcement. Finally, they analyzed standards that select state Medicaid programs and managed care plans place on behavioral health facilities, including facilities that may be considered IMDs, how Medicaid agencies enforce these standards, and state laws governing consumer protection in IMDs.

For more information, contact: 

  • Kathryn Ceja, Director of Communications, Medicaid and Children’s Health Insurance Program Payment and Access Commission, 1800 M Street Northwest, Suite 650 South, Washington, District of Columbia 20036; 202-350-2000; Fax: 202-273-2452; Email: Kathryn.Ceja@macpac.gov; Website: https://www.macpac.gov/

On March 31, 2020, federal approval expired for the New York Medicaid Delivery System Reform Incentive Payment Program (DSRIP). The New York Department of Health (DOH) had asked the Centers for Medicare & Medicaid Services (CMS) to extend the DSRIP in two phases. The first phase would have extended the waiver through March 2021 and allowed the state to use $625 million in unspent funds from its original $7.4 billion program. The second phase, stretching into March 2024, sought $8 billion more in federal funding to continue the DSRIP. However, on February 21, 2020, CMS notified the New York Department of Health (DOH) that it would consider the first phase proposals but would not consider extending DSRIP.

CMS had approved the state’s waiver for the DSRIP on April 14, 2014. Under the current DSRIP waiver, Performing Provider Systems (PPS), regional networks of provider organizations, work in partnerships to collaborate in a regional project plan focused on improving health outcomes while reducing avoidable hospital readmissions. The projects included expanding medication assisted treatment into primary care and emergency room settings, targeting seriously mentally ill populations for enhanced supports, and addressing housing and other social determinants of health. Without the extension, the PPSs must decide whether they will continue to operate without federal support.

In its denial letter dated February 21, 2020, CMS noted that the initial DSRIP award in 2014 was intended to be a time-limited one-time investment in system transformation that could be sustained through ongoing reimbursement mechanisms and/or state and local initiatives. CMS said it intended to maintain that agreement and preserve the original expiration of the DSRIP expenditure authority. Further, the letter noted that if CMS were to approve an extension, it would be rebased consistent with new CMS policy. The rebasing would mean that the state basis would be limited to just five years of its current budget neutrality savings. As a result, CMS believes its staff would not be able to adequately assess New York’s proposal for the second phase. CMS said it was continuing to review the phase one proposal in light of the federal goal of increasing value-based care (VBC) in the Medicaid program. The state’s VBC efforts will continue beyond the planned expiration of the DSRIP program. Those plans were released in January 2020 as “New York State Roadmap For Medicaid Payment Reform, A Path Toward Value Based Payment: Annual Update June 2019: Year 5.”

The state’s Medicaid program serves more than 6 million beneficiaries. It contracts with more than 50 fully and partially capitated managed care plans. Eligible services include inpatient hospital care, outpatient hospital services, clinics, nursing homes, managed care, prescription drugs, home care and services provided in a variety of community-based settings (including mental health, addiction treatment, developmental disabilities services, school-based services, and foster care services). The proposed 2021 budget included $76.7 billion for the Medicaid program.

On March 19, 2020, the New York Medicaid Redesign Team II (MRT II) approved reforms to reduce the state’s Medicaid spending by $2.5 billion annually. The recommendations were sent to the governor and legislature for consideration in the state budget. Governor Andrew Cuomo had formed the MRT II on February 4, 2020 to develop proposals to restore financial sustainability to the Medicaid program while connecting other program initiatives that would advance core health care strategies.

On April 3, 2020, Governor Cuomo signed the state’s $177 billion fiscal year 2021 budget. It includes Medicaid changes recommended by MRT II to help close a $6 billion budget gap, but includes language to delay any provisions that might make the state ineligible for $6.7 billion in short-term federal aid to enhance Medicaid payments as part of the federal response to the COVID-19 public health emergency. On March 29, Governor Cuomo said he intended to refuse the short-term federal aid because the maintenance of effort requirements would prevent implementing the MRT II Medicaid redesign proposals, one of which would shift Medicaid costs from the state to localities.

For more information, contact:

  • Jonah Bruno, Director of Communications, New York State Department of Health, Empire State Plaza, Corning Tower, Albany, New York 12237; Email: dohweb@health.ny.gov; Website: https://www.health.ny.gov/health_care/medicaid/redesign/mrt2/.

On April 8, 2020, the Centers for Disease Control and Prevention (CDC) issued interim workplace safety practices for critical infrastructure workers with potential exposure to a person with suspected or confirmed COVID-19. Critical infrastructure workers include those working in the following sectors:

  • Federal, state, and local law enforcement
  • 911 call center employees
  • Fusion Center employees (Fusion centers are state-owned and operated centers that organize localized domestic intelligence gathering of threat-related information. The centers receive, analyze, gather, and share data between the Department of Homeland Security; federal intelligence, law enforcement at the federal, state, local, tribal and territorial levels; and private sector partners.)
  • Hazardous material responders from government and the private sector
  • Janitorial staff and other custodial staff
  • Workers, including contracted vendors, in food and agriculture, critical manufacturing, informational technology, transportation, energy, and government facilities

This guidance does not pertain to health care, first responder, or correctional facility workers for which the CDC had already issued guidelines. The federal Occupational Safety and Health Administration (OSHA) requires employers of workers in the health care industry, emergency response organizations (e.g., emergency medical, firefighting, and law enforcement services), and correctional institutions to make work-relatedness determinations for cases of COVID-19. Employers outside these industries in areas where there is ongoing community transmission of COVID-19 will not be required to make work-relatedness determinations.

The CDC defined a potential exposure as being a household contact or having been in close contact (within six feet) of an individual with confirmed or suspected COVID-19 up to 48-hours before the individual started showing symptoms. Workers who have been exposed but are not showing symptoms can work, but should have their temperatures monitored before starting their shifts, and the worker should wear a face mask. Workers who become symptomatic during the day should be sent home immediately. The work site should compile information on other workers in close contact with an exposed worker being monitored. In the case that a worker becomes sick, other workers who had close contact with that worker should be considered exposed.

In workplaces where critical infrastructure workers were exposed to COVID-19 but remain asymptomatic, the employer and worker should adhere to the following practices prior to and during their work shift:

  • Pre-screen: Employers should measure the worker’s temperature and assess symptoms prior to them starting work. Ideally, temperature checks should happen before the individual enters the facility.
  • Regular monitoring: As long as the worker is asymptomatic (no temperature or symptoms), the worker should self-monitor under the supervision of the employer’s occupational health program.
  • Wear a mask: The worker should wear a face mask at all times while in the workplace for 14 days after last exposure. Employers can issue face masks or can approve worker’s supplied cloth face coverings in the event of shortages.
  • Social distance: The worker should maintain a six-foot distance from others (social distancing) as work duties permit in the workplace.
  • Disinfect and clean work spaces: The employer should ensure that shared common areas (offices, bathrooms, break rooms) and electronic equipment are cleaned and disinfected regularly.

Generally under OSHA’s recordkeeping requirements, COVID-19 is a recordable illness, and employers are responsible for recording cases of COVID-19 if the case is confirmed, and the case is work-related. However, in a guidance memo issued on April 10, 2020, OSHA advised that in areas where there is ongoing community transmission of COVID-19, it will not require other employers (other than health care, emergency response, and corrections) to make the same work-relatedness determinations unless there is objective evidence that a COVID-19 case may be work-related. This evidence could include a cluster of COVID-19 cases without an alternate explanation that develop among workers in close proximity or who share common areas, or could include information given to the employer by employees or in the ordinary course of managing its business and employees. This loosening is because employers, other than those in health care, emergency response, and corrections may have difficulties determining whether a worker contracted COVID-19 at work. This guidance is limited to the current public health crisis.

For more information, contact:

  • Division of Public Affairs, Centers for Disease Control & Prevention, 1600 Clifton Road, Atlanta, Georgia 30329-4027; 404-639-3286; Fax: 404-639-7394; Email: media@cdc.gov; Website: https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/businesses-employers.html
  • Elizabeth Grossman, Director of the Office of Statistical Analysis, Occupational Safety and Health Administration, Department of Labor, 200 Constitution Avenue Northwest, Washington, District of Columbia 20210; 202-693-2225; Website: https://www.osha.gov/SLTC/covid-19/

On April 3, 2020, California launched Project Roomkey, an initiative to use hotel and motel rooms to isolate homeless individuals deemed extremely vulnerable to COVID-19 in an effort to limit the spread of the disease. Additionally, the state has also contracted with Chef José Andrés’s World Central Kitchen to provide three meals a day to select Project Roomkey hotels through a statewide contract to support local efforts as needed. The goals of Project Roomkey are to protect public health by isolating the medically vulnerable, reducing the shelter population for social distancing, slowing the rate of spread of COVID-19 and, in turn, flattening the curve.

The state secured approval from the Federal Emergency Management Agency (FEMA) for a 75% federal cost share for the rooms, and wraparound supports such as meals, security, and custodial services. Counties will pay the remaining 25% of the cost, as well as cover the cost of case managers and counselors. The state has distributed $150 million to counties to help pay for the rooms and other homelessness services.

Project Roomkey isolation units are intended for the following populations experiencing homelessness:

  • Individuals who are asymptomatic, but at high risk, such as people over 65 or who have certain underlying health conditions. The goal is to move them into motel or hotel units where they can more safely self-isolate and avoid exposure to COVID-19.
  • Individuals who have been exposed to COVID-19 or are COVID-19 positive (as documented by a state or local public health official, or medical health professional) who do not require hospitalization, but need isolation or quarantine to avoid further spread of COVID-19 in congregate shelter settings or homeless encampments.

The initiative targets hotels in counties with significant homeless populations that are also experiencing high concentrations of COVID-19 transmission. The state seeks to secure up to 15,000 rooms for this purpose. Some of the leases being negotiated include an option for the state or county to purchase the entire hotel/motel property to provide for permanent homeless housing. However, no information has been released about the status of these negotiations.

Local governments to date have secured 6,867 hotel and motel rooms for Project Roomkey. However, state and local health officials have not released a comprehensive list of participating hotels/motels. The local governments are responsible for identifying which shelter clients or encampment residents are selected for these hotel isolation placements and transporting them to the hotels for intake. The counties can contract with a provider organization to manage the isolation placements. As of early April, counties had moved 869 homeless individuals off the street and/or out of shelters into isolation. Essential behavioral health and health care services are being provided by the local governments and community partners, as needed.

For more information, contact: 

  • California Governor Gavin Newsom, 1303 10th Street, Suite 1173, Sacramento, California 95814; 916-445-2841; Fax: 916-558-3160; Website: https://govapps.gov.ca.gov/gov40mail/

The President’s 2021 budget proposal for the Department of Health and Human Services (HHS) includes five provisions intended to expand behavioral health services. However, overall, the HHS budget request of $94.5 billion is about 10% lower than the 2020 enacted level of funding. The HHS budget proposes $1.6 trillion in net mandatory health savings and reducing longer-term deficits by eliminating wasteful spending.

The federal budget proposal was released on February 10, 2020, as “A Budget For America’s Future, Fiscal Year 2021.” A fact sheet about the budget highlighted the following provisions affecting behavioral health:

  • Combat the opioid epidemic. The budget allocates $5 billion to fund research, surveillance, prevention, treatment, access to overdose reversal drugs, and recovery support services. This funding includes $1.6 billion, an $85 million increase from the 2020 enacted level, for State Opioid Response grants, which support prevention, treatment, and recovery support services. States are also given flexibility to use these funds to address emerging drug issues, such as the increasing number of overdoses related to psychostimulants, including methamphetamines.
  • Fund Certified Community Behavioral Health Clinics (CCBHC) expansion grants. The budget includes $225 million for the CCBHC expansion grants and extends, through 2021, the CCBHC Medicaid demonstration programs to improve community mental health services for the eight states currently in the demonstration.
  • Fund mental health prevention and screening. The budget allocates $125 million to help schools, community organizations, first responders, and other entities identify mental health issues and help affected youth and other individuals get the needed treatment.
  • Fund primary health care services for homeless individuals. The budget allocates $25 million to expand primary care services for homeless individuals in cities with high rates of homelessness.
  • Modify the Medicaid funding exclusion on Institutions of Mental Disease (IMDs) to allow states flexibility to use IMDs to provide inpatient mental health services to Medicaid beneficiaries with serious mental illness (SMI) as part of a comprehensive strategy that includes improvements to community-based treatment. In 2018, 47.6 million adults had a mental illness, of whom 11.3 million had SMI, meaning their mental illness substantially interfered with or limited major life activities.

The fact sheet and a summary of the major savings and reforms called out additional proposals affecting the health and social service field. They address Medicare, Medicaid, rural health access, public health, and child welfare.

Medicare

  • Eliminate wasteful Medicare spending, and incentivize quality and efficiency. The budget proposes to align payments for the four main post-acute care settings (skilled nursing facilities; home health provider organizations; inpatient rehabilitation facilities; and long-term care hospitals) and transition to site-neutral payments over five years (with certain exceptions for long-term care hospitals). Currently each setting uses a different prospective payment system. It revives a proposal to pay physicians the same fee whether services are provided by a hospital outpatient facility or a private practice.
  • Reform uncompensated care payments by removing the payment from the Medicare payment system, moderating the rate of growth of spending, and establishing a new process to distribute uncompensated care amounts to hospitals based on their share of charity care and non-Medicare bad debt.
  • Implement bipartisan drug pricing proposals. The budget supports legislative efforts to improve the Medicare Part D benefit by establishing an out-of-pocket maximum, improving incentives to contain costs, and reducing out-of-pocket expenses for seniors. It also calls on Congress to pass legislation to reduce the prices paid for prescription drugs. The administration also supports changes to Medicare Part D to reduce the cost of generic and biosimilar drugs. The budget proposal calls for spending $130 billion less for Medicare prescription drugs.
  • Allow people age 65 or older to opt out of Medicare entirely. Additionally, Medicare beneficiaries enrolled in a high-deductible health plan would be allowed to accumulate more tax-free savings for health expenses.

Medicaid

  • Improve consistency between work requirements in federally funded public assistance programs, such as Medicaid and Temporary Assistance for Needy Families (TANF). All able-bodied, working-age individuals, aged 18 to 65 years old and with or without children in the home, would be required to find employment or participate in individualized work activities for a minimum of 20 hours per week, in order to receive welfare and Medicaid benefits, unless they fall into an exempt category or have an individual or geographic hardship.
  • Create a permanent Money Follows the Person option, giving states flexibility to provide additional transitional services to promote care in the community. States with high rates of institutionalization would receive time-limited enhanced funding to support necessary structural changes.
  • Allow states to consider savings and other assets in determining Medicaid eligibility. The goal is to focus Medicaid spending on individuals who lack significant assets.

Rural health

  • Expand access to telemedicine services by offering increased flexibility to provider organizations who serve predominantly rural or vulnerable populations, including Indian Health Service (IHS) provider organizations and those participating in Medicare payment models requiring financial risk.
  • Modify payments to Rural Health Clinics to ensure that Medicare beneficiaries continue to benefit from primary care services in their communities.
  • To address the trend of rural hospital closures, the budget proposes to allow critical access hospitals to voluntarily convert to rural standalone emergency hospitals and remove the requirement to maintain inpatient beds.
  • Maintain funding for Rural Health Outreach grants in the Health Resources Services and Administration (HRSA).

Public health

  • Fund the initiative to end the HIV epidemic. The budget allocates $716 million for the initiative’s second year. The avocation includes $371 million for the Centers for Disease Control (CDC) and $302 million for Health Resources and Services Administration (HRSA) to deliver HIV care through the Ryan White HIV/AIDS Program and to supply testing, evaluation, prescription of PrEP, and associated medical costs through the Health Centers program; $27 million to the Indian Health Service (IHS) to tackle the epidemic in American Indian and Alaska Native communities; and $16 million for the National Institutes of Health (NIH) for evaluation activities to identify effective interventions to treat and prevent HIV.
  • Fund initiatives to improve maternal health. The budget allocates $74 million in new resources to reach the following goals: achieve healthy outcomes for women of reproductive age by improving prevention and treatment; prioritizing quality improvement for prenatal care and birth services; optimize postpartum health; and improve data and support research.

Other social services

  • Reduce the TANF block grant by 10%, and eliminate the TANF Contingency Fund, as it fails to provide well-targeted counter-cyclical funding to states. Add a requirement that states spent at least 30% of all TANF funds on activities that directly promote work. All TANF spending would be limited to families with income below 200% of the federal poverty line (FPL). All work-eligible individuals receiving TANF cash assistance would be expected to participate in individualized work activities a minimum of 20 hours per week, unless they fall into an exempt category or have individual or geographic hardship. New proposals require that TANF expenditures be directly related to achieving TANF’s purposes and by phasing out the ability for states to use TANF funds for, “activities authorized solely under prior law,” an outdated expenditure category; states would be accountable for achieving employment outcomes to incentivize cooperation and service integration between TANF and programs through the Workforce Innovation and Opportunity Act to promote work. All states
  • Eliminate funding for the Social Services Block Grant (SSBG). The budget notes that the administration believes that the SSBG lacks strong performance measures, is not well targeted, and is not a core function of the federal government. It funds services that are also funded through other federal programs, such as early childhood education.

For more information, contact:

  • The White House, 1600 Pennsylvania Avenue Northwest, Washington, District of Columbia 20500; 202-456-1414; Website: https://www.whitehouse.gov/

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.

On January 28, 2020, Michigan enacted Public Act 12 of 2020 (formerly House Bill 4051), which calls for creation of a statewide mental health hotline – the Michigan Crisis and Access Line (MCAL) – effective April 26, 2020. The law codifies a requirement in Michigan’s Mental Health Code for the Michigan Department of Health and Human Services (MDHHS) to contract with a vendor to develop and operate the hotline. The hotline will be available for anyone in the state in need of immediate mental health or addiction services. The hotline is to be staffed 24 hours a day, seven days a week. Information about a potential request for proposals (RFP) related to the hotline is not yet available.

Hotline operators are to refer and connect callers with local care providers and resources, including up-to-date availability of psychiatric and substance abuse services offered to the community. The hotline is to uphold caller privacy and information security practices; however, the hotline may collect general information for evaluation and quality management purposes, track the hotline’s success, and to identify trends in service needs and outcomes. MDHHS is to develop a “relationship management database infrastructure” to track, monitor, assign, follow up, and report on access line operations. This consumer relationship management database infrastructure must provide appropriate community and provider access.

Information about mental health professionals providing mental health services, and providers of substance use disorder treatment and rehabilitation services, will be obtained from the Department of Licensing and Regulatory Affairs internal state databases, and other publicly available resources such as the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Services Locator). MDHHS is to have operational oversight for the hotline, including access to and utilization of, the relationship management infrastructure. MDHHS’ contracted prepaid inpatient health plans and community mental health services programs will also utilize the consumer relationship management database infrastructure to optimize hotline operations and to facilitate more efficient programmatic compliance and communication with MDHHS (e.g., service inventory profiles, consumer service issues, certification/credentialing requirements, service applications).

A link to the full text of “Michigan House Bill 4051 Of 2020” (now known as “Michigan PA 12 of 2020”) may be found at www.openminds.com/market-intelligence/resources/012820mihb4051mhhotline.htm.

For more information, contact:

  • Bob Wheaton, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4974; Email: WheatonB@michigan.gov; Website: https://www.michigan.gov/

The federal Department of Justice (DOJ) concluded Maine’s system of services for people with intellectual/developmental disability (I/DD) violates the Americans with Disabilities Act (ADA) because it limits access to home- and community-based services (HCBS) under its Section 21 waiver. On February 10, 2020, the DOJ responded to a complaint filed in May 2018 by a Maine resident with I/DD. The DOJ concluded that Maine failed to provide necessary services in the most integrated setting appropriate to the individual’s needs. The Maine Department of Health and Human Services (DHHS) is determining how to respond.

The DOJ advised DHHS to promptly remedy the situation and prevent ADA civil right violations of people receiving Section 21 services by taking the following steps:

  1. Modify the Section 21 waiver’s 84-hour cap on Home Care Quarter Hour services by establishing and implementing a process for individuals to obtain an exception to the cap, such that individuals can receive Section 21 waiver services in the most integrated setting appropriate to their needs unless the provision of such services would constitute a fundamental alteration.
  2. Modify the Section 21 waiver’s service planning process to ensure that the services a member receives, and the setting(s) in which they are received, are determined by the member’s individual needs and preferences, rather than by provider organization preference.
  3. Inform individuals currently receiving, or who may be eligible to receive, Section 21 waiver services, including individuals currently receiving services in agency placements, those receiving Quarter Hour services, and those receiving Medicaid services in intermediate care facilities (ICFs) who may be eligible for Section 21 waiver services, about the exceptions process and providing personal planning that is sufficiently focused on the member’s individual needs and preferences.
  4. Inform state employees, agents, and contractors, including case managers, as well as others, including provider organizations, who serve on personal planning teams, and employees implementing the exceptions process, about the modifications implemented, including the exceptions process, how to apply for an exception under the process, and how the exceptions and personal planning processes should operate to ensure that individuals can receive services in the most integrated setting appropriate to their needs.
  5. Ensure that the state has sufficient provider capacity to fulfill the individual’s authorized Section 21 waiver service hours.
  6. Pay compensatory damages to the individual for injuries caused by the state’s actions.
  7. Provide the DOJ with written status reports delineating all steps taken to comply with these requirements, including the date(s) on which each step was taken, and, where applicable, information sufficient to demonstrate compliance.

Maine’s Medicaid Section 21 waiver provides comprehensive services for people with I/DD and autism who live in their own homes or in another home in the community, but not necessarily with their families. The available services include assistive communication assessment/technology, career planning, community support, counseling, crisis assessment and intervention services, employment specialist services, home accessibility upgrades, in-home support, medical equipment and supplies, therapy (occupational, physical, or speech), residential services, respite, shared living services, transportation, and work support.

The individual at the center of the DOJ complaint is an adult with several disabilities who lives with his parents. Since 2009 he has received Section 21 waiver home support services, which include personal assistance with activities of daily living and instrumental activities of daily living. In 2014, the state capped the individual’s service hours at 84 per week, citing the state’s cap on services Section 21 waiver recipients can receive while living in their own (or family) homes. The family challenged the denial. The state contested the challenge but acknowledged that the individual needed 168 hours of services per week. The DOJ noted that the state’s failure to provide needed in-home services resulted from the state’s service planning process, which determined his placement/services based on provider organization preference, rather than identifying the most integrated setting appropriate.

In February 2017, the administrative challenge was concluded, and the state cut the individual’s service hours to 84 per week. However, in March 2019, the state granted an exception to the cap during the DOJ investigation. The exception permitted the individual to receive 168 hours per week of home support services in his home; however, the 84-hour cap otherwise remained in force. Further the state failed to ensure that the licensed service provider organization actually fulfills the authorized hours, and the state failed to identify additional provider organizations to fill the gaps. Despite the exception, the individual continues to receive about 84 hours per week of in-home services.

As a result, the individual is at risk of being institutionalized to receive the needed services. The only alternative placements he has been offered are an ICF or a in a multi-person group home. An ICF is considered an institutional setting. If the individual lived in an ICF or a group home, he would not have access to the community at the same level as living at home with adequate services.

A link to the full text of “The United States’ Findings & Conclusions Based On Its Investigation Of The State Of Maine Under Title II Of The Americans With Disabilities Act” may be found at www.openminds.com/market-intelligence/resources/021020dojadaltrmaineiddhcbs.htm.

For more information, contact:

  • Jackie Farwell, Communications Director, Maine Department of Health and Human Services, 109 Capitol Street, 11 State House Station, Augusta, Maine 04333; 207-446-3319; Email: Jackie.Farwell@Maine.gov; Website: https://www.maine.gov/dhhs/.

Primary care physician (PCP) practices reporting on electronic clinical quality measures (eCQM) for an evidence-based cardiovascular care approach took a median of 8.2 months to submit data. The practices participated in EvidenceNOW Southwest, which provided nine months of coaching to improve the ABCS of heart health (Aspirin, Blood pressure control, Cholesterol management, and Smoking cessation). Practices also received support for ABCS eCQM reporting from an electronic health record, a registry, or a third-party platform.

Key findings were as follows:

  • The time needed to report differed by eCQM. Blood pressure was reported the fastest at a median of 7.8 months. Cholesterol management was reported the slowest at 10.5 months.
  • Practice characteristics were linked to how quickly the practice reported the blood pressure eCQM and the cholesterol eCQM.
  • For the blood pressure eCQM, those participating in an accountable care organization (hazard ratio 1.88) or quality demonstration programs (hazard ratio 1.58) were more able to report on the measure. Hospital-owned practices were more able to report on the measure than Federally Qualified Health Centers (hazard ratio 2.66).
  • For the cholesterol eCQM, those practices that used clinical guidelines for cardiovascular disease management reported 1.35 time more quickly. Practices owned by a clinical professional reported cholesterol eCQMs 0.52 times more slowly than Federally Qualified Health Centers.

These findings were reported in “Primary Care Practices’ Ability to Report Electronic Clinical Quality Measures in the EvidenceNOW Southwest Initiative to Improve Heart Health” by Kyle E. Knierim, M.D.; Tristen L. Hall, MPH; L. Miriam Dickinson, Ph.D.; et al. The researchers analyzed quality reporting by 211 PCPs in Colorado and New Mexico participating in EvidenceNOW Southwest between February 2015 and December 2017. The practices also received nine months of support from a practice facilitator, a clinical health information technology advisor, and the research team. The PCPs were instructed to report their baseline ABCS eCQMs as soon as possible. The researchers analyzed the association between practice characteristics and reporting speed. About 48% of the practices were owned by clinical professionals. About 71% were located in an urban or suburban area.

The full text of “Primary Care Practices’ Ability to Report Electronic Clinical Quality Measures in the EvidenceNOW Southwest Initiative to Improve Heart Health” was published on August 7, 2019, by JAMA Network Open. An abstract is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2747476.

For more information, contact:

Kyle Knierim, M.D., Assistant Professor, Department of Family Medicine, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, Colorado 80045; 720-848-9000; Email: kyle.knierim@cuanschutz.edu; Website: www.linkedin.com/in/kyle-knierim.

Community reentry following incarceration is more likely to be successful if the reentry interventions address dynamic factors that affect the overall success of reentries, according to a study by The Harvard University Institute of Politics. These dynamic factors include health, employment, housing, skill development, mentorship, and social networks.

Health

Community-based organizations should prioritize providing reentering citizens with quality health care that properly addresses any mental and physical health conditions and addiction. This is especially important for female reentering citizens, who often have greater health-related needs than the general reentering population. The researchers recommend that organizations should specifically target services to women, especially in the form of trauma and counseling services.

Employment

Community-based programs are most effective when they provide training and placement services to returning citizens, using a holistic approach focused on both training and job placement. The success of these services also depends largely on the job opportunities available in the neighborhoods into which their clients are reentering. The researchers recommend that community organizations should partner with prisons to better advise incarcerated individuals on which neighborhoods to return to.

Housing

Community-based organizations that offer transitional housing, with the end goal of eventually securing an independent living situation, are effective at improving outcomes. Those programs that also provide housing in combination with other services (such as employment services, health services, and socio-emotional development) are also successful at improving outcomes. The researchers recommend that organizations and programs focus on communities with the highest risk of homelessness, namely women, Black and Hispanic individuals, and the elderly. For women, additional concern may be needed when children are involved in the reentry.

Skill Development

Assistance with both education and interpersonal skills (such as anger management, time
management, goal setting, and parenting) should be provided to those reentering the community. For education, the researchers recommend that community-based organizations should provide a variety of educational programs (such as employment training programs, college enrollment assistance and referrals, GED preparation, testing referrals, and vocational training), and these programs should be tailored to the unique education needs of different age demographics. For interpersonal skills, programs should target the skills listed above, target antisocial peer relationships, and offer appropriate cognitive behavioral programs.

Mentorship

The researchers recommend that community-based organizations that offer reentry services should also prioritize mentorship programs which match reentering citizens with mentors who share similar backgrounds. These matches could be based on gender, racial and ethnic identities, and age-related priorities.

Social Networks

The researchers also recommend programs that emphasize the role of family connection and cohesiveness, especially for young reentering individuals. Reentry programs should specifically address such needs through services that support building stronger familial ties and provide therapy, mentorship, life skills training, domestic violence education, and safe homes. They also recommend that programs subsidize or cover travel and communication costs to connect with family members when necessary.

These recommendations were presented in “Successful Reentry: A Community-Level Analysis” by researchers affiliated with the Harvard University Institute of Politics Criminal Justice Policy Group. The report focuses on how various factors significantly affect successful reentry and how existing community-based organizations tailor interventions to address those factors. The report also provides recommendations for the best practices community-based reentry programs can follow. The researchers analyzed a number of reentry case studies, social theory papers, and programs across the United States. The goal was to determine the ideal circumstances for successful outcomes for those exiting jails and prisons, and acclimating to community life.

The full text of “Successful Reentry: A Community-Level Analysis” was published in December 2019 by The Harvard University Institute of Politics’ Criminal Justice Policy Group. A copy is available online at https://iop.harvard.edu/sites/default/files/sources/program/IOP_Policy_Program_2019_Reentry_Policy.pdf.

For more information, contact: 

  • Institute of Politics, Harvard University, 79 John F. Kennedy Street, Cambridge, Massachusetts 02138; 617-495-1360; Fax: 617-496-4344; Email: ioppolicy@gmail.com; Website: https://iop.harvard.edu/

New clinical guidelines for treating attention deficit/hyperactivity disorder (ADHD) recommend psychosocial supports, in addition to medication, as essential treatment for children and adolescents with ADHD. Treatment for children with complex ADHD should focus beyond improving ADHD symptoms to improving functional outcomes in behavior, social interactions, and academics. Psychosocial interventions to improve function may include classroom-based management tools like positive reinforcement tools, a daily report card, posted expectations and consequences, parent education, organizational skills training, approaches to improve appropriate peer interactions, and school services, such as 504 plans and special education individualized education plans (IEPs).

Complex ADHD is defined as diagnosis under age 4 or over age 12, the presence of co-morbid conditions, moderate to severe functional impairments, diagnostic uncertainty, or inadequate response to treatment. ADHD and co-morbid conditions may affect children’s function across multiple settings, such as home, school, with peers, and in the community. A child with ADHD is at-risk for adverse health and psychosocial outcomes in adulthood.

To better serve children and adolescents with ADHD and complex ADHD, the guidelines recommend the following five approaches:

  1. Children under 19 with suspected or diagnosed complex ADHD should receive a comprehensive assessment by a clinical professional with specialized training or expertise, who should develop a multi-faceted treatment plan. The plan should be designed to diagnose and treat ADHD and other coexisting disorders, as well as complicating factors including other neurodevelopmental disorders, learning disorders, mental health disorders, genetic disorders, and psychosocial factors like trauma and poverty.
  2. The evaluation should verify previous diagnoses and assess for other conditions by including a psychological assessment based on a child’s functional disabilities, and intellectual and developmental level.
  3. All children with complex ADHD should receive behavioral and educational interventions addressing behavioral, educational, and social success.
  4. Treatment of complex ADHD should also include coexisting conditions, such as autism spectrum disorder or addiction, and focus on areas of impairment, rather than just reducing symptoms.
  5. Monitoring and treatment of complex ADHD should continue throughout life.

The recommendations were issued in “Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder” by William J. Barbaresi, M.D., and a panel of colleagues affiliated with the Society for Developmental and Behavioral Pediatrics. The panel developed the guidelines over three years; they conducted a literature review of research related to each action statement and approach. The goal was to facilitate integrated, interprofessional assessment and treatment of children and adolescents with complex ADHD.

The guidelines include summary diagnostic and treatment flowcharts for the following:

  • Behavioral/education treatment for children 6 years and older;
  • Medication treatment for children 6 years and older;
  • Treatment of ADHD plus a coexisting disorder including autism spectrum disorder, tics, addiction, anxiety, depression, or disruptive behavior disorders; and
  • Preschool general medication treatment for children age 3 up to 6 years.

The full text of “Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder” was published in the February/March 2020 issue of Journal of Developmental & Behavioral Pediatrics. An abstract is available online at https://journals.lww.com/jrnldbp/Citation/2020/03001/Society_for_Developmental_and_Behavioral.3.aspx.

For more information, contact:

  • William Barbaresi, M.D., Physician, Division of Developmental Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Fegan, 10thFloor, Boston, Massachusetts 02115; 617-355-7025; Email: william.barbaresi@childrens.harvard.edu; Website: http://www.childrenshospital.org/directory/physicians/b/william-barbaresi.

In 2016, suicide accounted for 30.7% of all deaths in local jails (333 of 1,071 deaths), and 6.2% of all deaths in state and federal jails (255 of 4,117 deaths). Between 2015 and 2016, the trend in overall deaths and suicide deaths differed by incarceration setting. Overall jail deaths declined as did suicide deaths. State prison deaths rose as did suicide deaths. Federal prison deaths declined while suicide deaths remained static.

Additional findings about the trends between 2015 and 2016 were as follows for each setting:

  • Overall, jail deaths due to any cause declined by 1.9% between 2015 and 2016. Jail deaths due to suicide decreased 10% from 2015 to 2016; the suicide rate declined from 52 to 46 deaths per 100,000 jail inmates.
  • State prison deaths due to any cause rose by 1.3%, from 3,682 in 2015 to 3,729 in 2016. State prison deaths due to suicide rose by 16.7% from 2015 to 2016, the rate rose from 18 to 21 deaths per 100,000 state prison inmates.
  • Federal prison deaths due to any cause declined by 15%, from 455 deaths in 2015 to 388 in 2016. Federal prison deaths due to suicide remained the same at 12 deaths per 100,00 federal inmates in 2015 and 2016.

Long-term trends by setting also varied, as follows:

  • Jails: From 2000 through 2016, there were 5,207 jail suicide deaths out of a total of 16,962 deaths, for a long-term suicide rate of 31%. The overall jail mortality rate remained similar from 2000 to 2016, with 151 deaths per 100,000 jail inmates in 2000 to 149 deaths per 100,000 in 2016. From 2000 through 2016, jail suicide rates ranged from a low of 25.4% of total deaths in 2002 to a high of 35.0% in 2011. Jail inmate suicides in general housing units accounted for 46.7% of all inmate suicides from 2000 to 2016.
  • State prisons: From 2001 through 2016, there were 3,300 suicide deaths in state prisons out of a total 53,051 deaths, for a long-term suicide rate of 6.2%. State prison suicide rates between 2001 and 2016 ranged from a low of 5.5 % of total deaths in 2011 and 2013 to a high of 7.1% in 2014.
  • Federal prisons: During the same period, in federal prisons, there were 260 suicide deaths out of a total 5,985 deaths, for a long-term suicide rate of 4.3%. Federal prison suicide rates between 2001 and 2016 ranged from a low of 6 per 100,000 inmates in 2010 to a high of 14 per 100,000 inmates in 2014.

The jail findings were reported in “Mortality in Local Jails, 2000-2016 – Statistical Tables” by E. Ann Carson, Ph.D., a statistician with the Bureau of Justice Statistics (BJS) and Mary P. Cowhig, a former BJS statistician. The state and federal prison findings were reported in “Mortality in State and Federal Prisons, 2001-2016 – Statistical Tables” by Dr. Carson and Ms. Cowhig. The researchers analyzed local jail, state prison, and federal prison data from the BJS Mortality in Correctional Institutions data collection from 2000 through 2016. The goal was to report data regarding mortality in local jails, as well as in state and federal prisons.

A link to the full text of “Mortality in Local Jails, 2000-2016 – Statistical Tables” may be found at www.openminds.com/market-intelligence/resources/021520bjsjailmortality.htm.

A link to the full text of “Mortality in State and Federal Prisons, 2001-2016 – Statistical Tables” may be found at www.openminds.com/market-intelligence/resources/021520bjsprisonmortality.htm.

For more information, contact:

  • Tannyr Denby Watkins, Public Affairs Specialist, Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice, 810 Seventh Street Northwest, Washington, District of Columbia 20531; Email: tannyr.m.watkins@usdoj.gov; Website: https://www.ojp.gov/

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.

In 2018, about 46% of hospitals reported engaging in all four domains of interoperability (sending, receiving, querying and integrating data from external sources). The percentage of hospitals nationally engaging in each of these four domains varied as shown below:

  1. About 89% reported sending data electronically.
  2. About 78% reported receiving data electronically.
  3. About 65% reported electronically querying to find data.
  4. About 62% reported the ability to integrate care records from sources outside their health system.

Approximately 76% of hospitals reported using more than one electronic method to send health information, while 63% reported using more than one electronic method to receive health information. On average, hospitals used 3.3 electronic methods to send information, and 2.6 electronic methods to receive information. About 46% of hospitals used state, regional, or local health information exchange organizations (HIOs) to electronically find or query consumer health information from sources outside their health system; 38% used interface connections between electronic health records (EHR); and 34% used their EHR vendor’s network.

The most frequently reported barrier to electronic exchange was difficulty exchanging data across different EHR vendor platforms. Although 62% of hospitals used electronic patient health information received from outside sources, the top reasons for not using this information (as reported by the approximately 38% of hospitals that “seldom” or “never” used this information included:

  • Information was not always available when needed (e.g., not timely): 52%
  • Information was available but not integrated into the EHR: 50%
  • Information was not presented in a useful format (e.g., too much information, redundant, or unnecessary information): 34%

These statistics were presented in “State of Interoperability among U.S. Non-federal Acute Care Hospitals in 2018,” by Yuriy Pylypchuk, Ph.D.; Christian Johnson, MPH; and Vashali Patel, Ph.D., MPH. The researchers analyzed data from the American Hospital Association (AHA) Information Technology Supplement to the AHA Annual Survey for 2018. Sixty-four percent of all non-federal acute care hospitals responded to the survey. The total number of hospitals used in the analysis was not reported by the authors. The goal was to report the extent to which hospitals engage in interoperability, the methods they use to exchange patient health information and the top barriers to interoperability.

For more information, contact:

  • Peter Ashkenaz, Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, 330 C Street Southwest, Floor 7, Washington, District of Columbia 20201; 202-690-7151; Fax: 202-690-6079; Email: onc.request@hhs.gov; Website: https://www.healthit.gov/

The city of Rockford, Illinois is on track to end homelessness by the end of 2020 through its participation in the “Built for Zero” initiative, by Community Solutions. In 2010, the city had more than 700 homeless people. In 2018, Rockford reached “Functional Zero” in unsheltered homelessness for more than 100 homeless veterans, and for people with disabilities and chronic homelessness. “Functional Zero” is reached when the number of homeless individuals is no greater than the monthly housing placement rate for these individuals. The city now seeks to end homelessness for all remaining populations, including families, youth, and single adults who have been homeless for only a short time. If successful, Rockford will be the first city in the United States to effectively end homelessness completely.

Built for Zero works with over 80 communities across the U.S. to measurably end homelessness, beginning with veteran or chronic homelessness. Communities harness real-time, person-specific data to find and remove individual and systemic barriers that keep people trapped in homelessness. Cities that choose to work with the Built for Zero program receive support from an “improvement advisor” at Community Solutions. They also receive coaching from the Community Solutions data team and access to support data visualization software from the Tableau Foundation. Communities first work to build comprehensive, real-time, by-name data, unify local agencies around the shared goal of ending homelessness, and work to reduce homelessness in a single population at first. Once success is reached in one population, the city can then move to end homelessness for additional populations. To date, 82 cities are part of the Built for Zero network, which seeks to completely end homelessness. Twelve have reached “functional zero” for some segment of the homeless population, and 42 have reduced homelessness. More than 182,000 individuals have been housed nationally through the Built for Zero program.

Rockford began working with Built for Zero in 2015, when the city first concentrated on reaching Functional Zero for veteran homelessness. While the city had a housing voucher program (that covers housing expenses after a veteran pays 30% of their income towards housing), coordination between groups that serve homeless individuals, and those that serve veterans were put in place by local leaders in Rockford, with support from Built for Zero. Quality, real-time data was published monthly to create community accountability and involvement. After reaching “functional zero” homelessness for the city’s veteran population, Rockford translated the approach to address other populations.

Community Solutions is a New York City-based non-profit organization. It works with communities across the United States to create a lasting end to homelessness.

Additional information about the impact of the Built for Zero program can be found in “Getting to Proof Points: Key learning from the first three years of the Built for Zero initiative,” published in March 2018 by Community Solutions. The report can be found at https://community.solutions/wp-content/uploads/2019/10/bfz_impact_report_-_final.pdf. Current nationwide results of the program can be found at https://public.tableau.com/profile/esther4177#!/vizhome/BuiltforZeroResults-NewWebsite/BFZResults2.

For more information, contact: 

  • Built for Zero, Community Solutions, 60 Broad Street, Suite 2510A, New York, New York 10004; 646-797-4370; Email:communications@community.solutions; Website: https://www.joinbuiltforzero.org/

On February 17, 2020, the California Department of Health Care Services (DHCS) announced it had completed the reorganization of its Behavioral Health functions, that were formerly called Mental Health/Substance Use Disorder functions. The reorganization began on July 1, 2019. The goal was to better integrate behavioral health functions into the DHCS overall health care system, but still preserve the unique policy/program area of behavioral health. The reorganization furthers DHCS’ goal to improve consumer outcomes, and increase departmental efficiencies..

The divisions that previously fell under the former Mental Health and Substance Use Disorder Services, and their new categories, include:

  • Community Services (now under Behavioral Health) led by Marlies Perez.
  • Licensing and Certification (now under Behavioral Health) led by Janelle Ito-Orielle.
  • Medi-Cal Behavioral Health (now under Behavioral Health) led by Brenda Grealish.
  • Local Governmental Financing (now under Health Care Programs’ Health Care Financing) led by Rafael Davtian.

Kelly Pfeifer is the Deputy Director of the Behavioral Health division. Lindy Harrington is the Deputy Director of Health Care Financing. Both report to Chief Deputy Director for Health Care Programs and State Medicaid Director Jacey Cooper.

A link to the full text of “California Department Of Health Care Services Organization Chart As Of February 17, 2020” may be found at www.openminds.com/market-intelligence/resources/021720cadhcsreorgchart.htm.

For more information, contact:

  • Office of Public Affairs, California Department of Health Care Services, Post Office Box 997413, Sacramento, California 95899; 916-440-7660; Fax: FAX; Email: DHCSPress@dhcs.ca.gov; Website: http://www.dhcs.ca.gov/

On February 27, 2020, BlueCross BlueShield of Western New York (BCBSWNY) announced that it entered into a value-based reimbursement (VBR) arrangement with Value Network, LLC, IPA, a network of behavioral health provider organizations in Western New York. The contract includes an upside-risk agreement. Thomas Schenk, M.D., senior vice president and chief medical officer at BCBSWNY, said it is the organization’s “first payment model designed to directly enhance quality care for our members with mental health and/or substance use disorder diagnoses.”

The VBR arrangement with Value Network is based on the BCBSWNY “Best Practice” model, a consumer-centered, population-based care model that reimburses provider organizations based on the full scope of care management. The model uses a per member per month capitated payment along with some fee-for-service payments, specifically in preventive care. The capitation payments are based on historical claims and nontraditional consumer engagement methods such as telehealth. Provider organizations who serve consumers that require more complex care receive additional compensation. Value Network is eligible for bonus payments based on quality outcomes performance. A BCBSWNY spokesperson said the quality targets and metrics for the agreement are based on industry benchmarks around behavioral health care.

Value Network was formed in June 2017, and achieved state approval to become an Independent Practice Association (IPA) in January 2018. It is a collaborative of 23 provider organizations licensed through the New York State Office of Mental Health or New York State Office of Addiction Services and Supports, as well as designated home- and community-based service provider organizations. The network was founded by Howard Hitzel, chief executive officer (CEO) of BestSelf Behavioral Health; Anne Constantino, CEO of Horizon Health; Bruce Nisbet, CEO of Spectrum Health and Human Services; and Elizabeth Mauro, CEO at Endeavor Health Services.

The network has 65 other partners, including hospitals, primary care partners, prevention agencies, care coordination entities, and other organizations. Andrea J. Wanat, vice president of operations for Value Network, said the arrangement aligns with its mission to “design and implement a health service delivery system that improves the quality, cost effectiveness, and overall experience of care in Western New York.” Value Network serves about 70,000 people annually.

For more information, contact:

  • Amber M. Hartmann, Public Relations Manager, Marketing and Communications, BlueCross BlueShield of Western New York, 257 West Genesee Street, Buffalo, New York 14202; 716-887-8962; Fax: 716-887-7911; Email: Hartmann.Amber@bcbswny.com; Website: https://www.bcbswny.com/
  • Bruce Nisbet, Value Network Co-founder, and President and Chief Executive Officer, Spectrum Health and Human Services, 2040 Seneca Street, Buffalo, New York 14210; 716-539-5329; Email: nisbetb@shswny.org; Website: https://shswny.org/

About one-third of consumers have never used a ‘patient portal’ to view their medical records, despite provider organizations’ widespread adoption of the tools. According to an online survey by DrFirst, a health care technology company, individuals who did not use a health portal to access their records gave the following reasons for not using the technology:

  1. Do not know how to access information (37%)
  2. No health information portal offered by their health care professional (31%)
  3. No time to access (18%)
  4. Access process is too confusing (14%)

Additional findings suggest consumers and their families currently do not have satisfactory options for accessing and maintaining health records electronically. Among the findings:

  1. Approximately 59% of consumers say they’ve always been successful getting their requested medical records, either electronically or on paper.
  2. Approximately 19% of consumers report always being able to obtain documents in a digital format, while 81% of consumers report receiving records as a combination of paper and digital.
  3. Almost one-third of consumers who have received health records electronically print and keep a paper version rather than storing the documents on a computer or online.

DrFirst released the survey results in a press release. Respondents were online consumers pre-selected for having requested medical records from a physician or hospital, whether for themselves, or for a family member. The goal was to determine whether health care information portals and other technologies are meeting the needs of consumers.

For more information, contact:

  • Sofia Kosmetatos, Amendola Communications for DrFirst.com, Inc., Email: skosmetatos@acmarketingpr.com; Website: https://drfirst.com/press-releases/drfirst-survey-reveals-that-consumers-still-struggle-to-obtain-medical-records-electronically-despite-widespread-availability-of-online-solutions/

Due to a legal ruling issued on March 4, 2020, the Michigan Department of Health and Human Services (MDHHS) has ceased enforcing the state’s Medicaid Healthy Michigan community engagement participation and reporting requirements for the Medicaid expansion population. The requirement initially went live on January 1, 2020, and the state’s 674,000 non-disabled Medicaid beneficiaries ages 19 to 64 were required to report their work hours of at least 80 hours per month, participation in education, or participation in other approved activities. By the middle of February, MDHHS was preparing to issue warning notices to 80,000 people who failed to report or failed to report sufficient hours. About 90% of those who failed to report meeting the target in January did not report their hours at all. If they again failed to report or failed to meet the target for February and March, they were slated to lose Medicaid coverage on May 31, 2020.

However, on February 14, 2020, a federal circuit court in Washington, D.C., ruled that the federal Department of Health and Human Services (HHS) acted capriciously when it approved Medicaid waivers submitted by Arkansas and Kentucky to impose community engagement and work requirements as a condition of Medicaid eligibility. The Circuit Court upheld a District Court ruling that vacated HHS approval for the waivers.

Michigan’s requirements established in 2018 were very similar to the Arkansas and Kentucky requirements. Since taking office in 2018, Michigan Governor Gretchen Whitmer’s administration sought to repeal the community engagement requirements, but the legislature had refused. Michigan officials believed that the state’s requirements were illegal for the same reasons the district court stated. Given the federal circuit court ruling on February 14, on February 25, 2020, Governor Whitmer’s administration requested a quick court ruling in Michigan’s requirements. The ruling issued on March 4, 2020 means MDHHS cannot enforce the work requirements.

Recently released research had already indicated that about 60% of Michigan’s expansion population was working or enrolled in school during 2017, and would have met the reporting requirements. Additionally, the share of the expansion population participating in activities that would have met the state’s Medicaid community engagement requirements rose between 2016 and 2017, from 54% to 60%. The researchers noted that changes in employment and student status were not associated with improved health status.

The rise in community-engagement participation between 2016 and 2017 was reported in “Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan” by Renuka Tipirneni, M.D., MS; John Z. Ayanian, M.D., MPP; Minal R. Patel, Ph.D., MPH; et al. The researchers surveyed 4,090 non-elderly, adult Healthy Michigan Plan enrollees from March 1, 2017 to January 31, 2018. The initial survey response rate was 53.7%, and the follow-up survey response rate was 83.4%.

The full text of “Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan” was published January 31, 2020, by JAMA Network Open. An abstract is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2759843.

A link to the full text of “D.C. Circuit Court Ruling In Gresham v. Azar” may be found at www.openminds.com/market-intelligence/resources/021420greshamvazardcruling.htm.

PsychU last reported on this topic in “Michigan Sued Over Planned Medicaid Work Requirements,” which published on January 20, 2020. The article is available at https://www.psychu.org/michigan-sued-over-planned-medicaid-work-requirements/.

For more information about the MDHHS Medicaid program, contact: 

  • Lynn Sutfin, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4772; Email: SutfinL1@michigan.gov; Website: https://www.michigan.gov/healthymiplan/0,5668,7-326-90904_90941—,00.html

For more information about the study findings, contact:

  • Renuka Tipirneni, M.D., MSc, Assistant Professor, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, North Campus Research Complex, Building 16, Room 419W, Ann Arbor, Michigan 48109-2800; Email: rtipirne@med.umich.edu; Website: https://ihpi.umich.edu/our-experts/rtipirne

How might the use of marijuana or its components affect behavioral or physical health? During this webinar, Joseph McEvoy, MD, and Heather Davidson, PhD, discuss with Nichole Neugebauer, PhD, the potential risks and purported benefits of marijuana with the goal to inform health care providers and foster open dialogue between health care providers and patients about marijuana. Also examined are the changing regulatory landscape in the United States, the effects of cannabis on the endocannabinoid system, and the benefits and risks of cannabis use for individuals with a mental health condition.

Featuring:

  • Joseph McEvoy, MD
    Professor and Case Distinguished Chair in Psychotic Disorders Augusta University Medical College of Georgia
  • Heather Davidson, PhD
    Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.
  • Nichole Neugebauer, PhD
    Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

Joseph McEvoy, MD, is a Professor at Augusta University Medical College of Georgia, where he holds the Case Distinguished Chair in Psychotic Disorders. Dr. McEvoy received his MD and completed his residency in psychiatry at the Vanderbilt University School of Medicine. He is also Director of Public Psychiatry at the Georgia Department of Behavioral Health and Developmental Disabilities at Augusta University and Medical Director of Serenity Behavioral Health Services.

Heather Davidson, PhD, is Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc. Dr. Davidson received her PhD in physiology and neuroscience from the Medical University of South Carolina in Charleston, SC, and completed her postdoctoral fellowship in pharmacology and toxicology at the Medical College of Georgia in Augusta, GA. She has 20 years of experience as a neuroscientist studying the neurobiology of substance use disorders, adolescent brain development, and severe mental illnesses.

Ideally, the people around you will understand your illness and encourage you. But the important people in your life might not know much about mental illness. They may want to help you, but not know how to help. You can give friends and family a better chance to help by thinking ahead about how to tell them about your mental illness.

The National Alliance on Mental Illness (NAMI) developed “Disclosing To Others Fact Sheet” to provide tips and resources on disclosing mental illnesses, covering topics such as:

  • Reasons to talk with others
  • When to tell
  • Who to tell
  • At work
  • In personal relationships
  • How and what to talk about

 

Download Resource

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.

Overdose deaths in San Francisco, California, rose by 16% between 2017 and 2018. In 2017, there were 222 overdose deaths, and there were 259 overdose deaths in 2018. During the first six months of 2019, there were 182 overdose deaths. Data for the last six months of 2019 has not yet been released.

These findings were reported in “Drug Overdoses and Drug Use San Francisco Health Commission: February 18, 2020,” and “Interim Report on Poisoning Fatalities from Opioids, Cocaine, and Methamphetamine in San Francisco, 2010-2019,” both by DPH. Researchers for DPH analyzed data from the California Electronic Death Registration System (CA-EDRS) via the Vital Records Business Intelligence System (VRBIS). The goal was to present current trends in San Francisco overdose deaths.

For more information, contact:

  • Jenna Lane, Behavioral Health Communications Specialist, San Francisco Department of Public Health, 101 Grove Street, San Francisco, California 94102; 415-554-2687; Email: jenna.lane@sfdph.org; Website: https://www.sfdph.org/dph/

According to the U.S. Government Accountability Office (GAO), the Department of Veterans Affairs (VA) spending on long-term care services rose by 33%, from $6.8 in 2014 to $9.1 billion in 2018. During this period, the number of veterans using VA long-term care services rose by 14%, from 464,071 in 2014, to 530,327 veterans in 2018. Veteran eligibility for long-term care is primarily based on the extent of a service-connected disability. The VA projects that demand will continue to increase and that spending will double from about $6.9 billion in 2017, to about $14.3 billion by 2037.

VA-provided care ranges from assistance with daily activities of living, to clinical care for spinal injuries or dementia. The VA’s Geriatrics and Extended Care office (GEC) provides, or pays for, long-term care through three institutional programs, and 11 noninstitutional programs. Institutional programs typically provide more acute skilled nursing care in a residential facility. Noninstitutional programs provide care to veterans in their homes or communities. All veterans enrolled in the VA health care system are eligible for the VA’s basic medical benefits package, which includes certain institutional and noninstitutional long-term care services.

Additional findings include:

  • In fiscal years 2014 through 2018, the average daily census increased for two of VA’s three institutional programs: Community nursing homes increased by 26% (from 7,771 to 9,808); and state veterans homes increased by 1% (from 23,176 to 23,423).
  • In fiscal years 2014 through 2018, five of the 11 noninstitutional programs experienced increases in their workload over this period, ranging from 8% to 48%.
  • In fiscal years 2014 through 2018, institutional program obligations declined as a proportion of total obligations, from 74% to 67%, while the proportion of noninstitutional program obligations rose from 26% to 33%.

The GAO concluded that the VA must improve plans for providing long-term care to aging veterans. VA identified that there is not yet a consistent approach to managing the 14 long-term care programs; VA also identified an inconsistent approach in determining the amount of noninstitutional services veterans need, and has developed but not yet implemented a tool for VA medical centers to use to improve that consistency.

VA currently faces three key challenges meeting the growing demand for veteran long-term care: workforce shortages, geographic alignment of care (particularly for veterans in rural areas), and difficulty meeting veterans’ needs for specialty care. Therefore, VA must also develop measurable goals for addressing these challenges in meeting the demand for long-term care.

The GAO also recommended three executive actions to the Secretary of VA. These include:

  • Direct GEC leadership to develop measurable goals in effort to address the three key long-term care challenges listed previously.
  • Direct GEC leadership to set implementation time frames, and successfully implement a consistent GEC structure at VA Medical Centers.
  • Direct GEC leadership to set time frames for, and implement a VAMC-wide standardization of the tool for assessing the noninstitutional program needs of veterans.

These findings were reported in “VA Health Care: Veterans’ Use of Long-Term Care Is Increasing, and VA Faces Challenges in Meeting the Demand,” by the GAO. Researchers for the GAO analyzed VA data and documents on the long-term care programs that are overseen by VA’s GEC for fiscal years 2014 through 2018. VA also conducted interviews with VA officials about the programs. The goal was to describe the use of and spending for VA long-term care.

A link to the full text of “VA HEALTH CARE: Veterans’ Use Of Long-Term Care Is Increasing & VA Faces Challenges In Meeting the Demand” may be found at www.openminds.com/market-intelligence/resources/021920gaovaltc.htm.

For more information, contact:

  • Chuck Young, Managing Director, Public Affairs, U.S. Government Accountability Office, 441 G Street Northwest, Room 7149, Washington, District of Columbia 20548; 202-512-4800; Email: youngc1@gao.gov; Website: http://www.gao.gov/

From 2013 to 2016, private equity firms acquired 355 physician practices. This breaks down to 59 practices in 2013, 72 practices in 2014, 88 practices in 2015, and 136 practices in 2016. These acquisitions included 1,426 sites and 5,714 physicians. There are approximately 18,000 unique group medical practices in the U.S. Each practice has one or more sites.

Additional findings include:

  • The most commonly acquired medical groups were anesthesiology (19.4%), multispecialty (19.4%), emergency medicine (12.1%), family practice (11.0%), and dermatology (9.9%).
  • Within the acquired practices, anesthesiologists represented about 33.1% of all physicians; emergency medicine specialists represented 15.8%; family practitioners represented 9.0%, and dermatologists represented 5.8%.

The researchers concluded the results of their analysis support equity firms’ typical investment strategy of acquiring “platform” practices. These practices have large community footprints (with several sites and many physicians). Equity firms then increase the value of the acquisitions by recruiting additional physicians, acquiring smaller groups, and expanding market reach. They suggest further research to understand the effect of acquisitions by equity firms, and to mitigate unintended consequences of these acquisitions.

These findings were reported in “Private Equity Acquisitions of Physician Medical Groups Across Specialties, 2013-2016” by Jane M. Zhu, M.D., MPP, MSHP; Lynn M. Hua, BA; and Daniel Polsky, Ph.D., MPP. The researchers identified acquisitions by private equity firms through the Irving Levin Associates Health Care M&A data set, then lined those acquisitions to the SK&A data set, a commercial data set of verified physician- and practice-level characteristics for U.S. office-based practices. The goal was to report on acquisitions by private equity firms.

The full text of “Private Equity Acquisitions of Physician Medical Groups Across Specialties, 2013-2016” was published February 18, 2020 by JAMA Network. An abstract is available online at https://jamanetwork.com/journals/jama/fullarticle/2761076.

For more information, contact:

  • Jane M. Zhu, M.D., MPP, MSHP, Assistant Professor, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, Oregon, 97239; Email: zhujan@ohsu.edu; Website: https://ohsu.pure.elsevier.com/en/persons/jane-zhu

The city of Denver’s new strategic framework for improving behavioral health calls for a greater use of data to guide policy to ensure that communities promote well-being, broadly improve access to care, provide early crisis services, and provide integrated and coordinated care. The goal is to improve existing services, systems, and responses to ensure they provide consistent and comprehensive care.

The framework recommends building on the Colorado Health Observation Regional Data Service (CHORDS), a regional partnership among the metro-Denver area public health departments that uses electronic health record data to aggregate medical and behavioral health data from provider organizations. CHORDS uses the data to support public health evaluation and monitoring efforts. To further leverage data to guide behavioral health policy, the framework recommends the following:

  • Develop data collection mechanisms for behavioral health status at the population level, including positive outcomes, as well as data by race, ethnicity, and gender and for people across the lifespan, new parents, immigrants and refugees, and individuals with intellectual/developmental disabilities (I/DD).
  • Develop an official data set for Denver that captures available addiction treatment services and the demand for those services.
  • Improve care coordination by implementing a data-sharing system among providers of mental health care, physical health care, jails, and social services.
  • Enact data sharing agreements that allow multiple stakeholders, including hospitals, medical professionals, and first responders, to enable secure and timely treatment.
  • Increase family and consumer support and education for understanding health data sharing, privacy, and release of information forms.

To improve access to services, the recommendations were as follows:

  • Create a platform for Denver residents to find and access support services based on unique circumstances. Build upon existing tools such as 211 and Colorado Crisis Services.
  • Train community members (e.g., schools, religious groups, workplaces) to recognize behavioral issues in themselves and others and how to engage appropriately.
  • Collaborate with employer groups to implement workforce supports and training.
  • Expand access to supportive services such as housing assistance, food, and transportation.
  • Identify and develop care navigation and coordination plans that address the needs of specific populations.
  • Increase funding opportunities for behavioral health services and other support services to share spaces.

To increase access to integrated, coordinated care, the recommendations were as follows:

  • Expand and support Denver’s behavioral health workforce through multiple strategies, including retain existing clinical professionals; train clinical professionals to offer trauma-informed services that meet the cultural and linguistic needs of different groups; identify pathways to hire individuals with lived experience with mental health and addiction; and boost access to effective supervision models and resiliency and peer support training.
  • Develop a center to provide 24/7 care for people with behavioral health conditions, including access to treatment, social support services, legal services, and transportation.
  • Provide an accessible continuum of addiction treatment that stretches from prevention to treatment to community-based recovery.
  • Align with efforts underway through the Denver Opioid Response Strategic Plan to increase access to harm reduction services and treatment on demand.
  • Eliminate systems-level barriers to providing comprehensive care, such as reimbursement and payment structures that prioritize treating one health issue instead of the whole person, and lack of training in treating addiction and mental health issues together.
  • Promote broad adoption and use of standardized screening and processes for mental health and addiction by all health care facilities in Denver, including primary care, school-based clinics, and emergency departments.
  • Identify and fund supportive, creative strategies that build trust and strengthen relationships between city residents and service provider organizations.

To ensure that crisis behavioral health services are provided early and in appropriate settings, the recommendations were as follows:

  • Establish a first response mechanism that is distinct from law enforcement, fire, and emergency medical professionals to connect people experiencing behavioral health crises with behavioral health provider organizations directly.
  • Support legislation to allow for diversion of people in crisis to appropriate treatment and care rather than sending them to jail or the emergency room.
  • Invest in and adopt alternative crisis response models.
  • Increase the availability and integration of peer support services.
  • Expand training in trauma-informed care for law enforcement, people who work in the criminal justice system, first responders, and others who make up Denver’s behavioral health crisis response system.

The recommendations were issued in “Road To Wellness: A Strategic Framework to Improve Behavioral Health in Denver.” The goal is to provide a roadmap for stakeholders in the behavioral health community to help navigate towards shared objectives around building a healthy community. The city began developing the plan in October 2018 when the mayor convened a steering committee. The committee was charged with scanning the current state of behavioral health services in Denver, identifying gaps, examining best practices, and providing recommendations. During the process, more than 100 individuals and 50 organizations participated to provide input.

A link to the full text of “Road To Wellness: A Strategic Framework to Improve Behavioral Health in Denver” at www.openminds.com/market-intelligence/resources/011420denverroadtowellness.htm.

For more information, contact:

  • Theresa Marchetta, Director, Strategic Communications and Media Policy, City and County of Denver and the Denver Health and Hospital Authority, 1437 North Bannock Street, Room 350, Denver, Colorado 80202-5390; 720-865-9000; Email: Theresa.Marchetta@denvergov.org; Website: https://www.denvergov.org/.

In most community mental health centers and federally qualified health centers that had telehealth capabilities in 2018, telepsychiatry was used as an adjunct to in-person care. In a study that included 20 health centers, all offered any telepsychiatry services, and 13 offer telepsychiatry as an adjunct to in-person care. When services could be provided either in person or via telehealth means, the health centers often considered consumer preference, acuity, and insurance status to decide whether to offer telepsychiatry services.

For those health centers that offered telepsychiatry services, the main reason given is that they were unable to recruit or maintain in-person clinical professionals. Some centers said that the decision to offer these services was to address a vacancy caused by the departure of a clinical professional, or to continue working with a clinical professional who moved out of state.

For those health centers that do not offer telepsychiatry, the primary reason given is that they are able to meet consumer demand for care without it. Therefore, these centers instead recruit and retain providers for in-person services. Additional reasons for not offering telepsychiatry services included potential technical difficulties that would create a bad experience for consumers, potentially high no-show rates, belief that mental health therapy should be offered in person to establish good relationships, and concerns about maintaining information confidentiality and safety.

The researchers concluded that many drawbacks to telepsychiatry may be somewhat mitigated by offering telepsychiatry as an adjunct to in-person care. Examples of this include requiring all intake interviews be conducted in person prior to telepsychiatry use, and requiring occasional in-person visits when telepsychiatry is used by a consumer.

These findings were reported in “Use of Tele–mental Health in Conjunction With In-person Care: A Qualitative Exploration of Implementation Models” by Lori Uscher-Pines, Ph.D.; Pushpa Raja, M.D.; Nabeel Qureshi; Haiden A. Huskamp, Ph.D.; Alisa B. Busch, M.D.; Ateev Mehrotra, M.D. The researchers analyzed data from the 2018 Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Services Locator database, and solicited participation from varied health centers in 20 states across the U.S. Twenty health centers in 14 states participated in an interview regarding the use of telehealth. The goal was to determine trends in telehealth use in these locations.

The full text of “Use of Tele–mental Health in Conjunction With In-person Care: A Qualitative Exploration of Implementation Models” was published January 30, 2020 by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900386.

For more information, contact: 

Lori Uscher-Pines, Ph.D., Policy Researcher, RAND Corporation, Post Office Box 2138, Santa Monica, California 90401-2138; 703-413-1100; , ext. 5167; Email: Lori_Uscher-Pines@rand.org; Website: https://www.rand.org/about/people/u/uscher-pines_lori.html

Out-of-network (OON) primary care is associated with higher median quarterly costs for Medicare beneficiaries attributed to a Medicare Shared Savings Plan (MSSP) accountable care organization (ACO). Median per-beneficiary spending for ACO beneficiaries was $401 per quarter between 2012 and 2015. Each percentage point increase in OON primary care spending was associated with a $10.97 increase in total quarterly spending per beneficiary. Additionally, each percentage point increase in OON primary care was associated with quarterly per-beneficiary increases in outpatient costs, skilled nursing facility costs, and emergency department costs. Changes in OON specialty care were not significantly associated with total spending or spending in any specific setting.

About 82% of specialist care for ACO beneficiaries takes place OON. Some ACOs have focused on reducing specialty care. However, the researchers said their findings suggest that ACO administrators may have overlooked the impact of OON primary care in their efforts to reduce OON specialty care.

These findings were reported in “Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs,” by Sunny C. Lin, Phyllis L. Yan, Nicholas M. Moloci, Emily J. Lawton, Andrew M. Ryan, et al. The researchers analyzed national Medicare data between 2012 and 2015 from 1,604,809 unique beneficiaries. The goal was to determine the relationship between out-of-network care and spending.

The full text of “Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs” was published in the February 2020 issue of Health Affairs. An abstract is available online at https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00181.

For more information, contact:

  • John M. Hollingsworth, M.D., MS, Associate Professor of Urology, Management and Policy, School of Public Health, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Room 112W, Ann Arbor, Michigan 48109; 734-763-2797; Fax: 734-232-2400; Email: kinks@med.umich.edu; Website: https://sph.umich.edu/faculty-profiles/hollingsworth-john.html

To improve behavioral health in the United States, Well Being Trust recommends that policymakers adopt a new framework with five engagement points to increase the frequency of behavioral health assessments and better facilitate access to care. The framework includes recommendations to promote mental wellness, prevent and/or treat mental illness, and maintain mental wellness. The five engagement points are health systems, judicial systems, education systems, workplace and unemployment, and “the whole community.” In this framework, promotion and prevention are supported by seven community conditions that provide civic belonging, a thriving natural world, reliable transportation, lifelong learning, meaningful work and wealth, humane housing, and basic needs for health and safety. The framework identifies barriers to behavioral wellness including stigma, cost, social isolation, and problems accessing behavioral health services.

The framework recommends that the federal government take the following five actions:

  1. Ensure that hospital payment models and quality programs encourage a mental health assessment at every interaction, not only during wellness visits. This should include integrating screening and treatment into episode-based payment models for health conditions for which there are frequent mental health co-morbidities, such as cardiovascular diseases, cancers, and pulmonary diseases.
  2. Provide long-term funding for states to continue programs such as Money Follows the Person and the Balancing Incentive Program to ensure that people with intellectual/developmental disabilities (I/DD) and behavioral health conditions have consistent access to comprehensive, high-quality services and support outside of institutional settings.
  3. Increase incentives for individuals to join the mental health workforce and for training programs to actively recruit and effectively train diverse individuals to meet underserved needs and provide more culturally competent care.
  4. Create a seed fund that supports primary care provider organizations, especially Federally Qualified Health Centers and Rural Health Centers, in developing the necessary capacity to begin seeking sustainable reimbursement for integrated mental health care services.
  5. Create incentives in funding programs for municipalities that have created effective policies or strategies for ensuring access to affordable housing.

Additionally, the framework recommends that special considerations be given to focus populations, as follows:

  1. Create incentives for policy reforms that improve school culture and/or student mental health and provide additional financing for schools that implement effective strategies that reduce disparities in belonging and safety for students who identify as LGBTQ, including specialized services for suicide prevention.
  2. Make Medicaid coverage for women up to one-year postpartum a mandatory eligibility category for coverage and include measures of screening and effective coordination of care for maternal behavioral health in hospital incentive programs for care transitions and quality/safety.
  3. Ensure that the Indian Health Service and the Veteran’s Health Administration are engaged in the same reform efforts as the Centers for Medicare & Medicaid Services for mental health and increase funding to build capacity.
  4. Make it impermissible that any information related to the seeking of behavioral health treatment be used in any aspect of immigration enforcement and provide funding to disseminate this information to immigrants and for education about the availability of behavioral health services as part of immigration services.
  5. Allow Medicaid funds to reimburse for the education of housing authorities concerning the risks of housing insecurity and what resources are available to meet those needs.

These recommendations were issued in “Healing the Nation: Advancing Mental Health and Addiction Policy” by Well Being Trust. The framework focuses on multiple angles for engagement with a specific emphasis on five main entry points for policy. It also specifically highlights populations that have been impacted differently by current mental health and addiction treatment crises. In total, the report makes 50 recommendations.

Well Being Trust is a national foundation focused on advancing mental, social, and spiritual health. The organization was created to include participation from organizations across sectors and perspectives to innovate and address mental health challenges facing America, and to transform individual and community well-being.

The full text of “Healing the Nation: Advancing Mental Health and Addiction Policy” was published in January 2020 by Well Being Trust, available online at https://healingthenation.wellbeingtrust.org/.

For more information, contact:

  • Benjamin F. Miller, Psy.D., Chief Strategy Officer, Well Being Trust, 436 14thStreet, Suite 1120, Oakland, California 94612; Email: ben@wellbeingtrust.org; Website: https://healingthenation.wellbeingtrust.org/

On February 13, 2020, the Oregon Health Authority (OHA) launched Family Connects to offer universal home visiting services to all families with newborns up to six months of age, including foster and adopted babies. The state’s current home visiting programs are not designed to reach all families. By offering universal home visiting, the state seeks to make population-level change to address low birth weight, postpartum depression, and other infant and maternal health outcomes.

Through the voluntary program, families will receive one to three visits from a state-licensed registered nurse. Family Connects Oregon is based on the work of Family Connects International. The program will start in eight communities and be phased in statewide over six years. Funding for the program was made available through Oregon Senate Bill (SB) 526, passed by the Oregon legislature in 2019.

The home visiting nurses will collaborate with hospitals and birth attendants to engage parents of newborns, preferably face-to-face, to schedule a home visit prior to leaving the birthing facility. Participation is voluntary; however, evidence shows that about 70% of families offered such services, accept them. Through the program, a nurse home visitor will work with families to identify resources needed from local organizations to provide an individualized program. The support provided includes referral to other, more intensive, home visiting programs, health and social supports around the state, such as obstetric, primary care, and pediatric visits, child-care, mental health services, housing agencies, and lactation support organizations.

Family Connects Oregon will leverage federal Medicaid funding and engage commercial health plans to offer services to all families of newborns regardless of income. SB 526 requires all health plans in the state to reimburse the cost of the universal newborn nurse home visiting services. The coverage must be provided without any cost-sharing, coinsurance, or deductible applicable to the services. The health plan must notify an enrollee about the services whenever an enrollee adds a newborn to coverage. The health plan may use in-network provider organizations or may contract with local public health authorities to provide the services. The health plan can reimburse for the cost of services using any method the health plan and provider organization agree upon, including a value-based payment methodology, a claim invoicing process, capitated payments, or a payment methodology that takes into account the need for a community-based entity providing the services to expand its capacity to provide the services and address health disparities.

The following eight agencies and communities are the first to launch the program:

  1. Clatsop County Department of Public Health.
  2. Eastern Oregon Early Learning Hub, a consortium covering three counties—Baker, Malheur, and Wallowa—with members representing health, K-12 education, social services, early learning programs, and businesses.
  3. The Early Learning Hub of Central Oregon, a partnership between the Crook, Deschutes, and Jefferson counties’ public health departments, the Confederated Tribes of Warm Springs Health & Human Services, and regional early care and education stakeholders.
  4. Four Rivers Early Learning Hub, including Gilliam, Hood River, Sherman, Wasco, and Wheeler counties.
  5. Lane County Health and Human Services Department, Public Health Division.
  6. The Early Learning Hub of Linn, Benton, and Lincoln Counties.
  7. Marion & Polk Early Learning Hub, including Marion County Public Health, Polk County Public Health, Family Building Blocks/Healthy Families, Lancaster Family Medical, and Confederated Tribes of Grand Ronde.
  8. Washington County Public Health Maternal Child & Reproductive Health.

Analysis of the Family Connects International program has shown that the nurse home visiting program has helped families make more connections to community resources in the first six months of a newborn’s life; resulted in more positive parenting behaviors with infants, such as nurturing touch and reading; mothers experienced 28% less clinical anxiety at six months; and had a higher quality home environment. Specifically, the Family Connects program evaluation showed fewer emergency room visits for infants at 6, 12, and 24 months, and an estimated savings of $3.02 for every dollar invested in the program, primarily from reduced infant emergency care.

For more information, contact:

  • Jonathan Modie, Lead Communications Officer, Oregon Health Authority, 800 Oregon Street, Portland, Oregon 97232; 971-246-9139; Email: phd.communications@dhsoha.state.or.us; Website: https://www.oregon.gov/OHA/PH/HEALTHYPEOPLEFAMILIES/BABIES/HOMEVISITING/Pages/Family-Connects-Oregon.aspx.

On February 14, 2020, a federal circuit court in Washington, D.C., ruled that the federal Department of Health and Human Services (HHS) acted capriciously when it approved Medicaid waivers submitted by Arkansas and Kentucky to impose community engagement and work requirements as a condition of Medicaid eligibility. The Circuit Court upheld a District Court ruling that vacated HHS approval for the waivers.

The District Court for the District of Columbia had previously held that HHS had acted in an arbitrary and capricious manner because it failed to analyze whether the waiver demonstrations would promote Medicaid’s primary objective of furnishing medical assistance. Kentucky subsequently ended its demonstration project in late 2019. The Arkansas Works demonstration is ongoing, and requires beneficiaries to participate in at least 80 hours of work or community engagement activities monthly, and to report those hours in a timely manner. Failure to meet the threshold or to report for three continuous months results in loss of Medicaid eligibility for the rest of the year. During the first five months of Arkansas Works, about 25% of those subject to the work requirement lost coverage, representing more than 18,000 people.

The Circuit Court considered whether the HHS authorization of the Arkansas demonstration was legal, and agreed with the District Court that approval of the plan was arbitrary and capricious. The ruling noted that HHS prioritized a non-statutory objective to the exclusion of the statutory purpose of Medicaid. Because the HHS approval of the Arkansas waiver was deemed as such, the Circuit Court affirmed the district court judgment vacating HHS approval.

The Circuit Court noted that instead of analyzing whether the demonstrations would promote Medicaid’s primary objective of providing coverage for health care services, HHS identified the following three alternative objectives:

  1. Whether the demonstration as amended was likely to assist in improving health outcomes;
  2. Whether it would address behavioral and social factors that influence health outcomes; and
  3. Whether it would incentivize beneficiaries to engage in their own health care and achieve better health outcomes.

The opinion noted that while the three alternative objectives point to better health outcomes as the objective of Medicaid, the current Medicaid statutes do not mention that objective, and specifically address only coverage. Additionally, both Arkansas and HHS characterized the HHS approval letter as stating that transitioning beneficiaries away from governmental benefits through financial independence or commercial coverage as an objective promoted by the Arkansas Works demonstration. The Circuit Court said that argument misrepresents the HHS Secretary’s approval letter, which has a section for the determination that the project will assist in promoting the objectives of Medicaid. The letter cites the health outcome goals, but does not mention transitioning beneficiaries away from benefits. The letter has no reference to commercial coverage. The only reference to beneficiary financial independence is in a section summarizing public comments. The letter does not justify the approval based on a belief that the demonstration will help Medicaid-eligible people gain sufficient financial resources to be able to purchase private insurance. The Circuit Court said that while it is not arbitrary or capricious to prioritize one statutorily identified objective over another, it is an entirely different matter to prioritize non-statutory objectives to the exclusion of the statutory purpose.

PsychU last reported on this topic in “From June To November 2018, 17,000 People Lost Arkansas Medicaid Benefits Over Failure To Meet Work Requirements,” which published on February 18, 2019. The article is available at https://www.psychu.org/june-november-2018-17000-people-lost-arkansas-medicaid-benefits-failure-meet-work-requirements/.

PsychU last reported on Kentucky’s effort to implement community engagement requirements in the following articles:

  • “Under Kentucky Medicaid Work Requirements, About 15% Of Non-Exempt Beneficiaries Would Fail To Meet Criteria,” which published as a News Report on September 9, 2019, at https://www.psychu.org/under-kentucky-medicaid-work-requirements-about-15-of-non-exempt-beneficiaries-would-fail-to-meet-criteria/.
  • “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published as a News Report on February 10, 2020, at https://www.psychu.org/kentucky-announces-cancellation-of-medicaid-managed-care-contracts-to-be-rebid-in-january/.

For more information about Gresham v. Azar, contact:

  • Andy Diantonio, Communications Associate, National Health Law Program, 1444 I Street NW, Suite 1105, Washington, District of Columbia 20005; Email: dantonio@healthlaw.org; Website: https://healthlaw.org/
  • Kevin De Liban, Attorney and Economic Justice Practice Group Leader, Legal Aid of Arkansas – West Memphis, 310 Mid-Continent Plaza, Suite 420, West Memphis, Arkansas 72301; 870-732-6370, ext. 2206; Email: kdeliban@arlegalaid.org; Website: http://arlegalaid.org/
  • Trevor Hawkins, Staff Attorney, Legal Aid of Arkansas, 714 South Main Street, Jonesboro, Arkansas 72401; 870-972-9224, ext. 6313; Email: thawkins@arlegalaid.org; Website: http://arlegalaid.org/

On February 3, 2020, the Texas Department of Family and Protective Services (DFPS) reported that turnover for its Adult Protective Services (APS) caseworker fell from 25.2% in fiscal year 2018, to 20.7% in fiscal year 2019. Based on data from the first quarter of fiscal year 2020, DFPS believes that turnover could be 17% or lower in fiscal year 2020.

DFPS believes that the decrease in turnover can be partially attributed to three events:

  • A recent legislative decision to provide APS caseworkers and front-line supervisors a raise of $750 a month.
  • More than 40 caseworkers were added to the statewide workforce, and placed in areas with the most need.
  • A mentorship program for APS caseworkers was implemented in the state.

As of August 31, 2019, APS had 512 caseworkers on staff. Of these caseworkers, 97 had been hired within the year prior, 142 had been on staff for one to three years, and 273 had been on staff for more than three years. The Arlington region had the most active caseworkers (103), followed by Houston (97), San Antonio (64), and Austin (56). During fiscal year 2019, both the Beaumont and Tyler regions had 0% turnover. El Paso region (4.8%, with just 1 turnover out of 20.8 average active caseworkers) and Lubbuck (7.1%, with just 2 turnovers out of 28.3 average active caseworkers) join these regions in the lowest turnover rates in the state.

DFPS maintains an interactive webpage with statistics at https://www.dfps.state.tx.us/About_DFPS/Data_Book/Employee_Statistics/APS/Staff_Turnover.asp.

For more information, contact: 

  • Patrick Crimmins, Media Relations Manager, Texas Department of Family and Protective Services, Post Office Box 149030, Austin, Texas 78714-9030; Email: patrick.crimmins@dfps.state.tx.us; Website: http://www.dfps.state.tx.us/

On February 24, 2020, a representative from Northern Maine Medical Center (NMMC) confirmed that a “Meds-to-Beds” program is in the process of being launched. The program will ensure that a consumers prescriptions for post-discharge medications are filled, and delivered to his or her room, before the consumer leaves the hospital. Upon the consumer’s request, these prescriptions will be delivered by a staff member during business hours, and a pharmacist will counsel consumers on the medication. After business hours, consumers can pick up their prescription at NMMC’s Pharmacy. Additionally, before discharge, NMMC pharmacy staff will conduct a consumer medication reconciliation to reduce the risk of duplicate or missing medications.

Prescriptions filled by the Meds-to-Beds program are considered an outpatient pharmacy service. Payment, or an insurance copay, is collected when services are rendered. NMMC will bill insurance provider organizations directly for the prescription. If there are financial issues that may prevent a consumer from filling their needed prescription(s), the NMMC pharmacist can access financial resources and troubleshoot by making a referral to the Patient Financial Advocate, prior to the consumer leaving the hospital.

In May 2018, Northern Maine Medical Center purchased a retail pharmacy, MADRx. Through this integration, NMMC has access to consumer clinical records, lab work, hospital medications, discharge medications, and original home medications, which will support the Meds-to-Beds program.

For more information, contact:

  • Amy Vaillancourt, Pharmacist, Northern Maine Medical Center, 194 East Main Street, Fort Kent, Maine 04743; Email: amy.vaillaincourt@nmmc.org; Website: https://www.nmmc.org/

A recent report revealed that from 2010 to 2017, the number of nurse practitioners (NPs) increased from about 91,000 to 190,000, which resulted in the RN workforce contracting by as much as 80,000. RNs returning to school to become NPs is a phenomenon occurring in every region of the country. At the same time, more than one million RNs are approaching retirement.

Additional findings in the report include:

  1. Employment for NPs was concentrated in hospitals, physician offices, and outpatient care centers.
  2. The fastest growth for NP employment overall was in outpatient care centers, which also had the highest salaries.
  3. Growth of NPs was most rapid in the east south-central region of the country, which includes Alabama, Kentucky, Mississippi, and Tennessee.
  4.  It is projected that there will be two NPs for every five physicians in 2030, compared to one NP per five physicians in 2016.

The researchers concluded that hospitals must determine and test new ways to replace RNs who have left their positions to become NPs. Hospitals must also determine solutions in response to low, or fluctuating, RN staffing.

These findings were reported in “Implications Of The Rapid Growth Of The Nurse Practitioner Workforce In The US” by David Auerbach, Peter Buerhaus, and Douglas Staiger, as published in Health Affairs. The researchers analyzed occupational data from the Census Bureau’s American Community Survey (ACS).

The full text of “Implications Of The Rapid Growth Of The Nurse Practitioner Workforce In The US” was published in February 2020 by Health Affairs. An abstract is available online at https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00686.

PsychU last reported on this topic in “Nurse Practitioners May Represent 27% Of The Family Practice Workforce By 2025,” which published on May 23, 2018. The article is available at https://www.psychu.org/nurse-practitioners-may-represent-27-family-practice-workforce-2025/.

For more information, contact: 

  • David I. Auerbach, Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University, Anna Pearl Sherrick Hall, Bozeman, Montana 59717; Email: davea@alum.mit.edu; Website: http://healthworkforcestudies.com/about/auerbach.html

Jane Guo, MBA, PharmD, is a Managed Market Liaison­, Northeastern Region, with Otsuka. Her career started in retail pharmacy. She then moved over to managed care at Express Scripts as a Pharmacist Supervisor in front-end operations. At Otsuka, she works on the managed care side as well, focusing on relevant products and on-demand resources. Guo graduated from the Albany College of Pharmacy and Health Sciences with a Doctor of Pharmacy degree, and she has a Master of Business Administration degree from The College of William and Mary.

Guo agreed to be interviewed by PsychU about the clinical and payer implications of the study outlined in “Telemedicine Provision: One State as Case Study,” based on research conducted in Minnesota.

The conversation has been edited for clarity and brevity.

PsychU: What is the hope of telemedicine? What do we want it to do for us?

Guo: Mostly it is the convenience factor. Individuals who live in rural areas and those who seek specialists face difficulty gaining access to services. Telemedicine allows them to connect with a medical professional able to provide quality care.

Also, we are seeing a newer generation of individuals who grew up with technology, and telemedicine may seem natural to them. You have a new mother with a baby, and she can connect with someone who will prescribe antibiotics for an ear infection. She doesn’t have to schedule an appointment and wait a day or more for it, then get in the car, or go to urgent care and sit there for an hour or two. So ease of access and convenience are definitely key.

From a payer perspective, it’s a long-term investment. You have to look at it from that vantage point because you’re seeking to improve overall health by providing better access, which hopefully will lead to lower costs because you have a healthier population.

PsychU: The research study referenced in the summary found that telemedicine was used differently in metropolitan versus rural regions. Could you speak to that?

Guo: Sure. In non-metropolitan areas, it is more about access to specialists, particularly psychiatrists and other mental health care professionals—there is a well-known shortage of them. When I am out in the field, in more rural areas, I hear, “We don’t have the clinicians we need.”

In metropolitan regions, it’s the opposite. In New York City, for instance, what I hear instead is there are plenty of providers, but sometimes it’s just difficult to schedule an appointment and then take time out of your day to go to it. In the city, telemedicine tends to be more about improving access to primary care. The convenience factor, for people on the go.

Another difference the study found was that in rural areas, telemedicine tends to be real-time provider-initiated care; in metropolitan areas, consumers are more likely to initiate the encounter.

In both metropolitan and non-metropolitan locales, I think telemedicine will play a large role in coordinating care.

PsychU: That’s interesting. As you know, our theme for 2020 is bridging the care continuum. How does telemedicine close care gaps and become part of integrated care?

Guo: Well, telemedicine allows a doctor or nurse practitioner to easily put a patient in touch with a specialist. It can be a warm handoff, as opposed to a primary care provider writing a referral to a specialist. That’s when you sometimes lose that patient. By supplementing care—rather than supplanting it—telemedicine care help bridge care gaps.

PsychU: Would you say that alternative payment models that require providers to take on financial risk, such as accountable care organizations (ACOs), foster innovative uses of telemedicine?

Guo: I don’t know if those payment models do or not, but from a quality standpoint, there is an incentive to use telemedicine to improve continuity of care, thereby improving quality of care. When you improve care and outcomes, while managing costs, you get a bigger reward in the form of a better quality ranking or bigger bonus reimbursement from the government.

PsychU: What do you see ahead?

Guo: Increasing buy-in from both patients and providers. For anyone, really, the focus is “What can this do for me?” I think clinicians will increasingly see how telemedicine can improve outcomes efficiently, while being convenient. And it is likely to increase patient satisfaction, another positive attribute. If reimbursement increased, that obviously would drive adoption.

As for individuals, convenience is key. Ease of use will encourage more individuals to try it and hopefully like it.

Up to 75% of individuals in North America experience trauma at some point in their lives. Rape, combat, childhood abuse—all are sources of trauma that can give rise to post-traumatic stress disorder, or PTSD, which affects between 2.5% and 3.5% of individuals in North America. PTSD has numerous symptoms, among them:

  • Intrusive thoughts and flashbacks (intrusions).
  • Effort to avoid situations that trigger memories.
  • Hypervigilance.
  • Hyperarousal—an uncomfortable state of being in high alert.
  • Negative alterations in cognition and mood.

Additionally, some with PTSD experience dissociation and derealization; these individuals are diagnosed with a PTSD subtype, PTSD+DS.

A team of researchers, led by Margaret C. McKinnon of the Department of Psychiatry and Behavioural Neurosciences at McMaster University in Hamilton, Ontario, Canada, have published a literature review about the efficacy of mindfulness-based treatments for PTSD and the neurobiological evidence for the mechanisms of action that underlie the disorder and how mindfulness-based therapies mitigate its symptoms. Entitled “Mindfulness-Based Treatments for Posttraumatic Stress Disorder: A Review of the Treatment Literature and Neurobiological Evidence,” it is the basis for this summary, which covers its key points. Those wishing a deeper dive are encouraged to read the original.

Therapy for PTSD

Therapy for PTSD is often prolonged exposure (PE) therapy and cognitive processing therapy (CPT). These therapies target feelings of avoidance and negative processing of traumatic events. Though they are considered effective, the reality is that more effective approaches are needed: after treatment with PE, between 60% and 72% of individuals continue to experience distressing symptoms. What’s more, attrition in treatment tends to be high, as great as 40%.

Mindfulness-based therapy emphasizes nonjudgmental acceptance of thoughts and feelings as they unfold in the present moment through a deliberate focusing of attention on the here and now. Mindfulness-based stress reduction (MBSR) is one type of therapy. It typically consists of eight weeks of two-hour group sessions, punctuated around week six by a full-day silent meditation retreat. Another therapy in this realm is mindfulness-based cognitive therapy (MBCT), which incorporates cognitive behavioral therapy (CBT) principles. It promotes an awareness that thoughts can be changed (“thoughts are not facts”), targeting residual symptoms.

The Thought Behind the Treatment

Avoidance, hyperarousal, emotional numbing, shame, dissociation: these are core features of PTSD that mindfulness can help attenuate. Keeping one’s attention firmly fixed on the present teaches attentional control and may reduce attentional bias toward trauma-related intakes. A mindful cognitive style may limit a tendency to harken back to trauma, leading to reductions in anxious thoughts.

This chart shows the symptoms and the hypothesized effect of mindfulness:

PTSD Symptoms Mitigating Effects of Mindfulness
Intrusions Shifting attention to present reduces vulnerability to trauma stimuli; increased attentional control
Avoidance Increased openness to experiencing challenging stimuli
Alterations in mood and cognition Nonjudgmental acceptance of thoughts and feelings

 

Hyperarousal Reduced attentional bias
Dissociative symptoms Reduced attentional bias to trauma-related and aversive stimuli, greater ability to stay in the present

Neurobiological Mechanisms of PTSD

Significant overlap exists between the literature about PTSD and the literature on mindfulness. Evidence suggests that undermodulation of emotions (associated with hyperarousal and intrusions) are targeted by mindfulness, as is overmodulation (associated with dissociation). This chart summarizes the different neurobiological mechanisms involved in PTSD and how mindfulness helps attenuate them:

Symptoms Neurobiological mechanism How it affects PTSD symptoms
Emotional dysregulation in people with PTSD A top-down inhibition of limbic systems leads to excessive emotional responses, such as hypervigilance and an exaggerated startle response. There is evidence that mindfulness helps manage limbic regions, leading to increases in emotional modulation.
Hyperarousal, impairments in self-referential processes, dominance of threat circuitry Three key networks are implicated: default mode network (DMN), the salience network (SN), and the central executive network (CEN). Mindfulness is linked with activity within and connections among the three systems; it fosters appropriate activation of the different networks.
Hyperarousal, hypervigilance, excessive mind-wandering Excessive connectivity between the thalamus and the DMN. Promotes decreased dissociation.

Discussion

Mindfulness-based therapies hold promise for PTSD treatment, reducing symptoms and with medium to large effect sizes. Low dropout rates for mindfulness-based therapies suggest that they are more tolerated than CPT or EP, where dropout rates, as previously mentioned, as high as 40%. To date, MBSR—that is to say, mindfulness-based stress reduction—has proven most effective.

Most studies the researchers reviewed did not report on specific symptoms impacted, but among those that did, significant reductions in re-experiencing, avoidance, numbing, and hyperarousal were noted. Additionally, nonreactivity and acting with awareness—both part of mindfulness—have been shown an association with reduced hyperarousal.

Limitations

No study compared standard first-line treatments for PTSD with mindfulness-based ones, although similar effect sizes have been observed. Much remains before mindfulness-based therapies may be considered first-line treatment.

Conclusion

The evidence, while preliminary, indicates the practice of mindfulness as taught in mindfulness-based therapy is efficacious in treating PTSD, with neurobiological studies lending support. As researchers better understand the neurobiology of the disease, the specific impact of mindfulness on PTSD symptomology is expected to grow clearer.

This summary was developed independently from the authors.

Authors declared the following conflicts: no conflicts of interest.

During 2019, merger and acquisition volume within the United States health care sector dropped by 1.5%, from 1,239 in 2018 to 1,221 in 2019. Total deal value was $91.2 billion in 2019. This is a 26.6% decrease from $66.9 billion in 2018. Health service sub-sectors analyzed include hospitals, home and hospice business, managed care plans, rehabilitation, physician medical groups labs, behavioral care, and “other services.” No definition for “other services” is provided.

Additional findings include:

  • “Hospitals” was the only sub-sector whose volumes grew on a year-over-year basis in each of the last three quarters of 2019. However, the home health and hospice, and managed care plans subsectors also finished the year with a stronger positive volume growth.
  • Three sub-sectors grew in terms of both volume and value: Managed care, long-term care, and hospitals. Additionally, Labs, MRI, and Dialysis deal value grew 503%; however, volume was flat.
  • Four sub-sectors experienced deal value declines: Physician medical groups, other services, behavioral care, and home health and hospice.

These findings were reported in “US Health Services Deals Insights Year-End 2019 Online Report” by PwC. The researchers analyzed publicly announced merger and acquisition transactions in specified sub-sectors. The goal was to compile data metrics and analysis of the announced 2019 mergers and acquisitions in the U.S. health care sector.

The full text of “US Health Services Deals Insights Year-End 2019,” was published in January 2020 by PwC. A free copy is available online at https://www.pwc.com/us/en/industries/health-industries/library/health-services-quarterly-deals-insights.html

For more information, contact:

  • Nick Donkar, Partner and West Region Health Services Deals Leader, PwC US, PricewaterhouseCoopers LLP, 300 Madison Avenue, New York, New York 10017; Website: https://www.pwc.com/us/en/industries/health-industries/health-research-institute.html. 

The number of announced behavioral health acquisitions slowed by 21% between the third and fourth quarters of 2019, from 19 in the third quarter to 15 in the fourth quarter. The fourth quarter 2019 deal volume was 46% below the 28 deals announced for the fourth quarter 2018.

Discovery Behavioral Health was the most active acquirer during the quarter, with a total of three transactions targeting companies specializing in drug and alcohol treatment programs: Authentic Recovery Center in Los Angeles, California; Casa Palmera in San Diego, California; and New Life Addiction Counseling & Mental Health Services in Pasadena, Maryland. Of the 15 announced transactions in the fourth quarter, only one disclosed a transaction price: Thomas H. Lee Partners acquired Centria Healthcare from Martis Capital and Lorient Capital for $415 million.

These findings were reported in “The Behavioral Health Care Acquisition Report 2019” by Irving Levin and Associates. The researchers analyzed publicly announced merger and acquisition transactions and pricing statistics. The goal was to compile data metrics and analysis of the 2019 mergers and acquisitions market.

For more information, contact: 

  • Irving Levin Associates, Inc., 268 ½ Main Avenue, Norwalk, Connecticut 06851; 203-846-6800; Fax: 203-846-8300; Email: info@levinassociates.com; Website: https://www.levinassociates.com/

Sarpy County, Nebraska is planning to open a new 400-bed jail in 2022 that will include space for mental health resources and programs for those about to leave jail. The current jail was designed to hold 148 individuals, and it does not have space for mental health and reentry programs, which are considered best practices. Currently, a jail employee provides case management functions, setting up services and identifying treatment options. Mental health care is currently provided by a contracted medical professional.

Preliminary plans for the new jail include space for community partners who can connect inmates to services that will get them on a path of rehabilitation, reintroduce them to society, and help them avoid recidivism. As the new jail nears completion, the county anticipates evaluating all of its contracts and moving forward with a plan for mental health care. The new jail will also offer flex space in the jail where different service provider organizations, including those offering mental health care and programming, can offer their services to the inmates during and after their time in incarceration.

The next steps are anticipated during early 2020, which include the county approving an architectural agreement, and starting formal design. The county will pay DLR Group more than $4.7 million for design and architectural services. Design of the facility is expected to take between 12 and 18 months, and the facility is slated to open in the fall of 2022. Preliminary estimates put the cost of the new jail facility near $65 million, which includes site preparation, design, and construction.

At the same time it is developing plans for the new jail, Sarpy County is also exploring a options for diverting citizens with mental health disorders from entering jail. The county hopes to establish a partnership with Nebraska Medicine to open a mental health crisis stabilization center on the Nebraska Medicine campus in the county. The center would provide short-term treatment and stabilization for those dealing with mental health crises. However, the partnership negotiations are still on-going. As a result, no firm decisions have been made about the type of facility, services, or size.

For more information, contact:

  • Megan Stubenhofer-Barrett, Sarpy County Communications, 1210 Golden Gate Drive, Papillion, Nebraska 68046; 402-593-4132; Email: mbarrett@sarpy.com; Website: https://www.sarpy.com/; or Chairman Don Kelly, District 1, Sarpy County, Nebraska, 1210 Golden Gate Drive, Papillion, Nebraska 68046; 402-593-2100; Website: https://www.sarpy.com/

A recent biennial data analysis found that approximately 14.6% of adult emergency department visitors were prescribed opioids at discharge during the 2016 to 2017 time period. This is a 6.9% decrease since the 2010 to 2011 time period. Top diagnoses associated with an opioid prescribed at discharge included dental pain, urolithiasis (stones in the kidney, bladder, or urinary tract), fracture injuries, back pain, and extremity pain.

Additional findings include:

  1. The rate of decrease was highest among visits by younger adults aged 18 to 44: from 25.5% in 2010 and 2011, to 15.3% in 2016 and 2017.

These findings were reported in “Trends In Opioids Prescribed At Discharge From Emergency Departments Among Adults: United States, 2006–2017” by Pinyao Rui, MPH, Loredana Santo, M.D., MPH, and Jill J. Ashman, Ph.D. The researchers analyzed data from the emergency department component from the National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is an annual probability sample survey of U.S. hospital emergency departments and outpatient departments, conducted by the U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics. The goal was to determine current trends in opioids prescribed at discharge from emergency departments.

A link to the full text of “Trends In Opioids Prescribed At Discharge From Emergency Departments Among Adults: United States, 2006–2017” may be found at www.openminds.com/market-intelligence/resources/122619erdischargeopioidtrends.htm.

For more information, contact: 

  • National Center for Health Statistics, U.S. Centers for Disease Control and Prevention, Hyattsville, Maryland 20782; 800-232-4636; Email: paoquery@cdc.gov; Website: https://www.cdc.gov/nchs/

The Colorado legislature is considering a proposal that would have the state’s Medicaid program reimburse for behavioral health peer support professional services. The legislation, House Bill (HB) 20-1139, was introduced on January 16, 2020. HB 20-1139 intends to add definitions for “peer support professional” and “recovery support services organization” as new types of professionals and provider organizations.

The legislation defines a “peer support professional” as a peer support specialist, a recovery coach, peer and family recovery support specialist, a peer mentor, a family advocate, or a family systems navigator. A peer support professional is an adult age 18 and older who self-identifies as having experienced the process of recovery for mental illness, trauma, or addiction disorder. A “recovery support services organization” is defined as an organization led and governed by representatives of local communities of recovery. Approval from the Colorado Department of Human Services (DHS), Office of Behavioral Health (OBH) will be required to be considered a recovery support services organization. On or before January 1, 2022, recovery support services organizations with OBH approval may bill for services including:

  • Peer-delivered support services
  • Peer-run drop-in centers, recovery and wellness centers, and employment services
  • Prevention and early intervention activities
  • Peer mentoring for children and adolescents
  • Consumer and family support groups
  • Warm lines
  • Advocacy services

The legislation details the specific criteria that OBH will use to approve recovery support services organizations for billing peer support services. It gives DHS authority to establish other criteria and standards as needed.

The bill also creates a state income tax credit for eligible peer support professionals, in which each will receive a refundable tax credit of $1,000. If the amount exceeds the individual’s state income tax liability, the balance of the credit will be refunded to the individual. The credit will be available for tax years 2021 through 2030. However, the tax credit program will be limited to $100,000 per tax year, meaning that credits can be provided to only 100 people annually. OBH will issue the credit certificates in the order they were requested.

To be eligible for the credit, the peer support professional must meet one of the following requirements:

  • Employed in Colorado as a peer support professional at least part-time in the behavioral health sector for at least three years and be enrolled in a undergraduate or graduate degree from an accredited Colorado institution of higher education with at least 12 credit hours per academic year. For these individuals, the credit will be available for four years.
  • Previously employed in Colorado as a peer support professional at least part-time in the behavioral health sector for at least three years, graduated from an accredited Colorado institution of higher education, and have been subsequently employed in Colorado as a behavioral health care professional. For these individuals, the credit will be available for three years.

A link to the full text of “Colorado House Bill 20-1139: Concerning Supporting The Peer Support Professional Workforce” may be found at www.openminds.com/market-intelligence/resources/011620copeersupportbill.htm.

For more information about the legislation, contact the bill sponsors:

  • Yadira Caraveo, State Representative, House District 31, Colorado General Assembly, 200 East Colfax, Room 307, Denver, Colorado 80203; 303-866-2918; Email: caraveo.house@state.co.us; Website: https://caraveoforcolorado.com/
  • Rod Pelton, State Representative, House District 65, Colorado General Assembly, 200 East Colfax, Room 307, Denver, Colorado 80203; 303-866-3706; Email: pelton.house@state.co.us; Website: https://leg.colorado.gov/legislators/rod-pelton

For more information about Colorado Medicaid’s current provisions, contact:

  • Mark Techmeyer, Communications Director, Colorado Department of Human Services, 1575 Sherman Street, 8thFloor, Denver, Colorado 80203-1714; 303-866-5700; Fax: 303-866-5563; Email: mark.techmeyer@state.co.us; Website: https://www.colorado.gov/cdhs

On January 21, 2020, the California Department of Corrections and Rehabilitation (CDCR) and the California Correctional Health Care Services (CCHCS) began screening inmates at all 35 state institutions for an enhanced integrated substance use disorder treatment (ISUDT) program. The program will offer participants medicated assisted treatment (MAT), comprehensive cognitive behavioral interventions, and safe, therapeutic housing. This initiative will focus on whole-person treatment from incarceration through return to the community.

During roll out, CDCR is focusing on three priority populations; however, an individual not identified in one of these groups can request assessment and treatment. At full capacity, the program will be available to any inmate needing treatment for addiction disorder. The three priority populations are:

  • Those currently receiving MAT
  • Those leaving within 15 to 24 months
  • Those considered high risk due to previous overdose, current clinical symptoms, Hepatitis C, or infections

The ISUDT provides services within the state facilities. CCHCS and CDCR have hired new staff to administer the program, and current staff are also being trained. Contracted cognitive behavioral intervention counselors will use a standardized curriculum based on the American Society of Addiction Medicine criteria.

The CDCR’s plans for ISUDT were noted in “CDCR Vision, Mission, Values, and Goals.” The program is just one method CDCR will use to continue toward the goal of “reflecting the joint priorities of creating a prison environment that provides the incarcerated population with the tools necessary to be drug-free, healthy, and employable members of society upon their release.” Additional steps the CDCR has taken to uphold this goal include:

  • Addressing criminality: The CDCR has increased capacity in cognitive behavioral intervention (CBI) programs focused on criminal thinking, anger management, family relationships, and victim impact by almost 300% since 2015.
  • Career training: The CDCR has more than doubled the capacity of career technical education opportunities for real-world job skills. They have also launched “Microhome” initiatives at the Correctional Training Facility in Soledad, and Folsom State Prison in Sacramento, which provide training for in-demand trades and careers to help individuals succeed when they return to society.
  • College education: The CDCR offers face-to-face community college programming in 34 prisons. A total of 740 people have enrolled, with an additional 200 enrolled in distance learning courses. Face-to-face instruction at Kern Valley State Prison, offered through Bakersfield College, has served 498 individuals.
  • Restorative justice: In 2019, The CDCR awarded grants to eligible non-profit organizations to implement victim impact programs in California prisons. These programs share a common goal of giving victims the opportunity for their voices to be heard, and for incarcerated men and women to fully understand the consequences of their actions.
  • Reentry: Since 2014 and 2015, The CDCR has increased its “Transitions” reentry program capacity 753% from 2,430 to 20,734. Transitions is a five-week program, provided near the end of an individual’s incarceration, to focus on their community reentry needs (such as financial literacy, job search skills, and community resources).
  • Community partnerships: The CDCR cultivates relationships with community partners throughout the state. Through a partnership with CAL FIRE, California Conservation Corps, and the Anti-Recidivism Coalition, CDCR opened an innovative firefighter training program for recently-paroled individuals who served as firefighters while incarcerated.

The full text of “CDCR Vision, Mission, Values, and Goals” was published January 7, 2020. An online copy is available at https://www.cdcr.ca.gov/about-cdcr/vision-mission-values/.

For more information, contact:

  • Krissi Khokhobashvili, Chief, External Communications, Office of Public and Employee Communications (OPEC), California Department of Corrections and Rehabilitation, 1515 S Street, Sacramento, California 95811; 916-445-4950; Email: OPEC@cdcr.ca.gov; Website: https://www.cdcr.ca.gov/
  • Elizabeth Gransee, Communications, California Correctional Health Care Services, Post Office Box 588500, Elk Grove, California 95758; 916-691-6714; Fax: 916-691-6183; Email: Lifeline@cdcr.ca.gov; Website: https://cchcs.ca.gov/

The COVID-19 pandemic isn’t affecting physical health only; it has an impact on mental health as well. In this webinar, Paul Gionfriddo, President of Mental Health America, and Christine Moutier, MD, psychiatrist and Chief Medical Officer for American Foundation for Suicide Prevention, discuss the impact of the novel coronavirus (COVID-19) pandemic on mental health with Stephen Murray, PharmD, MBA, Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

Our speakers examine the effects of social distancing, isolation, and stress of this crisis and their impact on overall health. Dr. Moutier shares her expert advice on self-care tips for providers along with her perspectives on using digital technology to engage patients. Mr. Gionfriddo discusses the effects of this crisis on individuals with underlying mental health conditions and shares some useful tips for family engagement during this period of isolation.

Featuring:

  • Paul Gionfriddo
    President and CEO of Mental Health America & PsychU Stigma Section Advisor
  • Christine Moutier, MD
    Chief Medical Officer at the American Foundation for Suicide Prevention & a Psychiatrist

Paul Gionfriddo is the President & 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.

Christine Mouter, MD, is the Chief Medical Officer at the American Foundation for Suicide Prevention. Since earning her medical degree and training in psychiatry at the University of California San Diego, Dr. Mouthier has been a practicing psychiatrist, Professor and Dean in the UCSD School of Medicine, Medical Director of the inpatient psychiatric unit at the VA Medical Center in La Jolla.

Nonadherence to medication is a serious problem in mental health care. In this webinar, Dawn Velligan, PhD, and Craig Chepke, MD, will discuss the current state of adherence and the limitations encountered. They will also introduce new technologies that are being used to measure and address adherence, as well as talk about the future state of technological adoption for treatment adherence in behavioral health.

Featuring:

  • Dawn Velligan, PhD
    Director, Division of Community Recovery, Research Training, University of Texas Health Science Center, San Antonio, TX
  • Craig Chepke, MD, FAPA
    Medical Director, Excel Psychiatric Associates, PA, Huntersville, NC

Dawn Velligan, PhD, earned her PhD in clinical psychology from the University of California in Los Angeles. She is the Director of the Division of Community Recovery, Research and Training, and is the Henry B Dielmann Chair of the Department of Psychiatry at the University of Texas Health Science Center in San Antonio. Her internationally recognized research program focuses on developing and testing psychosocial treatments to improve outcomes in patients with schizophrenia.

Craig Chepke, MD, FAPA, attended New York University School of Medicine and completed his residency at Duke University. He is a board-certified psychiatrist and has been named a Fellow of the American Psychiatric Association. He founded Excel Psychiatric Associates and is an Adjunct Assistant Professor of Psychiatry at the University of North Carolina School of Medicine. His research interests include movement disorders, neuropsychiatric conditions, and severe-persistent or treatment-resistant mental illness.

What is the ideal way to provide behavioral health care in a locale where stigma against it runs deep? Integrate behavioral health care into primary care, collocate its delivery with where primary care services are delivered, and try to make it culturally responsive to the population it serves.

That was the conclusion reached by nurse leaders at a clinic offering primary care in a low-income, urban neighborhood. Efforts to provide integrated, coordinated, and culturally responsive primary and behavioral care under one roof are detailed in an article published in the Journal of Community Health Nursing. In  “Using the Omaha System to Evaluate the Integration of Behavioral Health Services into Nurse-Led Primary Health Care” (2020), Jeana M. Holt and her colleagues, all affiliated with the College of Nursing at the University of Wisconsin–Milwaukee, evaluate the success of behavioral health integration efforts using the Omaha System taxonomy. Developed by nurse researchers and in use since 1975, the Omaha System taxonomy captures multiple elements of the patient-provider exchange and is in use across the globe. (See box.)

The Omaha System Taxonomy

Originally developed to record the practices of visiting nurses in Omaha, NE, the Omaha System taxonomy quantifies the holistic aspects of nursing, mapping environmental, psychosocial, physiological, and health-related behavior. In addition to these patient-related factors, the system captures the interventions the clinician performs under these categories:

·         Health Teaching, Guidance, and Counseling

·         Treatment and Procedures

·         Case Management

·         Surveillance

The nurse-led clinic is situated in a federally designated health provider shortage area, and it has been in operation for 30 years. Known locally as a community nursing center, it operates under the auspices of the University of Wisconsin–Milwaukee’s College of Nursing Institute for Urban Health Partnerships, whose mission is to eliminate health disparities.

In 2017 the clinic received federal funding to integrate behavioral health care into its primary care services. Operating in a lower-income African-American community, the clinic worked to normalize behavioral health care services, against which there existed considerable stigma in their patient base; the authors cite multiple studies that have found high levels of stigma about behavioral health conditions and treatment in African-American communities.

Going for the Gold: Integrated, On-Site Primary and Behavioral Care

The clinic’s aim was to provide integrated, collocated care that was:

  • Collaborative and patient centered. Integrated behavioral and primary care delivered under one roof best serves patients’ needs and suits their preferences, the nurse-led care team concluded.
  • Population based. The care team developed workflows that incorporated screening primary care patients for behavioral health needs.
  • Evidence based and measured. Individuals’ scores on behavioral health screening instruments were tracked over time in a patient registry. This data was used to assess if treatments were effective, allowing the care team to take a new approach if warranted.

To accomplish these goals, the care team needed a new balance of providers. The racially diverse care team before behavioral health integration was composed of the following roles:

  • One full-time (FTE) clinical nurse specialist/clinic director = 100% FTE
  • Two part-time family nurse practitioners = 135% FTE
  • Two part-time registered nurse case managers = 40% FTE

After the team was augmented, it looked like this in terms of roles:

  • One full-time (FTE) clinical nurse specialist/clinic director = 100% FTE
  • One full-time licensed behavioral health provider = 100% FTE
  • One consulting psychologist = 10% FTE
  • Two part-time family nurse practitioners = 65% FTE
  • Two part-time registered nurse case managers = 80% FTE

The measurement periods pre- and post-intervention were January 1–December 31, 2016, and January 1–December 31, 2018.

Achievements

The primary clinician team performed a retrospective descriptive analysis of the impact of behavioral health care service integration on the types of health problems identified, treatments provided, and patients’ ratings of several items, including psychosocial health literacy, self-management behaviors, and severity of psychosocial conditions.

The study’s authors say that the patient sample remained consistent over the study period, with about 30% of individuals uninsured and about 64% of individuals on Medicaid. Documented problems, interventions, and outcomes were assessed for a total of 189 primary care patients. From 2016 to 2018, there was an almost tenfold increase—900%—in the number of psychosocial concerns identified. In 2018, there were 50 problems with interpersonal relationships identified among patients; in 2016, none were.

All four intervention categories in the Omaha System taxonomy were used: Health Teaching, Guidance, and Counseling; Treatment and Procedures; Case Management; and Surveillance. In 2018, clinicians identified 2,326 targeted interventions in the psychosocial realm, an increase from 2016 of 266%. Case management was the most often documented intervention category. From 2016 to 2018, the number of documented case management interventions grew from 152 to 1,112, a 631% increase. In this category, the most frequent target for intervention was social work and counseling care, going from 34 in 2016 to 500 in 2018.

Also assessed were primary care patients’ psychosocial health literacy, self-management behaviors, and condition severity outcomes. For this, the clinic team used the 5-point Omaha System Problem Rating Scale for Outcomes. Eighty-seven primary care patients had at least two outcomes ratings in the psychosocial realm over the evaluation period. A paired samples t-test revealed improvement in self-management behaviors with the integrated health team approach. No significant changes were detected in either health literacy or condition severity.

Going Forward

Integrating behavioral health care into an existing primary care clinic achieved dramatic increases in the identification of psychosocial problems for care—a 900% jump. Case management was the most often prescribed intervention, write Holt and her colleagues.

The study’s limitations include the demographics of its patient base, which may limit its generalizability. Another limitation is the pervasive stigma in African-American communities against behavioral health care, which could have depressed the number of patients who accepted behavioral health care recommendations and appointments. Finally, the sample size was small.

Despite these limitations, the authors write that the integration efforts were a success. In addition to the results reported above, the authors note that the integration of behavioral health care services  enhanced the team’s whole-person, whole-health approach to care.

On January 30, 2020, Oklahoma Governor Kevin Stitt announced SoonerCare 2.0, a plan to revamp the state’s Medicaid program by implementing an alternative Medicaid expansion. The plan calls for the Oklahoma Health Care Authority (OHCA) to seek a Medicaid Healthy Adult Opportunity (HAO) waiver to implement a block grant funding structure. The state estimates that there are 220,000 in the expansion population, and that 180,000 are likely to enroll in SoonerCare 2.0.

Oklahoma intends to submit a state plan amendment to expand Medicaid to low-income adults up to 138% of the federal poverty limit, effective July 1, 2020. The state also intends to simultaneously pursue approval from the Centers for Medicare & Medicaid Services for a 1115 waiver that will be synced with health care delivery system reform in 2021. Neither of these documents had been publicly released as of February 23, 2020. Governor Stitt’s announcement said the 1115 waiver will request approval to establish new flexibility through a per person expenditure cap, to charge premiums for the expansion population and to waive retroactive coverage requirements, as well as to pursue community engagement requirements. These policy changes are only for the expansion population: core Medicaid beneficiaries (children; pregnant women; and aged, blind, and disabled) will not fall under these provisions.

Other components of the proposal are as follows:

  • Enhance rural health care access and addiction treatment programs
  • Manage non-emergency medical transportation

The HAO is a Medicaid demonstration initiative launched on January 30, 2020, that provides a range of program and benefit flexibility, including the option for block grant financing. The HAO applies to the Medicaid expansion population of low-income, non-disabled adults under age 65 who are not otherwise eligible for Medicaid. States implementing the HAO will be able to use fee-for-service, managed care, or premium assistance models without obtaining separate waivers or authorities.

For more information, contact:

  • Shelley Zumwalt, Chief of Communications, Oklahoma Health Care Authority, 4345 North Lincoln Boulevard, Oklahoma City, Oklahoma 73105; 405-522-7266; Email: shelley.zumwalt@okhca.org; Website: http://www.okhca.org/individuals.aspx?id=24454.

Residential care settings such as assisted living communities will need to fill more than 1.2 million direct care jobs between 2018 and 2028. This includes filling new jobs, as well as positions that become available as existing workers leave the field or the labor force. There are currently 720,480 positions in residential care settings, and another 500,000 will be added by 2028 to meet the expected demand of 1.2 million. Demand will also be high for in-home care settings. There are currently nearly 2.3 million home-care positions, and another 2.4 million will need to be filled by 2028 to meet expected demand of 4.7 million openings.

Additional findings include:

  1. Nursing homes will need to fill 621,000 direct care positions through 2028.
  2. A total of 720,500 residential care aide positions will need to be filled in assisted living communities, adult family homes, and other community-based residential care settings through 2028.
  3. About 86% of the total 1,203,900 positions to be filled in the direct care workforce through 2028, will be available because of workers leaving the labor force due to retirement, disability or other health-related reasons, or because they move into other occupations.
  4. The median hourly wage for direct care workers in 2018 was $12.07. This is a 2% increase since 2008.
  5. The median annual earnings for direct care workers in 2017 were $20,200.
  6. About 38% of direct care workers receive some form of public assistance.

These findings were reported in “It’s Time to Care: A Detailed Profile of America’s Direct Care Workforce,” by PHI National. Researchers for PHI analyzed data from the Bureau of Labor Statistics’s Occupational Employment Statistics program, and the American Community Survey and Current Population Survey from the U.S. Census Bureau. The goal was to determine trends in direct care worker needs, and estimate future shortages.

A link to the full text of “It’s Time to Care: A Detailed Profile of America’s Direct Care Workforce” may be found at https://phinational.org/wp-content/uploads/2020/01/Its-Time-to-Care-2020-PHI.pdf.

PsychU last reported on this topic in “States Programs To Offset Long-Term Care Costs Need To Address Direct Care Workforce Issues,” which published on September 23, 2019. The article is available at https://www.psychu.org/states-programs-to-offset-long-term-care-costs-need-to-address-direct-care-workforce-issues/.

For more information, contact: 

  • Kezia Scales, Ph.D., Director of Policy Research, PHI National, 400 East Fordham Road, 11thFloor, Bronx, New York 10458; 718-402-7766; Fax: 718-585-6852; Email: kscales@PHInational.org; Website: https://phinational.org/expert/kezia-scale

On February 6, 2020, the City of Los Angeles launched a pilot entrepreneurship program for people with insecure housing or who are homeless. The program, LA: EnterpRISE, will provide entrepreneurship and financial literacy training, as well as access to startup funding opportunities. During the first year about 200 people will be able to participate. Business startup assistance will be offered for any industry of interest to the participants.

Participants will be referred by provider organizations serving homeless and at-risk individuals. The provider organizations will identify those seeking to launch a business and refer them to LA: EnterpRISE. Each participant will receive entrepreneurship training through workshops facilitated by the Mayor’s Office of Economic Development. Upon completion, participants will be referred to one of the city’s WorkSource Centers or BusinessSource Centers. LA: EnterpRISE is a public-private partnership with the Mayor’s Office of Economic Development, the Downtown Women’s Center, Target, the Mayor’s Fund for Los Angeles, and PACE WorkSource/BusinessSource Centers.

The program will expand its long-term training capacity with a year-long “train-the-trainer” program facilitated by FreeFrom, a gender-based violence survivor advocacy organization. FreeFrom will partner with Coalition to Abolish Slavery and Trafficking (CAST) and Safe Place for Youth (SPY) to train facility case managers to function as business start-up coaches. CAST and SPY will each receive $5,000 in program support, which could be used to fund the LA: EnterpRISE participants’ business start-up costs. During the first year, this initiative aims to train 15 case managers, who can then each provide dozens of individuals with entrepreneurial skills training.

The “train-the-trainer” program will be designed and implemented by FreeFrom founder and Chief Executive Officer Sonya Passi. She will serve as the mayor’s 2020 Entrepreneur-in-Residence. In the announcement, Ms. Passi said, “Folks experiencing homelessness possess tremendous resilience, talent, and creative potential that is rarely talked about. If their case managers are equipped with the tools and knowledge to support them in building income through small business creation and self-employment, then they can create their own pathways to financial security and long-term stability.”

For more information, contact:

  • Eric Garcetti, Mayor, City of Los Angeles, 200 North Spring Street, Los Angeles, California 90012; 213-978-1028; Email: lamayornews@lacity.org; Website: https://www.lamayor.org/
  • Sonya Passi, Founder and Chief Executive Officer, FreeFrom, 12405 Venice Boulevard, Suite 422, Los Angeles, California 90066; Email: sonya.passi@freefrom.org; Website: http://www.freefrom.org/

In December 2019, officials in Vigo County, Indiana signed closing documents to allow the construction of a new 500-bed jail facility. Construction of the jail began on December 2, 2019, and is slated for completion by December 2, 2021. The new jail is part of the county’s efforts to resolve long-running litigation about overcrowding and poor conditions at the current jail, which has 268 beds. A federal court concluded the current jail is overcrowded when it exceeds 80%, or 214 inmates, and that the overall condition of the jail violates the inmates’ constitutional rights. As of September 30, 2019, the county’s jail population included 326 housed at the Vigo County Jail and another 33 housed at other county jails.

The construction of the new facility stems from a lawsuit, Jauston Huerta, et al. v. Greg Ewing, et al., filed in 2016 by past and present inmates at the Vigo County, Indiana Jail, and by the American Civil Liberties Union of Indiana. The plaintiffs alleged that the overcrowding and poor conditions violated their rights under the Eighth and Fourteenth Amendments. They sought an injunction, and asked the court to force the county Commissioners and the county Council to “appropriate sufficient funds to repair the present Jail or in the alternative, to mandate the Vigo County Commissioners, and County Council members, to alleviate the present conditions in the Jail or construct a new jail in conformity with recommendations to be made by the Indiana Department of Corrections.” The plaintiffs also requested damages.

On May 19, 2017, the court certified a class for the purposes of declaratory and injunctive relief for all inmates in the care and custody of Vigo County from October 1, 2016 to the present. The class includes current and future inmates incarcerated at the Vigo County Jail or transported to another county jail because the Vigo County Jail is overcrowded. The court found conditions at the Vigo County Jail to be unconstitutional. On October 10, 2018, the court ordered the county to remedy the “ongoing constitutional violations” at the Jail as quickly as possible, and to periodically report steps being taken to address the violations. The county agreed to open a new jail. Under the order, before the new jail opens, the county was required to commit sufficient staff and take all other steps necessary to ensure that all prisoners are offered, at a minimum, at least three hours a week of recreation outside of their cell areas and to commit sufficient staff to make sure that the health and safety of prisoners is safeguarded.

On July 21, 2018, the county released the first part of a required assessment of the jail and the county’s criminal justice system. At a hearing on November 1, 2018, the county submitted a written plan to the court that details the anticipated dates for meeting relevant construction benchmarks, and the opening date of the new jail. The county was also required to submit the population capacity of the new jail and staffing numbers for the new facility.

For more information, contact:

  • Michael Wright, Attorney, Vigo County, Indiana, 127 Oak Street, Vigo County Government Center, Terre Haute, Indiana 47807; Website: https://www.vigocounty.in.gov/
  • Ariella Sult, Media Office, American Civil Liberties Union of Indiana, 1031 East Washington Street, Indianapolis, Indiana 46202; 317-635-4059; Fax: 317-635-4105; Email: asult@aclu-in.org; Website: https://www.aclu-in.org/

Behavioral health services delivered via telemedicine now account for nearly one-third of all telemedicine visits for Excellus BlueCross BlueShield (BCBS), according to a review of the company’s 2019 claims data. In 2018, behavioral health services accounted for less than 25% of all telemedicine visits for this payer.

In late 2019, Excellus BCBS commissioned a survey of upstate New York adults. The survey was conducted by One Research. The survey found that among 2,000 respondents:

  1. The top mental health conditions for which plan members seek telemedicine treatment are generalized anxiety disorders, major depressive disorders, persistent depression (dysthymic disorders), post-traumatic stress disorders, and adjustment disorders.
  2. The top specialists seen via telemedicine for behavioral health treatment include social workers, psychologists, counselors, and nurse practitioners.
  3. About 17% are receiving counseling for a mental health condition.
  4. About 28% of adults are taking medication for a mental health condition.
  5. About 35% say they will consider using telemedicine for treatment of a mental health condition.
  6. About 58% of participants who said they take a medication or are receiving counseling for a mental health condition say they will consider using telemedicine to connect with a health care professional.
  7. Using telemedicine to access behavioral health services is most popular among younger consumers. A review of health plan claims data found that approximately 70% of users are 40 years old or younger. About 25% of users are 20 years old or younger.

Excellus BCBS is a non-profit health insurance company headquartered in Rochester, New York. It is part of the Blue Cross Blue Shield Association. Excellus BCBS serves more than 1.5 million members across 39 counties in upstate New York.

Excellus BlueCross BlueShield released the review findings on February 4, 2020. Extrapolating the health plan’s member claims data to reflect the entire statewide population, Excellus estimates that New Yorkers logged more than 80,000 telemedicine visits for behavioral health services in 2019. The findings can be viewed online at https://news.excellusbcbs.com/news-room/releases/-/asset_publisher/26WPXjKp2c3P/content/use-of-telemedicine-for-behavioral-health-increasing-year-over-year.

For more information, contact: 

  • Jim Redmond, Vice President, Communications, Excellus BlueCross BlueShield, 165 Court Street, Rochester, New York 14647; 585-238-4579; Email: jim.redmond@excellus.com; Website: https://www.excellusbcbs.com/

Seventy-eight unique programs, involving 917 hospitals nationwide, spent $2.5 billion on programs focused on social determinants of health (SDOH) between January 1, 2017 and November 30, 2019. SDOH is defined as topics concerning economic stability (employment, poverty, housing instability, food insecurity); education (early childhood education and development, high school graduation, enrollment in higher education, language, literacy); social and community context (civic participation, discrimination, incarceration, social cohesion); health and health care (access to health care, access to primary care, health literacy); and neighborhood and built environment (access to foods that support healthy eating patterns, crime and violence, environmental conditions, quality of housing). Approximately $1.6 billion was spent on 52 programs that were committed to housing-focused interventions. Additional focus areas for spending include:

  1. About $1.1 billion was spent on 28 employment-focused interventions.
  2. About $476.4 million was spent on 14 education-focused interventions.
  3. About $294.2 million was spent on 25 food security-focused interventions.
  4. About $253.1 million was spent on 13 social and community context-focused interventions.
  5. About $32 million was spent on six transportation-focused interventions.

These findings were reported in “Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19” by Leora I. Horwitz, Carol Chang, Harmony N. Arcilla, and James R. Knickman. The researchers analyzed public announcements given by U.S. health systems of new programs that had direct financial investments in social determinants of health between January 1, 2017 and November 30, 2019. The goal was to determine total spending on social determinant programs.

The full text of “Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19” was published in February 2020 by Health Affairs. An abstract is available online at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01246.

For more information, contact: 

  • Leora I. Horwitz, Associate Professor, Department of Population Health, New York University Grossman School of Medicine, 227 East 30thStreet, 6th Floor, New York, New York 10016; 646-501-2685; Email: leora.horwitz@nyulangone.org; Website: https://nyulangone.org/doctors/1841334810/leora-horwitz

About 20% of emergency departments in the United States use some form of telepsychiatry, according to a national survey. In a separate survey, about 59% of emergency departments that use some form of telepsychiatry reported that telepsychiatry is their emergency department’s only form of emergency psychiatric services. About 25% of emergency departments that use some form of telepsychiatry reported that they have individuals that receive services at least once a day.

Additional findings include:

  • Characteristics associated with higher likelihood of emergency department telepsychiatry receipt included higher annual total visit volumes, rural location, and designation as a Critical Access Hospital (i.e., very small health care locations that provide “critical access” to people who live in remote areas).
  • Characteristics associated with lower likelihood of telepsychiatry receipt included being an autonomous freestanding emergency department.

The researchers concluded that telepsychiatry is used to fill a critical need in emergency departments. They recommend additional research to identify barriers to implementing telepsychiatry in emergency departments that do not have access to emergency psychiatric services.

These findings were reported in “National Study of Telepsychiatry Use in U.S. Emergency Departments” by Rain E. Freeman, MPH, Krislyn M. Boggs, MPH, Kori S. Zachrison, M.D., M.Sc., Rachel D. Freid, MPH, Ashley F. Sullivan, MS, MPH, Janice A. Espinola, MPH, and Carlos A. Camargo Jr., M.D., Dr.P.H. The researchers surveyed 5,375 emergency departments in the United States to characterize emergency care in 2016. Fifteen percent of those emergency departments that reported receiving telepsychiatry services were randomly re-surveyed to confirm telepsychiatry use in 2017, and to collect data on emergency psychiatric services and applications of telepsychiatry in each emergency department. The goal was to investigate the prevalence and applications of telepsychiatry in general emergency departments in the U.S.

The full text of “National Study of Telepsychiatry Use in U.S. Emergency Departments” was published February 5, 2020 by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900237.

For more information, contact: 

  • Carlos A. Camargo, Jr., M.D., Dr.P.H., Professor, Department of Epidemiology, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, Massachusetts 02114; 617-726-5276; Email: ccamargo@partners.org; Website: https://www.hsph.harvard.edu/carlos-camargo/

On December 4, 2019, the New Mexico Human Services Department (HSD) announced it had settled with the last five of the 10 behavioral health provider organizations that sued the state because their Medicaid reimbursements were frozen in June 2013 due to allegations of fraud by the previous administration of Governor Susana Martinez. The five organizations are Santa Maria El Mirador (formerly Easter Seals El Mirador); Border Area Mental Health Services; Southwest Counseling Center, Inc.; Southern New Mexico Human Development, Inc.; and Families and Youth, Inc. They agreed to share a settlement of $10 million.

In 2013, the Martinez administration hired an independent auditor that estimated that 15 behavioral health provider organizations had been overpaid by $36 million over a three-year period. The state said this represented a “credible allegation of fraud” and imposed a Medicaid payhold. The payhold meant that the organizations could not bill for any new Medicaid claims and would not be paid for $11.5 million in unpaid claims submitted before the payhold was imposed. Without the state Medicaid payments, many of the organizations could not sustain operations and went out of business within a few months. In 2015, 10 of the provider organizations sued the state to protest the audit methodology. As of June 2017, HSD, the state Medicaid agency, had held fair hearings with eight of the organizations. An HSD spokesperson said these hearings “established in excess of $5 million in overpayments.” On July 7, 2017, the governor’s office alleged that at least $9.4 million in overpayments were received by the provider organizations. By July 2017, the attorney general’s investigations had cleared each of the organizations; the investigations alleged approximately $1.16 million in overbilling by the organizations, but found no evidence of fraud. The investigation findings were forwarded to HSD for further action.

In 2019, the newly-elected administration of Governor Michelle Lujan Grisham reached agreements with the behavioral health provider organizations. In the settlements, the state admitted no liability, and each organization agreed that it would not appeal or otherwise revive its lawsuit. Additionally, Governor Grisham charged HSD with fixing New Mexico’s “broken” behavioral health care system by working with the New Mexico Behavioral Health Collaborative to build a new behavioral health provider network, develop community-based mental health services for children and families, effectively address addiction disorder, and effectively address the behavioral health needs of justice-involved individuals.

The provider organizations agreed to settle their lawsuits, and to share a $10 million settlement. In addition to the settlement agreement/addendum, three of the organizations will receive additional funds. The settlements are as follows:

  • Santa Maria El Mirador (formerly Easter Seals El Mirador) will receive 29.4% of the $10 million settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $127,240.40.
  • Border Area Mental Health Services will receive 21.4% of the settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $96,201.73. Another $226.27 in fee-for-service amounts will be paid to HSD.
  • Southwest Counseling Center, Inc., will receive 21.4% of the settlement.
  • Southern New Mexico Human Development, Inc., will receive 10.4% of the settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $88,239.79. Another $157.21 in fee-for-service amounts will be paid to HSD.
  • Families and Youth, Inc. will receive 17.4% of the settlement.

For more information, contact:

  • Jodi McGinnis-Porter, Director, Communications, New Mexico Human Services Department, Post Office Box 2348, Santa Fe, New Mexico 87504; 505-476-7203; Email: McGinnis-Porter@state.nm.us; Website: https://www.hsd.state.nm.us/default.aspx
  • Angie Carreón, Executive Assistant, Families and Youth, Inc., 1320 South Solano Drive, Las Cruces, New Mexico 88001; 575-522-4004; Email: acarreon@fyinm.org; Website: https://www.fyinm.org/
  • Southern New Mexico Human Development, Inc., 820 Highway 478, Anthony, New Mexico 88021; 575-882-5101
  • Kathy Luzmoor, Board Chair, Southwest Counseling Center, Inc., 2300 Foothill Boulevard, Rockwell Springs, Wyoming 82901; 307-352-6677; Fax: 307-352-6614; Email: kluzmoor@swcounseling.org; Website: http://www.swcounseling.org/
  • Border Area Mental Health Services, 315 North Hudson Street, #6, Silver City, New Mexico 88061; 575-388-4497; Email: mbonacci@bamhs.com; Website: https://www.facebook.com/nmbamhs/
  • Patsy Romero, Chief Executive Officer, Santa Maria El Mirador, 10 A Van Nu Po, Santa Fe, New Mexico 87508; 505-424-7707; Email: info@eselm.org; Website: https://www.santamariaelmirador.com/

The first-known telepsychiatry-enabled model of perinatal integrated care resulted in a 100% perinatal/postpartum depression screening rate, and a higher than expected treatment engagement rate. About 19% of the mothers screened were found to have perinatal depression and/or behavioral health needs, and about 96% of them started treatment. Available data indicate that only 15% to 20% of mothers receive routine perinatal depression screening, and that of those identified, only 60% start treatment. Perinatal depression is defined as depression during pregnancy or up to one year after giving birth.

The telehealth-enabled integrated care model was implemented within a specialty obstetrics clinic serving an at-risk, socioeconomically disadvantaged population. It consisted of three components:

  • Universal depression screening: The Edinburgh Postnatal Depression Scale (EPDS) was administered at a post-natal appointment for all consumers, and the two-question Patient Health Questionnaire (PHQ-2) was administered at all other perinatal visits.
  • Virtually embedded behavioral health clinical professional (BHC): A BHC was embedded at the clinic via video conferencing to oversee the perinatal screenings, follow up on positive screens and other referrals, support coordination of virtual psychiatric consultation, provide brief intervention and treatment as needed, and refer and coordinate ongoing behavioral health and social services.
  • Virtual integration of telepsychiatry services into an evidence-based collaborative care model in primary care: The BHC served as the coordinator across the care team, consulting with the care team to make diagnostic and medication-related recommendations.

Additional findings include:

  • Under the telepsychiatry-enabled model, 12% of non-twin infants of mothers with perinatal depression were born at a low birth weight. Nationally, about 23.5% of infants of mothers with perinatal depression are born at a low birth weight.
  • Positive intervention outcomes have provided new support for the expansion of telepsychiatry-supported models of integrated care from primary care into specialty care settings.
  • There was evidence demonstrating a bidirectional relationship such that depression was associated with lower rates of breastfeeding. Among those mothers who attended their six-week postnatal visit and were able to breast feed, 85% engaged in breastfeeding.

The researchers concluded that the program improved screening and diagnosis of perinatal behavioral health issues, increased access to treatment and consumer engagement, and improved consumer outcomes. The researchers also noted that telepsychiatry is a potentially effective tool for expanding models of perinatal-integrated care.

These findings were reported in “Evaluation of Telepsychiatry-Enabled Perinatal Integrated Care” by Jay H. Shore, M.D., MPH., Maryann Waugh, M.Ed., Jacqueline Calderone, M.D., Amy Donahue, M.D., Jennifer Rodriguez, LCSW, Danielle Peters, LCSW, Marshall Thomas, M.D., and Alexis Giese, M.D. The researchers collected behavioral health screening data from 712 consumers at an urban women’s clinic, as well as in-depth process and outcome measures for 135 consumers from this same clinic. The goal was to describe the implementation of the first known telepsychiatry-enabled model of perinatal integrated care and to report initial results following implementation.

The full text of “Evaluation of Telepsychiatry-Enabled Perinatal Integrated Care” was published February 5, 2020 by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900143.

For more information, contact: 

  • Jay H. Shore, M.D., Director of Telemedicine, Helen and Arthur E. Johnson Depression Center, University of Colorado Anschutz Medical Campus, 13199 East Montview Boulevard, Suite 330, MS F550, Aurora, Colorado 80045; Email: depression.center@ucdenver.edu; Website: https://ttspsworld.com/jay-h-shore-md-mph

Federal legislation signed into law on March 6, 2020 to address national preparation and response to 2019-Novel Coronavirus (COVID-19) includes provisions that waive Medicare restrictions on telehealth for care related to COVID-19. The bill, House Resolution (HR) 6074 – Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, provides a total of $8.3 billion, with $7.76 billion to federal, state, and local agencies to combat the virus and authorizes an additional $500 million to pay for the waivers of Medicare telehealth restrictions. About $2.2 billion is earmarked for activities to prevent virus spread, and another $3 billion is earmarked for vaccine research.

COVID-19 is a new virus that presents with a fever and respiratory symptoms, similar to influenza, from two to 14 days after exposure. The symptoms range from mild to severe. It emerged in Wuhan City, Hubei Province, China. The first infections were linked to a live animal market; however, the virus is now spreading person-to-person. The Centers for Disease Control and Prevention (CDC) says that the virus seems to be spreading easily in the community, meaning that people are infected, but it is not sure how or where they were exposed. Globally, as of March 9, 2020, there had been 109,578 confirmed cases and 3,809 deaths, a death rate of 3.5%. Cases had been identified in 105 countries/territories. On March 13, 2020, the United States declared a national state of emergency due to COVID-19.

The legislation will allow Medicare fee-for-service beneficiaries living in a COVID-19 emergency area (or a portion of such an area) to receive telehealth services related to coronavirus during any portion of any emergency period. Services related to COVID-19 include a virtual check-in to discuss possible COVID-19 symptoms that the beneficiary may be experiencing. If the beneficiary shows more physical symptoms, a subsequent virtual check-in can allow a health care professional to offer recommendations about next steps and precautions that the beneficiary should take before visiting a physician office or hospital. The goal is to keep beneficiaries with mild symptoms in their homes, while increasing access to health care professionals. However, for any other services not specifically related to potential symptoms of COVID-19, Medicare’s normal telehealth restrictions apply. Medicare beneficiaries living in rural areas can continue to use communication technology to have full visits with their health care professionals.

Prior to this bill, Medicare limited payment for telehealth visits to services furnished to beneficiaries in certain types of health care facilities located in rural areas. Beneficiaries in rural areas could not receive telehealth visits in their home except under certain exceptions for the treatment of addiction or a co-occurring mental health disorder, or for monthly clinical assessments related to end-stage renal disease (ESRD).

The telehealth virtual check-ins for COVID-19 are billable services, and the Medicare coinsurance and deductible would apply to these services. The virtual check-ins must be provided by a clinical professional who has an established relationship with the beneficiary or who is in the same practice as the professional who has that relationship. Covered telehealth services can be provided via a smartphone with audio and video capabilities sufficient to provide two-way, real-time interactive communication. Physicians and other authorized clinical professionals may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010).

Medicare also pays for beneficiaries to communicate with their physicians by using online consumer health portals. The individual communications, like the virtual check ins, must be initiated by the beneficiary; however, health care professionals may educate beneficiaries on the availability of this kind of service prior to initiation. The communications can occur over a seven-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable. The Medicare coinsurance and deductible would apply to these services.

For more information, contact:

  • Office of Communications, 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/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
  • Center for the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Email: ncirddvdinquiry@cdc.gov; Website: https://www.cdc.gov/ncird/index.html; or Michelle Bonds, Director, Division of Public Affairs, Office of the Associate Director for Communication, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, MS D-25, Atlanta, Georgia 30333; Email: Media@cdc.gov; Website: https://www.cdc.gov/media/subtopic/contact.htm

On January 1, 2020, Blue Cross and Blue Shield of North Carolina (Blue Cross NC), in collaboration with Quartet Health, launched a new value-based payment model called Blue Premier Behavioral Health. Behavioral health professionals who meet or exceed quality benchmarks will be able to earn higher reimbursement rates. Independent, outpatient behavioral health professionals who serve members of Blue Cross NC commercial (non-government) plans may enroll by May 31, 2020.

Behavioral health professional performance will be evaluated on a series of measures in three domains: Access, communication with primary care, and health outcomes. The participants can receive a maximum bonus payment of up to 10% of their total behavioral health service reimbursement for the year. For those with quality scores greater than 95%, Blue Cross NC will offer an additional $5,000 bonus. This new value-based payment program is part of Blue Premier, an initiative launched by Blue Cross NC in 2019 to enhance primary care services, integrate behavioral health into primary care, and move to reimbursement based on performance.

This Blue Cross NC value-based payment initiative is using the Quartet Health technology platform to measure quality of behavioral health care. Participating professionals will use Quartet’s technology to facilitate referrals and enable data collection and measurement of quality outcomes. Physicians and case managers can refer consumers for mental health care through the platform. The platform facilitates on-going communication between primary care physicians and behavioral health professionals.

In 2019, Blue Cross NC began efforts to better integrate behavioral health with physical health and to transform health care through value-based payments. This new approach also integrates with Blue Premier, the company’s value-based care program that holds network provider organizations and Blue Cross NC jointly accountable for improving care and lowering costs. As part of the integration efforts in 2019, Blue Cross NC began offering Quartet’s services to primary care and behavioral health provider organizations free of charge.

Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. It serves more than 3.9 million members, including approximately 1.1 million served on behalf of other Blue plans. Kate Hobbs Knutson, M.D., Blue Cross NC head of behavioral health said, “Blue Premier Behavioral Health will expand access, improve coordination with primary care, and help achieve better health outcomes.”

PsychU last reported on this topic in “Sutter Health Teams Up With Quartet Health To Better Integrate Mental & Physical Health Care,” which published on October 16, 2017. The article is available at https://www.psychu.org/sutter-health-teams-quartet-health-better-integrate-mental-physical-health-care/.

For more information, contact:

  • Kevin Kumler, Chief Operating Officer, Quartet Health, 119 West 40th Street, 5th Floor, New York, New York 10018; Email: help@quartethealth.com; Website: https://www.quartethealth.com/
  • Susan Foosness, Senior Business Operations Advisor, BlueCross BlueShield of North Carolina, 1965 Ivy Creek Boulevard, Durham, North Carolina 27707; 984-960-3697; Email: susan.foosness@bcbsnc.com; Website: https://www.bluecrossnc.com/

During 2019, salaries for assisted living community administrators averaged $100,622, up 3.6% over the 2018 average salary of $97,126, according to a year-to-year trend analysis for facilities that participated in salary surveys in both 2018 and 2019. Across all facilities that reported in 2019, the national average administrator salary was $76,939. Across the states, average administrator salaries ranged from $63,452 in North Carolina to $97,349 in Maryland.

At smaller facilities (74 beds or less), administrator salaries averaged $71,882. At facilities with 75 or more beds, administrator salaries averaged $80,676. At for-profit facilities, administrator salaries averaged $74,933. At non-profit facilities, administrator salaries averaged $87,380.

These statistics were reported in the 22nd annual “Assisted Living Salary & Benefits Report” by Hospital & Healthcare Compensation Service. The report was published in cooperation with LeadingAge and supported by the National Center for Assisted Living. The report covers 20 management and 29 non‐management positions. In total, 1,360 assisted living communities participated in the study and provided data for over 87,400 employees. The report includes data from communities structured as assisted living facilities (80%), personal care facilities (5%), and residential care facilities (16%). The data are reported according to for‐profit (86%) and non-profit (14%) status, revenue size, unit‐size, state, and geographic region.

The full text of “Assisted Living Salary & Benefits Report” was published by Hospital & Healthcare Compensation Service. It can be purchased at https://www.hhcsinc.com/hcs-reports.html.

For more information, contact:

  • Rich Cioffe, Client Services, Hospital Healthcare & Compensation Service, Post Office Box 376, Oakland, New Jersey 08436; 201-405-0075, ext. 10; Email: rjcioffe@hhcsinc.com; Website: https://www.hhcsinc.com/

The Arizona Health Care Cost Containment System (AHCCCS) and the three Medicaid managed care organizations (MCOs) for the Arizona Long Term Care System (ALTCS) are implementing initiatives to increase the size of the state’s Medicaid long-term care workforce. The MCO contracts require the MCOs to build a long-term care workforce within their AHCCCS networks.

The ALTCS MCOs are Mercy Care, Banner-University Family Care, and United Healthcare Community Plan. The three organizations were awarded contracts in 2017. ALTCS provides acute care, long term care, behavioral health, home- and community-based services, and case management for two Medicaid populations that are served through separate contracting arrangements. AHCCCS requires in contract that each MCO hire a Workforce Development Administrator to routinely assess the capacity and capabilities of the contracted health care workforce, produce a Workforce Development Plan, and create and support workforce development initiatives that strengthen the long-term care workforce.

The ALTCS population includes nearly 56,000 beneficiaries who are aged 65 and older, blind, or disabled and who are at risk of institutionalization. More than 30,000 ALTCS beneficiaries have developmental disabilities. Their services are provided by UnitedHealthcare Community Plan and Mercy Care under contracts with the Arizona Department of Economic Security (DES) Division of Developmental Disabilities (DDD) effective October 1, 2019. AHCCCS also requires the DDD to have a workforce development administrator to build the long-term care workforce.

The state’s goal is “to ensure that Arizona is prepared to meet the projected need for licensed and unlicensed” caregivers in the coming decades, according to AHCCCS spokeswoman Heidi Capriotti. Ms. Capriotti said the MCO initiatives include supporting innovative high school-based technical education programs, developed by the Arizona Department of Education, that prepare graduating seniors to enter the long-term-care workforce. She also added that AHCCCS supports legislation to require training and testing of direct-care workers and assisted-living caregivers to help increase career mobility and decrease training and hiring costs..

PsychU last reported on this topic in “Arizona Medicaid Announces ALTCS Managed Long-Term Care Contract Awards,” which published on April 3, 2017. The article is available at https://www.psychu.org/arizona-medicaid-announces-altcs-managed-long-term-care-contract-awards/.

For more information, contact:

  • Heidi Capriotti, Media Relations and Public Information Officer, Arizona Health Care Cost Containment System, 801 East Jefferson Street, Phoenix, Arizona 85034; 602-417-4729; Email: Heidi.Capriotti@azahcccs.gov; Website: www.azahcccs.gov.

The Texas Health and Human Services Commission (HHSC) is expanding its Texas Targeted Opioid Response (TTOR) Emergency Medical Service (EMS) Emergency Response pilot program into the Austin area. TTOR uses emergency response services to connect opioid overdose survivors to integrated services needed for long-term recovery. These services include providing individuals, their families, and supportive allies with overdose reversal medication, as well as information on how to reverse an overdose. Those served are offered same-day initiation of medications used to treat opioid use disorder and alleviate withdrawal symptoms. Paramedics and peer recovery coaches also provide ongoing support to individuals to assist in their recovery and engagement in long-term treatment. Paramedics and peer recovery coaches can refer individuals to outside services when needed.

HHSC is working with Austin-Travis County Emergency Medical Services (ATCEMS) to help provide TTOR services. On September 19, 2018, the Substance Abuse and Mental Health Administration (SAMHSA) awarded Texas $46.2 million in State Opioid Response (SOR) funds to extend and expand HHSC’s response to the opioid crisis. On May 6, 2019, the state received a $24.1 million supplemental award under this grant bringing total potential SOR funding to over $116 million over the two-year period.

Since 2018, the state has implemented TTOR in Bexar, Harris, and Williamson counties. Each site receives about $500,000 annually from the HHSC to fund the pilot services. The pilot sites are selected according to various characteristics such as overdose rates, existing community resources, existing infrastructure, and population, to test models that could be easily replicated in other counties. HHSC said in Harris County, 85% of the program’s 500 participants received and remained in treatment for more than 30 days. HHSC will select nine additional pilot sites based on community need, interest, and the ability to implement the program, however a timeline for future implementation has not been established.

The TTOR program was originally created in May 2017. TTOR funding comes to HHSC through federal grants awarded by SAMHSA. Federal grant funding covers the cost of the evidence-based prevention, treatment, and recovery support strategies. As soon as a person participating in an EMS Opioid Response pilot program transitions from the treatment induction phase into long-term treatment, a determination is made whether the cost of long-term treatment is covered by private health care insurance, Medicaid, or if the person is eligible for state-funded treatment. TTOR encompasses four grant opportunities from SAMHSA totaling more than $176 million over the expected funding periods. The funding for all grants is awarded evenly on an annual basis, with the ability to extend contingent on availability of federal funds. The grants include:

  1. State Targeted Response (STR) funds: $54,724,714. This was a two-year grant in effect from May 1, 2017 to April 30, 2019.
  2. SOR funds: $116,589,770. This is a two-year grant in effect from September 30, 2018 to September 29, 2020.
  3. The Texas Strategic Prevention Framework for Prescription Drugs (SPF-Rx) grant: $1,858,080. This is a five-year grant in effect from September 1, 2016 to August 31, 2021.
  4. The Texas First Responders – Comprehensive Addiction and Recovery Act (FR-CARA) grant: $3,200,000. This is a four-year grant in effect from September 30, 2017 to September 29, 2021.

For more information, contact: Lisa Ramirez, Director, Texas Targeted Opioid Response, Texas Health and Human Services Commission, 4900 North Lamar Boulevard, Austin, Texas 78751-2316; 512-380-4955; Email: Lisa.Ramirez@hhsc.state.tx.us; Website: https://hhs.texas.gov/

On February 3, 2020, Epic, an electronic health record (EHR) vendor, asked its health system clients to sign on to a letter urging the federal Department of Health and Human Services (HHS) to modify a pending federal interoperability rule to address concerns about consumer privacy, non-standardized data exchange, lack of protection of the intellectual property of EHR developers, and the proposed implementation timeline for fines. The letter says, “While we support HHS’ goal of empowering patients with their health data and reducing costs through the 21st Century Cures Act, we are concerned that ONC’s Proposed Rule on interoperability will be overly burdensome on our health system and will endanger patient privacy. Specifically, the scope of regulated data, the timeline for compliance, and the significant costs and penalties will make it extraordinarily difficult for us to comply.” Some 60 health systems signed the letter, which was then sent to the federal Department of Health and Human Services (HHS).

HHS is preparing to release two interoperability rules, one from the Office of the National Coordinator of Health Information Technology (ONC) and the other from the Centers for Medicare & Medicaid Services (CMS) to support the 21st Cures Act and MyHealthEData. The ONC proposed rule was released in March 2019; the final rule is expected in early 2020. It had not been released as of February 16, 2020. ONC proposed adopting Health Level Seven’s (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standards as the standard to which developers must certify their application programming interfaces (APIs) and proposes language to support an ecosystem for the secure flow of information. The goal is to promote secure and more immediate access to health information for consumers and their health care professionals. Use of standardized APIs is intended to allow individuals to use smartphones and other mobile devices to easily and securely access structured and unstructured electronic health information.

In the letter, Epic and the health systems recommended that HHS make the following changes to the proposed rule:

  • Allow health systems to hold companies that seek access to consumer data to the same privacy and security standards elsewhere in the health care industry. Health information about family members should not be used or disclosed by non-HIPAA regulated organizations without family members’ knowledge and permission.
  • Standardize data exchange, and focus the rule on the medical and financial data that is most useful to the consumer and can be exchanged in a standardized format. The rule should not require exchange of non-standardized data, even if there are existing APIs.
  • Protect the intellectual property of EHR developers to allow them to continue to innovate for health systems and consumers.
  • Give organizations at least 12 months to prepare before information blocking is enforced and 36 months for development of new technology required by the rule. Further, HHS should allow a grace period for education before fines are levied.

Epic’s letter was signed by the following health systems: Access Community Health Centers; Community Health Center Network, Alameda Health Consortium; Altru Health System; Atrius Health; Adventist Health Portland; Affirmant Health Partners; Lovelace Health System; Arc; UT Health Athens; Ardent Health Services; Bay Health; Buffalo Medical Group; Christie Clinic; Deaconess Health System; Genesis Healthcare System; Catholic Health; Community Health Network; Exact Sciences, Group Health Cooperative, South Central Wisconsin; Charlotte Eye Ear Nose & Throat Associates; Confluence Health; Fresenius Medical Care; Gundersen Health System; Guthrie; HonorHealth; Institute for Family Health; Mercy; UnityPoint Health-Meriter Hospital; Hospital Sisters; HSHS Wisconsin; Iowa Specialty Hospitals & Clinics; Mercy Care; VHS; HSHS St. Clare Memorial Hospital; HSHS St Joseph’s; HSHS Illinois; Mary Washington Healthcare; Mercy Health Services; Middlesex Health; Beth Israel Lahey Health, Mt. Auburn; NYU Langone Health; PeaceHealth; Piedmont Healthcare; Northshore’s Evanston Hospital; OhioHealth; Pembia County Memorial Hospital; Pine Rest Christian Mental Health Services; Norton Healthcare; Parkview Health; Permanente Dental Associates; Prevea Health; River Valley Primary Care Services; Singing River Health System; University Health System; Vancouver Clinic; Riverside; Southcoast Health; Titus Regional Medical Center; UT Health San Antonio; Wellstar Medical Group; Self Regional Healthcare; SSM Health; UHS Inc. and UHS Hospitals; UW Health; and West Virginia University Health System.

PsychU reported on the ONC proposed rule in “HHS Issues A Proposed Rule For API Standards For Electronic Health Information,” which published on April 1, 2019. The article is available at https://www.psychu.org/hhs-issues-a-proposed-rule-for-api-standards-for-electronic-health-information/.

For more information, contact:

  • Epic Systems, 1979 Milky Way, Verona, Wisconsin 53593; 608-271-9000; Fax: 608-271-7237; Email: info@epic.com; Website: https://www.epic.com/
  • Peter Ashkenaz, Media Contact, Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, 330 C Street Southwest, Floor 7, Washington, District of Columbia 20201; 202-260-6342; Email: peter.ashkenaz@hhs.gov; Website: https://www.healthit.gov/topic/laws-regulation-and-policy/notice-proposed-rulemaking-improve-interoperability-health
  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

On December 23, 2019, the state of Georgia submitted the Georgia Pathways 1115 Demonstration Waiver and the Georgia Access 1332 State Relief and Empowerment Waiver to the federal government. The 1115 waiver requests approval to implement a partial Medicaid expansion, and impose premiums, copayments, and requirements for community engagement of at least 80 hours per month. Although there are the approximately 408,000 adults in the state who earn less than 100% federal poverty level (FPL) and do not currently qualify for Medicaid, the state estimates first year enrollment at 25,000, and thereafter, at about 50,000 annually.

The population eligible for Georgia Pathways includes parents, caretakers, or guardians with household incomes from 35% to 100% of the FPL who are not currently eligible for Medicaid. It also includes adults ages 19 to 64 without dependent children with household incomes up to 100% of the FPL who are not currently eligible for Medicaid. The state intends to enroll the expansion population into alternative benefit managed care programs operated by its current four Medicaid Care Management Organizations: Amerigroup Community Care, CareSource, Peach State Health Plan, and WellCare.

As a precondition for coverage through Georgia Pathways, potential beneficiaries must meet the income eligibility and must meet a threshold of 80 hours per month of engagement in a qualifying activity such as employment, community service, or education, and have an income less than 100% of the FPL. Georgia Pathways beneficiaries can participate in job training for no more than six weeks during any 12-month period. Community service must be limited to projects that serve a useful community purpose in fields such as health, social service, environmental protection, education, urban or rural redevelopment, welfare, recreation, public facilities, public safety, and child care. Individuals who meet the income eligibility but not the engagement hours requirement will not be enrolled in Georgia Pathways. Short-term exceptions to the monthly hours requirement will be available in the case of a family emergency, birth or death of a family member, serious illness or hospitalization of the beneficiary or a family member, severe inclement weather, and temporary homelessness.

DCH seeks a waiver of non-emergency transportation benefits, and a waiver to retroactive and presumptive eligibility, with the goal of making the benefit package more consistent with commercial plan benefits. However, young adult beneficiaries ages 19 and 20 years will be eligible for Medicaid state plan benefits for Early and Periodic Screening, Diagnostic, and Treatment services.

Beneficiaries earning between 50% and 100% of the FPL will be required to pay premiums and copayments. The premiums, which will not exceed more than 2% of household income, will be deposited into a Member Rewards Account, which the member can use to cover copayments or purchase other health-related items. Failure to pay premiums for three months will result in disenrollment. The waiver will implement a mandatory premium assistance program for employer-sponsored insurance.

A link to the full text of “Georgia Pathways To Coverage 1115 Demonstration Waiver” may be found in at www.openminds.com/market-intelligence/resources/122319gapathwayswaiver.htm.

For more information, contact

  • Fiona Roberts, Press Secretary, Georgia Department of Community Health, 2 Peachtree Street, Atlanta, Georgia 30303; 404-651-7086; Email: fiona.roberts@dch.ga.gov; Website: https://dch.georgia.gov

Sixteen U.S. states allow home health care aides to work only 40 hours per week to avoid violating the Department of Labor (DOL) Home Care Rule. These states include Arkansas, Florida, Idaho, Kansas, Kentucky, Maine, Montana, New Hampshire, New Jersey, New Mexico, Oklahoma, Iowa, Missouri, Tennessee, Virginia, and Wyoming. Thirty-two states allow home care aides to work more than 40 hours per week, but set a cap on the number of hours that can be worked without special permission. In these states, the capped hours typically range from 45 to 50 hours. This variation comes from varied interpretations of the DOL’s rules affecting hours worked for in-home personal care aides who provide home- and community-based services.

Additional findings of a study assessing compliance with fair labor laws for home care aides include:

  • Seventeen states have an exceptions policy for individuals who need more hours of home care service than the state’s cap allows. These states include California, Connecticut, Florida, Georgia, Hawaii, Illinois, Kentucky, Massachusetts, New York, Ohio, Pennsylvania, South Carolina, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. (Specific information on the exceptions policy could not be determined.)
  • Thirteen states allow self-directing program participants exercising budget authority to authorize overtime pay if they have sufficient funds in their budgets to cover the costs. These states include Alabama, Arizona, Colorado, Florida, Georgia, Kansas, Illinois, Louisiana, Minnesota, New Jersey, North Carolina, Texas, and West Virginia.
  • Eleven states allow claiming of the live-in exemption to the overtime pay requirement. These states include Colorado, District of Columbia, Georgia, Illinois, Kansas, New Jersey, Pennsylvania, Vermont, Virginia, West Virginia, and Wisconsin.

The DOL issued the final Home Care Rule on October 1, 2013. This rule was put in place to update regulations concerning the Fair Labor Standards Act of 1938 (FLSA) domestic service employee exemptions. The Home Care Rule extended minimum wage and overtime protections to most home care workers. This ensured that these workers had the same basic wage protections as most United States workers, including those who provide similar types of assistance to people with disabilities residing in nursing homes and group homes.

The U.S. Department of Justice together with HHS’s Office of Civil Rights and, separately, the HHS Centers for Medicare & Medicaid Services issued written guidance regarding this rule. The guidance specifically counseled states to avoid imposing a 40-hour hard cap limiting the Medicaid billable hours per week that workers employed by self-directing program participants would be permitted to work, with no or only very restricted exceptions. The guidance cautioned states that if workers’ hours were limited to 40 per week without hardship exceptions, this could result in putting Medicaid program participants living at home at high risk of requiring nursing home placement or other adverse consequences associated with unmet needs for assistance with daily living tasks. This would violate the Supreme Court’s 1999 Olmstead ruling affirming the rights of people with disabilities of all ages under the 1990 Americans with Disabilities Act. The ruling stated that these people should receive Medicaid or other disability-related publicly-funded services to which they were otherwise entitled in non-institutional settings, unless medically harmful.

These findings were reported in “Analysis Of State Efforts To Comply With Fair Labor Standards Act Protections To Home Care Workers” by Pamela J. Doty, Ph.D., and Marie R. Squillace, Ph.D., of the Office Of The Assistant Secretary For Planning And Evaluation (ASPE) within the U.S. Department Of Health And Human Services, and by Edward Kako, Ph.D., of Mission Analytics Group, Inc. The researchers first conducted interviews with a home health care stakeholder group to gather information. The researchers then collected data on self-directed home care programs from the period January 2017 through July 2019. Case studies were also conducted to illustrate both state variations in FLSA implementation and adoption of promising practices. The goal was to describe and document changes states have made to their Medicaid or other publicly-funded consumer directed home care programs for seniors and individuals with disabilities to comply with the 2013 update to FLSA regulations.

A link to the full text of “Analysis Of State Efforts To Comply With Fair Labor Standards Act Protections To Home Care Workers” may be found at www.openminds.com/market-intelligence/resources/010820aspeflsahomecarestatecompliance.htm.

PsychU last reported on this topic in “DOL Opinion Allows Pay For Home Health Aides To Vary Weekly As Long As Meeting Minimum Wage Standards,” which published on February 11, 2019. The article is available at https://www.psychu.org/dol-opinion-allows-pay-home-health-aides-vary-weekly-long-meeting-minimum-wage-standards/.

For more information, contact:

  • Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services, 200 Independence Avenue Southwest, Room 415F, Washington, District of Columbia 20201; 202-690-7858; Website: https://aspe.hhs.gov/

On November 21, 2019, the U.S. Department of Justice (DOJ) indicted four former employees of Outcome Health—including the two co-founders and two former executives—for defrauding the company’s clients, lenders, and investors of an estimated $1 billion. Prior to January 2017, the company was known as ContextMedia. It sold digital advertising in physician offices; most of its clients were pharmaceutical companies. The defendants are accused of selling millions of dollars of advertising inventory from 2011 to 2017 that did not exist, which inflated its financial statements. The DOJ alleged that the former executives used the inflated financials to raise nearly $1 billion in debt and equity financing in 2016 and 2017.

Outcome Health itself is not under indictment; it entered a Non-Prosecution Agreement (NPA) with the DOJ on October 30, 2019. After the fraud surfaced, Outcome Health engaged in “extensive remedial measures” including requiring the co-founders to give up all financial interests in the company or representation on the company’s board, and retaining a new management team. Additionally, Outcome Health provided more than $65 million in restitution to its client pharmaceutical companies.

The company provided physician practices with free waiting-room video screens, consumer-education tablets, wallboards, wi-fi access points, and free health education content. The platform provided consumers at the physician practices with health care information and advertising. The content library included assessments, 3D anatomical models, recipes for healthy living, and information about treatment options. ContextMedia/Outcome Health generated revenue by selling ads on the platform.

The DOJ alleged that Outcome sold advertising inventory—digital tablets in physician offices—that the company did not have, and then under-delivered on its advertising campaigns. Outcome allegedly invoiced its clients as if it had delivered in full. The indicted former executives and employees are accused of concealing the under-deliveries by falsifying affidavits and proofs of performance to make it appear that Outcome was meeting its contract requirements. The defendants allegedly inflated consumer engagement metrics for how frequently consumers in the physician offices engaged with Outcome’s tablets that provided health education and targeted advertising. Additionally, some of the contracts included return on investment (ROI) guarantees. One of the defendants is accused of altering studies presented to clients to make it appear that the digital campaigns were more effective than they actually were.

The under-delivery resulted in a material overstatement of Outcome’s revenue for 2015 and 2016. The company’s outside auditor signed off on the 2015 and 2016 revenue numbers because the indicted individuals fabricated data to conceal the under-deliveries from the auditor. The inflated revenue figures in Outcome’s 2015 and 2016 audited financial statements were allegedly used to raise $110 million in debt financing in April 2016, $375 million in debt financing in December 2016, and $487.5 million in equity financing in early 2017. The co-founders were allegedly paid dividends totaling $37.7 million on the $110 million debt financing. The $487.5 million equity financing allegedly resulted in a $225 million dividend to the co-founders.

On November 7, 2017, the investors sued the founders of the Company and related entities following a report that from 2014 through 2016 the company misled advertisers about the number of physician offices using the health education platform. The lawsuit, Global Private Opportunities, et al., v. Rishi Shah; Outcome Holdings, LLC; ContextMedia Health Holdings, LLC; Outcome, Inc.; Gravitas Holdings, LLC; and Shradha Agarwal, came after the company had announced on September 27, 2017 that its network included more than 140,000 installed devices, and that it had also recently received independent certification from BPA Worldwide iCompli that the platform size estimates and audience qualification complied with industry standards. On October 19, 2017, Outcome Health announced it was taking steps to ensure transparent and accurate impression measurement. On November 15, 2017, the company announced it had joined the IAB, a large trade association for digital advertising and marketing comprised of more than 650 media and technology companies that sell, deliver, and optimize digital advertising and marketing campaigns.

A link to the full text of “October 17, 2019 Letter From the DOJ Regarding Outcome Health” may be found at www.openminds.com/market-intelligence/resources/101719dojletterreoutcomehealth.htm.

A link to the full text of “Department Of Justice Indictment Of Former Outcome Health Employees” may be found at www.openminds.com/market-intelligence/resources/112119outcomehealthindictment.htm.

A link to the full text of the 2017 investor lawsuit, “Global Private Opportunities, et al., v. Outcome Health, et al.,” may be found at www.openminds.com/market-intelligence/resources/110717lawsuitoutcomehealth.htm.

For more information about Outcome Health, contact:

  • Kendall Day, Partner, Gibson, Dunn & Crutcher, LLP, 1050 Connecticut Avenue Northwest, Washington, District of Columbia 20036-5306; Email: kday@gibsondunn.com; Website: https://www.gibsondunn.com/lawyer/day-m-kendall/.

On Jan. 17, 2020, the Department of Veterans Affairs (VA) proposed a rule that will ease compliance requirements for faith-based organization social service contractors. Currently, faith-based organization contractors are required to refer potential beneficiaries who object to the provider organization’s religious character to other organizations. The faith-based organizations must also post notices about this referral procedure. However, other contractors are not required to follow similar procedures about their referral policies. The proposed rule eliminates the referral notice requirements.

Comments on the proposed rule, “Equal Participation of Faith-Based Organizations in Veterans Affairs Programs: Implementation of Executive Order 13831,” will be accepted through Feb. 18, 2020. VA says the goal is to ensure that its social service programs are implemented in a manner consistent with the requirements of federal law, including the First Amendment to the Constitution and the Religious Freedom Restoration Act.

The proposed rule language clarifies that a faith-based provider organization participating in VA-funded programs or services can retain its autonomy, right of expression, religious character and independence from government (federal, state or local). None of the guidance documents that VA or a state or local government uses to administer VA’s financial assistance shall require faith-based organizations to provide assurances or notices where similar requirements are not imposed on secular organizations. Any restrictions on the use of grant funds shall apply equally to faith-based and secular organizations.

Additionally, VA’s notices or announcements of award opportunities and notices of awards or contracts will include language clarifying the rights and obligations of faith-based organizations that apply for and receive federal funding. The language will clarify the following:

  • Faith-based organizations may apply for awards on the same basis as any other organization.
  • VA will not discriminate against an organization based on the its religious exercise or affiliation.
  • Any faith-based organization that participates in a federally funded program retains its independence from the government and may continue to carry out its mission consistent with religious freedom protections in federal law.

A link to the full text of “Equal Participation of Faith-Based Organizations in Veterans Affairs Programs: Implementation of Executive Order 13831” may be found at www.openminds.com/market-intelligence/resources/011720vaprfbo.htm, and https://www.whitehouse.gov/presidential-actions/executive-order-establishment-white-house-faith-opportunity-initiative/.

For more information, contact:

  • Conrad Washington, Acting Director, Center for Faith and Opportunity Initiative, Office of Public and Intergovernmental Affairs, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, District of Columbia 20420; 202-461-7689; Website: https://www.va.gov/cfbnpartnerships/
  • Public Relations, U.S. Department of Veterans Affairs, 810 Vermont Avenue Northwest, Washington, District of Columbia 20420; 202-461-7600; Email: va.media.relations@va.gov; Website:https://www.va.gov/. 

For 2020, about 2% of eligible clinical professionals participating in the Medicare Merit-based Incentive Payment System (MIPS) earned a negative payment adjustment ranging from -0.01% to -5.00%. The remaining 98% of MIPS participants received a positive or neutral payment adjustment, ranging from 1.68% to 0.00%, based on their 2018 MIPS performance data. The Centers for Medicare & Medicaid Services (CMS) noted that the positive payment adjustment received in 2020 is modest because under current law, the positive and negative payment adjustments must be budget-neutral. In general, if a clinical professional is eligible for MIPS, they will choose whether to participate at the individual or group level.

CMS reported the 2018 Quality Payment Program (QPP) performance results and payment adjustments in a January 6, 2020 blog post. In total, 889,995 clinical professionals received a MIPS payment adjustment in 2018, either positive, neutral, or negative. Of the total number of clinical professionals receiving a payment adjustment, 872,148 MIPS eligible clinical professionals will receive a neutral or positive payment adjustment through their individual, group, or Alternative Payment Model (APM) participation.

In total, 183,306 eligible clinical professionals earned Qualifying APM Participant (QP) status under the Advanced APM track of the QPP. Another 47 eligible clinical professionals received partial QP status during 2018. In 2017, the number of eligible clinical professionals who met QP status was 99,076 and partial QP status was 52.

CMS noted significant successes in MIPS participation during the second year of the program. The MIPS participation rate was higher in 2018 than in 2017, which was the first year of the program. More clinical professionals avoided a negative payment adjustment, 2% in 2018 compared to 5% in 2017. The overall national average and median MIPS scores increased from 2017. Additionally, those who participated in MIPS through an APM had a mean score of 98.77 and a median score of 100.

Based on MIPS 2018 data, the payment adjustments were as follows:

  • 84% of MIPS eligible clinical professionals received an additional adjustment for exceptional performance (with scores of 70.00 to 100.00 points). The minimum payment adjustment for this group was 0.21% and the maximum was 1.68%.
  • 13% of MIPS eligible clinical professionals received a positive adjustment for earning between 15.01 and 69.99 points. The minimum payment adjustment was 0.00% and the maximum was 0.20%.
  • No MIPS eligible clinical professionals earned 15.00 points to earn a neutral payment adjustment of zero.
  • 2% of MIPS eligible clinical professionals earned 0 points to receive a negative payment adjustment ranging from -0.01% to -5.00%.
  • 97% of MIPS eligible clinical professionals in rural practices received a positive payment adjustment, compared to 93% in 2017.
  • 84% of MIPS eligible clinical professionals in small practices received a positive payment adjustment, up from 74% in 2017.

MIPS is one track of the QPP established to implement certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MIPS requires eligible clinical professionals to submit performance data on certain measures and activities in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. Performance in the four categories determines whether participating MIPS eligible clinical professionals receive a positive, neutral, or negative adjustment to their Medicare part B allowed charges for covered professional service under the Physician Fee Schedule. Three of the four performance categories allow the MIPS eligible clinical professional to choose the measures and activities they report. In the 2017 and 2018 performance years, MIPS eligible clinical professionals included physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, osteopathic practitioners, and chiropractors who billed Medicare Part B covered professional services. MIPS eligible clinical professionals who did not participate in MIPS for the 2017 performance period were subject to a negative 4% payment adjustment in 2019.

The CMS announcement is posted online at https://www.cms.gov/blog/2018-quality-payment-program-qpp-performance-results (accessed January 22, 2020).

For more information, contact

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: https://www.cms.gov/.

This fact sheet provides an overview of long-acting injectable antipsychotics and the advantages/disadvantages associated with this treatment option.

Serious mental illness (SMI) is a disabling condition—and because it develops early in life, it brings with it a lifetime of costs. But while researchers have long believed that early intervention for SMI has lifelong benefits for patients, there has been little evidence that weighs whether these efforts can be considered cost effective.

This led a team of researchers and scientists to employ a simulation model to attempt to estimate the lifetime costs of SMI for patients diagnosed by age 25. In “Measuring the Lifetime Costs of Serious Mental Illness and the Mitigating Effects of Educational Attainment,” these scholars provide current outcome statistics and present their methodology and the conclusions for measuring the potential economic effect of early intervention.

SMI’s Effects and the Intervention Opportunity: A Quick Overview

As noted, serious mental illness (SMI)—including psychoses, major depressive disorder, and bipolar disorder—is disabling and costly, with an economic impact that is similar to that of cancer and diabetes. And since it is often diagnosed between the ages of 15 and 30, SMI carries other costs, too. It impacts educational attainment and dropout rates, employment status, annual earnings, and even life expectancy, with previous reports documenting anywhere from 10 to 30 years of potential life lost.

But the trend toward early diagnosis and treatment of SMI as a means to improve patient-based and economic outcomes has continued to grow. Potential strategies integrate patient-centered interventions—such as addressing substance use disorders and relationship issues—with clinical trials that demonstrate the benefits of early interventions like medication management, family involvement, and education/employment support. Indeed, a variety of studies have shown such positive early intervention outcomes as:

  • Improved quality of life
  • Reduced depression
  • Increases in academic enrollment, course completion, and employment

However, evidence that defines the economic impact of these interventions has been limited.

Research Aimed at “Filling the Gap”

Based upon findings of various studies, it might be logical to infer that intervention strategies resulting in increased educational attainment and employment could improve the quality of life and reduce the lifetime financial burden of people with SMI. In fact, policy makers in the United States have been actively exploring potential strategies.

But efforts may be hindered because long-term benefits of these strategies have not been measured—and there is limited evidence of these interventions’ long-term return on investment (ROI). Researchers Seth A. Seabury et al. have thus attempted to fill that gap by providing new data on the lifetime benefits of improving educational or employment outcomes for people who experience SMI early in life, using a research model to project the impact on health and economic outcomes.

A Brief Look at Methodology

With the growing emphasis on early identification and treatment of mental illness to help improve long-term health and economic outlooks, the research team sought to obtain evidence via simulated differences in life expectancy, quality of life, medical spending, and economic outcomes.

The research team simulated lifelong outcomes using the Future Americans Model (FAM), a dynamic microsimulation model that uses data on Americans ages 25 and older to project health, medical spending, social service use, and economic outcomes over time. FAM builds estimates based on the paths of individual health and economic outcomes rather than on average characteristics—thus allowing for more accurate estimations.

FAM combines data from several large, nationally representative surveys. As a result, it enabled the research team to:

  • Estimate transitions between health state;
  • Project health care spending; and
  • Assess quality of life.

FAM also allowed the team to compare people with a self-reported diagnosis of SMI by age twenty-five to those without a diagnosis of SMI by age twenty-five, including those diagnosed later in life.

How FAM Was Used

The model measured transition probabilities for specified health states based upon predictors such as age, gender, and health condition as derived from questions in the nationally representative Panel Study of Income Dynamics (PSID).

Detailed information on simulation scenarios, trial details, and study limitations can be found in the report referenced below.

Simulation Revealed Key Findings

While outcomes varied based upon educational attainment, the overall findings during one year of simulation showed that those with an SMI diagnosis by age 25:

  • Have lower educational attainment. In the simulation, about 23.4% had less than a high school diploma, compared to 11.3 percent for those who never developed SMI.
  • A re more likely to be female and white. They also had more restrictions to activities of daily
  • Have a lower life expectancy. The average life expectancy from age 25 was 45.7 years—10.4 years (19%) lower than those without SMI by age
  • Have substantially higher lifetime medical spending. Total lifetime medical spending was $96,500 (24%) higher, even though people with SMI are much more likely to be on Medicaid or uninsured.
  • Earn substantially less over their lifetime. Earnings were an average of $537,100 (48%) less per person, with 2 (55 %) fewer years of full-time work. This also corresponded to increased lifetime benefit payments of 500% for Social Security Disability Insurance and 809% for Supplemental Security Income (SSI).

What Comes Next?

While early intervention to improve the educational attainment of people with SMI has clear benefits, interventions can be costly. But at the same time, a significant number of Seabury et al.’s simulations also demonstrated that, at least in part, early intervention can reduce the high economic burden.

Recap: The Opportunities and the Challenges

Overall, the simulation’s findings highlight both the opportunities and the challenges to improve SMI’s economic outcomes.

The Good News

  • An estimated $1.85 million per-patient cost can be reduced by $73,600 through use of an education-based intervention. Indeed, SMI patients as a whole experience nearly a quarter of a trillion dollars in economic burden, and improvement in educational attainment would reduce that by over $8.9 billion.
  • Relatively low-cost interventions that focus on helping young SMI patients enroll in school and have accommodations from/interaction with teachers and administrators can have large impacts on school participation.

The Challenge

While intervention can flexible and implemented across a variety of geographic settings (urban, suburban, and rural), these gains would be spread across many years, which suggests:

  • The potential need for public investment or subsidy
  • The hiring and training of additional providers

Many assessments of intervention programs focus on outcomes that can’t easily measure long-term effects, but Seabury et al.’s work has provided new evidence.

And resulting from their generally optimistic findings, the Seabury et al. team urges that future interventions and evaluations should use objective and clearly defined outcome measures that can be linked to publicly available data sources.

This, in turn, could foster additional measurement of the long-term economic impact of early interventions—and, potentially, provide further evidence that supports their adoption and leads to lifelong benefits for SMI patients.

This summation was developed independently of the authors.

The year after Cascadia Behavioral Healthcare (Cascadia) implemented a certified Community Behavioral Health Clinic (CCBHC) integrated care model, the number of emergency department (ED) visits was reduced by 18% and inpatient admissions by 23% among individuals who’d previously utilized the ED or inpatient facilities. Before implementing the CCBHC integrated care model in 2017, Cascadia reported 3.74 ED visits/inpatient admissions per consumer for April 2016 through April 2017. After becoming a CCBHC, Cascadia reported 3.07 ED visits/inpatient admissions per consumer for 2018. Cascadia reported the outcomes on December 17, 2019.

Cascadia anticipates that the reduction will result in substantially lower annual health care costs. The cost savings estimates are based on data from HealthShare, one of the state’s Medicaid coordinated care organizations (CCO). The CCO tracks ER utilization for adults age 18 and older with mental illness as a quality measure to reduce disparity in outcomes. The goal is to reduce the disproportionately higher emergency department utilization among those experiencing mental illness by increasing awareness and engagement with appropriate points of primary and mental health care. ED visits for mental health and chemical dependency services are not included in the ED visit count.

As a CCBHC, Cascadia introduced care coordination and primary care services to its continuum of care. Cascadia currently serves over 3,700 consumers.

Cascadia’s Chief Medical Officer Jeffrey Eisen said “These are significant results that support the need for continued funding for the CCBHC model, which has enabled an integrated care approach for our clients. By providing preventative and proactive services, we can significantly change quality of care and health outcomes for individuals, as well as reduce financial strain on our health care system and our payers.” Cascadia is continuing to refine its integrated model through population health efforts that emphasize diabetes management, chronic pain management, decreased emergency department utilization and medical admissions, and tobacco cessation.

For more information, contact:

  • Jennifer Moffatt, Senior Director of Communications, Cascadia Behavioral Healthcare, Post Office Box 8459, Portland, Oregon 97207; 503-402-8117; Email: jennifer.moffatt@cascadiabhc.org; Website: https://cascadiabhc.org/

Cigna reports its commercial members with integrated medical, pharmacy, and behavioral benefits had annual medical costs of averaging $207 less per covered life than members enrolled in non-integrated plans. For Cigna members with health improvement opportunities (such as weight management and smoking cessation), being enrolled in a plan with integrated benefits reduced annual medical costs by an average of $850 per person.

Per-person savings were realized for members with more intensive health needs who were enrolled in a combined plan. Per-person savings attributable to the combined plan totaled $7,372 for members with conditions requiring a specialty medication. For members with an oncology diagnosis, per-person savings totaled $11,679 and their inpatient oncology costs were 24% lower.

Members of Cigna’s integrated plans also were found to have:

  • 17% higher engagement in wellness programs including counseling for conditions such as diabetes and heart disease; lifestyle or wellness coaching to help with weight management and smoking cessation; and personal case management for complex conditions such as rheumatoid arthritis or cancer.
  • 32% lower mental health readmission rates.
  • 18% fewer out-of-network behavioral claims.
  • 5% higher utilization of in-network high-performing provider organizations.
  • 4% lower out-of-network claims.
  • 15% higher treatment rate for opioid misuse, and 30% reduction in subsequent post-treatment overdoses compared to the previous year.

Cigna reported these findings as the key outcomes of its fourth annual 2019 Value of Integration report. These findings are based on a two-year internal analysis of more than 2.3 million claims from Cigna customers who receive coverage through their employer. Half of the population had comprehensive medical, behavioral, and pharmacy benefits administered by Cigna, while the other half had only medical benefits with minimal behavioral benefits administered by Cigna. Customers were matched between the two groups on key attributes, including demographics, health condition, access to health improvement services, plan design, and geographies. The study methodology was reviewed and validated by KPMG LLP in 2018. However, KPMG did not conduct an independent analysis to verify any results, and KPMG did not audit the data or the programming code used to conduct the study.

Based on the findings, Cigna asserts that with connected medical, pharmacy, and behavioral health benefits customers are more engaged in their health and well-being and are more likely to stay in-network for their care. Cigna also believes that consumers enrolled in a plan with integrated benefits are more informed about their care options.

Cigna reported the 2019 Value of Integration report findings at https://www.cigna.com/newsroom/news-releases/2020/combining-medical-pharmacy-and-behavioral-benefits-delivers-annual-savings-of-more-than-850-per-customer-with-an-identified-opportunity (accessed January 23, 2020).

For more information, contact:

  • Meaghan MacDonald, Enterprise Media Relations, External Communications, Cigna Corporation, 3 Waterside Crossing, Windsor, Connecticut 06095; 860-226-0576; Email: Meaghan.MacDonald@cigna.com; Website: https://www.cigna.com/

A new U.S. Department of Veterans Affairs (VA) five-city pilot program pairs older veterans with volunteer “companions” to help these veterans remain in their homes, rather than move into health care institutions. The program is being piloted in five locations: San Antonio, Texas; Colorado Springs, Colorado; Las Vegas, Nevada; Pittsburgh, Pennsylvania; and Glendive, Montana.

The program called “Choose Home Initiative” relies on Senior Corps volunteers from the Corporation For National and Community Service (CNCS). The program partnership was first announced on June 27, 2019.

VA invested seed money to recruit and train about 250 volunteers, aged 55 or older, to help veterans in their homes. Senior Corps volunteers receive training about Veteran-specific concerns, including suicide awareness and prevention, before providing services in veterans’ homes. CNCS volunteers then assist veterans with activities of daily living, such as light housekeeping and preparing meals. They may also offer companionship and alert family members if issues arise. Respite care services are available through the volunteers who can stay with the veteran so the family caregiver can take time away from home. CNCS estimates the volunteers will serve approximately 600 households over a three-year period.

CNCS is the federal agency that leads national volunteering and service efforts. Senior Corps is a nationwide network of service programs for volunteers who commit their time to a wide range of community needs. CNCS mobilizes Senior Corps volunteers to provide homemaker and in-home respite care services to eligible veterans, so those veterans can remain in their own homes, live more independently, and stay close to their families, caregivers, and support services.

For more information, contact:

  • Samantha Jo Warfield, Media Contact, Corporation for National and Community Service, 250 E Street Southwest, Washington, District of Columbia 20525; 202-606-6775; Email: info@cns.gov; Website: https://www.nationalservice.gov/
  • Public Relations, U.S. Department of Veterans Affairs, 810 Vermont Avenue Northwest, Washington, District of Columbia 20420; 202-461-7600; Email: va.media.relations@va.gov; Website: https://www.va.gov/

Despite the well-known prevalence of mental health conditions, they are woefully undertreated. Consider this: About one in five Americans has a behavioral condition, but fewer than half—only 41%—receive treatment of any kind. Among those with a serious mental illness (SMI), only 37% have care.

One barrier to treatment is stigma, and another is access to individuals trained to intercede during a mental health crisis.

Looking at surveys finding that a large segment of the public trusts their community pharmacist, the authors of a concept paper published in Pharmacy (2019) offer a proposal. They suggest training pharmacists to recognize and respond to signs of emotional distress and mental illness in their customers, absent the judgment that comes with stigma. Authors Nathaniel Rickles of the Department of Pharmacy at the University of Connecticut, Albert Wertheimer of Nova Southeastern University’s pharmacy department, and Yifan Huang—who, like Rickles, hails from the University of Connecticut’s Department of Pharmacy—explicate their proposal in “Training Community Pharmacy Staff How to Help Manage Urgent Mental Health Crises.”

Deploying pharmacists in the service of helping customers in crisis requires that pharmacists recognize signs of mental illness, they possess the capacity to intervene, and they examine and reckon with stigma—society’s stigma, individuals’ self-stigma, and their own stigmatizing attitudes to those with mental illnesses.

Need on a Continuum

The authors point out that behavioral health exists on a continuum, from mental wellness to mental illness:

Mental Wellness Struggling Mental Illness
Typified by predictable mood changes, readiness to face challenges, sense of humor, competent performance of daily work and life tasks, healthy sleep patterns, energy to get things done, and avoidance of excessive substance use and addictive behaviors. Characterized by mood fluctuations, difficulty facing challenges, little sense of humor, diminished performance of work and life obligations, irregular sleep, lower levels of energy, anxiety, and engagement in unhealthy behavior patterns. Significant mood fluctuations that may include outbursts, labile moods, intense anger or anxiety, unusual thoughts and behaviors, disrupted sleep, dysfunction in the performance of work and life tasks, substance use and/or addictive behaviors, and self-harm or harm to others.

Some individuals have behaviors that span the continuum, and some have general mental wellness but go through a period of struggle. The point is that when a crisis occurs, intervention can be very helpful—indeed, in some circumstances, lifesaving.

Why Pharmacists?

Effects of Poor Mental Health

·         Greater comorbidity compared with the general population.

·         Earlier death (average: 25 years less).

·         Diminished quality of life.

·         Significant health care costs.

·         Economic losses to the tune of $193.2 billion per year.

Pharmacists are widely accessible, serving numerous clients on any typical day. Rickles and his coauthors points to the results of a 2012 study by The College of Psychiatric and Neurological Pharmacy (CPNP) and the National Alliance on Mental Illness (NAMI). Surveying 1,031 people who either had some kind of behavioral health condition or cared for someone with such a condition, CPNP/NAMI found that 91% of respondents felt very comfortable in their community pharmacy, and 81% felt that their pharmacist respected them.

Not a bad base from which to launch outreach efforts, in other words.

The Impact of Stigma

Stigma is pernicious, infecting society such that people distrust, dislike, and even fear those with mental illness. And it creeps into the consciousness of those who are struggling with a mental health condition, poisoning them against themselves and dissuading many from seeking help that could heal them and improve their lives.

Health care professionals, including pharmacists, are by no means free of stigmatizing attitudes. The authors write that studies have generally found that while pharmacists have positive views of people with mental illness, they are often uncomfortable with those individuals. Getting beyond stigma, then, becomes part of the effort to help when there is a need.

Rx: Mental Health First Aid

Mental Health First Aid is a program that trains anyone from any walk of life how to recognize and respond to someone having a mental health crisis. The brainchild of two Australian researchers, it was launched in 2001 and it has proven effective in reducing stigma and aiding in outreach to those who are suffering. The National Council of Behavioral Health recommends the eight-hour program for anyone with frequent contact with those who may be in crisis, such as police officers, front-line care providers, and clergy. The National Community Pharmacist Association developed a version of the course specifically for pharmacists, using pharmacy-specific examples.

Mental Health First Aid consists of these steps, represented by the acronym ALGEE:

  • Assess for signs of suicide or harm.
  • Listen non-judgmentally.
  • Give reassurance and information.
  • Encourage appropriate professional help.
  • Encourage self-help and other support strategies.

Studies among different populations—among them university students, pharmacy graduate students, and pharmacists—found good results from the Mental Health First Aid program. The primary effects were these:

  • Reductions in stigma, which might prevent outreach.
  • Better recognition of signs of mental illness.
  • Greater confidence in the ability to intervene in a crisis and assist an individual in distress.

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 summation was prepared independently of the authors.

The authors declare no conflicts of interest, and this research involved no external funding.

Mental health providers may detect a small portion of their patients who experience increased symptom severity.1 Implementing symptom-rating scales to monitor outcomes helps promote communication and may provide objective data which can be factored into treatment plans. During this PsychU webinar, the speakers identify four levers to optimize clinical and mental health provider performance.

Featuring:

  • Greg Downing, DO, PhD
    Founder, Innovations Horizons, LLC
  • Rebecca Plonsky, LICSW
    Corporate Director of Business Development, Fellowship Health Resources, Inc

Greg Downing, DO, PhD, currently serves as the Founder of Innovations Horizons, LLC, a Washington, DC–based consultancy focused on the applications of data in health care delivery transformation initiatives. At Innovation Horizons, LLC, Dr. Downing assists organizations by designing programs, strengthening infrastructure, and enhancing leadership capabilities that are aimed collectively at raising their innovation capacity. Dr. Downing is also Adjunct Professor of Practice at Georgetown University, where he leads the innovation in health care management track. Dr. Downing’s current research interests are in metrics and outcomes-based approaches to health care transformation, including specialty interests in behavioral entrepreneurship and social impact innovation practices. He is the author of more than 80 peer-reviewed publications, as well as multiple books and monographs on biomedical and health care research practices.

Rebecca Plonsky currently serves as Corporate Director of Business Development for Fellowship Health Resources, Inc., in addition to being a senior associate at OPEN MINDS. Prior to joining OPEN MINDS, Ms. Plonsky served as the National Vice President of Development for Prospect Integrated Behavioral Health, part of Prospect Alta Hospital Systems, LLC. Based in the Northeast, Ms. Plonsky was responsible for national growth and development of the integrated behavioral health service lines, and she was assigned to lead multiple projects to improve care quality. Ms. Plonsky also served as the Senior Behavioral Health Program Manager for the Rhode Island Executive Office of Health & Human Services. The primary leader for the division, she was responsible for behavioral health Medicaid strategy, program innovation and implementation, policy, and contracting.

On December 11, 2019, Blue Cross Blue Shield of Michigan (BCBSM) announced a new “Blueprint for Affordability” payment model. Under the model, seven preferred provider organizations (PPOs) that provide care to BCBSM members will share financial risk for consumer care and consumer outcomes.

The risk-sharing agreements became effective January 1, 2020 and cover Blue Cross Commercial PPO and Medicare Advantage PPO plans. “Blueprint for Affordability” participating organizations represent approximately 30% of the state’s total Commercial PPO and Medicare Advantage market. The seven PPOs include:

  • Ascension Michigan (Genesys Provider Health Organization physician-hospital organization (PHO), Partners in Care, St. Mary’s PHO)
  • Henry Ford Health System
  • Michigan Medicine
  • Oakland Southfield Physicians
  • The Physician Alliance
  • Trinity Health – Michigan (Saint Joseph Mercy Health System, Mercy Health, Mercy Health Physician Partners, Integrated Healthcare Associates)
  • United Physicians

The goals of the Blueprint for Affordability payment model include: improve quality of care; avoid unnecessary tests, scans, and emergency room visits; reduce complications and rehospitalizations; and better coordinate consumer care across all points of service. Under the model, health systems and physician organizations agree to annual targets for the cost of providing care to Blue Cross members. Aggregate costs that come in below those financial targets will result in financial rewards for the provider organizations involved. If costs cannot be managed within the target, the provider organization will rebate Blue Cross, and ultimately its consumers, a portion of the amount spent beyond the target. This enables costs to be predictable for Blue Cross customers, and encourages the provider organizations to improve care delivery cost, quality, efficiency, and coordination.

For more information, contact: 

  • Meghan O’Brien, Public Relations & Social Media Manager, Blue Cross Blue Shield of Michigan
    600 East Lafayette Boulevard, Detroit, Michigan 48226-2927, Phone: 313-549-9884, Email: newsroom@bcbsm.com, Website: https://bcbsm.com/

A pilot collaboration program between Georgetown Home Care (GHC) and Medstar Georgetown University Hospital reduced preventable readmissions by 44% among people who had spinal surgery. Within two months, the readmission rate dropped from 12.1% to 6.7%.

The collaboration is called the Key Program. For the program, GHC nurse practitioners trained in hospital readmission mitigation, visit recently discharged consumers in their homes. The first visit takes place within 48 hours of discharge. In the initial visit, and in subsequent visits over the next few weeks, the nurse practitioner helps coordinate the consumer’s care with the hospital staff and the consumer’s primary care physician. The goal is to ensure a smooth and safe transition home.

According to Ruth Adonizio, Director of Readmission Reduction at Medstar Georgetown University Hospital, after the pilot ended, the readmission rate returned to the previous level. Based on the pilot outcomes, GHC signed a contract with Medstar Georgetown University Hospital to continue and expand this program to more departments within the hospital for fiscal year 2020.

GHC is a non-medical home care and staffing agency in the District of Columbia metro area. It provides a wide range of in-home care services and relevant workforce solutions in the District of Columbia, Maryland, and Virginia.

For more information, contact:

  • John Bradshaw, Owner, Georgetown Home Care, 3301 New Mexico Avenue, Suite 214, Washington, District of Columbia 20016, Phone: 202-831-4536, Email: johnbradshaw@georgetownhomecare.com, Website: https://www.georgetownhomecare.com

Approximately 87.8% of workers with disabilities had health insurance in 2017. This was a 7.9 percentage point increase from 79.9% in 2009, prior to the implementation of the Patient Protection and Affordable Care Act (PPACA). Despite coverage gains, cost-related barriers to accessing medical care did not change much after the PPACA for any group. Workers with disabilities experienced an increase in structural access barriers, from 18.4% before PPACA to 24.8% after PPACA. People with disabilities are defined as those who report being limited in the type or amount of work they can perform due to a physical, mental, or emotional problem.

The increase in health insurance for workers with disabilities was the result of an 11 percentage point increase in the share of that population with Medicaid coverage between 2014 and 2017 (compared with 2001 through 2009), and a five percentage point increase in privately purchased coverage over those periods. These increases were accompanied by an 11 percentage point decline in the share with employer-sponsored coverage.

Researchers concluded that the gain in insurance coverage for workers with disabilities is an important benefit of the PPACA. However, they recommended more investigation and monitoring to understand whether PPACA coverage will translate into improvements in access to needed health care.

These findings were reported in “Insurance Coverage And Access To Care For Workers With Disabilities, 2001–2017” by Anna Hill, M.H.A., Ph.D.; and Jody Schimmel Hyde, Ph.D. The researchers analyzed data from 2007 through 2017 from the National Health Interview Survey. The goal was to determine how PPACA changed insurance coverage and access to care for workers with disabilities, and compare those changes to changes among other groups.

The full text of “Insurance Coverage And Access To Care For Workers With Disabilities, 2001–2017” was published in January 2020 by Disability and Health Journal. An abstract is available online at https://www.sciencedirect.com/science/article/pii/S1936657419301530 (accessed January 20, 2020).

For more information, contact:

  • Jody Schimmel Hyde, Ph.D., Researcher, Mathematica Policy Research, 1100 First Street Northeast, 12th Floor, Washington, District of Columbia 20002, Email: jschimmel@mathematica-mpr.com, Website: https://www.mathematica.org/

On January 1, 2020, Indiana implemented a Medicaid waiver amendment that will allow the state to receive reimbursement for short-term services for people age 19 to 64 with serious mental illness (SMI) who are treated at privately run institutions for mental disease (IMD). The waiver excludes treatment provided at Indiana’s six state-operated psychiatric hospitals. This waiver amendment augments an earlier waiver approved on February 1, 2018, that allows the Indiana Family and Social Services Administration (FSSA) to reimburse for inpatient treatment in private IMDs for Medicaid members with a primary diagnosis of an addiction disorder. FSSA implemented that waiver’s IMD provisions in early 2018, and according to an interim evaluation released in October 2019, by the end of calendar year 2018, there were 17 Medicaid-enrolled IMDs that provided addiction treatment to 4,026 beneficiaries. Without the waivers, Medicaid statutes prohibit federal reimbursement for services provided in an IMD, which is defined as any hospital, nursing facility, or other institution with more than 16 beds that provides treatment primarily for people with mental illness.

Under this new waiver amendment, the IMD services will be covered for beneficiaries with SMI who are primarily receiving withdrawal management services or short-term inpatient or residential treatment for an addiction disorder. The goal is to create consistency in treatment for the 25% of beneficiaries with SMI with a co-occurring addiction disorder.

FSSA can claim federal financial participation (FFP) for individual stays of up to 60 days, as long as by a mid-point assessment at December 31, 2022, the state can show that the average length of stay (ALOS) is 30 days or less. If the state does not meet the ALOS target by the assessment, FSSA will only be able to claim FFP for stays of up to 45 days until it meets the ALOS target.

Special terms and conditions (STCs) of the waiver require FSSA to ensure that psychiatric hospitals provide intensive pre-discharge, care coordination services to help beneficiaries transition into appropriate community-based outpatient services. The STCs include the following requirements:

  • Involve community-based provider organizations in transition efforts, such as allowing initial contact with a community-based provider organization while the beneficiary is still at the IMD, or by hiring peer support specialists to help beneficiaries connect with available community-based provider organizations and make plans for employment.
  • Assess the housing situation of a beneficiary transitioning to the community, and connect those who are homeless or who have unsuitable or unstable housing with provider organizations that coordinate housing services.
  • Require psychiatric hospitals to have protocols in place to ensure contact is made by the treatment setting with each beneficiary within 72 hours of discharge, and ensure follow-up care is accessed by those individuals by contacting them directly and by contacting the community-based provider organizations to which they were referred.
  • Implement strategies to prevent or decrease the length of stay in emergency departments (EDs) among beneficiaries with SMI/serious emotional disturbance (SED) or SED. This could include the use of peers and psychiatric consultants in EDs to help with discharge and treatment referral.
  • Develop and enhance interoperability and data sharing between disparate physical, addiction treatment, and mental health provider organizations to enhance coordination and improve clinical outcomes for beneficiaries with SMI/SED or SED

The STCs require FSSA to increase access to a continuum of care, including crisis stabilization services by doing the following:

  • Establish a process focused on crisis stabilization services to annually assess the availability of mental health services throughout the state. The assessment must provide updates on steps taken to increase availability.
  • Commit to implementing the SMI/SED financing plan included in the approved waiver.
  • Improve the state’s capacity to track available inpatient and crisis stabilization beds to help connect individuals in need with that level of care as soon as possible.
  • Require provider organizations, plans, and utilization review entities to use an evidence-based, publicly available consumer assessment tool, preferably endorsed by a mental health provider organization association to determine appropriate level of care and length of stay.

Further, FSSA must implement strategies to facilitate earlier identification and engagement in treatment for those with SMI/SED or SED, as follows:

  • Identify and engage adolescents and young adults in treatment earlier through supported employment and education programs.
  • Increase integration of behavioral health care in non-specialty care settings including schools and primary care practices, to improve early identification and improve awareness of and linkages to specialty treatment provider organizations.
  • Establish specialized settings and services, including crisis stabilization services, focused on the needs of young people.

The intent of the waiver amendment is to shift services for beneficiaries with SMI from less appropriate settings to facilities such as hospitals and larger mental health treatment facilities. As a result, FSSA anticipates that costs related to lack of access to appropriate care settings and overuse of the emergency department for mental health problems and psychiatric crises will decrease. The IMD services will be for eligible individuals with SMI who are primarily receiving short-term treatment and withdrawal management services.

FSSA had submitted the “SMI/SED Amendment Request for the Healthy Indiana Plan (HIP) Section 1115 Waiver (Project Number 11-W-00296/5)” on June 24, 2019. FSSA data indicates that in state fiscal year 2019, about half of Indiana’s traditional Medicaid members receiving inpatient psychiatric services received them at an IMD.

For more information, contact:

  • Jim Gavin, Director of Communications and Media, Indiana Family and Social Services Administration, 402 West Washington Street, W461, Indianapolis, Indiana 46204-2739, Phone: 317-234-0197, Fax: 317-233-4693, Email: Jim.Gavin@fssa.IN.gov, Website: https://www.in.gov/medicaid/

Six months after attending abstinence-based addiction treatment, 35.6% of more than 1,400 consumers reported that they had been abstinent for the past 30 days. The 35.6% includes consumers who reported an earlier relapse but current abstinence (7.9%) and continuously abstinent consumers (27.7%). About 8.5% said they were not abstinent in the past 30 days; of this group, two-thirds reported using at a lower frequency than before entering treatment. Of the remaining consumers, 0.5% had died, 0.2% were in jail, and the recent abstinence status of 2.4% was unknown. About 52.8% failed to respond to multiple contact attempts.

The percentage of consumers reporting abstinence declined between one month and six months post-treatment and then stabilized.   At one month after treatment, 42.8% said they had remained abstinent. At six months after treatment, 35.6% said they had abstained from all drugs and alcohol in the past 30 days. At 12 months, 36.2% said they had abstained from all drugs and alcohol in the past 30 days, and 25.3% had remained abstinent for the entire year.

Slightly more than half (54.8%) of the people followed up with six months after treatment had successfully completed treatment.  Among these, 43.8% were abstinent at six months after treatment.  Among those who did not complete treatment, 25.4% were abstinent.

About 23% of those who relapsed during the 12 months post-treatment did so during the first few days after leaving treatment. Half reported relapsing within the first month, and 79% of relapses happened within three months after treatment.

These findings were reported in “Learnings From Three Years Of Addiction Treatment Outcomes Research” by researchers with Vista Research Group. The report summarizes information about 23,428 people attending addiction treatment between March 1, 2016 and September 15, 2019. The individuals were receiving treatment at facilities enrolled in Vista Research Group’s INSIGHT Addiction™ and/or INSIGHT Detox™ progress monitoring research. The treatment centers are predominantly abstinence-based commercial facilities based in the United States. A small portion of these participants have also been selected to be contacted after treatment via Vista’s RECOVERY 20/20™ service to learn how they are feeling and if they have been able to remain abstinent at one month, six months, and 12 months post-treatment.

During the three-year period, there were 17 participating addiction treatment facilities for whom the researchers followed up with at least 25 patients six months post-treatment. The number of individuals who were reachable and claimed to have been abstinent for at least the last 30 days at six months post-treatment varied between 22% and 47% across these facilities.

Vista was able to contact between 49% and 56% of the participants at one month (3,163), six months (1,421), and 12 months (392) post-treatment by reaching out 10 to 15 times by text, email, and/or phone for each survey. The post-treatment results in this current report are predominantly based on responses from the 1,421 participants who Vista attempted to contact six months after they left treatment.

When the participants entered treatment, 47% reported having experienced all 11 of the DSM-5 symptoms of addiction disorder during the year prior to treatment. The majority reported moderate to severe levels of depression, anxiety, and/or post-traumatic stress symptoms. About 37% said they wished they were dead or would not wake up during the 30 days before entering treatment; 10% had some intention to commit suicide; and 6% had actively planned, prepared, or attempted suicide. In addition to having an addiction disorder, 6% were cutting or engaging in other self-harm. Some were also managing sex addiction or personality disorder. In the 30 days before they began treatment, 15% of the participants were hospitalized, 11% were arrested or jailed, 7% overdosed, and 3% were ordered into treatment by the criminal justice system.

About two-thirds of the study participants successfully completed treatment. About 80% of them said their treatment goals were met, and two-thirds said they were very satisfied with the treatment they were receiving.

Individuals who reported participating in the following activities for at least a month post-treatment were more likely to say they were abstinent at six-months post-treatment compared to those who did not report abstinence:

  1. Recovery support meetings: cited by 67% of those who were abstinent, and 34% of those who were not.
  2. Sober housing: cited by 27% of those who were abstinent, and 8% of those who were not.
  3. Alumni program involvement: cited by 17% of those who were abstinent, and 5% of those who were not.
  4. After-care monitoring: cited by 16% of those who were abstinent, and 3% of those who were not.
  5. Random drug/alcohol testing: cited by 35% of those who were abstinent, and 17% of those who were not.
  6. Seeing a therapist: cited by 39% of those who were abstinent, and 26% of those who were not.
  7. Attending additional treatment: cited by 23% of those who were abstinent, and 15% of those who were not.

For more information, contact:

  • Vista Research Group, Inc., 1330 Cape Saint Claire Road, #656, Annapolis, Maryland 21409. Phone: 800-215-3201, Email: info@Vista-Research-Group.net, Website: https://www.vista-research-group.com/ 
  • Joanna L. Conti, Founder and Chief Executive Officer, Vista Research Group, Inc., 1330 Cape Street, Claire Road, #656, Annapolis, Maryland 21409, Phone: 800-215-3201, Email: jconti@vista-research-group.com, Website: https://www.vista-research-group.com/

On December 11, 2019, PursueCare announced the launch of new telehealth addiction treatment programs for rural populations in Kentucky and in West Virginia. The programs provide telehealth counseling via a smartphone app and medication-assisted treatment. The purpose is to transition consumers with opioid use disorder (OUD) from emergency departments and rural health clinics into treatment at home. During 2020, the company plans to expand to Connecticut, Maine, Ohio, Pennsylvania, Vermont, and Virginia, with services in Connecticut and Vermont launching in early March.

PursueCare is in-network with Medicare, Medicaid, all managed care organizations (MCOs), and most commercial insurances in Kentucky and West Virginia. It also works with employee assistance programs, and participates with veterans’ plans under TRICARE. PursueCare is forming partnerships with organizations that received Kentucky Opioid Response and Education grants (KORE), which will implement and leverage PursueCare services as a resource. The company is also opening a physical clinic in Somerset, Kentucky for consumers who may need more intensive in-person assessments.

The company holds LegitScript certification for addiction treatment. LegitScript certifies companies that provide addiction treatment via any platform, including facility-based, outpatient office-based, and online via telehealth. LegitScript certification is used by Google and Facebook to verify the compliance, legality, and legitimacy of addiction treatment provider organizations marketing their products and services to consumers. PursueCare’s mail-order and specialty recovery pharmacy, CompreCare, also earned The Joint Commission’s Gold Seal of Approval Accreditation.

For more information, contact:

  • Reginald Miller, Partnership Development Coordinator PursueCare, 101 Centerpoint Drive, Suite 221, Middletown, Connecticut 06457, Phone: 860-317-0586, Email: reg.miller@pursuecare.com, Website: https://www.pursuecare.com

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.

Approximately 15% of men and 30% of women jailed have a serious mental illness (SMI).1 Educated first responders can potentially safely de-escalate situations involving a behavioral health crisis. Crisis Intervention Teams (CIT) are trained responders that recognize common signs and symptoms of mental illness and co-occurring disorders. An important component of the CIT model is a central designated psychiatric emergency access site with a no-refusal policy, hopefully reducing incarceration rates and increasing mental health treatment.

Featuring:

  • MSgt Corey Nooner
    Oklahoma City Police Department
  • Kathy Day, MPA, BA, AA
    Caregiver and Mental Health Advocate
  • Charlotte Anderson, BA
    9-1-1 Center and Mental Health Advocate

MSgt Corey Nooner is an Officer with the Oklahoma City Police Department. He is part of the Crisis Intervention Team Model, which is a collaborative approach to safely and effectively addressing the needs of Oklahomans with mental illness, by linking them to appropriate services within the community and diverting them from the criminal justice system if appropriate.

Kathy Day, MPA, BA, AA is a caregiver for a close family member with schizophrenia and is starting a non-profit organization for caregivers. She is an active advocate for people with serious mental illnesses by helping run online support groups, writing a blog about schizophrenia, and educating people about serious mental illnesses whenever the opportunity arises. Ms. Day is a former member of the Sacramento County Mental Health Board and has been active in legislative reform at local and federal levels.

Charlotte Anderson, BA works with the local 9-1-1 Center to address care given to callers struggling with mental health issues. She has worked with Hotline, a crisis intervention and information center, and has led a merge with Trident United way to implement 2-1-1, which responds to over 50,000 calls annually. She has served as the Crisis Division Director for the American Association of Suicidology and was part of the steering committee for the SAMHSA National Suicide Prevention Lifeline.

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.

Smartphones are nearly ubiquitous features of modern American life. Findings from a January 2018 Core Trends Survey from the Pew Research Center illustrates this fact: 78% of the American adults surveyed (n=2,002) had access to a smartphone. Usage among individuals living with a mental illness is also high. A 2018 survey among psychiatric patients indicated that 90% of private clinic patients and 67% of Department of Mental Health (DMH) clinic patients owned a smartphone.

One feature of smartphones—the ability to run and support applications (apps)—has the potential to increase access to mental health services by providing novel outreach and service provision, reaching users with lower levels of access to traditional behavioral health providers, services, and facilities. The availability of mental health apps is on the rise, a trend that continues to hold promise for increased engagement with mental health supports.

Despite the plethora of mental health apps available, users do not download or maintain usage of these apps with the level of fervor expected. What accounts for this discrepancy? Research focused on understanding consumer preference and engagement in apps relies upon user engagement indicators (UEIs), like ease of use and satisfaction, to measure and evaluate apps like those developed for mental health. In the case of mental health apps, however, there is no true consensus on what “engagement” is, making the development, definition, selection, and interpretation of UEI study results problematic.

To shed light on the variations within the literature related to UEIs for mental health apps, a group of researchers, led by Michelle Ng of the Division of Digital Psychiatry at Harvard Medical School, recently conducted a systematic literature review. Their findings were published in “User Engagement in Mental Health Apps: A Review of Measurement, Reporting, and Validity,” which was published in 2019 by Psychiatric Services.

Study Design

The review analyzed 40 studies focused on apps for depression, bipolar disorder, schizophrenia, and anxiety in order to examine how UEIs are evaluated within the current literature. The researchers hypothesized that methods to evaluate UEIs in the readily available literature would be inconsistent. This inconsistency, they posited, would create a comparison between “apples and oranges,” causing confusion about the efficacy of mental health mobile apps. It also makes research-wide comparisons between program engagement difficult.

Researchers combed six databases in July 2018 to create their literature sample. Studies were included if they were novel, at least one week in length, involved a mobile application designed for target diagnoses (e.g., depression, bipolar disorder, schizophrenia, anxiety), and included reporting on UEIs. UEIs were designated objective or subjective. Objective UEIs included measures like frequency of use and retention rate. Subjective UEIs includes measures such as user satisfaction and perception of the app.

Results

The results of the systematic review yielded very mixed results. Multiple studies confounded their results by referring to objective and subjective UEIs interchangeably. Some studies even utilized one measure to verify another. UEI measurements in the studies examined were imprecise, as many used a blunt, universal scale across all measures. Almost half of the studies (48%) heralded positive engagement based solely on one category of UEI (either objective or subjective respectively). Scales focused on subjective measures largely developed their own measurement tools rather than utilizing readily available assessments, thereby limiting cross-sectional analysis. Finally, across the 40 studies, all posited positive results on their apps’ UEIs. The researchers discussed the possibility that these findings reflected inherent bias in the literature to present positive results for specified apps, rather than presenting objective measures of mental health app UEI.

Ng et al. concluded that establishing a priori UEI measures with distinctive and validated assessment tools and significance thresholds would further research into the rationale behind deficient user engagement with mental health apps. They also discuss the need for studies to utilize UEI measurements that cross both subjective and objective categories in order to facilitate building a body of knowledge that spans more than a single study.

This summation was developed independently from the author.

Authors declared the following conflicts: no conflicts of interest.

New technologies, changing reimbursements, and corporate consolidations are amongst the many drivers evolving the health care landscape.1 During this webinar archive, the speakers discuss strategies for future sustainability in ever-changing industry.

Featuring:

  • Kimberly Bond
    Senior Associate, OPEN MINDS
  • Paul Duck
    Senior Associate, OPEN MINDS

Kimberly Bond brings over thirty years of experience providing behavioral health treatment in the public and community settings to the OPEN MINDS team. She currently serves as the Executive Vice President of Business Development and Marketing. Prior to joining OPEN MINDS, Ms. Bond served concurrently as a Program Coordinator III and Clinical Manager of Adult Services and a Program Coordinator II and Clinical Manager of Recovery Services for the Ozark Guidance Center. In these roles, Ms. Bond was responsible for the administrative and clinical oversight of the adult outpatient and adult intensive mental health services on the Springdale Campus and the adult recovery/co-occurring services, including domestic violence and anger management treatment as well as treatment services for Drug Court.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

New technologies, changing reimbursements, and corporate consolidations are amongst the many drivers evolving the health care landscape.1 During this webinar archive, the speakers discuss strategies for future sustainability in ever-changing industry.

Featuring:

  • Kimberly Bond
    Senior Associate, OPEN MINDS
  • Paul Duck
    Senior Associate, OPEN MINDS

Kimberly Bond brings over thirty years of experience providing behavioral health treatment in the public and community settings to the OPEN MINDS team. She currently serves as the Executive Vice President of Business Development and Marketing. Prior to joining OPEN MINDS, Ms. Bond served concurrently as a Program Coordinator III and Clinical Manager of Adult Services and a Program Coordinator II and Clinical Manager of Recovery Services for the Ozark Guidance Center. In these roles, Ms. Bond was responsible for the administrative and clinical oversight of the adult outpatient and adult intensive mental health services on the Springdale Campus and the adult recovery/co-occurring services, including domestic violence and anger management treatment as well as treatment services for Drug Court.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

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 Blue Cross Blue Shield Association (BCBSA) is creating a national provider organization network composed of health care provider organizations and professionals who routinely offer high quality care at lower prices. BCBSA announced the new network on November 13, 2019. The network will be called Blue High Performance Network (HPN); it is slated to launch in January 2021 in 55 markets.

Blue HPN is designed for large national and regional employers. It is expected to reach more than 185 million people. BCBSA represents 36 independent Blue companies. The goal is that Blue HPN will provide more consistent pricing to help large employers control medical costs and enhance care for their workers. About 16% of large employers have built a high performance network into their health plan. BCBSA predicts that Blue HPN could generate more than 10% average cost savings on top of the savings already offered by the existing BCBS preferred provider organization network.

In June 2019, BCBSA issued an infographic explaining how it defines a high-performance network. Provider organizations will be selected for Blue HPN by the independent Blue plans based on existing quality measures and relationships. About 70% of the 74 million BCBS members are already in a value-based contract. Provider organizations selected for Blue HPN will be provided with data and insights; BCBSA will also align financial incentives for the participating provider organizations.

BCBSA released the full text of “Defining High-Performance Networks” and the info graphic in June 2019. A free copy is available online at https://www.bcbs.com/smarter-better-healthcare/infographic/defining-high-performance-networks (accessed December 10, 2019).

For more information, contact: Tess Thomson, Media Contact, Blue Cross Blue Shield, 225 North Michigan Avenue, Chicago, Illinois 60601; 202-942-1082; Email: press@bcbsa.com; Website: https://www.bcbs.com/

Those with an eating disorder (ED) frequently have psychiatric comorbidities; estimates range between 56% and 98%. Such comorbidities contribute to longer periods of illness and poorer outcomes. Major depression and substance use disorder are common ones, with the former affecting 28%–95% of individuals with ED and the latter 17%–46%. Both conditions pose special risks for patients with ED: depression compromises outcomes for individuals with anorexia nervosa, and substance use disorder on top of an eating disorder has proven lethal. Both major depressive disorder and substance use disorder have been identified as increasing the risk of relapse and early death.

Most individuals eventually recover from ED. But do their comorbidities persist? A group of researchers, led by Ani C. Keshishian of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital, sought to answer that question. In “Eating Disorder Recovery Is Associated with Absence of Major Depressive Disorder and Substance Use Disorder at 22-Year Longitudinal Follow-Up,” published in Comprehensive Psychiatry (2019), the authors detail the findings from their study of ED and comorbidities.

Do Comorbidities Persist?

Between 1987 and 1991, the researchers recruited 246 women with either anorexia nervosa or bulimia nervosa. Of the 228 surviving participants, 176 (77.2%) completed the study. The average age of participants at the 22-year follow-up was 46.3. They were assessed using the Eating Disorders Longitudinal Interval Follow-up Evaluation (LIFE-EAT II) and the Psychiatric Status Rating (PSR); those whose score on the latter was 1 or 2 for at least a year were deemed recovered from their eating disorder. The women in the study were evaluated with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-1) to determine presence or absence of major depressive disorder and substance use disorder.

More than a third of the participants (36%) had an active eating disorder, 28% met criteria for major depressive disorder, and 6.3% had substance use disorder. Absence of an eating disorder correlated with an absence of major depressive disorder and substance use disorder. Those who recovered from ED were 2.17 times more likely not to have major depressive disorder and 5.3 times more likely not to have substance use disorder compared with those who still had active ED. Some 22% of women recovered from ED had major depressive disorder compared with 38% of those whose ED remained active; for substance use disorder, the proportions were 3% vs. 13%.

Good News, Bad News

What is positive in the researchers’ findings is that most women in their study recovered from ED, and those who recovered were much more likely than those who did not to be free of major depression and substance use disorder. This flies in the face of psychodynamic theory that predicts symptom substitution—such as substance use—occurs after ED remission. But the study here under discussion found that the rate of substance use disorder in the recovered group was comparable to the rate in the general population.

However, the rate in the recovered group for major depressive disorder is more than double that in the population at large. This is concerning. Eating disorders in themselves may contribute to depression. And depression and substance use disorder may exacerbate eating disorders. Given that the persistence of major depressive disorder and substance use disorder in some women with ED may lengthen course of illness and contribute to premature death, those individuals with active ED and also major depression and/or substance use disorder should be considered especially vulnerable, say the study’s authors.

The authors caution that the specificity of the population studied—women seeking treatment for an eating disorder in Boston 20-plus years ago—may make the findings not generalizable. It is also possible that today’s evidence-based ED treatment may make contemporary ED populations too unlike the studied group.

The researchers suggest one avenue of further research, which is to drill down into the comorbidities associated with specific ED diagnoses.

Authors declared the following conflicts: no conflicts of interest.

This summation has been developed independently of the authors.

Individuals with schizophrenia struggle to interact with others due to impaired social cognition. Four capabilities in particular are compromised: 1.) the ability to recognize emotion in others, for instance by interpreting facial affect; 2.) the discernment to read social cues; 3.) attributional style (e.g., an individual may see hostility where none exists); and 4.) mentalizing, or inferring the mental state behind another’s behavior.

Current antipsychotic mediations do not ameliorate these social cognition impairments, which can be debilitating in social situations. In “Treatment of Social Cognition in Schizophrenia: Current Status and Future Directions,” William P. Horan of Greater Los Angeles Healthcare System and Michael F. Green from University of California–Los Angeles looked at multiple studies to see where social cognition treatment is today and where it might be headed.

The Current Landscape Is an Optimistic One

The past 20 years have seen treatment for social cognition deficits in schizophrenia steadily advance. More recent interventions that target one social cognitive domain—most often, facial affect perception—have delivered positive results. Studies have shown that remediation is possible, thereby laying the groundwork for more comprehensive intervention studies that target multiple domains of social cognition.

The findings of various analyses, including Kurtz et al. (2016), give researchers and clinicians reason for optimism:

  • A variety of interventions—for example, Social Cognition and Interaction Training (SCIT) and Social Cognitive Skills Training (SCST)—can improve at least one of the four main domains of social cognitive impairment.
  • Social cognition interventions are well tolerated by participants. What’s more, evidence shows that these studies can be conducted effectively outside their original academic setting, in a variety of languages and cultures.
  • Social cognitive improvement is not dependent on non-social neurocognition improvements; rather, evidence suggests that they can happen independently of each other. Social cognitive interventions can impact the neural systems that underlay difficulties in this area, too.

Despite Optimistic Findings, Some Caveats Remain 

The studies under review have some limitations, including limited data and varied methodology.

  • Sample sizes were generally small and some used quasi-experimental design versus trials with strict pre- and post-intervention controls.
  • A diverse range of outcome measures was employed, which can lead to considerable variation in measured results.
  • Measured success has been shown to be most consistent for facial affect perception over the other three domains; for example, attributional bias studies used the Ambiguous Intentions Hostility Questionnaire, which has been known to blur the lines between schizophrenia and healthy controls, and may apply only to those patients exhibiting paranoia.

Key Considerations in Developing Social Cognitive Treatment

While more evidence-based studies are needed, certain learnings have emerged that may serve as guideposts for further research in treating schizophrenia spectrum disorders by targeting social cognition.

Appropriate Cognitive Outcome Measures Are Needed. The lack of consensus on measures makes this aspect challenging, and psychometric properties of available instruments is either poor or unknown. But NIMH has recently sponsored initiatives—the Social Cognition Psychometric Evaluation (SCOPE) project and Social Cognition and Functioning (SCAF) in schizophrenia—to identify or develop these measures.

Long-Term Effect Must Be Studied. Thus far, there are mixed results as to whether social cognitive interventions lead to enduring improvements in social cognition after the conclusion of treatment. This is a key area to be explored in future research and treatment.

Addressing Generalization Is Key: Certainly, the goal of social cognitive interventions is to enhance daily life for people with schizophrenia. But until functional outcomes are defined more precisely and there is more agreement on which assessment tools to use, understanding outcomes will be challenging.

Timing of Interventions May Matter: Chronically ill participants were the focus of the treatment studies in the Kurtz et al. review. But experts agree that social cognitive impairments appear early after onset of psychotic disorders. Thus earlier interventions—where there is a recent diagnosis or even when there are prodromal syndromes, before full onset of illness—may be more effective than interventions after patterns become entrenched.

There Is No “One Size Fits All”: Not all patients benefit from all social cognitive interventions; there are different profiles of impairment among those with psychosis. Tailoring treatment to the individual is important.

Promising Approaches Could Enhance Efficacy and Generalizability

Although a concerted effort was made two decades ago to separate social cognitive skills training from other treatment components, it may be most effective when used in combination with other interventions. The landscape offers opportunity for improvement of social cognitive interventions, including some novel ones. Integrated strategies could include:

  • Bridging activities. Designed to help participants apply learned skills to their daily life, these activities play a key role in generalization of benefits from psychosocial skills training and cognitive remediation—and could be used to enhance the generalizability of social cognitive interventions.
  • New technologies. Three potential approaches for leveraging technology include:
    • Computerized interventions: Unlike interventions for cognitive remediation, these have rarely been tested as a treatment for social cognition.
    • Virtual reality: Simulators could allow patients to experience a wide variety of complex, dynamic, and interactive situations, and to practice social cognitive skills in a safe environment without negative repercussions.
    • Mobile devices: Services can be delivered via smartphone apps (self-initiated or automated), text message prompts (e.g., for behaviors or homework), and experience monitoring (e.g., mood or symptom monitoring with prompts for coping behaviors).
  • Combining psychopharmacology with social cognitive training. Because not all participants benefit from social cognitive training programs, the combination of psychopharmacology with social cognitive training is a promising direction that needs more exploration.

What’s Next?

Much work remains to be done before implementing social cognitive interventions in community mental health settings. But consistency in improvements and better-controlled studies are isolating treatment benefits. So despite the small number of existing studies and their limitations, the outlook is optimistic.

A key goal must be to move from small pilot studies to research that leads to new psychosocial and non-psychosocial approaches. This will include validating the endpoints for clinical trials, identifying predictors of treatment outcomes, conducting large and rigorous randomized controlled trial studies, and tackling the important challenge of generalizability.

In short: creative new approaches are needed to help link the benefits of social cognitive treatments to meaningful improvements in community functioning for people with schizophrenia.

Following-up to the 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition, Deb Adler and Paul Duck discuss trends and shifts in the market and the impacts on population health management. From 2017 to 2019, specialty care coordination programs increased by 50%, behavioral health readmissions prevention programs increased by 74%, and emergency department diversion programs for behavioral emergencies increased by 43% for all health plans1. Service provider organizations are adapting to this shift by utilizing peer support specialists, adopting telehealth, and increasing consumer engagement via emails and text messages.

Featuring:

  • Deb Adler, CPHQ
    Senior Associate at OPEN MINDS
  • Paul Duck
    Senior Associate at OPEN MINDS

Deb Adler, CPHQ, has more than 20 years of experience in executive health care roles, serving in a variety of capacities, including network executive, quality management executive, and COO. She is the former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for over 185,000 providers. In this role, she developed the largest performance-tiered behavioral health network, the largest telemental health network, and the largest medication-assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models. Currently, she serves as a Senior Associate at OPEN MINDS. Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management, focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

Following-up to the 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition, Deb Adler and Paul Duck discuss trends and shifts in the market and the impacts on population health management. From 2017 to 2019, specialty care coordination programs increased by 50%, behavioral health readmissions prevention programs increased by 74%, and emergency department diversion programs for behavioral emergencies increased by 43% for all health plans1. Service provider organizations are adapting to this shift by utilizing peer support specialists, adopting telehealth, and increasing consumer engagement via emails and text messages.

Featuring:

    • Deb Adler, CPHQ
      Senior Associate at OPEN MINDS
  • Paul Duck
    Senior Associate at OPEN MINDS

Deb Adler, CPHQ, has more than 20 years of experience in executive health care roles, serving in a variety of capacities, including network executive, quality management executive, and COO. She is the former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for over 185,000 providers. In this role, she developed the largest performance-tiered behavioral health network, the largest telemental health network, and the largest medication-assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models. Currently, she serves as a Senior Associate at OPEN MINDS. Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management, focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

Eight health plans earned the highest 5.0 rating from the National Committee for Quality Assurance (NCQA) for 2019. Five of the plans are operated by Kaiser Permanente. In 2018, 14 plans earned the top 5.0 rating, and nine were operated by Kaiser Permanente.

For the 2019 ratings, NCQA studied more than 1,300 health plans and rated 1,131: 438 private (commercial), 475 Medicare Advantage, and 218 Medicaid managed care organization (MCO) plans. The ratings are based on consumer satisfaction with the plan, the plan’s provision of preventive services, and how well the plan’s network professionals provide evidence-based treatment. Of the plans that earned the top 5.0 rating, two are commercial health plans, four are Medicare Advantage plans, and two are Medicaid MCO plans. These plans also held the top ranking in 2018.

NCQA Top Rated Plans For 2019, Commercial, Medicare & Medicaid
Commercial
State(s) Type Consumer Satisfaction Prevention Treatment
Group Health Cooperative of South Central Wisconsin Wisconsin HMO 3.5 4.5 4.5
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. District of Columbia, Maryland & Virginia HMO 2.5 5.0 4.5
Medicare
State(s) Type Consumer Satisfaction Prevention Treatment
Kaiser Foundation Health Plan, Inc.- Southern California California HMO 3.5 5.0 4.5
Kaiser Foundation Health Plan of Colorado Colorado HMO 3.5 5.0 4.5
Kaiser Foundation Health Plan, Inc.- Northern California California HMO 3.5 5.0 4.5
Medical Associates Health Plan, Inc. Illinois and Iowa HMO 5.0 5.0 4.0
Medicaid
State(s) Type Consumer Satisfaction Prevention Treatment
Jai Medical Systems Managed Care Organization, Inc. Maryland HMO 4.5 4.5 4.0
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Maryland HMO 3.0 5.0 4.5

Data for the rating for each health plan is from the plan’s combined scores on the Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and NCQA Accreditation standards scores as of June 30, 2019. Plans that are ranked in the top 10% of all plans reviewed receive a score of 5.0. Plans in the top third of plans, but not the top 10% receive a score of 4.0. Plans in the middle one-third receive a score of 3.0. Plans in the bottom third of plans (but not the bottom 10%) receive a ranking of 2. Plans that are ranked in the bottom 10% of the plans reviewed receive a score of 1.0.

The NCQA Health Insurance Plan Ratings for 2019 are posted online at http://healthinsuranceratings.ncqa.org/2019/Default.aspx (accessed November 4, 2019).

PsychU last reported on this topic in “12 Health Plans Earn Top NCQA Rating For 2018,” which published on November 5, 2018. The article is available at https://www.psychu.org/12-health-plans-earn-top-ncqa-rating-2018/.

For more information, contact: Matt Brock, Communications Director, National Committee for Quality Assurance, 1100 13th Street Northwest, 3rd Floor, Washington, District of Columbia 20005; 202-955-1739; Fax: 202-955-3599; Email: brock@ncqa.org; Website: https://www.ncqa.org/. 

Mergers and acquisitions (M&A) continue in the health and human service field at a rapid pace. Future sustainability is the big driver of M&A with integrated care, value-based reimbursement, and new competition challenging the margins of organizations in the field (see 24% Of Health Care Executives Say Integration Was The Top Driver For Mergers & Acquisitions. There were 90 hospital/health system mergers in 2018 and hundreds of mergers, acquisitions and affiliations in other sectors of the health and human service field.

The question for executives of specialty provider organizations is – how to know when your organization is ready for some type of affiliation and, if so, how to find the right partner. That question was the focus of the session, “Are You Ready For A Merger Or Affiliation? How To Prepare Your Organization To Find The Right Partner” at The 2019 OPEN MINDS Executive Leadership Retreat. The session featured three executives with ‘hands on’ M&A experience—Mandy Fauble, Ph.D., LCSW, Executive Director, Safe Harbor Behavioral Health of UPMC Hamot; Jeremy Klemanski, President & Chief Executive Officer, Helio Health, Inc.; and Jeff Klimaski, President & Chief Operating Officer, The Columbus Organization. The executives had three key insights to share with other specialty provider organization executives:

  • Consider your competitive market positioning and infrastructure
  • Plan for payer and health plan contracting when creating merger plans
  • Use mergers and affiliations to ‘fill the holes’ in your service offerings

Consider your competitive market positioning and infrastructure – Identifying major market factors and assessing your organization’s competencies and infrastructure help inform the decision to merge, acquire, or affiliate. Dr. Fauble explained that Safe Harbor Behavioral Health of UPMC Hamot was small and operated in a state that had a new Certified Community Behavioral Health Clinic demonstration grant, a push for more VBR, and physician recruitment issues. Due to the organization’s size and lack of infrastructure, Safe Harbor executives agreed to be acquired by a larger organization with the technological infrastructure needed to meet the demands of the environment. “Where I was finally won over was the ability to do transformational things,” Dr. Fauble explained, “We came out on the other side better positioned to do our mission and meet our contemporary environment demands”.

Plan for payer and health plan contracting when creating merger plans – Gaining size in terms of revenue and number of consumers served is crucial to finding a seat the table with health insurers and other stakeholders. Columbus Organization executives believe the best way to position themselves with payers is, which is why Columbus actively seeks M&A partners. Mr. Klimaski explained that, when seeking partners, the company looks for organizations that have a strong reputation in the market and a critical mass of consumers to increase the organization’s footprint.

Use mergers and affiliations to ‘fill the holes’ in your service offerings – Helio Health began acquiring and affiliating with other organizations after company executives identified a gap in the available mental health services in central New York. Rather than take the time to develop mental health service lines, Helio Health chose to acquire that capability. Mr. Klemanski explained that organizations should have a very clear strategic plan and reason for M&A. Without the “why,” organizations will find the process much harder and are at risk of affiliating with an organization that might be a bad fit. For Helio Health the strategic target is not a revenue number, instead the focus is on having a specific geographic and service line target. Ultimately the goal is to meet an unmet care need with quality, evidence-based care.

On September 18, 2019, a physician formerly employed by the Washington Permanente Medical Group, P.C. sued the organization for wrongful termination, alleging that its consumer satisfaction scoring methodology encourages physicians to prescribe opioids, even when medically unnecessary. The physician worked in a Kaiser Permanente emergency department from 2012 through December 2017; she alleged she was terminated for failing to accept the consumer satisfaction scoring tools. A trial is scheduled for March 17, 2021.

The complaint is Eryn Alpert Vs. Washington Permanente Medical Group Pc. The plaintiff alleged that her consumer satisfaction scores had a wide range, and that the differences were due to consumer retaliation to her resistance to prescribing or providing unnecessary opioids. The wide variation in consumer satisfaction scores prevented her from gaining shareholder status with the Washington Permanente Medical Group for three consecutive years, and ultimately contributed to her termination. The complaint alleged that “By requiring its employee physicians to achieve certain patient satisfaction scores in departments where those scores are closely related to a physician’s willingness to prescribe opioids, other addictive medications, and to order unnecessary medical testing (e.g. labs, radiology) in response to patient demand, Kaiser’s intent was to increase its profits so that … its executives and physicians would receive higher bonus compensation.”

Lawsuit alleges policies encouraged opioid prescriptions to boost profits

The lawsuit alleges that “nearly every patient complaint for Dr. Alpert involved patients who had been denied narcotics.” Further, it alleged “Kaiser’s management denied Dr. Alpert shareholder status at least in part on the basis of financial concerns that advancing Dr. Alpert would result in reduced revenues and that other physicians would follow her example and refuse to prescribe or provide medications that were not medically indicated, further reducing the profitability of Kaiser Permanente’s business operations in the northwest region and nationally.” The financial concerns were later explained in her allegation that, “Upon information and belief, Kaiser’s business records will substantiate that revenue from Kaiser Permanente’s pharmacy operations is among the most profitable components of Kaiser’s business operations. Information from the national database of drug sales maintained by federal Drug Enforcement Administration reveals that Kaiser and Kaiser-related entities operate three of top five pharmacies in Washington state that received the highest number of pain pills between 2006 and 2012.” Kaiser Permanente said the organization does not comment on pending litigation, and did not provide comment or clarification about the allegations.

2018 study finds that reducing opioid use does not lower consumer satisfaction scores

Interestingly, a study published in June 2018 by researchers affiliated with the Kaiser Permanente Southern California Department of Research & Evaluation, “Satisfaction With Care After Reducing Opioids for Chronic Pain,” found that reducing opioid use among members with chronic pain did not result in lower consumer satisfaction scores. The researchers Adam L. Sharp, M.D., MS; Ernest Shen, Ph.D.; Yi-Lin Wu, MS; and colleagues analyzed encounter data for 2,492 members who used high doses of opioids for at least six months. They compared consumer satisfaction scores for those whose dose was reduced to a lower level for at least 30 days following the encounter on which the satisfaction score was linked and those without such a reduction.

The researchers specifically noted that “Physicians are often concerned they will receive lower satisfaction scores if they reduce opioids for patients who are accustomed to high opioid doses to manage chronic pain.” The analysis indicated that “reducing opioids for chronic pain did not result in lower satisfaction scores.” The key findings were as follows:

  • 29% of encounters resulted in an opioid dose reduction.
  • 86% of encounters resulting in an opioid dose reduction maintained favorable overall satisfaction scores.
  • 14% of encounters resulting in opioid dose reduction had an unfavorable overall satisfaction score.
  • Reducing opioid doses for chronic pain was overall not associated with unfavorable consumer satisfaction scores. The odds of an unfavorable score were 1.31 times higher for the dose reduction group, but not statistically significant. However, the higher odds could have been due to chance.
  • The odds of a favorable satisfaction rating were higher when opioids were reduced by a member’s regularly assigned primary care physician (PCP) versus a different physician. The odds of an unfavorable score were not significant when the reduction was done by the member’s assigned PCP. However, the odds of an unfavorable score were significantly 1.50 times higher when the reduction was done by an unassigned physician.

Although there was a small difference in overall consumer satisfaction, Dr. Sharp noted that even for the small subset of physicians reducing opioids for members under the care of other physicians, the difference in overall consumer satisfaction was small. The researchers found no evidence to support an interaction between an opioid reduction and a PCP satisfaction score. Unadjusted favorable satisfaction scores were statistically less common after opioid reduction for both unestablished physician encounters (82.8% versus 88.0%) and encounters with an assigned PCP (90.8% versus 89.5%). The researchers said the absolute difference in each group was “of questionable clinical relevance.”

The full text of “Satisfaction With Care After Reducing Opioids for Chronic Pain,” was published June 8, 2018 in The American Journal of Managed Care. A copy is posted at https://www.ajmc.com/journals/issue/2018/2018-vol24-n6/satisfaction-with-care-after-reducing-opioids-for-chronic-pain (accessed October 28, 2019).

For more information about the plaintiff’s position, contact: Tamara Lindale Roe, Attorney, Montgomery Purdue Blankinship & Austin, 701 5th Avenue, Suite 500, Seattle, Washington 98104-7096; 206-682-7090; Fax: 206-625-9534; Email: troe@mpba.com; Website: https://www.mpba.com/attorneys/tammy-roe/.

For more information about the plaintiff’s position, contact: Tamara Lindale Roe, Attorney, Montgomery Purdue Blankinship & Austin, 701 5th Avenue, Suite 500, Seattle, Washington 98104-7096; 206-682-7090; Fax: 206-625-9534; Email: troe@mpba.com; Website: https://www.mpba.com/attorneys/tammy-roe/.

For more information about the study findings, and about Kaiser Permanente’s policies for physician performance or opioid management, contact: Sara Vinson, Communications Consultant, Kaiser Permanente, One Kaiser Plaza, Oakland, California 94612; 510-271-5953; Email: Sara.Vinson@kp.org; Website: https://about.kaiserpermanente.org/.

During this interview, Terence Ketter explains what PsychU means to him and its impact on the mental health community.

Terence Ketter, MD, is the Bipolar Disorder Section Advisor of PsychU. Mr. Ketter is Emeritus Professor, Psychiatry & Behavioral Sciences Stanford University; Founder and Founding Chief, Bipolar Disorders Clinic, Stanford University.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

In 2018, Medicare beneficiaries over age 65 with UnitedHealthcare commercial insurance who saw high-value physicians for more than 75% of their care had about 21% lower risk-adjusted spending compared to beneficiaries who saw physicians who were not considered “high-value.” UnitedHealthcare defines a high-value physician as one that meets the quality and cost-efficiency criteria established by the UnitedHealth Premium Program. Members who saw high-value physicians had 64% fewer inpatient hospital days, and 35% fewer emergency department visits. As a result, their risk-adjusted spending was $95 lower per member per month.

These findings were reported in “High-Value Physicians Can Save the Medicare Program over $286 Billion in Health Care Costs” by researchers with UnitedHealth Group. The UnitedHealth Premium Program draws upon quality metrics from the National Quality Forum, the National Committee for Quality Assurance (NCQA), and other leading clinical quality organizations. Cost-efficiency measures are based on local market benchmarks for cost-efficient use of resources and referral patterns in providing care.

Additional findings include:

  • The greatest average per-consumer or per-episode Medicare savings for those who saw high-value physicians was for those who saw nephrology professionals, which totaled 11.8% in savings. This was followed by those who saw neurology professionals (11.1% in savings), and those who saw cardiology professionals (10.1% in savings).
  • Of all specialties evaluated, primary care physicians saw the highest volume of consumers (58.7%). Improving the cost-efficiency of these physicians represents the greatest total savings opportunity of an estimated $14.5 billion in 2020, and $202.9 billion by 2029, for those who already meet the quality criteria.
  • Improving the cost-efficiency of cardiologists, neurologists, and pulmonologists who already meet the quality criteria could save seniors and the Medicare fee-for-service program $4.3 billion in 2020, and $61.2 billion by 2029.

The full text of “High-Value Physicians Can Save The Medicare Program Over $286 Billion In Health Care Costs” was published September 25, 2019 by UnitedHealth Group. An abstract is available online at https://www.unitedhealthgroup.com/newsroom/posts/2019-09-24-high-value-physicians-medicare-costs.html (accessed October 28, 2019).

To learn more about the criteria for the UnitedHealth Premium Program, go to https://www.uhcprovider.com/en/reports-quality-programs/premium-designation.html (accessed October 28, 2019).

PsychU last reported on this topic in “Medicare Fee-For-Service Spending For Primary Care Ranges From 2% To 5%,” which published on September 23, 2019. The article is available at https://www.psychu.org/medicare-fee-for-service-spending-for-primary-care-ranges-from-2-to-5/.

For more information, contact: Eric Hausman, Corporate Communications, UnitedHealth Group, Post Office Box 1459, Minneapolis, Minnesota 55440-1459; 952-936-3963; Email: eric.hausman@uhg.com; Website: http://www.unitedhealthgroup.com/

During this interview, Robin Nelson explains what PsychU means to him and how mental health professionals can collaborate with each other.

Robin Nelson, MD, is the Major Depressive Disorder Section Advisor of PsychU. Mr. Nelson is a psychiatrist at DGR Behavioral Health LLC & Caron Treatment Centers.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

There is great debate over whether consumers shop for health care services; like comparing prices and using performance and quality data to make decisions. A recent story about a man who drove five hours for hernia surgery because he discovered a cost difference of $30,000 versus $3,000 (see Man Drives Five Hours For Surgery Insurance Won’t Cover)1 and news that about 1.9 million Americans have become medical tourists to get cheaper care (see U.S. Medical Tourists Seek Cheap Health Care Abroad)2 make me believe we’re entering a new phase of health care consumerism.

While price transparency is a priority (see Presidential Order Requires Price Transparency For Hospital Charges And Out-Of-Pocket Expenses), there is controversy over mandates for transparency and experts question why consumers are not really shopping to get the best prices.

What’s causing the delay? One health care executive, quoted in a Los Angeles Times story, said, “We overestimated the ability of consumers to be good stewards of their health care dollars.”

We may need more time to see a real shift from a doctor-knows-best environment to one in which consumers, like the Texas man noted above, look at health care like other purchases.

There are a few trends that might support more active consumerism. First, employers like Walmart are taking action to steer employees to specific physicians in its markets based on quality data. And Walmart is not alone. An increasing number of employers and health plans are implementing strategies to influence consumer health choices with value-based benefit designs and decision support tools (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System).

The Center for Medicare & Medicaid Services (CMS) has several new initiatives that are focused on engaging consumers in health care decisions. CMS implemented a new rating system for nursing homes this month, Nursing Home Compare (try out the tool: https://www.medicare.gov/nursinghomecompare/search.html). And starting October 23, CMS will add a graphic alert to listings for nursing homes cited for abuse, neglect or exploration.

CMS is also requiring health plans to use its star ratings, which are influenced by consumer satisfaction, on health insurance exchanges (see CMS Requiring Star Ratings Displayed For Health Plans Sold On 2020 Health Exchanges). And it’s planning to update and expand the Hospital Compare site in 2021 based on public hearings and other stakeholder input.

When you combine these efforts with existing NCQA, HEDIS and health plan efforts to highlight health provider performance ratings, consumers will have more information at their fingertips. We see evidence that out-of-pocket costs will increasingly influence consumer choice (see News Reports about a Weakening Economy Impacting How Some Patients Seek Medical Treatment)3 and lead them to use these tools. The bigger question is how do we teach consumers how to use this information the same way they use Rotten Tomatoes to assess movie choices and Yelp when looking for restaurants?

“We are moving quickly toward Priceline health care,” said OPEN MINDS Senior Associate, Paul Duck. As consumers gain a better understanding of their options, shopping will become more common, which is why he advises executives to prepare. A few approaches to consider:

  • Review your organization’s ratings from health plans and independent organizations.
  • Assess how consumers find you online.
  • Review the consumer experience on your website.
  • Assess wait times for consumers scheduling appointments on the phone.

Learn more in upcoming coverage of the consumerism issue and check out these resources in the PsychU Resource Library:

  1. The Next Wave Of Consumer Price Shopping For Health Care
  2. Considering Cash & Consumerism in Service Line Planning
  3. Integration, Interoperability & Consumer Engagement
  4. The Big Rewards Of Health Care Through The Consumer Lens
  5. Answering The Question – Who Can Afford Their Health Services?

1 https://www.cbsnews.com/news/man-drives-five-hours-for-surgery-insurance-wont-cover-hernia-surgery-central-texas-2019-10-11/

2 https://newsroom.transunion.com/news-reports-about-a-weakening-economy–impacting-how-some-patients-seek-medical-treatment/

During this interview, James T. Kenney, explains what PsychU means to him and how it can impact patients and health care professionals.

James T. Kenney, RPh, MBA, is a PsychU Section Advisor, President of the Academy of Managed Care Pharmacy, and Founder and President of JTKENNEY, LLC. Mr. Kenney also serves on the Massachusetts Pharmacists Association Government and Legislative Affairs Committee. Mr. Kenney earned his MBA from the Massachusetts College of Pharmacy and Allied Health Sciences.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

During this interview, Sloan Manning explains what PsychU means to him and how mental health professionals can collaborate with each other.

Sloan Manning, MD, is the Primary Care Provider Section Advisor of PsychU. Mr. Manning is the Medical Director, Novant Health Urgent Care & Occupational Medicine and Adjunct Associate Professor, School Of Medicine, University Of North Carolina.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

OPEN MINDS last survey of health plans found a marked increase in the reported required use of professional guidelines – 59% in this year’s survey, compared with 41% in 2017 (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System). These guidelines include level-of-care and diagnostic criteria—tools to help clinical professionals make better-informed decisions with consumer care.

Health plans expect their contracted provider organizations to use their selected care standards. OPEN MINDS Senior Associate Deborah Adler explains:

These clinical guidelines are used during the utilization review process to ensure services are being used appropriately. During a claims audit or an annual review, health plans will evaluate a provider organization’s adherence to their selected clinical guidelines and evidence-based practices. For example, several NCQA HEDIS measures are focused on specific diagnostic categories (i.e., depression, attention-deficit hyperactivity disorder, addiction disorder) and can be audited for adherence to specific guidelines through claims data. From a provider organization perspective, knowing those guidelines will decrease denials.

Looking at heath plan adoption of the guidelines, the most significant increase was in Medicare plans, increasing to 79% in 2019 from 11% in 2017. In comparison, 43% of commercial health plans used these guidelines, an increase from 4% in 2017. It’s interesting to see that Medicaid showed a slight decrease in utilization in 2019 with 44% of Medicaid health plans using the tools compared with 61% in 2017. One explanation is that state Medicaid agencies develop policies and criteria so other approved guidelines are used as secondary resources.

So, what do these tools look like?

  • Cigna’s clinical guidelines for pediatric depression screening refers professionals to the U.S. Preventive Services Task Force’s recommendations published in the Annals of Internal Medicine (see Cigna HealthSpring Clinical Practice Guidelines1 and Screening For Depression In Children And Adolescents: U.S. Preventive Services Task Force Recommendation Statement)2.
  • Aetna has a Level of Care Assessment Tool (LOCAT) for evaluating and determining whether a specific level of care is medically necessary for individuals with mental health disorders (see Level Of Care Assessment Tool3 and LOCAT, ABA & ASAM Guidelines)4.
  • UnitedHealthcare’s clinical guidelines refers professionals to the American Psychiatric Association’s practice guidelines for treatment of addiction disorders (see UnitedHealthcare Clinical Practice Guidelines)5.
  • Aetna’s policy for care programs and quality assurance refers health care professionals treating addiction disorders to criteria developed by the American Society of Addiction Medicine or ASAM (see An Introduction To The ASAM Criteria For Patients And Families6 and LOCAT, ABA & ASAM Guidelines)7.

 

Guidelines can help care teams identify strategies that improve consumer outcomes and those that do not. Health plans expect provider organizations to evaluate their own results and show they are achieving reliable outcomes, says Ms. Adler, who added:

I do think it’s important for provider organization managers to be aware of these guidelines and use their own internal resources to evaluate their performance against those guidelines. As health plans increasingly tie payments to quality and cost, consistency in clinical practice will be more important.

See more guidelines on the Mental Health Treatment Best Practices Resource Center (see Mental Health Treatment Best Practices) on PsychU. And for more on health plan initiatives, as well as adopting evidence-based practices to prepare for value-based reimbursement, check out these resources in the PsychU Resource Library:

  1. Why Clinical Guidelines Matter More With Risk-Based Contracting
  2. What Are Health Plans Actually Doing?
  3. VBR @ Scale—Changes Required
  4. No Whole Person Care Without Person-Centered Organizations

During this interview, Monica Oss explains what PsychU means to her and how mental health professionals can collaborate with each other.

Monica Oss, M.S. is the founder of OPEN MINDS. For the past two decades, Ms. Oss has led the OPEN MINDS team and its research on health and human service market trends and its national consulting practice. Prior to founding OPEN MINDS, Ms. Oss served as an executive with a national managed behavioral health organization, with responsibility for market development and for actuarial analysis and capitation-based rate setting. She also held a position as a vice president of the U.S. risk management and underwriting division of an international insurance company. Ms. Oss has been the keynote speaker at the conferences of dozens of national associations and has been published in a wide range of professional journals and trade publications.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

During this interview, René Kahn explains what PsychU means to him and how psychiatrists can learn and interact with each other.

René Kahn, MD, PhD, is a Schizophrenia Section Advisor for PsychU and Esther and Joseph Klingenstein Professor and System Chair for the Department of Psychiatry at the Icahn School of Medicine at Mount Sinai. Dr. Kahn has published over 800 research papers, and in 2015 and 2016 was named Thomson Reuters’s highly cited researcher, an award representing some of the world’s most influential scientific minds.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

During this interview, Madhukar Trivedi explains what PsychU means to him.

Madhukar Trivedi, MD, is the Major Depressive Disorder Section Advisor of PsychU. Dr. Trivedi is the Director, Center For Depression Research & Clinical Care and the Betty Jo Hay Distinguished Chair, Mental Health & Julie K. Hersh Chair, Depression Research & Clinical Care, UT Southwestern Medical Center

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

Consumer access to care remains a ‘top of mind’ issue—from access to psychiatrists, waiting lists for treatment programs, and follow-up appointments with therapists. Executives realize that care delayed is often never received, which can lead to more expensive care.

In 2017, only 48.2% of members with a commercial HMO plan had a follow-up visit within seven days after discharge from the hospital for mental illness1. And just 37.0% and 32.2% of consumers who have Medicaid and Medicare coverage had follow-up visits within seven days post-discharge, respectively. Only 37.1% of adolescents or adults with episodes of alcohol or other drug dependence who had commercial insurance initiated treatment within 14 days of diagnosis2. For consumers with Medicaid and Medicare, 42.4% and 32.6% initiated treatment within 14 days, respectively.

What are health plans doing to address the barriers of accessing care? A survey of more than 4,000 U.S. health plans revealed answers. There are three overarching initiatives to improve consumer access to care: telehealth (increasingly referred to as virtual care, a more expansive term embracing all the technologies deployed to support behavioral health), targeted specialty network expansion, and supported consumer appointment scheduling.

Telehealth—The delivery of health care services remotely through telecommunications technology is the most widely used strategy across health plans to improve access to care. Ninety-six percent of health plans have adopted telehealth including 68% of commercial plans, 98% of Medicaid plans, and 99% of Medicare plans, according to Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System. Plans are partnering with telehealth companies to build or expand service offerings and purchasing telemental health companies to expand access. And looking ahead, 66% of plans have some form of text-based therapy on their roadmap.

Targeted network expansion—Connecting consumers with the right type of therapists is one of the challenges with consumer access to care. Health plans are selectively recruiting new provider organizations for their networks that can provide applied behavioral analytics (ABA) and medication-assisted treatment (MAT) for addiction. Eighty-four percent of all health plans, 68% of commercial health plans, 97% of Medicaid, and 98% of Medicare have adopted MAT. ABA, or the process of systematically applying interventions based upon the principles of learning theory to improve behavior, has been adopted by 80% of all plans, 67% of commercial plans, 91% of Medicaid, and 92% of Medicare plans.

Supported appointment scheduling and ‘quick access’ initiatives—This is a popular approach to addressing access with 78% of health plans supporting initiatives to assist consumers and 70% of plans creating a ‘rapid access’ network or initiative (see ‘Rapid Access’ Might Just Be Your Next Health Plan Conversation).

To learn more on health plan initiatives related to access, innovation, consumer engagement, and more—check out the full results of our survey, published in the newly-released 2019 national survey of health plans, Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System. And for more on increasing access as well as drafting a strategic plan to include increased access, check out these resources from the PsychU Resource Library:

  1. Health Insurance Coverage Vs. Access To Care—The Gap Between Them
  2. If There Are Enough Psychiatrists, Why Is Access Such A Problem?
  3. Is 2019 The Year Of The Telehealth Tipping Point?
  4. Network Adequacy Doesn’t Equal Consumer Access
  5. Jumping The ‘Strategy-To-Execution Gap’?

On September 3, 2019, a federal judge ruled that Mississippi’s mental health system discriminates against people with serious mental illness (SMI), despite the state’s efforts to develop its capacity to provide community-based services. The judge ordered the state and the Department of Justice (DOJ) to submit three names of potential special masters and a proposal for the special master’s role by October 4, 2019. The special master will help the state expedite and prioritize community-based care for people with SMI. A hearing will be scheduled later this fall. The judge urged the state and the DOJ to confer before submitting their lists to discuss the possibility of a jointly agreed upon candidate respected, competent, and neutral enough to do the job.

In 2011, the DOJ had issued a findings letter summarizing the results of its investigation into the State of Mississippi’s mental health system. The DOJ concluded that Mississippi was “unnecessarily institutionalizing persons with mental illness” in violation of the integration mandate of the Americans with Disabilities Act (ADA). However, negotiations failed to result in an agreement on how to correct the state’s mental health system. In 2016, the DOJ sued the state. The order in United States of America v. State of Mississippi summarized the testimony presented over a four-week bench trial in June and July 2019. In the order, the court recognized that the state has made efforts toward expanding community-based care. In 2017, the state attorney general formed the Mississippi Mental Health Task Force to create recommendations for improving mental health services.

The DOJ alleged that Mississippi over-relies on state psychiatric hospitals, which violates the Olmstead decision and the ADA. Adults with SMI have been forced into segregated hospital settings instead of being able to stay in their communities with the help and support of their families and local services. The DOJ alleged that as a result, many state residents with SMI are denied the most integrated setting in which to receive services, and are at serious risk of institutionalization. Mississippi’s system has pushed thousands of people with SMI into segregated hospital settings that could have been avoided with community-based services. At discharge, these individuals are at high risk of re-institutionalization due to the lack of community-based services.

The Mississippi Department of Mental Health (DMH) funds and operates four state hospitals: Mississippi State Hospital in Whitfield (MSH); East Mississippi State Hospital in Meridian (EMSH); North Mississippi State Hospital  in Tupelo (NMSH); and South Mississippi State Hospital in Purvis (SMSH). The system has 438 state hospital beds, at a cost ranging between $360 and $474 per person per day. During 2018, a total of 2,784 people were admitted to a state hospital. More than 700 have been hospitalized multiple times. The order noted that Mississippi has relatively more hospital beds and a higher hospital bed utilization rate than most states. The totals do not include forensic beds or forensic commitments. Forensic beds have been generally excluded from this lawsuit because the beds serve a need in the criminal justice system to provide pretrial mental health evaluation and competency restoration, or to treat people found “not guilty by reason of insanity.”

DMH descriptions of the services provided by 14 community mental health centers (CMHCs) are adequate, but the descriptions do not match what is actually provided and where it is provided. The order listed the following concerns about the current system of CMHC services:

  1. Programs of Assertive Community Treatment (PACT), the most intensive community-based service, is unavailable in the majority of counties. Where PACT is available, it is under‐ PACT services do not exist in 68 of Mississippi’s 82 counties. PACT services are offered through eight PACT teams that together cover 14 counties. As of September 2018, however, only 384 people in the state were receiving PACT services. The state PACT penetration rate is much lower than the national average.
  2. Mobile Crisis Services are illusory. All 14 CMHC regions established mobile crisis response teams in 2014 that are supposed to be available 24 hours a day, 7 days a week, 365 days a year, per DMH regulations. However, in some regions, a caller seeking mobile crisis services is directed to go to the state hospital. In other regions, the county sheriff’s department is dispatched to assist the caller.
  3. Crisis Stabilization Units (CSUs) are not available. Not all of the CMHCs have crisis stabilization units. There are nine CSUs across the state located in Batesville, Brookhaven, Cleveland, Corinth, Grenada, Gulfport, Laurel, Newton, and Jackson. The CSUs are to provide psychiatric supervision, nursing, therapy, and psychotherapy to individuals experiencing psychiatric crises. They are also designed to prevent civil commitment and/or longer-term inpatient hospitalization by addressing acute symptoms, distress, and further decompensation.
  4. Community Support Services: Community support services are similar to PACT services, but are less intensive. The services include in-home services, such as medication management and referrals to other service provider organizations. Medicaid reimburses for up to 100 hours of community support services per person per year.
  5. Peer Support Services: The services are provided by Certified Peer Support Specialists (CPSS), who are individuals or family members of individuals who have received mental health services. They provide person-centered activities to help the individual build resiliency. CPSS workers may work at a state hospital as part of PACT or mobile crisis response teams, or may work for CMHCs or other provider organizations. In a key problem, Peer Support Services are not billed. Peer support services are included in the Mississippi Medicaid State Plan, but there is no indication that the service is being utilized across the state. The order noted that in the three most populous regions of the state, CMHCs billed Medicaid for a total of 17 persons who received peer support services in 2017. Meanwhile, Mississippi has only two peer‐run drop‐in centers for people with SMI.
  6. Supported Employment is minuscule. In 2018, 257 Mississippians received supported employment services. The state admits that its penetration rate is quite low.
  7. CHOICE supported housing is far too small. The CHOICE housing program is grossly underutilized. Overall, about 400 Mississippians have benefited from CHOICE, including 205 during fiscal year 2017. In seven CMHC regions, fewer than five people were enrolled in CHOICE. There are an estimated 2,500 CHOICE beds.

The order also noted other management concerns about DMH oversight and relationship with CMHCs. DMH executives admitted during the hearing that they do not regularly review data on community‐services utilization, much less use that data to drive programmatic changes. DMH views CMHCs as independent, autonomous organizations; however, DMH sets the standards for the CMHCs and gives them grants for programs. The order said it is ultimately the responsibility of DMH to manage the expansion of community‐based services at CMHCs.

A DMH spokesperson noted that much of the information and data discussed during the trial is from fiscal year (FY) 2018 and in many cases does not reflect DMH performance in 2019. The spokesperson said that in 2019, Mississippi currently has a total of 401 inpatient psychiatric beds in DMH programs (75 continued treatment beds and 326 acute psychiatric beds), not the 438 referenced in the order. During FY 2018, there were 2,373 acute psychiatric admissions to state hospitals, and in FY 2019, there were 2,212 admissions. Regarding PACT teams, in FY 2019,a total of 500 people received PACT services, which the spokesperson said are now are available in 20 counties. Regarding Certified Peer Support Specialist (CPSS), there were 201 CPSSs in the state in FY 2019. Also in FY 2019, the CHOICE housing program housed its 600th person through the program in June.

Regarding Crisis Stabilization Units, DMH shifted funding from its institutional budgets in FY 2019 to provide funding to CMHCs that did not have CSUs. Previously, there were eight, 16-bed Crisis Stabilization Units across the state. The funding shift from DMH programs to the DMH Service Budget in FY19 allowed additional crisis stabilization beds to open in CMHC regions that did not have CSUs: LifeCore Health Group (Region 3) opened eight crisis beds in Tupelo; Community Counseling Services (Region 7) opened eight beds in West Point; Singing River (Region 14) opened eight beds in Gautier; Hinds Behavioral Health Services (Region 9) opened 12 beds in Jackson; and Region One Mental Health Center opened eight beds in Marks.

Wendy D. Bailey, DMH chief of staff said, “Our goal is to provide hope to Mississippians by supporting a continuum of care for people with mental illness, alcohol and drug addiction, and intellectual or developmental disabilities. By inspiring hope, helping people on the road to recovery, and improving resiliency, Mississippians can succeed. To help in our mission, over the past several years many services and supports have been expanded and new ones implemented, including mobile crisis response teams, community transition homes, crisis stabilization beds, Programs of Assertive Community Treatment, Intensive Community Outreach and Recovery Teams, supported employment, supported housing, Mental Health First Aid trainings for the public, court liaisons, and Crisis Intervention Teams. We are also working to enhance our transition planning as people leave the state hospitals and return to their communities. We have and always will acknowledge weaknesses along with strengths, and we have and always will seek improvement and continue our commitment to the mission of our agency and the people we serve.”

PsychU last reported on this topic in “DOJ Sues Mississippi For Discriminating Against Adults With Mental Illness,” which published on September 16, 2016. The article is available at https://www.psychu.org/doj-sues-mississippi-discriminating-adults-mental-illness/.

For more information, contact:

  • Wendy D. Bailey, Chief of Staff, Mississippi Department of Mental Health, 239 North Lamar Street, Jackson, Mississippi 39201; 601-359-6251; Email: wendy.bailey@dmh.ms.gov; Website: http://www.dmh.ms.gov/
  • Office of Public Affairs, Department of Justice, 950 Pennsylvania Avenue, Northwest, Washington, District of Columbia 20530-0001; 202-514-2007; Email: Press@usdoj.gov; Website: https://www.justice.gov/opa/pr/justice-department-sues-mississippi-discriminating-against-adults-mental-illness

On September 18, 2019, Blue Shield of California, in collaboration with the Blue Cross Blue Shield (BCBS) Institute and Lyft, began piloting the rideQSM non-emergency medical transportation program. Through this pilot, Blue Shield of California is providing its members in Sacramento with free rides to certain physician offices and other health care provider organizations. The pilot is for Blue Shield members with health maintenance organization (HMO) or preferred provider organization (PPO) health plans through their Sacramento-area employers. More than 1,000 Blue Shield members are eligible to participate.They will be able use the Lyft application to schedule rides to the Elk Grove and Galt offices of Associated Family Physicians, Inc. of Hill Physicians. The Blue Shield of California pilot program will run for 12 months. Analysis of the pilot outcomes will determine whether rideQ is expanded to other areas of California.

To use the rideQ service, members must have a mobile phone with short message service (SMS) texting capability. Members call Blue Shield to self-enroll in the program.

According to Kim Kellogg, external communications at Blue Shield of California, Lyft was selected as a partner for the rideQ program due to the focus alignment of non-emergency medical transportation. Lyft provides curb-to-curb services for rideQ: Lyft drivers pick up riders at the designated pickup location, but the member must be capable of entering and exiting the vehicle on their own. For door-to-door services or for members that use wheelchairs, members can book wheelchair-accessible vehicles directly through the rideQ platform. As the rideQ transportation provider organization, Lyft directly handles payment to drivers through their normal payroll processes.

According to Ms. Kellogg, the BCBS Institute has previously launched the rideQ pilot program in nine markets across the United States in collaboration with seven BCBS plans. The rideQ program is evaluated by each of the Blue Shield health plans participating in the program. The pilot programs are being measured according to both leading and lagging indicators.

  • The leading indicators include both member satisfaction and retention which include respectively a 99% satisfaction rate and an 85% retention rate.
  • The lagging indicators include outcome measurement such as change in avoidable emergency room use and hospitalizations, change in site of service, and decrease in physician office visit no-show rates.

Due to the relative newness of the service, lagging indicators are not yet being calculated. However, the goal for the Blue Shield of California rideQ pilot is to test this service, gather data and determine if the program can be extended. Metrics will be assessed, including member adoption rates in using the service, consistency and frequency of use, and the impact on members’ overall health and well-being. The analysis will include quantitative metrics and qualitative measures that will include feedback and analysis from the medical practice participating in this program.

The BCBS Institute first partnered with Lyft in 2017 for nationwide non-medical transportation in areas with limited access to reliable transportation options; however, specific locations for these services are unknown. Non-medical transportation though Lyft was originally offered for BCBS-member medical appointments, and was expanded to include rides to and from pharmacies for prescription medication pick-up in 2018. BCBS Institute subsequently launched “rideQ” as the named partnership with Lyft, in 2018.

PsychU last reported on this topic in “California Medi-Cal Covers Non-Medical Transportation Benefit,” which published on November 12, 2018. The article is available at https://www.psychu.org/california-medi-cal-covers-non-medical-transportation-benefit/.

For more information, contact: Pooja Bhatt, Program Manager, rideQ/Lyft medical transportation Program, Blue Shield of California, Post Office Box 272540, Chico, California 95927-2540; Email: pooja.bhatt@blueshieldca.com; Website: https://www.blueshieldca.com/.

During this interview, Surinder Singh explains what PsychU means to him and how mental health professionals can collaborate with each other.

Surinder Singh, PhD, MBA is a founding member of PsychU. Dr. Singh is the Vice President, Field Medical Affairs for Otsuka Pharmaceutical Development and Commercialization.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

During this interview, Megan Ehret explains what PsychU means to her and how mental health professionals can collaborate with each other.

Megan Ehret, PharmD, MS, BCPP, is the Pharmacist Corner PsychU Section Advisor of PsychU. Ms. Ehret earned her Doctor of Pharmacy from the University of Toledo in Ohio and a Master’s in Clinical and Translational Research at the University of Connecticut Health Center. Ms. Ehret completed a Psychiatry Pharmacy Residency at Louis Stokes Cleveland Veterans Affairs Medical Center and a Psychopharmacology and Pharmacogenomics Fellowship at Nova Southeastern University.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

On September 24, 2019, Kaiser Permanente reached a tentative four-year contract agreement with the Coalition of Kaiser Permanente Unions, which had voted to strike. The unions agreed to withdraw the strike threat. The Coalition union members are voting on whether to ratify the contract. Voting is expected to be completed by the end of October. The Coalition of Kaiser Permanente Unions represents more than 85,000 unionized employees enrolled in 11 local unions across the United States. If ratified, the four-year contract will have an effective date of October 1, 2019. The contract will cover 67,000 employees in California; 8,300 in Oregon and Washington; 3,100 in Colorado; 5,000 in Maryland, Washington, D.C., and northern Virginia; and 1,000 in Hawaii. The Coalition employees represent hundreds of job classifications, from optometrists and pharmacists to maintenance and service workers.

However, Kaiser has reached no agreement with the National Union of Healthcare Workers (NUHW), which represents 4,000 clinical professionals employed by Kaiser in California, whose contract expired more than a year ago. The NUHW members rejected a contract proposal in July 2019. The NUHW members continue to push for further negotiations with Kaiser to settle a contract that adequately addresses issues with its mental health program and provides workers with the same benefits and wage increases as the 120,000 Kaiser employees who recently settled contracts with Kaiser.

The new tentative agreement with the Coalition includes the following seven key points:

  1. Guaranteed wage increases each year through 2023 in northern and southern California, Colorado, Hawaii, the Mid-Atlantic States (northern Virginia, Maryland, and Washington D.C.), Northwest (Oregon and southwest Washington), and Washington regions.
  2. Opportunities for career growth: Kaiser Permanente employees will have the opportunity to move into new roles in a training capacity after pursuing the education needed for the job, at an adjusted Step 1 pay scale. They are guaranteed they will not be compensated less than in their former position. Once experience requirements are met, they will continue in the normal steps for the position at the full rate.
  3. Workforce development fund: A new multi-million-dollar fund will be created to provide educational opportunities for Californians who may not otherwise be able to pursue a career in health care.
  4. Retirement security: The agreement preserves the existing defined benefit pension plan along with other strong retirement benefits.
  5. Outsourcing: The parties have agreed to a list of jobs that will not be outsourced or subcontracted for the life of the contract.
  6. Career mobility: The agreement offers an additional $250 for employee travel as part of the tuition reimbursement program, raising the total to $750.
  7. Affordable health care: The agreement includes a pharmacy utilization approach that gives employees an incentive to use Kaiser’s mail-order prescription service.

In addition to seeking similar contract provisions as the Coalition contract, NUHW is also concerned about Kaiser’s scheduling practices for mental health services. Currently, NUHW believes Kaiser’s California mental health clinics are understaffed. As a result, Kaiser mental health clinicians often do not have time to provide critical patient care duties, and many Kaiser patients must seek mental health treatment from therapists outside of Kaiser.

To address some of the issues identified by NUHW as understaffing or scheduling problems, in July 2019, Kaiser announced that even without full contract ratification by NUHW, it intended to move forward with some items in its proposal. These actions are intended to address the increased demand for mental health care and the shortage of mental health care professionals. The actions are as follows:

  • Hiring more mental health professionals. In early July 2019, Kaiser added 300 new behavioral health professional positions in California.
  • Building a pipeline of future mental health professionals by moving forward with a $10 million expansion of its post-graduate training program across California.
  • Accelerating projects to expand and update Kaiser mental health care offices, with the goal of increasing care accessibility, convenience, comfort, and privacy. This work will more rapidly expand the number of therapist offices, group rooms, and telepsychiatry seats.

PsychU last reported on this topic in “Kaiser Permanente Behavioral Health Workers Hold Five-Day Strike In Early December Over California Staffing Ratios,” which published on February 11, 2019. The article is available at https://www.psychu.org/kaiser-permanente-behavioral-health-workers-hold-five-day-strike-early-december-california-staffing-ratios/.

For more information about the tentative agreement, contact:

  • Marc T. Brown, Media Contact, Kaiser Permanente Corporate Offices, One Kaiser Plaza, Oakland, California 94612; 510-271-6328; Email: Marc.T.Brown@kp.org; Website: https://about.kaiserpermanente.org/
  • Sean Wherley, Executive Director, Coalition of Kaiser Permanente Unions, Service Employees International Union-United Healthcare Workers, 560 Thomas L Berkley Way, Oakland, California 94612; 510-251-1250; Fax: 510-763-2680; Email: swherley@seiu-uhw.org; Website: https://www.unioncoalition.org/

For more information about the NUHW position, contact: Matthew Artz, Media Contact, National Union Of Healthcare Workers, 5801 Christie Avenue, Suite, Suite 525, Emeryville, California 94608; 510-435-8035; Email: martz@nuhw.org; Website: https://nuhw.org/contact/

During this interview, Reza Moghadam explains what PsychU means to him and its impact on the mental health community.

Reza Moghadam, PharmD, MBA, is the Senior Director of Population Health and Remote Customer Engagement for Otsuka Pharmaceutical Development and Commercialization, Inc. Mr. Moghadam earned his Doctor of Pharmacy from Rutgers University and his Master of Business Administration from Villanova University.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

During this interview, Marla Moses explains what PsychU means to her and how it impacts patients and health care professionals.

Marla Moses, FNP, PMHNP, is the Primary Care Provider PsychU Section Advisor of PsychU and Owner of Moses Mental Health. Previously, Ms. Moses held positions at Riley Hospital for Children and Lafayette-Arnett Indiana University Hospital.

Paul Duck is a Senior Associate at OPEN MINDS. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, Chief Executive Officer for Coastal Orthopedics, and Chief Executive Officer of Florida Radiology Imaging (FRi). Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University and his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

At the 2019 OPEN MINDS Executive Leadership Retreat, one area of focus was “growing” women in leadership positions in health and human services. Interestingly, this year, 51% of the attendees were women. There were two sessions at the retreat focused on women in leadership. Monica E. Oss held the first meeting of female chief executive officers in health and human services, and OPEN MINDS Executive Vice President, Casey Miller, facilitated a great discussion session, “Women In Leadership: A Small Group Discussion Session On Supporting Women In Management Roles.”

The focus on women is an important one at a time when talent is short, and women are under-represented in the management ranks. While women make up about 80% of the health care workforce overall, when it comes to holding leadership roles and c-suite executive positions, women comprise less than 20%.1 Just 3% of health care chief executive officers are women, and only another 3% serve as chief medical officers. These stats remain, despite evidence that having women in corporate leadership roles in positively associated with improved financial performance, and less discriminatory attitudes towards female leadership.2

In recent years, women in leadership roles has shown some growth, but it remains incredibly slow. Between 2015 and 2018, the percentage of women board members at Fortune 500 health care companies increased from 21% to just 22.6%, and the percentage of women executives only increased from 20.0% to 21.9%.3

The executives participating in the discussion had some great experiences to share – and some very concrete advice for organizations that want to increase the number of women leaders in their midst. That advice was to mentor potential women leaders, include women in succession planning, and address compensation disparities.

Mentor Potential Women Leaders—For executive team members and managers in leadership roles, it is important to have a deliberate program to provide mentorship for women with high leadership potential. Providing high potential young women with a “trusted advisor” is useful in assisting women is providing feedback and advice and assisting women in navigating organizational culture. Mentors can assist in getting their mentees exposure—to be “seen and heard” by the executive team—and develop a plan for building their leadership profile.

Include Women In Succession Planning—Organizations can use succession planning to boost gender diversity in the executive suite. This begins by identifying the best female candidates in the organization and providing them with a clearer pathway to the top of the organization and equipping them with the skills and knowledge to pave the way. The recruitment process for executive roles also needs to address gender diversity. For each senior role, organizations should assure there is a diverse shortlist. And, in an interesting study, organizations with a gender diverse board of directors are more likely to consider women in filling executive roles.

Addressing Compensation & Compensation Disparities—In adding more women to your roles, it is important to address compensation. Compensation and compensation disparities should be transparent. This starts with doing research to identify salaries for each role and assuring gender pay equity in each role. There is a $20,000 average different in compensation between male and female health and human service managers.4 And, gender pay disparities extend to physicians. Mean annual compensation for female physicians in family practice, internal medicine, and pediatrics is lower than that of their male counterparts—$219,995, $215,012, and $170,535, respectively, or $4,448, $29,211, and $23,402 less than men in similar positions.5 Talented women are less likely to stay in organizations where compensation disparities are not addressed.

Finally, to make these changes sustainable, executive leadership must be committed to an inclusive environment. The tone for not permitting bias and having an equal playing field for women—and all team members—starts at the very top. To retain the best women leaders, women must be represented in roles at all levels of the organization: the board of directors, the c-suite, and the direct service team.

For more on building your female talent pool, check out these resources from the PsychU Resource Library:

  1. Developing Female Leaders In Your Organization
  2. What I Learned From My Mentors & Why It Matters To Have Mentors
  3. Why It’s So Hard To Fill Those Executive Positions At Behavioral Health & Social Services Provider Organizations
  4. Courage As The Leadership Differentiator
  5. Great Leadership Is A Habit

It’s never too soon to think about growing the next generation of leaders if you’re in a specialty provider organization. In our recent national survey, Trends In Specialty Health & Human Services Executive Compensation & Retention: The OPEN MINDS 2019 Survey, about 25% of c-suite executives said they were planning on leaving in the next five years and another 25% were thinking about it.

Building the future leadership team was the focus of the session, Building The Next Generation Of Leaders: How To Develop The Leadership Team You Need For Success, at The 2019 OPEN MINDS Executive Leadership Retreat. The session featured Elizabeth Carey, President and Chief Executive Officer, Starr Commonwealth; John Sheehan, MBA, FACHE, President and Chief Executive Officer, Harbor Behavioral Health; and Vicki Daniel, MBA, Patient Experience Director, Wellspan Philhaven.

These executives, collectively, spoke to three keys for building the next generation of leaders—using personality profiles to identify candidates; not making a big leap all at once; and thinking creatively about staff.

Use personality profiles, but don’t stick to them—All three organizations use the DISC profile to help understand leadership and personality styles. This has improved their understanding of how their team members communicate and solve problems.

Ms. Daniel explained that they started by using the DISC profile with senior leadership staff. It was so successful that they used it with middle managers and provided a one-day training to middle managers on the profile. Middle managers are now beginning to use the profile with their staff as well. Ms. Carey explained that they assign everyone a bird based on their DISC profile that sits on their desk to help facilitate conservations. All three also cautioned that while the profiles are useful, most people fit multiple buckets and it’s important not to develop pre-conceived notions about preferences versus future capabilities.

Don’t take the big leap all at once—For many executives, one of the biggest challenges is transitioning clinical staff to administrative management roles. These roles often require different skill sets and not everyone is suited for both.

Ms. Carey explained that her organization addresses this issue by exposing staff to the administrative side of the business before offering them an administrative role. Clinical staff are invited to sit on the development of business plans and other administrative functions for the service line they work in. This allows staff to see if they like these functions and will self-select. Mr. Sheehan noted that you can’t just expect people to glide into these roles. It requires a lot of coaching, training, and opportunities. He also noted that it sometimes means having the tough conversations with people about taking on a different role if it doesn’t work out.

Think creatively about staff—Attracting and retaining talent doesn’t mean slotting them in a specific role or career path. Often, you will have talented people who grow out of their role or realize it isn’t really right for them. If you think those individuals have skills and attributes that are valuable to the organization, it may be worth moving them to a different role or creating a role that fits their skillsets.

Mr. Sheehan noted that it may be worth investing in non-traditional staff and remote staff. His organization started to provide telepsychiatry and their child psychiatrist is based in Texas. He says without her skill and expertise and being flexible in what it means to be a staff member, they could not be as successful as they are today.

For more on building the next generation of leaders, check out these resources from The PsychU Resource Library:

  1. How Do You Engage Employees & Improve Performance?
  2. Managing Your Team To ‘Tech Savvy’
  3. Staff Not Performing? What Does That Mean?
  4. From Clinician To Manager—Rethinking Best Practice
  5. 4 Ways To Retain & Grow Millennial Employees

At The 2019 OPEN MINDS Executive Leadership Retreat in Gettysburg, one statistic was really surprising. How many strategic plans actually get implemented? The answer: 10%. Not just for health and human service organizations, but for all types of organizations. Even though 65% of organizations have an agreed upon strategy, only 14% of employees actually understand the strategy, and 90% of organizations ultimately fail to achieve their strategic goals.

That was the opening challenge to the audience presented by Ravi Ganesan, President of Core Solutions, Inc., in his presentation, A Data Driven Strategy – A Blueprint For Organizational Success. His presentation on the state of planning had two big takeaways for improving the strategy implementation success rate—the importance of using data in planning and the need to adopt agile planning approaches. Mr. Ganesan explained that data-driven strategy (DDS) leverages the power of big data starting with data-informed strategy and transforming the organization through data-driven decision making. Agile principles give organizations the ability to adapt rapidly and cost-efficiently in response to changes in the business environment. He noted:

We still need long-term plans, but the idea that you will have a five-year plan will be very difficult in an environment where changes happen very fast. How do you work in an environment where change is fast, and the need to replace that five-year plan with what can be achieved in the next 3, 6, or 12 months? Put another way, what’s the minimum product I would accept moving forward in smaller increments at a time?

Mr. Ganesan raised the issue that traditional multi-year planning is fading—and that many organizations are operating on an antiquated strategic timeline. Executive teams need to marry DDS and agile strategy for success.

If you are unfamiliar with the concept of “agility” in strategy, it is basically a process for taking a large plan, executing it in shorter segments, and changing the plan over time as the market landscape changes. The fundamental concept is tracking your success on each plan element, pivoting away from likely planning failures based on the data. The key is a rapid learning and decisionmaking cycle—led by a dynamic (and adaptable) leadership team (See Speed Is The New Management Competency).

Mr. Ganesan noted that while the well-known adage “life is a marathon, not a sprint” is true in many instances, it is no longer true for planning. Business planning needs to be considered in “smaller chunks” and more executive teams need to think in an agile fashion about what can be done next quarter, not next year.

For more on the overlap of data-driven agile strategy, check out these resources from PsychU Resource Library:

  1. Anticipating The Looming Strategic Surprises
  2. Metrics-Based Managing As ‘Cause & Effect’
  3. ‘Agile Innovation’ Needed For The Challenges Ahead

What do mindfulness and organizational change have in common? More than you might think.

At The 2019 OPEN MINDS Executive Leadership Retreat, Monica Oss closed the retreat with her keynote, Your Organization Is Ready, Are You?, discussing how executives can build their “strategic leadership” skills—the ability to handle complex problems for which there is no obvious short-term solution. Strategic leaders can transform organizations in a complex environment.

The good news is that strategic leadership skills can be learned and improved. There are new techniques for “building” strategic leadership muscle — by practicing specific executive behaviors, visualization, and meditation are a part of that process.

At the retreat, we had executives focus on building their mindfulness skills in a session, Mind Full Or Mindful? Tools & Techniques For Decluttering The Busy Leader’s Mind, led by Harriet Stein, President of Big Toe in the Water. She explained the mindfulness construct as having complete awareness with non-judgment, and giving your full attention to the present moment. As Ms. Stein explained:

Mindfulness is about paying attention on purpose to the present moment with non-judgment. It is a practice of compassion. What it really comes down to is the idea that we need to be aware of what is going on in our thoughts. Having a “beginner’s mind” allows you to see every day as a new day, and every moment as a fresh moment.

Practicing mindfulness has nine elements related to one’s daily practice including acceptance, letting go, beginner’s mind, non-striving, gratitude, generosity, patience, non-judging, and trust. It is easy to learn and doesn’t require a significant time commitment. The practices can be easily integrated into your daily tasks and routines—and provide some immediate results. Ms. Stein noted:

You can bring awareness to your morning rituals and check in with your breathing; notice your commute to work and monitor tension throughout your body; take short breaks and go outside, even if it’s only for a few minutes; and bring awareness to the process as you leave work and re-enter your home.

For executives, mindfulness can mean the difference between rushing to make a choice that leads to failure versus thoughtfully making an informed-decision that leads to better. In the session, Ms. Stein discussed the five qualities that the practice of mindfulness enhances for leaders and executives—self-awareness, compassion, focus, responsiveness, and nonjudgment.

Self-awareness—Mindfulness practice can bring an increased sense of self to leaders and executives. A self-aware leader can better recognize their own strengths and weaknesses and take the necessary steps to prevent weaknesses from affecting the organizational environment. Humility is a key component within this. While the best leaders are able to celebrate their successes, they are also able to learn from their failures.

Compassion—By consistently bringing yourself to the present moment, compassion also improves with practice. And compassion is critical for leaders who are seeking to build a strong, collaborative team environment. Mindful communication with others not only enhances your ability to listen and learn, it better enables you to communicate your own vision and plans to others.

Focus—The practice of mindfulness also allows you to have the space to think, which is a major key in any leader’s strategic thinking. By giving yourself the space to think, mental clarity and focus improve, which in turn, leads to enhanced decisionmaking. This is key for the busy executive who has an endless list of deadlines, back-to-back meetings, and financial concerns, all of which place an intense demand on time, and can be physically and emotionally draining (see The Executive Body Is Business Relevant).

Responsiveness—Responsiveness is a critical skill for any leader, but particularly for a leader in the health and human service space. In a rapidly changing environment, executives must be ready to respond to the new challenges and circumstances they face as the environment around them changes). The practice of mindfulness allows you to stay focused in the present moment, rather than being stuck in the past or anxious about the future.

Nonjudgment—Mindfulness doesn’t mean you have to change who you are, but rather, understand and accept yourself and others with the compassion you cultivate by staying focused in the present moment. The practice of mindfulness better enables you to overcome negative thoughts by noticing how you feel, as well as noticing the story you tell yourself. A nonjudgmental environment provides leaders and front-line staff with the setting and resources to achieve their goals, and do their best work.

If you haven’t thought about incorporating mindfulness, meditation, and visualization into how you prepare to address the stressful issues of the day, this would be one more resource to add to your executive toolkit.

For more on leadership and the practice of mindfulness, check out these resources from the PsychU Resource Library:

  1. Mind Full Or Mindful?
  2. The Executive Body Is Business Relevant
  3. How “Fit” Is Your Executive Athlete?

Starting November 4, 2019, the Centers for Medicare & Medicaid Services (CMS) will penalize provider organizations participating in Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) if the provider organization had a previous affiliation with another provider organization or individual banned from participating in these programs. The rule is intended to enhance program integrity and prevent fraud. Participating provider organizations and suppliers will be required to disclose their current and previous affiliations with other provider organizations, professionals, and suppliers. CMS will have additional authority to deny or revoke a provider organization’s or supplier’s Medicare enrollment in specified circumstances if they were affiliated with unqualified, and potentially fraudulent, entities or individuals.

The final rule, “Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process,” was published in the Federal Register on September 10, 2019. The final rule with comment period is effective on November 4, 2019. Comments will be accepted through November 4, 2019.

The rule includes other authorities that give CMS greater ability to fight fraud. These authorities provide a basis for administrative action to revoke or deny Medicare enrollment in the following situations, as applicable:

  • A professional, provider organization, or supplier circumvents program rules by coming back into the program, or attempting to come back in, under a different name.
  • A professional, provider organization, or supplier bills for services and/or items from non-compliant locations.
  • A professional, provider organization, or supplier exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services, or drugs.
  • A professional, provider organization, or supplier has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.

CMS will be able to prevent applicants from enrolling in the program for up to three years if a professional, provider organization, or supplier is found to have submitted false or misleading information in its initial enrollment application. The rule expands the re-enrollment bar that prevents fraudulent or otherwise problematic provider organizations from re-entering the Medicare program. Previously, the re-enrollment ban lasted for up to three years; the ban will be extended up to 10 years. A professional, provider organization, or supplier revoked from Medicare for a second time can be blocked from reentering for up to 20 years.

For more information, contact: Frank Whelan, Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-6058-FC, Post Office Box 8013, Baltimore, Maryland 21244-8013; 410-786-1302; Website: https://www.cms.gov/newsroom/press-releases/cms-announces-new-enforcement-authorities-reduce-criminal-behavior-medicare-medicaid-and-chip; or Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email: press@cms.hhs.gov; Website: https://www.cms.gov/newsroom/press-releases/cms-announces-new-enforcement-authorities-reduce-criminal-behavior-medicare-medicaid-and-chip.

Nearly one-third of general practice physicians asked to identify and rank their consumers’ top three chronic health conditions failed to pick the top condition listed by the consumers. Agreement was very good for hypothyroidism; good for diabetes and high blood pressure; and poor for chronic anxiety disorder and chronic sleeping disorder.

The study was conducted using 153 physician-consumer pairs that each wrote a priority list of the consumer’s chronic conditions.  For 45 of the pairs (29.4%) the consumer’s first-listed priorities were not on the corresponding physician’s list, although other lower priority conditions were on the physicians’ lists. For 19 (12.4%) pairs, none of the lists matched.

These findings were reported in “Patient-Physician Agreement In Reporting And Prioritizing Existing Chronic Conditions” by Stéphanie Sidorkiewicz, Alexandre Malmartel, Lea Prevost, Henri Partouche, et al. The researchers asked 233 consumer-physician pairs to identify the consumer’s chronic conditions from a list of 124 items and to rank the three most important conditions. Of the 233 consumer-physician pairs, 153 generated a priority list. The goal was to assess the agreement between consumer self-reports and general practitioner (GP) reports of the top chronic conditions affecting the consumers. An additional goal was to assess the agreement between consumers and GPs on health priorities in a primary care setting.

Agreement between consumers and physicians regarding each reported chronic condition ranged from “very good” to “very poor,” depending on the condition. Agreement reliability was interpreted using Altman’s classification as “very good,” “good,” “moderate,” “fair,” “poor,” or “very poor,” depending on the strength of agreement between observations. Negative values occur where the level of agreement is lower than would be expected by guessing:

  1. Very good agreement: 0.8 to 1.0 strength
  2. Good agreement: 0.6 to less than 0.8 strength
  3. Moderate agreement: 0.4 to less than 0.6 strength
  4. Fair agreement: 0.2 to less than 0.4 strength
  5. Poor agreement: 0.0 to less than 0.2 strength
  6. Very poor agreement: -1.0 to less than 0.0 strength

A total of 134 (87.6%) consumer-physician pairs had at least one matching priority condition in their lists, but did not agree on the most important condition, and a total of 19 pairs (12.4%) had no matches. The 10 most frequently listed chronic conditions by both consumers and physician were (in order): high blood pressure, osteoarthritis, chronic anxiety disorder, chronic sleeping disorder, chronic low-back pain, gastroesophageal reflux disease or chronic gastritis, age-related hearing impairment, chronic rhinitis or sinusitis, asthma, and tobacco use.

The researchers concluded that there is need for more consumer-centered care for those with various chronic conditions. This shift to consumer-centered care may require a change in how models of care are designed, allowing better partnerships to exist between health care professions and consumers.” was published in the September/October 2019 issue of Annals of Family Medicine. An abstract is available online at http://www.annfammed.org/content/17/5/396.full (accessed September 29, 2019 ).

The full text of “Patient-Physician Agreement In Reporting And Prioritizing Existing Chronic Conditions” was published in the September/October 2019 issue of Annals of Family Medicine. An abstract is available online at http://www.annfammed.org/content/17/5/396.full (accessed September 29, 2019 ).

For more information, contact: Stéphanie Sidorkiewicz, M.D., Ph.D., Département de Médecine Générale, Université Paris Descartes, 24 Rue du Faubourg Saint-Jacques, Paris, France 75014; Email: stephanie.sidorkiewicz@parisdescartes.fr; Website: https://www.parisdescartes.fr/

In 2017, the average age-adjusted death rate in the five states with the highest death rates nationwide was 49% higher than the rate for the five states with the lowest death rates. Across the five highest states—Alabama, Kentucky, Mississippi, Oklahoma, and West Virginia—the average age-adjusted death rate was 926.8 per 100,000 standard population (0.93%). Across the five lowest states—California, Connecticut, Hawaii, Minnesota, and New York—the rate was 624.0 per 100,000 standard population (0.62%). The national age-adjusted death rate is 731.9 per 100,000.

These findings were reported in “Mortality Patterns Between Five States With Highest Death Rates and Five States With Lowest Death Rates: United States, 2017” by Jiaquan Xu, M.D. of the National Center for Health Statistics within the Centers for Disease Control and Prevention. This report compares average age-adjusted death rates by sex, race, and ethnicity; and five leading causes of death between the group of five states with the highest age-adjusted death rates and the five states with the lowest rates.

On average, the death rate per 100,000 standard population for age group 25 to 34 years was 103% higher in the states with the highest death rates compared to states with the lowest death rates (186.1 and 91.8, respectively). The death rate per 100,000 standard population for the age group 35 to 44 years was 112% higher in states with the highest death rates compared to states with the lowest death rates (302.0 and 142.4, respectively).

For the states with the highest rates compared to the states with the lowest rates, average age-adjusted death rates were 46% higher for heart disease (217.3 and 149.2, respectively), 29% higher for cancer (178.5 and 138.8, respectively), and 39% higher for stroke (45.3 and 32.5, respectively).  Average age-adjusted death rates for chronic lower respiratory diseases in the states with the highest rates were double that of the lowest states (62.0 compared to 31.0), and rates for unintentional injuries were nearly double (65.5 compared to 35.8) in the highest-rate states compared with the lowest-rate states.

PsychU last reported on this topic in “Heart Disease Was Leading Cause Of Death In 2017; Cause-Of-Death Rankings Remain Unchanged Since 2016,” which published on August 26, 2019. The article is available at https://www.psychu.org/heart-disease-was-leading-cause-of-death-in-2017-cause-of-death-rankings-remain-unchanged-since-2016/.

For more information, contact: Jiaquan Xu, Statistician, National Center for Health Statistics, U.S. Centers for Disease Control and Prevention, 3311 Toledo Road, Hyattsville, Maryland 20782; 301-458-4800; Email: paoquery@cdc.gov; Website: www.cdc.gov/nchs.

Innovation is on the top of strategy “to do” lists for most organizations and for good reason. I think the most fundamental challenge for the executives of most organizations serving complex consumers is coming up with “the next big thing” (see Coming Up With The Next Big Thing). For many organizations, the services that have been the foundation of sustainability are losing their market preference and their margins.

The drivers of this change? Preferences for integrated care coordination and service delivery models, value-based reimbursement, consumerism, technology, and competition for talent. All these market developments are making traditional services obsolete and driving demand for new approaches.

Even with a strategy that is heavy on innovation and new service line development, when it comes to implementation, most strategies and new service lines fail. The reasons are many, but generally fall in two categories—implementation planning and culture.

For organizations that must navigate these changing strategic waters, the question is how to proceed. In his presentation, Positioning Your Workforce For The Value-Driven Environment Of The Future at The 2019 OPEN MINDS Executive Leadership Retreat, OPEN MINDS Senior Ken Carr suggested that executives take some advice from Vijay Govindarajan and use the “three box solution.” The concept is to address the past, the present, and the future simultaneously in innovation implementation. (I find it interesting that the concept is based on the three gods of Hindu cosmology—Vishnu, the preserver, Shiva, the destroyer, and Brahma, the creator.)

In the context of managing a health and human service organization, the management translation is managing the present, selectively forgetting the past, and creating the future.

Managing the present—This is all about keeping the wheels on the bus and optimizing current service lines.

Selectively forgetting the past— This means closing service lines that no longer make sense and it is the tough one for most organizations. Mr. Carr explained:

Everyone can name one program that made sense five or ten years ago but may not be delivering on the mission or bottom line that it originally did. A couple of times a year, we need to review service lines and we have to say for some, we can’t do this anymore. We can’t drive new things if we are putting resources into old things that we are no longer about.

Creating the future—Finally, there is building the service lines for the future. It is taking new service line concepts and making them a reality, first in pilot projects and then at scale.

This simultaneous focus on the past, the present, and the future demands new leadership skills and the ability to manage complexity. In the closing session of the 2019 OPEN MINDS Executive Leadership Retreat, Your Organization Is Ready, Are You?, Monica Oss spoke to the need for new leadership skills and transformational leaders who can deal with the complexity of the current and the future simultaneously.

For executives of most health and human service organizations, the key questions as they look ahead are what will we be in the future, can we afford to get there, and who will lead us there? The first two are answered by strategy but making them happen is all about leadership.

 

At The 2019 OPEN MINDS Executive Leadership Retreat the session, The New Executive Strategy Role: Becoming The Agent Of Change For Your Organization, featured executive faculty members with three very different “change” situations.

Luanne Welch, President and Chief Executive Officer of Easterseals UCP North Carolina and Virginia led the $88 million organization through a turnaround and now is in the midst of a managed care transformation in both states of operation. Gary Bonalumi, the Patient Experience Director of WellSpan Health System—a 19,000-employee, $3 billion health system—is amid major mergers. And, Dyann Roth, President and Chief Executive Officer at Inglis, a $49 million organization serving people with complex physical disabilities, is in a community-based transformation.

What was the big takeaway? Leading these big changes requires an executive team with personal courage. To be successful with organizational transformation, the speakers spoke of “having the stomach” and fortitude to make necessary moves. That courage, however, is not strictly a characteristic of individual leaders. Ms. Welch explained:

In my experience, I initially had a “naïve” courage. I knew enough to know the closets had skeletons. Then came an “informed” courage. At some point, you move to a “whatever it takes” courage. The key is an ability to listen, and to listen to the right people. I think in our case, the right people are the front line. They know more than the c-suite most days. You also need a bias for action. In terms of an organizational ability, you need to bring different teams together so that you can bring different lenses together, so you have a broader view of the real issues. Then you can make great decisions.

So, what do you do if your organization is on the brink of a transformational change? In addition to taking your own “personal courage inventory”, these executives spoke to three other crucial tactics—basing action on data, leveraging the power of middle management, and engaging the board.

Basing action on data—All three executives spoke to the need for leaders to have “bias for action.” But, that said, that action plan needs to be based on data and on an understanding of the organization, market, and competition in front of them. With data in hand, “ruthless execution” is the goal but with the ability to change course as the situation changes. In organizational transformations, recalibration of tactics is the rule and not the exception. Ms. Roth noted:

What data is important and what is noise? And how can we base action on the data? What does the board, the executive team, and the management teams of service lines each need in terms of data and what are they going to do with it? We need enough balance of “inside and outside cats.” We need people who are really “out there” forming the relationships, selling the new identity, and positioning us, and enough inside folks continuously working on quality. Our top executives need to balance being both.

Leveraging the power of middle management—Plenty of great leadership visions have been derailed because leadership didn’t understand how to communicate that message throughout the entire organization. Not unexpectedly, all three executives spoke to communication, overcommunicating, and “you can’t communicate enough.” Leveraging the role of your organization’s middle managers is a fundamental part of this communication strategy. Mr. Bonalumi noted:

There is a unique role for the middle management levels of the organization. They are between the strategy makers and the largest number of employees. As change rolls out, it rolls out in different ways. You need folks that are persistent and patient, that recognize there is a process and there is an urgency, but they can respect the feelings that go along with it. And they can point out the opportunities that go along with it.

Ms. Welch also explained that there is a definitive process to change and culture management—and described how her organization profiles managers to find the “humble, hungry, and smart.” She discussed how executives need to direct the change process:

If you are in touch with your front line—the heart and soul of the organization—you know the manager controls your culture. You must include the manager as part of the solution and clarify their role. You as the executive can frame the issue, but if you aren’t bringing along your managers then you are missing an opportunity to move change forward. At first, staff will likely fear the change, then they will hate the change, then they will love the change, and finally they will embrace the change. You can shrink the time it takes for that process, but you can’t eliminate it. Change takes time to be successful.

Engaging the board—There is a big difference between talking to your board, and truly engaging the board in an organizational transformation. As these executives noted, many board meetings become an “information dump” with an occasional question and answer session included if there is time. This is not engagement in change. While it’s paramount to keep the board abreast of the latest information (and there is a lot of “the latest” in health and human services), it’s also important to keep them active and engaged. Mr. Bonalumi noted:

A lot of board meetings are about dumping information, and then maybe shoe horning in a question. You have this immense talent sitting around the table and rarely do you have a chance to ask them what their experience is with your issues, in their businesses. There must be more conversation and engagement.

While most health and human service organizations don’t know exactly what the future holds, planning for that future change is essential. Building the courageous leadership team to take that strategy from concept to action is the key to success.

For more on leading organizational transformation, check out these resources from The PsychU Resource Library:

  1. Bot, Anyone? The Question-What Services Can You Automate?
  2. Anticipating The Looming Strategic Surprises
  3. Even ‘Change Management’ Is Changing

In this interview, Catherine Judd, MS, PA-C, CAQ-Psy, discusses the role a physician assistant plays in the mental health team. Physician assistants have a broad-base, primary care medical background in medicine.

Catherine Judd 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.

For the 2020 open enrollment period, the Centers for Medicare & Medicaid Services (CMS) will require that the federal and state insurance exchanges publicly display the five-star Quality Rating System (star ratings) for each health insurance plan sold on the exchange. The star ratings, which were developed by CMS, rank health plans on a scale of one (lowest quality) to five (best quality) based on medical care, member experience, and plan administration. Open enrollment for 2020 is November 1 to December 15, 2019.

Public display of the star ratings is required under the Patient Protection and Affordable Care Act. CMS released additional guidance on the display in an informational bulletin on August 15, 2019. The display of star ratings were piloted in Virginia and Wisconsin in 2017 and 2018. Michigan, Montana, and New Hampshire were added to the pilot for 2019.

The rating system consists of 38 quality measures, 28 of which are clinical. The measures fit into three categories:

  • Medical care: Based on how well the plan’s network manages the care of enrollees
  • Member experience: Based on customer satisfaction surveys
  • Plan administration: Based on how well the health plan provides customer service, access to information, etc.

For plan year 2019, there were 185 health plans on the federal and state exchanges that were eligible to receive a star rating. About 95% of these health plans received a three-star rating or higher, 67% received a four-star rating or higher, and 19% received a five-star rating.

For more information, contact: Tom Corry, Director, Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: press@cms.hhs.gov; Website: https://www.cms.gov/.

Nurse practitioner-led medication reconciliation of those being admitted to a skilled nursing facility (SNF) reduced hospital readmissions within 30 days by about 29.7%. The hospital readmission rate was 19.2% prior to nurse practitioner-led medication reconciliation, and 13.5% following the reconciliation efforts. The national average hospital readmission rate is 21.1%.

SNFs are penalized for hospital readmissions within 30 days, and medication errors often precipitate hospital returns. The Centers for Medicare & Medicaid Services (CMS) mandates that health care professionals must determine whether medications pose significant risks and implement corrective actions.

These findings were reported in “A Nurse Practitioner–Led Medication Reconciliation Process To Reduce Hospital Readmissions From A Skilled Nursing Facility” by Rachel Anderson, DNP, APRN-C, LNHA; and Rita Ferguson, Ph.D., RN, CHPN, CNE. A pre- and post-implementation design was used to compare 30-day hospital readmission rates for those being released from a SNF over a 30-day project period. A total of 37 SNF consumers were included during the period studied. A full-time nurse practitioner used the workflow process to complete stabilization visits with medication reconciliation on each facility admission. The goal was to determine whether a nurse practitioner-led medication reconciliation on admission would reduce hospital readmissions from a SNF.

The researchers concluded that nurse practitioner-led medication reconciliation had positive benefits for the SNF. The benefits included fewer hospital readmissions and increased revenue because consumers remained in the SNF setting. The SNF had improved performance on quality measures, and received a “no deficiency” rating on the annual state survey. Additionally, the facility is now prepared to meet the CMS mandate for having a timely medication reconciliation at the time of the consumer’s admission to the facility.

The full text of “A Nurse Practitioner–Led Medication Reconciliation Process To Reduce Hospital Readmissions From A Skilled Nursing Facility” was published August 6, 2019, by Journal of the American Association of Nurse Practitioners. An abstract is available online at https://journals.lww.com/jaanp/pages/articleviewer.aspx?year=9000&issue=00000&article=99622&type=Abstract (accessed September 4, 2019).

For more information, contact: Rachel Anderson, DNP, APRN-C, LNHA, Owner, Ardent Healthcare, 13 Hiles Street, Suite 8039, Lynchburg, Tennessee 37352; 931-808-4926; Email: randerson@ardent-healthcare.com; Website: https://ardenthealth.com/

California Medicaid (Medi-Cal) will begin reimbursing for trauma screenings for adult beneficiaries. Starting January 1, 2020, professionals who complete trauma training will be eligible to receive the supplemental payment for conducting trauma screenings. Professionals will have until July 1, 2020, to attest that training has been completed. The screenings will also be covered in the fee-for-service (FFS) system at a rate of $29 per screening. The state’s managed care plans will receive a supplemental payment to cover payments for trauma screening provided by their network professionals at a negotiated rate. The proposed billing codes are CPT Codes G9919 for screening performed and positive with provision recommendation or G9920 for screening performed and negative.

The screening will assess the individual’s exposure to child abuse or neglect, household dysfunction, and other potentially traumatic events during childhood, such as major stressful events and community violence. It will also assess exposure to social concerns linked to health, such as discrimination and poverty.

Funding for the new trauma screening is through Proposition 56, the state’s tobacco tax. The specific focus on trauma is based on stakeholder feedback from the advisory group authorized by Assembly Bill (AB) 340 of 2017. AB 340 required the California Department of Health Care Services (DHCS), in consultation with the California Department of Social Services (CDSS) and other partners, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for screening children for trauma as defined within the Medi-Cal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. In 2018, DHCS convened the AB 340 advisory workgroup, which submitted its recommendations to DHCS and the legislature in January 2019.

For fiscal year 2019-2020, Governor Gavin Newsom’s budget proposed using $45 million (half Proposition 56 funds and half federal funds) to support screenings as the first step in trauma-informed care. These screenings will be billed and reimbursed in both the managed care and FFS delivery systems. These payments will be in addition to the amounts paid for the office visit that accompanies the screening in FFS scenarios or capitation paid by Medi-Cal managed care health plans (MCPs).

In March 2019, DHCS issued a trauma screening proposal, which is still being finalized. Based on stakeholder feedback, the trauma screening tool for adults will be the Adverse Childhood Experiences (ACEs) assessment.

To be eligible to receive the supplemental payment for trauma screening, health care professionals must complete training on trauma-informed care and trauma screening beginning in the fall of 2019. The training will be delivered by DHCS in partnership with the California Surgeon General’s Office.

For more information about the DHCS Medicaid trauma screening, contact: California Department of Health Care Services, Post Office Box 997413, Sacramento, California 95899-7413; Email: AB340@dhcs.ca.gov; Website: https://www.dhcs.ca.gov/provgovpart/Pages/TraumaCare.aspx.

The effects of trauma have been in the headlines too much over the past few weeks. Most recently, trauma from mass shootings to trauma from neighborhood gun violence. Likewise, the trauma from sexual assault and the trauma of childhood separation and mass incarceration are also in the headlines far too frequently.

Most professionals in the health and human service field are aware of the Adverse Childhood Experiences (ACEs) study1 and the long-term and lasting effects of trauma. The effects include mental health conditions (depression, anxiety, post-traumatic stress disorder), chronic physical health conditions (heart disease, stroke, cancer, COPD, diabetes, HIV, or sexually transmitted diseases), risky health behaviors (alcohol and drug abuse, unsafe sexual behaviors), and injury, among others1.

The question for health plan executives is how to best serve consumers who have experienced trauma—increasing their “wellness” and as a result decreasing their long-term use of more expensive care health resources. In a recent interview with Robert M. Atkins, M.D., MPH, Senior Medical Director, Aetna Medicaid, we learned about how one health plan is developing an evidence-based approach and standardized model to do just that. He explained:

We decided that since there was no standard model for identifying providers who are trauma-informed, we would create one. We are solving for the questions: How do we promote trauma-informed care in our network? And how do we have a network that is capable of providing trauma-informed care to the different populations that we serve?

Eighty percent of health outcomes are the result of factors other than health care. But we are overly focused on health care, somehow expecting that 20 percent contribution to create better outcomes. If you think about it, the best traditional health care can do is a perfect score on 20%. Trauma and adverse community experiences are a high proportion of the remaining. There is no way to separate trauma from other adverse community experiences that people face. I think organizations will continue to expand their scope as they become accountable for outcomes in the communities they serve.

And, sounding familiar, it’s important to recognize that trauma-informed care and social determinants of health (SDH) are intricately linked—Dr. Atkins noted that 80% to 90% of health outcomes are driven by common factors external and largely unrelated to health care. He shared that Aetna Medicaid’s Levels of Trauma-Informed Provider Practice model includes six levels of practice that provider organizations can aspire to. These levels include:

Level 1: Foundational awareness—Individual clinical professionals are aware of what trauma is and how common it is, and how sensitivity to it can affect outcomes.

Level 2: Enhanced routine clinical practice—Individual clinical professionals integrate Level 1 knowledge into routine clinical practice and the provider organization promotes trauma-informed universal supports.

Level 3: Basic trauma-informed care—Individual clinical professionals are qualified to deliver trauma-specific treatments, serve populations at high risk of trauma, and the provider organization performs universal trauma screening.

Level 4: Advanced trauma-informed care—Individual clinical professionals adopt a biopsychosocial model of care and provider organizations implement a trauma-informed center of excellence for at least one population.

Level 5: Collaboration in a merged practice—Provider organization include trauma-informed Individual clinical professionals on interdisciplinary care teams and maintain high levels of integration between behavioral health and physical health.

Level 6: Trauma-informed system of care—Provider organizations collaborate across sectors to meet the needs of consumers in a larger community context.

While the Aetna model is still in development, Dr. Atkins explained that there are a few basic desirable features that needed to be part of the “final” model—prioritizing member experience, a level of physical health/behavioral health integration, and being agnostic about the approach provider organizations use to become increasingly trauma-informed. This will allow for flexibility in finding and incorporating tools that will help engage consumers better. When looking for provider organizations to fit into this work, Dr. Atkins noted:

We’re developing the incentives now. We have some for patient-centered medical homes and meeting cultural competency goals. And we have a whole set of things already that are incorporated into our contracts with states. We have a whole set of expectations, such as value-based reimbursement, wellbeing, and health care equity. Trauma-informed transformation is the frame that ties all of that together, and fully integrates trauma and community conditions where people live, learn, work, and play.

For health care to be effective, people must be engaged and committed to working collaboratively with their providers. They need to trust the people they meet in the provider organization and they need to feel safe when they go there. As a managed care organization we need to know how to identify those provider organizations. We need to know people will feel safe. We need provider organizations that are trauma-informed, and we need to know they understand what that means when delivering care.

We are concerned that providers gather meaningful data about peoples’ experience on a routine basis, analyze it, and do something when they find actionable opportunities for improvement. How is that experience distributed among the people you serve? Where are the disparities? Where are the opportunities to work cross-sector to address adverse community conditions? Can you identify a population at higher risk of trauma, and work together to mitigate those risks? It’s the ability to see how questions around trauma informed by lived experience shed light on issues around health care equity. We tell providers, here is what we are looking for. We want to know whether you’ve implemented and documented these evidence-based models. We want to see that. If you say you are a trauma-informed provider organization, that’s great, but we need to see that and here are the things we are looking for.

For more on trauma-informed care, check out these resources from the PsychU Resource Library:

  1. Making Trauma-Informed Care An Operational Reality
  2. The Trauma Quandary
  3. Judging, Not Judging: Trauma-Informed Courts
  4. What Is The Alternative To Restraint?
  5. ‘Person-Centered’ Health Care Records Take Center Stage
  6. Would This List Bend The Cost Curve?

In this webinar, Monica Oss, M.S., and Paul Duck from OPEN MINDS discuss the current state of population health in the United States. They also discuss how data analytics are utilized by payers and providers in managing population health outcomes. The presenters also discuss the history and success of the PASSE in Arkansas.

Monica Oss, M.S.  is the founder of OPEN MINDS. For the past two decades, Ms. Oss has led the OPEN MINDS team and its research on health and human service market trends and its national consulting practice. Prior to founding OPEN MINDS, Ms. Oss served as an executive with a national managed behavioral health organization, with responsibility for market development and for actuarial analysis and capitation-based rate setting. She also held a position as a vice president of the U.S. risk management and underwriting division of an international insurance company. Ms. Oss has been the keynote speaker at the conferences of dozens of national associations and has been published in a wide range of professional journals and trade publications.

Ms. Oss is a graduate of the University of Minnesota.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics.

Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

On July 31, 2019, Pennsylvania Governor Tom Wolf issued an executive order focused on developing further support for home- and community-based services (HCBS). The governor directed state agencies to pursue “bold reductions” in institutionalization of children and adults, and transition them to HCBS in conjunction with reducing placements in child residential treatment facilities, nursing homes, and child congregate care settings.

In Executive Order 2019-05: Protection Of Vulnerable Populations, the governor further directed state agencies to strengthen oversight and implement policies to increase accountability, and establish new policies to address the impact of trauma. It also directs state agencies to upgrade information technology (IT) systems, and implement administrative efficiencies.

Strengthen oversight:

  • Institute more direct and timely referral processes to investigative authorities to reduce abuse and increase accountability for institutional bad actors.
  • Use data and analytics to identify high-risk provider organizations for additional oversight.
  • Issue guidance standardizing the time period to establish a plan of correction following the identification of a violation by a provider organization licensed by the commonwealth; verifying timely compliance with and implementation of a plan of correction; and taking licensing action against a provider organization that does not timely comply with a plan of correction.

Establish new policies:

  • Establish Pennsylvania as a trauma-informed state to better respond to the needs of people who have had adverse childhood experiences.
  • Establish sustainable housing and long-term services and supports for individuals exiting the corrections system with nursing facility level-of-care needs.

Technology and administration:

  • Implement a statewide child welfare case management IT system.
  • Launch an enterprise licensing and incident management IT system to be shared across multiple human services and health departments to increase data sharing.
  • Use LEAN process improvement to identify opportunities for efficiency in child welfare administrative functions.
  • Update Older Adult Protective Services mandatory reporter training.
  • Commission a study on the financial impact to Pennsylvania due to financial exploitation of older adults.

The executive order established an Office of Advocacy and Reform to be maintained by the governor’s office with an executive director. The Office of Advocacy and Reform includes a new child advocate position and integrates the state’s existing long-term care ombudsman. The order also established a Council on Reform with 25 voting members appointed by the governor. The members represent schools, counties and cities, advocates for vulnerable demographics (children, elders, individuals with disabilities, racial/ethnic minorities, and alternate sexual orientations), provider organizations, health care specialties (pediatrics, gerontology, psychology), and representatives of discrete communities (young adults, veterans with disabilities, older adults). The Wolf Administration cabinet secretaries or their designees are non-voting members of the Council. The council met immediately following the governor’s announcement. It will seek input from various stakeholder groups and will report its findings to the governor by November 1, 2019.

The order is expected to result in an overhaul of state services and systems to protect the most vulnerable residents. The effort will examine protection for vulnerable populations in terms of prevention and diversion, protection and intervention, and justice and support.

For more information, contact: Pennsylvania Governor Tom Wolf, 508 Main Capitol Building, Harrisburg, Pennsylvania 17120; 717-787-2500; Website: https://www.governor.pa.gov/. 

Why is access such a major priority for health plans? Improving access to care promotes better consumer engagement, increases consumer satisfaction, and results in better positive clinical and financial outcomes. Deb Adler, a Senior Associate at OPEN MINDS took a deep dive into this topic during a recent presentation she did with Guy Maytal, M.D., Chief Integrated Care & Psychiatric Oncology, Weill Cornell Medicine; Richard Rodriguez, Director, Behavioral Network Services, Optum; and Michael M. Siegel, M.D., Medical Director, Molina Healthcare of California.

While access to care is widely recognized as a major issue, there is still a lot of difficultly in measuring access issues and determining what is adequate availability for consumer populations. So, how do you determine if access is an issue in your market? During the presentation, Ms. Adler discussed several sample measures that health plans analyze when determining access and availability to care, including:

  • Structural measures, such as the percent of the of population covered by insurance. For example, currently, about 90% of the U.S. population is insured by managed care organizations, but coverage varies by geography and population.
  • Utilization measures to examine the use of services. For example, the penetration rate for Medicaid is in the teens, while the penetration rate for a commercial employee assistance program would be much lower, somewhere less than five percent.
  • Density measures to explore the ratio of clinical professionals to consumers in a geographic area. For example, typical managed care standards average out to about one provider for every 1,000 members; one inpatient provider for every 10,000 patients; and one psychiatrist for every 2,000 members.
  • Distance measures that examine how far consumers need to travel to receive care. The standards for these measures vary by location; for example, in an urban setting, a health plan may look for 95% of the membership to have access to outpatient behavioral health services within 20 miles, while in rural areas that may expand to access within 60 miles.
  • Time to appointment is a common measure that is frequently guided by the National Committee for Quality Assurance (NCQA). The NCQA accreditation standards for network management for behavioral health call for regular/routine access within 10 business days; urgent care appointments within 48 hours; and non-life-threatening emergencies within six hours.

For health plans, these measures help to paint a picture of access among their members and can help provider organization executives to determine payer “pain points” when it comes to access issues within their market. But this is only part of the access equation. As Ms. Adler pointed out, access is about so much more than just making an appointment—it’s also about the consumer experience. Consumer experience is about creating positive interactions and meaningful relationships with consumers.

Dr. Siegel noted that barriers to care aren’t always in the form of geography. Many consumers also face language and culture barriers, which can be a major detriment to receiving care. Dr. Maytal expanded on this, explaining that different populations have different needs, which may require added services and supports to ensure that consumers are receiving the most effective care—whether this is conducting comprehensive exams in the home and community to assess where there are gaps in care, delivering culturally competent materials in different languages, or providing care coordination for follow-up care and community resources.

Mr. Rodriguez discussed the importance of convenience, highlighting Optum’s ability to allow clinical professionals to provide their appointment availability as part of their telehealth platform. This feature of their platform improves the consumer experience by allowing the consumer to make an appointment online and in a more timely manner (ideally, with the time to get an appointment being under a week) compared to face-to-face appointments. Mr. Rodriguez also noted that in addition to convenience, there needs to be a focus on the quality of care, not just the quantity of services and provider organizations. He explained that Optum is focused on making it easier for consumers to have access to evidence-based practices, as well as the specialists and prescribers they need, as part of their assessments of network availability.

Improving access and availability are about delivering care in a timely manner and a convenient location—but it’s also about delivering effective quality care that is built around the needs of the consumer. It comes down to the ability to provide consumers with access to the “right care, in the right place, at the right time.” For provider organizations looking to demonstrate their value to health plans, the ability to improve access to care will continue to be a clear differentiator. Demonstrating the ability to deliver tech-enabled, person-centered, evidence-based, culturally competent care will give your organization the competitive advantage when building new payer partnerships.

Worldwide, nearly 800,000 people die of suicide each year.1 In this webinar, effective suicide prevention strategies, such as placing a focus on more sensitively identifying when a patient’s suicide risk is increased, are highlighted to reduce the risk of suicidality. Future research will build upon existing methods to develop customized prevention approaches.

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.

Featuring:

  • Christine Moutier, MD
    Chief Medical Officer, American Foundation for Suicide Prevention
  • Brian Ahmedani, PhD
    Director, Center for Health Policy & Health Services Research and Director of Research, Behavioral Health Services, Henry Ford Health System
  • David Jobes, PhD, ABPP
    Associate Director of Clinical Training, The Catholic University of America

 

Christine Moutier, MD, is the Chief Medical Officer at the American Foundation for Suicide Prevention, an organization dedicated to saving lives and bringing hope to those affected by suicide. Dr. Mouthier knows the impact of suicide first-hand. After losing colleagues to suicide, she dedicated herself to fighting this leading cause of death. Since earning her medical degree and training in psychiatry at the University of California San Diego, Dr. Mouthier has been a practicing psychiatrist, Professor and Dean in the UCSD School of Medicine, Medical Director of the inpatient psychiatric unit at the VA Medical Center in La Jolla, and has been clinically active with diverse patient populations such as veterans, Asian refugee populations as well as physicians and leaders with mental health conditions. She has presented at the White House and the National Academy of Sciences, testified before the U.S. Congress on suicide prevention, and has appeared as an expert in the New York Times, The Washington Post, Time Magazine, The Economist, The Atlantic, Anderson Cooper 360, The BBC, CNN, CBS, NBC Nightly News, and other television outlets.

Brian Ahmedani, PhD, is the Director of the Center for Health Policy & Health Services Research and Director of Research and Behavioral Health Services at the Henry Ford Health System. He served as Faculty Advisor for the Zero-Suicide Initiative, an expert panel member on suicide prevention for numerous national research and clinical groups and as an evaluator of Henry Ford’s Perfect Depression Care Initiative. Dr. Ahmedani currently serves as Principle Investigator of two NIH-funded, multi-site studies on suicide prevention and as co-investigator on numerous other projects in the field.

Dr. Ahmedani received his PhD and Master’s Degrees from Michigan State University, completed an NIH-funded research training fellowship in drug dependence epidemiology and has more than 90 published manuscripts since 2001.

David Jobes, PhD, ABPP, is a Professor of Psychology, Director of Suicide Prevention Laboratory, and Associate Director of Clinical Training at The Catholic University of America. He is also an Adjunct Professor of Psychiatry School of Medicine at Uniform Services University. Dr. Jobes is a Past President of the American Association of Suicidology, another PsychU supporting organization and he is the recipient of various awards for his scientific work including the 1995 “AAS Shniedman Award” for early career contribution to suicidology, the 2012 AAS “Dublin Award” for career contributions in suicidology, and the 2016 “AAS Linehan Award” for suicide treatment research. He has been a Consultant to the Centers for Disease Control and Prevention, the Institute of Medicine of the National Academy of Sciences, the National Institute of Mental Health, the Federal Bureau of Investigation, the Department of Defense, and Veteran Affairs. Dr. Jobes is a member of the Scientific Council and the Public Policy Council of the American Foundation for Suicide Prevention. He is a Fellow of the American Psychological Association and is Board Certified in Clinical Psychology.

Dr. Jobes maintains a private clinical consulting and forensics practice in Washington, D.C. He has published six books and numerous peer review journal articles.

Between 2013 and 2017, the number of physical, mental, and sexual abuse deficiencies in nursing homes rose by 103.5%. The deficiencies cited by the Centers for Medicare & Medicaid Services (CMS) state survey data doubled from 430 in 2013 to 875 in 2017. Physical abuse occurred most often in nursing homes at 46% from 2016 to 2017. Physical abuse was followed by mental/verbal abuse at 44%, and sexual abuse at 18%. In approximately 58% of the abuse deficiencies cited, staff were the perpetrators.

These findings were reported in “Nursing Homes: Improved Oversight Needed to Better Protect Residents From Abuse” by the United States Government Accountability Office (GAO). The GAO reviewed CMS guidance that was in effect from 2013 to 2017 to determine which federal standards and deficiency codes were relevant to resident abuse. The analysis was based on data collected by CMS from state survey agencies in all 50 states and the District of Columbia. Under agreement with CMS, a survey entity in each state assesses whether nursing homes meet CMS’s standards for participation in Medicare and Medicaid. The GAO analysis focused on the deficiency codes cited when state surveyors substantiate incidents of abuse.

Additional findings include:

  • At the state level, 32 states had more abuse deficiencies cited in 2017 than 2013. Six states had a consistent number, and the remaining 13 had fewer.
  • Approximately 42.6% of the 875 abuse deficiencies were categorized as causing actual harm or posing immediate jeopardy to residents in 2017, compared to 31.9% of the 430 abuse deficiencies in 2013.

The GAO also found gaps in CMS oversight, including:

  • Gaps in CMS processes that can result in delayed and missed referrals. Federal law requires nursing home staff to immediately report to both law enforcement and the state survey agency reasonable suspicions of a crime that results in serious bodily injury to a resident. However, there is no equivalent requirement that the state survey agency make a timely referral for complaints it receives directly or that it finds through surveys it conducts. CMS also does not conduct oversight to ensure that state survey agencies are correctly referring abuse cases to law enforcement.
  • Insufficient information collected on facility-reported incidents. CMS has not issued guidance on what nursing homes should include when they self-report abuse incidents to the state survey agencies. Officials from all five of the state survey agencies GAO interviewed said the facility-reported incidents can lack the information needed to prioritize investigations and may result in state survey agencies not responding as quickly as needed.

To address the findings of the study as well as gaps in oversight, the GAO made six recommendations, including that CMS should:

  • Require state survey agencies to submit data on abuse and perpetrator type, and that CMS systematically assess trends in these data.
  • Require state survey agencies to immediately refer to law enforcement any suspicion of a crime.
  • Develop guidance on what abuse information nursing homes should self-report.
  • Conduct oversight of state survey agencies to ensure referrals of complaints, surveys, and substantiated incidents with reasonable suspicion of a crime are referred to law enforcement in a timely fashion.
  • Develop guidance for state survey agencies clarifying that allegations verified by evidence should be substantiated and reported to law enforcement and state registries in cases where citing a federal deficiency may not be appropriate.
  • Provide guidance on what information should be contained in the referral of abuse allegations to law enforcement.

The U.S. Department of Health and Human Services concurred with all of GAO’s recommendations and identified actions it will take to implement them.

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

The most-used tool in health care for improving performance is the Healthcare Effectiveness Data Information Set (HEDIS®). HEDIS® asks how often insurers provide evidence-based care to support more than 70 aspects of health.1

In this annual update, the presenters review the 2020 HEDIS® measures related to substance use.

Featuring:

  • Lauren Niles, MPH, BS
    Senior Research Associate, Performance Measurement Department, NCQA
  • Junqing Liu, PhD, MSW
    Research Scientist, NCQA

Lauren Niles, MPH, BS, currently serves as a Senior Research Associate at The National Committee for Quality Assurance (NCQA). Ms. Niles has a background in the electronic specification of clinical quality measures using electronic health record (EHR) data and technology.

Ms. Niles earned an M.P.H. degree from The George Washington University and a B.S. in Biology from the University of Maryland, College Park. She is currently pursuing her DrPH degree in Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health as a Bloomberg Fellow with a focus on substance use, addiction and overdose.

Junqing Liu, PhD, MSW, is a research Scientist for NCQA. As the measure lead of NCQA’s behavioral health measures, Dr. Liu guides the re-evaluation and updates of HEDIS® behavioral health measures. Dr. Liu’s research focuses on access to mental health services, evidence-based treatment for behavioral health problems, and child welfare services. Dr. Liu was previously a research assistant professor at University of Maryland School of Social Work and conducted the evaluation of a federally funded research project on the implementation of evidence-based practices in child welfare systems in six states.

Dr. Liu holds a PhD and a Master’s degree in Social Work from University at Albany, State University of New York. She received her undergraduate degree from China Youth University for Political Sciences.

A quick look at the health and human service field finds what I like to think of as a living laboratory for change management—from newly empowered consumers, to rapid turnover of employees and leadership, and the increasingly difficult practice of “connecting the strategic dots” in the face of new tech, new competition, new financing systems, and new performance expectations. The requirements to “keep up” are changing so quickly, that the ability to thrive seems close to impossible for many leaders who are under the gun to deliver on value-based contracting. The demand for leaders that can lead provider organizations through change management initiatives—“change agents”—is extremely high.

For health and human service executives, the “change agent” mindset is key, and it means recognizing that change management is integral to all performance management—from identifying targets, setting goals, and managing a team with strong metrics. The question is, how do you become an effective change agent when most of what today’s executives know was learned during a previous era of more stable health care operations management?

Do you have multigenerational influence? Many leaders understand that the latest generation of professionals (the Millennials) to enter the workforce are key to adapting to the new market, but few have actively prepared for this shift. This is a mistake, as the talent, perspectives, and expertise (think technology) of this generation will be key to adapting to the future.

Do you have cultural intelligence? “Culture is the new currency for growth” is a great mantra, but only if leadership understands that building an organizational culture that values both staff and consumers from a wide variety of backgrounds is fundamental to adaptability and market staying power.

Do you meet consumer demand? This is common knowledge for most industries, but consumer behavior has just become one of the most powerful influences in how many health care provider organizations run their operations. If you don’t know what your consumers want and how to deliver it, no amount of change will be radically successful.

Have you invested in women leaders? Women are underrepresented in leadership (just 15% of executives are women), with fewer promotions (for every 100 women promoted to manager, 130 men are promoted) and smaller paychecks (women earn 80 cents for every dollar earned by a man). This state of affairs isn’t going to last at the most successful organizations and represents one of the key ways for organizations to build positive change into their strategies (see Developing Female Leaders In Your Organization).

Do you have an entrepreneurial attitude? Entrepreneurial and innovative are technically different but should still be fundamentally linked in any strategy for adapting to future change. They both demand creativity, vision, risk, and the ability to work with stakeholders and partners both in health care, as well as organizations that are making in-roads from other fields (see A Big Opportunity For Someone).

Have you invested in technology? More and more executives are asking about the role that tech plays in their organizations, which is good. But tech changes so quickly, and the opportunities for using it are easily missed (or adopted too late). Provider organizations need to make a tech scan a key part of their strategic planning, and hire the staff needed to adopt and utilize it (see After ‘Reinventing’ The CFO, It’s The CIO’s Turn).

Can you manage a crisis? For health care, “crisis” usually means dealing with consumers in crisis. But when it comes to change management, this means that leaders need the vision to identify major obstacles and changes coming down the pipe and position the organization to weather the change. In an increasingly competitive and changing market, this means understanding strategic advantage of an organization’s services and the financial metrics of sustainability.

Has your business model evolved? Everything on this list leads up to the primary challenge for today’s health and human service executive. How do you build a business model that can take all the changes into account and leverage solutions to the biggest change of all: value-based reimbursement (VBR)? No matter how you slice it, you will need to prove your business case, as well as demonstrate you have the operational ability to pull it off.

For more on change management, check out these resources from the PsychU Resource Library:

  1. Bot, Anyone? The Question-What Services Can You Automate?
  2. Anticipating The Looming Strategic Surprises
  3. Even ‘Change Management’ Is Changing

On July 11, 2019, New Jersey Governor Phil Murphy signed legislation to limit solitary confinement in state prisons. The Isolated Confinement Restriction Act, Assembly Bill 314, restricts the use of isolated confinement in New Jersey’s correctional 13 facilities, which includes prohibiting inmates from being put in solitary, or isolated, confinement unless there is “clear and convincing evidence that the inmate or others are at substantial risk of harm.” The law will be effective in August of 2020.

The legislation defined “isolated confinement” as confinement of an inmate in a correctional facility, pursuant to disciplinary, administrative, protective, investigative, medical, or other classification, in a cell or similarly confined holding or living space, alone or with other inmates, for approximately 20 hours or more per day in a state correctional facility with severely restricted activity, movement, and social interaction. According to the New Jersey Department of Correction January 2019 Offender Characteristics Report, there are approximately 19, 212 total inmates in New Jersey state correctional institutions and satellite units.

The provisions of the New Jersey Assembly Bill 314: Isolated Confinement Restriction Act include:

  • Isolated confinement should only be used when necessary, and should not be used against vulnerable populations or under conditions that foster psychological trauma, psychiatric disorders, or serious, long-term damage to an isolated person’s brain.
  • A clinician shall conduct a mental health and physical health status examination for each inmate placed in isolated confinement on a daily basis, in a confidential setting outside of the cell whenever possible, to determine whether the inmate is a member of a vulnerable population.
  • An inmate shall not be placed in isolated confinement for more than 20 consecutive days, or for more than 30 days during any 60 day period.
  • Cells or other holding or living space used for isolated confinement are to be properly ventilated, lit, temperature-monitored, clean, and equipped with properly functioning sanitary fixtures.
  • An inmate shall not be held in isolated confinement based on the inmate’s race, creed, color, national origin, nationality, ancestry, age, marital status, domestic partnership or civil union status, affectional or sexual orientation, genetic information, pregnancy or breastfeeding status, sex, gender identity or expression, disability, or atypical hereditary cellular or blood trait.
  • An inmate held in emergency confinement in a state correctional facility shall receive an initial medical and mental health evaluation immediately prior to placement in emergency confinement.

Editor’s note: Article was updated on 7/29 per the New Jersey Department of Corrections.

For more information, contact: Information Office, New Jersey Department of Corrections, Post Office Box 863, Trenton, New Jersey 08625; 609-292-4036; Fax: 609-292-9083; Email: pubinfo@doc.nj.gov; Website: https://www.state.nj.us/corrections/.

With all the changes facing the health and human service field from major mergers and acquisitions, new models for care delivery, and new payment models, managing change can be the most difficult task for leaders. Complex leadership theory is based on the need for leaders who can both run the current operations, while also building new program models focused on innovation and sustainability.

Complex environments require leaders to develop the structures and culture to enable adaptive response. Typically in times of change, leadership attempts to double down on hierarchical approaches and manage change from the top-down. This leads to a false sense of control for both managers and employees. Instead leaders need to run an organization with two parallel tracks. First, organizations must empower team members to take time to develop new business models and services lines based on their experience. Secondly, organizations must resist the idea that there are “winners” and “losers.” When team members are more concerned with failure than trying new innovations, orthodox business models remain. While these might return short-term wins, they will ultimately result in failure.

What is the priority? Current operations and profitability? Or that strategic (and now money-losing) initiative that the future depends on? The challenge is dividing your time and attention—almost equally—between the two strategic issues. To do this, you need to find an internal leader (other than you) that can help to focus on both.

PsychU asked a few former executives to get their advice on how to manage this new leadership role. Although each took their own unique spin on complexity leadership, there were three pieces of advice that stuck out in everyone’s response – celebrate the noble failures, learn to live with uncertainty, and decentralize management.

Fail nobly – The response we got most often from our former executives was the importance of being okay with failure and making sure to celebrate failures when appropriate. Ray Wolfe, Senior Associate, OPEN MINDS (and former chief operating officer of  Pittsburgh Mercy Health System) explained, “We often have cultures that reward those who sit back and do nothing controversial rather than those who try, fail, and learn. A noble failure can be an important tool and should be recognized and positively reinforced.” George Braunstein and Marge Conner-Levin both Senior Associates at OPEN MINDS (and former CEOs of Fairfax-Falls Church Community Services Board and Archway Programs, respectively) noted that failures are also learning opportunities for you, your agency, and your board. They represent a chance to try something new, learn from the experience, and to act differently the next time around.

Learn to live with uncertainty – Part of being a member of the c-suite is learning to be okay with chaos and uncertainty. Anthony Zipple, M.D., Senior Associate, OPEN MINDS (and former CEO of Centerstone of Kentucky) explained:

Leaders need to learn to live with uncertainty and ambiguity. Conditions change fast and leaders seldom have the luxury of a predictable environment. Even the best decision today may have massive unintended consequences tomorrow. Will a strategic alliance with another company allow my organization to compete in the future? Is a merger with a larger entity a good idea? Will a new value-based contract with an insurer result in a healthier bottom line or weaker cash reserves? What is the best EMR for the future? Behavioral health leaders need to make decisions like this today, knowing that it may be months or even years before they know if their decision was a good one. Living with that kind of uncertainty demands great personal courage and a high level of personal resilience.

Ms. Conner-Levin offered concrete advice on how to deal with uncertainty:

My best advice for leading through complexity is to not focus on the complexity issue or change issue. Both are constant and focusing on them will lead you to inertia. Instead keep your focus on defining what issue or challenge in the market place your organization can uniquely solve. 

Decentralized management – Being a leader in a complex environment requires trust in staff members and colleagues. One person cannot run the day-to-day operations and be the visionary for the future. Instead, Mr. Braunstein noted that the most important role for the CEO is to set the strategic vision for the organization, and then to find people they trust to make this vision a reality:

The challenges we face as leaders in this current environment cannot always be predicted nor does the source of the change always make sense. It is important not to try to control everything in your environment, but instead have a clear direction for your organization, an ability to be flexible with implementation using multiple scenarios, and, as much as possible, shift more decision-making to the point of impact. Find and trust people who can implement these visions. 

Mr. Wolfe elaborated on this theme, noting that it is impossible for CEOs to manage the day-to-day, while also being focused on long-term strategy:

Attempting to constantly shift gears between the day to day urgencies and your plan for change is personally exhausting. You need to have trusted management over day-to-day operations such that you can provide what little input that is needed in an hour or less. This kind of lean performance based operational system will be needed both today and tomorrow, so building it now is actually a strategic imperative.

Complexity leadership doesn’t come easily and it requires leaders to develop new skills. For more on meeting the leadership development challenge, check out these resources from the OPEN MINDS Circle Library:

  1. Long-Distance Leadership
  2. Meta-Leadership In Action
  3. Using Feedback To Build Your Leadership IQ
  4. Collaboration, Connectivity & Complex Leadership
  5. Technology Makes ‘Lifetime Learning’ A Leadership Must

Listen in as Dr. Joseph Goldberg discusses pharmacogenetics testing in the field of psychiatry and how it is evolving from the bench to the bedside. Dr. Goldberg reviews the pros and cons of using pharmacogenetics testing, including what it is used for and when may be relevant to utilize this type of testing. Interestingly, one of the proposed benefits of this testing is helping to detect individuals with different metabolisms and how a particular medication may affect them. As it currently stands, there are numerous variables that can have an impact, and Dr. Goldberg speaks to their inclusion in clinical practice into today’s practices.

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.

About 20% of high-risk hospital emergency department Medicare claims for services provided in 2016 to beneficiaries residing in a skilled nursing facility (SNF) indicated potential abuse or neglect. SNFs reported an estimated 16% of the incidents of potential abuse or neglect that led to a hospital emergency department visit.

During calendar year 2016, there were 37,607 high-risk hospital emergency department claims for services provided to 34,820 of the approximately 1.9 million Medicare beneficiaries who were SNF residents. Charges for these claims totaled $163 million. These high risk claims contained at least one of 580 diagnosis codes consisting of outpatient principal diagnosis codes and inpatient admitting diagnosis codes that were determined to be high risk for potential abuse or neglect. The 580 diagnosis codes included head injuries, bodily injuries, and safety and medical issues.

The estimate was reported in “Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated” by the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS). The OIG is conducting a series of reports about the identification, reporting, and investigation of incidents of potential abuse and neglect of vulnerable populations, such as the elderly and people with intellectual/developmental disabilities (I/DD). For this report, the OIG sought to determine the prevalence of incidents of potential abuse or neglect among Medicare beneficiaries residing in a SNF who had a hospital emergency department claim in calendar year 2016 that contained a high-risk diagnosis code. The 37,607 high-risk hospital emergency department claims included 27,127 hospital outpatient and 10,480 inpatient claims.

The OIG then checked other sources to determine whether the incidents of potential abuse or neglect were reported by the SNF properly, and whether the Centers for Medicare & Medicaid Services (CMS) and state survey agencies (Survey Agencies) reported findings of substantiated abuse to local law enforcement. The OIG also reviewed the extent to which CMS requires incidents of potential abuse or neglect to be recorded and tracked.

The OIG and the Survey Agencies in eight states reviewed supporting documentation for a sample of 256 high-risk hospital emergency department Medicare claims. The sample included 160 outpatient claims, and 96 inpatient claims. This review sought to determine whether the injuries or illnesses that required treatment were the result of incidents of potential abuse or neglect, and whether the incidents were reported to the Survey Agencies.

Key findings about the sample were as follows:

  • Within the sample of 256 claims, 51 were determined to be the result of an incident of potential abuse or neglect that should have been reported to the Survey Agencies.
  • The 51 claims included 26 head injuries, 16 injuries to other parts of the body (such as broken bones), 6 safety injuries due to medication overdoses or falls, and 3 medical issues due to aspiration pneumonia or sepsis. The individuals were treated on either an outpatient basis or inpatient basis if the injuries required a hospital admission.
  • Only eight of the 51 incidents  were reported to state Survey Agencies. For the remaining 43 unreported claims, 42 SNFs failed to report the incidents. As a result, the Survey Agencies could not review, prioritize, and conduct an immediate onsite investigation, if necessary, to determine whether abuse, neglect, or other violations had occurred. The OIG confirmed that none of the 43 incidents were reported to the state Adult Protective Services. Only one of the 43 incidents was reported to a Medicaid Fraud Control Unit.
  • The OIG asked each of the 42 SNFs why the incidents were not reported to the Survey Agencies. In total, 35 responded, but seven did not respond to repeated requests. The 35 SNFs indicated that they did not believe the incidents met federal reporting requirements, even though the Survey Agencies determined that the incidents of potential abuse or neglect had met the requirements according to the available documentation and should have been reported.
  • Based on the sample results for the 256 claims, the OIG estimated that 7,831 of the 37,607 high-risk hospital emergency department Medicare claims (21%) were the result of incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs. Additionally, the OIG estimated that SNFs failed to report 6,608 high-risk hospital ER Medicare claims (18%) were associated with incidents of potential abuse or neglect that were not reported by the SNFs to state Survey Agencies during calendar year 2016.

In the eight-state review, the OIG also reviewed incidents reported to the state Survey Agencies. This review found that in five of the eight states, the Survey Agencies did not report findings of substantiated abuse to local law enforcement for 67 of 69 incidents outside of the sampling frame. These incidents involved 34 SNFs. Two of the Survey Agencies reported their findings for 24 incidents of substantiated abuse to the MFCUs.

CMS did not require all incidents involving potential abuse or neglect to be entered in the Automated Survey Processing Environment Complaints/Incidents Tracking System (ACTS). Additionally, CMS did not require referrals to law enforcement and other agencies to be entered in ACTS. The system was designed by CMS to track, process, and report on complaints and incidents reported against health care provider organizations and suppliers regulated by CMS. ACTS was also designed to manage all operations associated with complaint and incident processing, from initial intake and investigation through the final disposition of the complaint or incident. ACTS is used by both the Survey Agencies and CMS.

The OIG recommended that CMS take four actions to ensure that all incidents of potential abuse or neglect of Medicare beneficiaries residing in a SNF are identified and reported. CMS agreed with the recommendations and intends to issue guidance specific to reporting and tracking of facility-reported incidents of potential abuse and neglect. The OIG recommendations are as follows:

  • Work with the Survey Agencies to improve training for staff of SNFs on how to identify and report incidents of potential abuse or neglect of Medicare beneficiaries
  • Clarify guidance to clearly define and provide examples of incidents of potential abuse or neglect
  • Require the Survey Agencies to record and track all incidents of potential abuse or neglect in SNFs and referrals made to local law enforcement and other agencies
  • Monitor the Survey Agencies’ reporting of findings of substantiated abuse to local law enforcement

In a related analysis, the OIG tested whether Medicare inpatient and outpatient claims could be used to identify beneficiaries who had been abused or neglected. The findings were reported in “CMS Could Use Medicare Data to Identify Instances of Potential Abuse or Neglect.” The OIG reviewed 34,664 Medicare inpatient and outpatient claims totaling $99.6 million for services provided from January 2015 through June 2017 to treat beneficiaries with at least 1 of 17 diagnosis codes related to potential physical abuse, sexual abuse or rape, neglect or abandonment, or other maltreatment. From this pool of claims, the OIG selected a stratified random sample of 100 Medicare claims, and reviewed the associated medical records to obtain evidence of potential abuse or neglect. About 89% of the sample claims had evidence of potential abuse or neglect.

Based on the ratios in the sample, the OIG estimated that 30,754 of the 34,664 Medicare claims with at least one of the 17 diagnosis codes under review would be supported by medical records that contained evidence of potential abuse or neglect. Additionally, of the estimated 34,664 claims, 2,574 claims would be for incidents allegedly perpetrated by a health care worker, 3,330 would be related to incidents that occurred in a medical facility, and 9,294 would be related to incidents that were not reported to law enforcement.

The OIG recommended that CMS compile a complete list of diagnosis codes that indicate potential physical or sexual abuse and neglect, and use that list to conduct periodic data extracts of all Medicare claims with at least one of the codes. CMS should also inform states that the extracted data could be used to help states ensure compliance with their mandatory reporting laws. Additionally, CMS should assess sufficiency of existing federal requirements, such as conditions of participation and other rules to report suspected abuse and neglect of Medicare beneficiaries, regardless of where services are provided. CMS agreed only with the last recommendation to assess sufficiency of existing requirements. CMS stated that claims data may not be timely enough to address acute problems in identifying and addressing potential abuse or neglect of Medicare beneficiaries.

For more information, contact: Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7th Street, Suite 3-500, San Francisco, California 94103; 415-439-7982; Fax: 415-437-8060; Email: Donald.white@oig.hhs.gov; Website: https://oig.hhs.gov/.

The Virginia Joint Legislative Audit and Review Commission (JLARC) recommends that the state allow more time to effectively deploy its System Transformation Excellence and Performance -Virginia (STEP-VA) mental health initiative, which would push back full implementation from July 2021 to July 2022. The nine-step initiative, which began in 2017, requires Virginia’s 40 local community services boards (CSBs) to implement the following: same day assessments, primary care screening, behavioral health crisis services, outpatient behavioral health, psychiatric rehabilitation, peer/family support services, veteran’s behavioral health, care coordination, and targeted case management. Between 2017 and 2019, all CSBs implemented the first step: same day assessments, and were on schedule to begin step two by July 2019: providing primary care blood pressure and body mass index screening to consumers with serious mental illness (SMI) or serious emotional disturbance (SED). After implementing the primary care screening for consumers with SMI or SED, the CSBs will expand the screenings to all consumers. The JLARC recommended that the Virginia Department of Behavioral Health and Developmental Services (DBHDS) extend the timeline for the remaining seven steps so that DBHDS can complete the requirements, performance measures, and funding allocation plans for each. Additionally, DBHDS should also conduct a pilot of the step two expanded primary care screening at a subset of CSBs before initiating it at all 40 CSBs.

STEP-VA is a long-term initiative designed to improve the community behavioral health system by expanding the services provided by the CSBs. The goals for STEP-VA focus on simplifying access to a uniform set of public mental health services and increasing CSB accountability. All 40 CSBs are required to implement STEP-VA. Currently, Virginia has appropriated a total of $60 million through fiscal-year 2020 to begin implementation, with full implementation expected by July 2021.

This recommendation was made in “Report To The Governor And The General Assembly Of Virginia: Implementation Of STEP-VA, 2019” by the Virginia JLARC. In 2018, the JLARC directed staff to review the initial implementation of the STEP-VA initiative. JLARC staff evaluated implementation through early June, 2019 and assessed CSBs’ overall preparedness to implement the remaining steps by July 2021. For this report, the JLARC staff conducted structured interviews and focus groups with Virginia Department of Behavioral Health and Developmental Services (DBHDS) leadership and staff, CSB leadership, stakeholders, and representatives from other states’ behavioral health systems. The staff also participated in site visits to seven CSBs, conducted a survey of CSB executive directors and chief executive officers, and reviewed state documents and research literature.

In their evaluation of implementation thus far, the researchers found that:

  • Nineteen of the 20 CSBs that currently track assessment data reported assessing at least 70% of individuals on the day they walk in during designated hours.
  • The number of hours and locations available for same-day assessments varied across CSBs, and it is not clear whether the availability of same-day assessments meets community needs.
  • In preparation for step two, in February 2019 DBHDS began providing funds so that CSBs could begin providing primary care screening by July 2019 to check the blood pressure and body mass index of consumers with SMI or SED.
  • CSBs are concerned that the effort needed to expand primary care screenings to all consumers will detract from other, higher priority STEP-VA services, such as expanded outpatient and crisis services.

Going forward in the implementation, the JLARC staff recommended the following regarding the roll-out:

  • DBHDS should work with CSBs to develop metrics that will measure if consumers are able to be assessed on the same day they visit a CSB, and whether same-day access hours are sufficient at each CSB.
  • DBHDS should pilot phase two of primary care screening at a subset of CSBs before initiating it at all 40 CSBs.

The JLARC staff made the following recommendations regarding the role of DBHDS and funding:

  • Require DBHDS to complete the requirements, performance measures, and funding allocation plans for each step before the Department of Accounts releases funding
  • Dedicate a full-time senior staff position to oversee and coordinate STEP-VA implementation
  • Prioritize the implementation of remaining steps based on CSB needs
  • Allow DBHDS to use a portion of future STEP-VA funding to support central oversight and coordination functions at DBHDS

STEP-VA is loosely based on the federal Certified Community Behavioral Health Clinic (CCBHC) model. Virginia was awarded a CCBHC planning grant; however, in October 2016, Virginia opted not to submit a proposal for a demonstration grant due to cost and infrastructure concerns. The STEP-VA model was developed as a sustainable Virginia-specific solution. The CSBs began working on STEP-VA after the 2017 Governor and the General Assembly provided $4.9 million in general fund dollars for an initial group of CSBs to implement same day access. The General Assembly required the remainder of STEP-VA services to be implemented over the next two biennia, with additional funding to be allocated in the coming years. The 2018 Governor and the General Assembly provided $5.9 million for a second group of 22 CSBs to implement same day access in fiscal year 2019. Each CSB will receive $270,000 in ongoing state mental health funds. Nine CSBs had already implemented some form of same day access and received funding on July 1, 2018 to address their implementation costs. By the end of the 2018 calendar year, all but five CSBs had implemented same day access. The remaining CSBs were on-track to implement same day access in early 2019 and did so in March.

PsychU last reported on this topic in “Virginia Community Services Boards Reach STEP-VA Goal Of Same-Day Access,” which published on June 17, 2019. The article is available at https://www.psychu.org/virginia-community-services-boards-reach-step-va-goal-of-same-day-access/.

For more information, contact: Jeff Lunardi, Unit Director, Health and Human Resources, Joint Legislative Audit and Review Commission of Virginia, 919 East Main Street, Suite 2101, Richmond, Virginia 23219; 804-371-4581; Email: jlunardi@jlarc.virginia.gov; Website: http://jlarc.virginia.gov/.

Approximately 72% of executives believe their organizations have the capabilities needed to support increased risk, and plan to take on additional risk in the next one to three years. About 64% of the same executives reported that they would assume additional risk through commercial payer contracting models. Roughly 57% said they would assume risk through Medicare contracting models, and 51% said they would assume risk through Medicare Advantage.

These findings were reported in “Providers Prepared to Increase Risk Model Participation” by Navigant. The report is based on a survey conducted by Navigant and the Healthcare Financial Management Association (HMFA) of 170 hospital and health system senior finance executives. The survey documents the readiness of health care provider organizations to assume increased levels of risk through commercial payer and Medicare contracting as well as the share of responding provider organizations that are partnering on or launching provider-sponsored health plans (PSHPs) as part of their risk-assumption strategy.

Of the provider organizations that were surveyed, the researchers found that 56% were not participating in PSHP plans, while 25% already were part of a PSHP, and 19% plan to launch a PSHP. In addition to assuming risk through commercial and Medicare payment models and participating in PSHP’s, the researchers surveyed provider organizations strategies for fee-for-service (FFS) and value-based revenue and margin growth. Strategies of the respondents included:

  • Engaging physicians to drive clinical standardization through a Hospital Quality and Efficiency Program, a contract between a health system and an accountable-care organization (ACO) or clinically integrated network
  • Focusing on cost reduction in more discrete areas, such as post-acute care, pharmacy care, and management of high-risk health care consumers
  • Emphasizing in-network customer retention by building tight provider network relationships through technological connectivity, a share referral management infrastructure, and common standards for access, quality, and cost

The full text of “Providers Prepared to Increase Risk Model Participation” was published in June 2019 by Navigant and HFMA. A free copy is available online at https://www.navigant.com/insights/healthcare/2019/risk-readiness (accessed July 9, 2019).

PsychU last reported on this topic in “25% Of Health Care Provider Organizations Ready To Take On Risk-Based Contracts,” which published on May 6, 2019. The article is available at https://www.psychu.org/25-of-health-care-provider-organizations-ready-to-take-on-risk-based-contracts/.

For more information, contact:

  • David P. Zito, Healthcare Segment Leader, Navigant, 1200 19th Street Northwest, Suite 700, Washington, District of Columbia 20036; 202-973-2400; Website: https://www.navigant.com/
  • Healthcare Financial Management Association, 3 Westbrook Corporate Center, Suite 600, Westchester, Illinois 60154-5732; 708-531-9600; Fax: 708-531-0032; Email: inquiry@hfma.org; Website: https://www.hfma.org/

Background & Purpose

There are continuing challenges in both the primary care and mental health workforce that bar individuals from receiving the health care services they require in a timely and convenient way. Unfortunately, the access problem continues to grow because there are not as many medical residents selecting primary care or psychiatry as their specialty. To compound the problem, the current primary care and psychiatric workforce continues to age and retire. This issue is a particular concern for rural communities, who often have less access to providers. One strategy to combat these workforce issues is expanding the practice scope or reducing the licensing barriers for other types of health care providers such as nurse practitioners (NPs) and physician assistants (PAs).

Approximately 87% of NPs are trained in primary care. Researchers have discovered that NPs in primary care, compared to physicians, provide many of the same services; NPs exhibit an equal caliber of high-quality care, they receive high patient satisfaction ratings, and they provide more cost-efficient services in some environments. Additionally, researchers have found NPs’ to be more willing to care for high-risk and vulnerable patient populations in rural areas that have a provider shortage. Researchers have also found NPs to be more willing to serve patients covered by Medicaid compared to their physician counterparts. It appears that this branch of the primary care workforce is positioned to alleviate access challenges. At this time, it is still unclear how much NPs will impact the field because longitudinal utilization data is limited.

A recent study conducted by Hilary Barnes, Michael R. Richards, Matthew D. McHugh, and Grant Martsolf, examined the use of NPs in physician-run primary care practices between 2008 and 2016, and the impacts of national and state policies and scope of practice changes on NP utilization. Their findings were published in a June 2018 edition of Health Affairs in “Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners.”

We invite you to listen to our interview with James McCreath, Ph.D., LCSW, VP of Behavioral Health and Psychiatry at Trinitas Regional Medical Center (TRMC) and St. Joseph’s Health. Dr. McCreath introduces listeners to TRMC, a 554-bed hospital and 120-bed long-term care facility that is a major center for comprehensive health services for those who live and work in Eastern and Central Union County in New Jersey. TRMC is a PsychU Supporting Organization and they are distinguished by no less than 10 Centers of Excellence, which include: the Trinitas Comprehensive Cancer Center; the Trinitas School of Nursing; the Center for Wound Healing & Hyperbaric Medicine; the Sleep Disorders Center; cardiology services, maternal/child health services; diabetes management; women’s services, renal care; behavioral health services, and senior services.

PsychU is proud to feature perspectives from experts and advocates in the field of mental health. It is an honor to have organizations like Trinitas Regional Medical Center as PsychU Supporters – as we work to improve mental health together.

James McCreath, Ph.D., LCSW, is the Executive Director of the Trinitas Regional Medical Center & St. Joseph’s Hospital & Medical Center Integrated Department of Psychiatry. James also serves as the Vice President for the Trinitas Department of Behavioral Health & Psychiatry. Dr. McCreath has been a leader in the field of Mental Health for over 20 years, serving in such capacities as a Board Member, President, Executive Director and CEO. He has worked in the Mental Health field for over 40 years with a focus on hospital based and community agency based operations. James is also a published author, public speaker and lecturer.

James McCreath earned his Ph.D. at the New York University School of Social Work.

So much happened in the past 90 days in the health and human market space. But what really matters? What are the “stop the presses” developments that executive teams need to incorporate in their strategic thinking? The themes were two-fold: One, the push for “whole person” approaches to care and, two, the integration/consolidation of organizations, functions, and financing. Here are five developments that have the potential to unravel the best laid plans of many organizations.

Among the many developments that can reshape strategy are payers increasing focus on social determinants. In the past quarter, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare Advantage plans in 2020 will be able to offer supplemental social service benefits if they diagnose, compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization (see Medicare Advantage To Offer Supplemental Benefits For Social Determinants In 2020). The second was UnitedHealthcare’s announcement that it expects its provider organizations to use the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) Z-codes, in categories Z55 to Z65, to capture information about the consumer’s reasons for a health care visit that further explain the need for the social support services. The idea is to expand efforts to identify consumers with social service needs (see UnitedHealthcare Expands Initiative To Use Diagnostic Codes To Capture Social Determinants Of Health).

The implications? There will be a new market for “packaged” social services. But these won’t be the social service of the past – they will be “prescribed” packages of support services for specific consumers with a carefully calculated return on investment (ROI). The availability of these new payment streams means that new competitors will enter the market space, forcing traditional social service provider organizations to ramp up their measurement of cost and outcomes.

Long-term questions: Will public social service budgets shrink as these services become “medicalized”? And, will the types of social services available to an individual vary by their health plan members (and whether they are insured)? These are big issues to watch.

There are now 23 states and the District of Columbia with health homes and more states are developing. And almost more importantly, the health home construct is now common in the commercial health insurance market and with accountable care organizations.

At the same time, retail pharmacy, and soon-to-be-insurer, CVS announced their own approach to whole person care in the form of one-stop-shopping HealthHubs. In 1,500 of its current retail locations, CVS plans to dedicate 20% of retail space to health care services like urgent care, telehealth, chronic disease management, and wellness. The HealthHUBs will offer a care concierge professional, seminars, kiosks, and iPads for wellness apps.

The implications? New competition for a number of provider organizations. Obviously, traditional primary care practices face a competitor with a consumer-centric approach and wide range of services. But specialty provider organizations face new competition as well. The model will include chronic care management and Minute Clinics already have telehealth services for specialty consultation. The HealthHub concept—if successful—is perfectly positioned to compete for care coordination, medical home, and health home contracts.

At the same time, the push to value-based forms of reimbursement entered Medicare primary care – with CMS unveiling five new models for value-based primary care reimbursement. CMS primary care payments will likely fall in one of two models.

The first model is called Primary Care First and will utilize a risk adjusted professional population-based payment with a flat primary care reimbursement fee. The second model is a direct contracting model that will pay a capitated, risk adjusted payment for enhanced primary care services. Overall, CMS estimates that 25% or 11 million Medicare FFS enrollees will be served under the new model.

The implications? This is reflective of the overall movement of Medicare away from fee-for-service reimbursement. There will be opportunities for specialty provider organizations to collaborate with primary care practices that, under this model, will be more likely to refer high-needs and complex consumers for specialty care – depending on the performance incentives. But certainly, this change in financing is going to drive the purchase of a host of digital health options by primary care practices who will be substituting tech-enabled interventions for staff time.

Finally, there are two notable mergers among health plans. Wellcare is being acquired by Centene and Anthem is acquiring Beacon Health Options (see Centene To Buy WellCare For $17.3 Billion and Anthem To Acquire Beacon Health Options). These mergers represent the continuation of two trends that have noted before—the consolidation of membership among a small number of health insuring organizations and the dwindling of the use of the horizontal carve-out for care financing and service delivery.

The implications? Centene will continue to be the largest insurer of Medicaid beneficiaries by far and Magellan and New Directions remain the only major national behavioral health carve-out companies (and New Directions is affiliated with the Blues system). The bigger picture is that the standardization of health service delivery will happen within national health insuring systems and not necessarily within geographic regions. While the health insuring organizations do have local plans with local control and local provider networks, we are seeing the advent of national contracts for a wide range of specialty services. This trends poses a market share threat to local provider organizations delivering those specialty services.

Strategy is more important than ever – but that strategy needs to be constantly adjusted with the changing market. What to do? William Arthur Ward quote, ” The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.” It’s all about adjusting the strategy sails, so to speak.

Walmart has selected Covera Health as a national provider of imaging and radiology services for Walmart’s employee health plan. Under this multi-year agreement announced on May 15, 2019, Walmart associates and dependents covered by the company health plan have access to imaging and radiology services provided by physicians and facilities participating in Covera Health’s nationwide Radiology Centers of Excellence Program. The centers are located in every major urban center and the majority of rural areas.

The Covera Health program has three components: a nationwide network of radiologists, ongoing quality assurance and monitoring, and actionable feedback for physicians. The goal is improved health outcomes for health care consumers by helping them avoid unnecessary treatment based on inaccurate MRI or CT radiology diagnoses. Covera Health collaborates with leading academic radiology centers to monitor the diagnostic accuracy of its Radiology Centers of Excellence.

A preliminary quality evaluation found that those served by a Covera Health Center of Excellence were more likely to receive correct care and return to work faster than people served by other radiologists and imaging facilities. The evaluation included approximately 80,000 health care consumers.

A separate analysis published in 2017 reported wide variation in findings of MRIs of a single person with low back pain who was scanned at 10 different imaging centers over a period of three weeks. The 10 examinations resulted in 49 distinct findings related to presence of a distinct pathology at a specific part of the back. Only one finding was reported in nine of the 10 evaluations. About 32.7% of the interpretive findings appeared only one time across all 10 of the examination reports. The findings were reported in “Variability In Diagnostic Error Rates Of 10 MRI Centers Performing Lumbar Spine MRI Examinations On The Same Patient Within A 3-Week Period” by Richard Herzog, M.D., FACR; Daniel R. Elgort, Ph.D.; Adam E. Flanders, M.D.; Peter J. Moley, M.D. The researchers concluded that where a person obtains an MRI and which radiologist interprets the examination may have a direct effect on the radiological diagnosis, subsequent choice of treatment, and clinical outcome.

Covera Health uses advanced data analytics to build programs for employers, health plans, and other health care entities that reduce misdiagnoses, improve patient outcomes, and reduce medical costs. Covera Health’s first solution, its innovative Radiology Centers of Excellence Program, operates in all 50 states and now covers over one million lives.

The full text of “Variability In Diagnostic Error Rates Of 10 MRI Centers Performing Lumbar Spine MRI Examinations On The Same Patient Within A 3-Week Period” was published in 2017 by The Spine Journal. A copy is available online at https://www.thespinejournalonline.com/article/S1529-9430(16)31093-2/pdf (accessed July 15, 2019).

For more information, contact:

  • Lena Cheng, M.D., Acting Chief Marketing Officer, Covera Health, 747 3rd Avenue, 37th Floor, New York, New York 10017; 650-822-7962; Email: press@coverahealth.com; Website: https://www.coverahealth.com/

Kory Lundberg, Sustainability Director, Walmart, 702 Southwest 8th Street, Bentonville, Arkansas 72716; 800-331-0085; Email: Kory.Lundberg@walmart.com; Website: https://www.walmart.com/

Nursing home care prices are rising faster than other medical care and consumer prices, with the lowest average daily rate of $121.90. Across the study period, the cumulative inflation between 2005 and 2010 was 20.2% in medical care (rising from an average of $323.23 to $388.44 per day), and 11.7% in consumer and general consumer prices (rising from an average of $195.30 to $218.05 per day). Meanwhile, nursing home prices across the U.S. increased an average of 24.7% (between about 15.2% and 30.2% per day, depending on location).

These findings were reported in “The Determinants and Variation of Nursing Home Private-Pay Prices: Organizational and Market Structure” by Sean Shenghsiu Huang, Jane Banaszak-Holl, Stephanie Yuan, et al. The researchers reviewed nursing home prices in eight states (California, Florida, Georgia, New York, Ohio, Oregon, Texas, and Vermont) between 2005 and 2010 to produce regression-adjusted results, which account for facility-level and market-level differences, as well as state or county fixed effects. The goal was to provide more transparency of the out-of-pocket prices of nursing home care.

The four types of nursing home structures analyzed include for-profit chain nursing homes, for-profit independent nursing homes, nonprofit chain nursing homes, and nonprofit independent nursing homes. Additional findings include:

  1. The highest nursing home price increase occurred in California (30.2%), while the lowest nursing home price increase occurred in Texas (15.2%).
  2. New York had the highest average nursing home price ($302.30) across all years, while Texas had the lowest ($121.90).
  3. Of all nursing homes, not-for-profit nursing homes charge the highest average prices ($228.60 per day) and for-profit nursing homes have the average lowest prices ($171.18 per day).
  4. Independent for-profit nursing homes have the fastest annual price growth (7.0%), and nonprofit chains have the slowest price growth (6.1%).
  5. The number of health deficiencies found in nursing homes were higher in for-profit nursing homes (an average of 6.46) than nonprofit nursing homes (an average of 5.18). Deficiencies include those listed in the Nursing Home Compare by the Centers for Medicare & Medicaid Services (CMS).
  6. On average, nonprofit chains receive 30.4% of their revenues from private-pay residents, while independent for-profit nursing homes receive 19.4% of revenues from private-pay residents.
  7. Chain nursing homes (both for-profit and nonprofit) tend to be located in areas with lower median household income.
  8. Independent nursing homes (both for-profit and nonprofit) are much more likely to be located in California (30%) and New York (34%), respectively.

The researchers conclude that when evaluating the value of nursing home care, the private price is an important factor to consider. They note that nursing homes have different organizational structures, have different staffing levels, and provide different levels of quality. However, because a negative relationship between prices and deficiencies was found, the researchers determined that nursing home prices are often correlated with clinical quality.

The full text of “The Determinants and Variation of Nursing Home Private-Pay Prices: Organizational and Market Structure” was published June 20, 2019, by Medical Care Research and Review. An abstract is available online at https://journals.sagepub.com/doi/abs/10.1177/1077558719857335 (accessed July 15, 2019).

Data regarding health deficiencies can be found on the CMS website at https://data.medicare.gov/Nursing-Home-Compare/Health-Deficiencies/r5ix-sfxw.

For more information, contact: Sean Huang, Ph.D., Associate Professor, Department of Health Systems Administration, Georgetown University, 3700 Reservoir Road Northwest, St. Mary’s Hall, Washington, District of Columbia 20057; 202-687-5494; Email: sean.huang@georgetown.edu; Website: https://www.georgetown.edu/

In 2016, when Donald Trump chose Indiana Governor Mike Pence as his running mate, it unexpectedly brought harm reduction to the forefront of the news. In 2014, the state of Indiana experienced a public health crisis— an HIV outbreak, spurred by intravenous drug use. It was reported that this outbreak was due, in part, to cuts in public health funding and Governor Pence’s opposition to sterile needle exchanges as an anti-drug policy. In the face of this public health crisis, Governor Pence allowed limited needle exchange programs to operate as part of the state’s response. When Governor Pence was announced as the Vice Presidential nominee, it spurred renewed public debate about needle exchanges and harm reduction as a strategy for reducing the negative effects of drug use.

Needle exchanges continue to be controversial but have slowly gained acceptance across the country. This year three states, Georgia, Idaho, and Florida, have approved bills to approve needle exchange programs. Unfortunately, many harm reduction strategies continue to be a lightning rod when it comes to addiction treatment. Safe injection sites are now making headlines and pose significant challenges. Earlier this spring the Justice Department sued the non-profit, Safehouse, which has plans to open a safe injection site in Philadelphia. A safe injection site would allow people who use drugs, to do so under the supervision of trained staff, who are prepared with naloxone in the event of overdose, and who can offer support in accessing treatment and social services. Though other countries have successfully used safe injection sites for years and some U.S. cities have explored these sites, Safehouse’s success could be the first official site operational in the U.S.

The controversy around needles exchanges and safe injection sites make it clear, that though we have made progress, many harm reduction strategies are still controversial and face challenges from policymakers, communities, and health care professionals. Harm reductionists advocate for policies, resources, and interventions that meet people where they’re at, support their needs and reduce harms associated with drug use — without judgement, discrimination, or coercion. Grounded in human rights and social justice, programs typically aim to provide health care and social supports for all people — spanning those who use drugs, and those who don’t. Harm reduction may include sterile syringe exchanges, safe environments for drug users, non-abstinence-based housing, psychosocial supports, and education on safe drug use.

Treating individuals with substance use disorders is complex and lies on a continuum—with total abstinence at one end, harm reduction strategies at the other, and medication-assisted treatment (MAT) falling somewhere in the middle. In the current environment, spurred by the attention that has been generated by the opioid and overdose death crisis, MAT, and some harm reduction strategies, are becoming more widely accepted.

At The 2019 OPEN MINDS Strategy & Innovation Institute, attendees learned more about the principles of harm reduction in the session, Addressing The Opioid Crisis: An Opportunity For Innovation In Serving High-Risk Consumers, featuring Devin A. Reaves, Co-Founder & Executive Director for Pennsylvania Harm Reduction Coalition; and Paul Bacharach, President & Chief Executive Officer at Gateway Rehab. Mr. Reaves discussed his work in harm reduction with the Pennsylvania Harm Reduction Coalition, an organization that advocates for policies that improve the quality of life for people who use drugs, people in recovery, and their communities. His key takeaway for provider organization executives in the room was this: If you aren’t looking for ways to help consumers where they are, you are missing an opportunity. He explained:

There is literally 30 years of data that supports this work. Millions of times people have shot up at overdose prevention sites. No one has ever died there. You are a trusted provider in your community. If you don’t have a syringe service program, or a harm reduction service, you are doing a disservice to your community.

Ultimately, how an organization decides to approach harm reduction is dependent on organizational mission, treatment philosophy, and culture. Despite a shift in thinking about addiction treatment and the necessity of these services, the high costs associated with addiction demands that provider organizations get creative with both advocacy (see The Strategic Impact Of Addiction Treatment Legislation) and strategic partnerships so that they can deliver effective services. For more resources on either addiction treatment or ways to think about harm reduction, check out these resources in the PsychU Resource Library:

  1. Opioid Clarity?
  2. The Strategic Implications Of HIV & The Addiction Epidemic
  3. Opioid Addiction By The Numbers
  4. The Stigma Of Addiction Treatment Medication
  5. For Addiction Treatment, Medication & Beyond

 

Most respondents treated under Medicare bundled payment programs reported positive perceptions of care quality. While respondents participating in the Bundled Payments for Care Improvement (BPCI) initiative were significantly less likely to report favorable feedback on several measures, differences were small in magnitude.

BPCI respondents were 1.90 percentage points less likely to indicate that they were “quite a bit” or “extremely” satisfied with their overall recovery since leaving the hospital than were comparison respondents, at 70.31 for the BPCI group versus 72.21 for the comparison group. However, the BPCI survey respondents reported the same functional status months after their hospitalization as those not in BPCI, indicating that the efficiency incentives in BPCI did not jeopardize functional recovery. More than 95% of both BPCI and comparison survey respondents felt their health needs were manageable after returning home. Nearly 95% of both BPCI and comparison survey respondents agreed that medical staff clearly explained how to take medications, and what follow-up appointments would be needed.

These findings were reported in “Association Of Medicare’s Bundled Payments For Care Improvement Initiative With Patient‐Reported Outcomes” by Matthew J. Trombley, Ph.D.; Sean R. McClellan, Ph.D.; Daver C. Kahvecioglu, Ph.D.; Qian Gu, Ph.D. et al. The researchers analyzed data from a random sample of BPCI beneficiaries, matched with comparison beneficiaries. Date were collected from nine rounds of surveys between 2014 and 2017 which yielded 29,193 BPCI, and 29,913 comparison respondents. All BPCI beneficiaries were treated by hospitals participating in BPCI Model 2. Both groups were similar in characteristics of age, Medicaid eligibility, function, pain, and condition treated. They then estimated risk‐adjusted differences in patient‐reported measures of care and changes in functional status, for beneficiaries treated by BPCI and the comparison hospitals. The goal was to determine whether the BPCI initiative affected patient‐reported measures of quality.

The Centers for Medicare and Medicaid (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative to encourage providers to deliver care more efficiently with equal or better quality. A bundled payment model focuses on outcomes rather than staffing, procedural reimbursement, or prescription reimbursement. Under a bundled payment model, individual episodes are reconciled to the target price and then netted with other episodes. Typical services included in the episode are physicians’ services, inpatient or outpatient hospital services that comprise of the Anchor Stay or Anchor Procedure (respectively), other hospital outpatient services, inpatient hospital readmission services, long term-care hospital (LTCH) services, inpatient rehabilitation facility (IRF) services, skilled nursing facility (SNF) services, home health agency (HHA) services, clinical laboratory services, durable medical equipment (DME), Part B drugs, and hospice services. After adjusting for quality measures, participants will either receive or owe a payment to CMS. A qualifying clinical episode is typically triggered by a claim submitted to Medicare by an Episode Initiator. Four different models exist within the BPCI initiative, each with different rules and incentives. Each BPCI participant can choose to enroll in one Model and any combination of 48 clinical episodes or groups of Medicare Severity Diagnosis Related Group (MS‐DRG).

Because of the slight difference in BPCI responses from consumers, the researchers concluded that better communications and better shared decision-making between consumers and BPCI care teams may result in favorable care experience across several measures. However, similar changes reported in functional status from before to after care episodes for the two groups should reduce concerns about the potential for BPCI incentives to result in harm to consumer health.

The full text of “Association of Medicare’s Bundled Payments For Care Improvement Initiative With Patient‐Reported Outcomes” was published April 30, 2019, by Health Services Research. An abstract is available online at https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13159 (accessed June 24, 2019).

On June 13, 2019, the Ohio Department of Medicaid (ODM) released a request for information (RFI) seeking comments in preparation for its next Medicaid managed care organization (MCO) procurement, which is scheduled for release on January 1, 2020. The RFI seeks comments from consumers, their advocates, and health care professionals and provider organizations. The RFI poses 39 questions in seven broad topic areas to elicit stakeholder comments. Responses to the RFI are due by July 31, 2019.

Ohio Governor Mike DeWine directed ODM to rebid the Medicaid MCO contracts to change the terms related to pharmacy benefit managers. Additional goals are to improve the quality of services and care to those served; use best practices to expand quality services and improve health outcomes; and improve the provider organization experience in managed care. The new contracts are tentatively scheduled to go live in January 2021.

ODM contracts with five MCOs selected in 2012: Buckeye Health Plan, CareSource, Molina Healthcare, Paramount Advantage, and UnitedHealthcare Community Plan. The MCOs are at risk for all medical benefits, behavioral health, and prescription medications. About 90% of Ohio Medicaid beneficiaries are enrolled in a Medicaid MCO. The MCOs also provide additional benefits, such as member services and care management. The reprocurement will not affect the MyCare Ohio program for adults age 18 and older who are eligible for both Medicare and Medicaid. The MyCare Ohio MCOs serve about 120,000 dual eligibles. The MyCare MCOs coordinate physical, behavioral, and long-term care services.

ODM seeks responses in the following topic areas:

  1. Communication and engagement with individuals: How easy is it for individuals to access health care and find a provider, and stay engaged in their health care efforts?
  2. Grievances and appeals: There are times an individual or provider may disagree with a decision made by the individual’s managed care organization; ODM is seeking first-hand experience and ideas regarding the grievance and appeals process.
  3. Provider organization support: What administrative processes or functions make it easier or more difficult to do business in a managed care environment? How might sharing data be improved?
  4. Benefits and delivery system: In what ways can the managed care program improve access to services, and what unique arrangements should ODM consider in place of a one-size-fits-all model of managed care?
  5. Care coordination and case management: As ODM focuses on improving outcomes for individuals with complex health needs, how can MCOs and partners work to ensure appropriate care coordination and case management?
  6. Population health: How can the managed care program improve health outcomes such as infant mortality, adult smoking, and cardiovascular disease?
  7. Performance measurement and management: How should ODM be measuring the performance of the managed care program and the individual managed care plans regarding both processes and outcomes?

The questions directed to provider organization support cover standardization across plans, communications, support, data sharing, workforce development, and payment innovation, as follows:

  1. Standardization across managed care plans: ODM seeks suggestions about how it could promote greater consistency of prior authorization requirements across managed care plans, other functions that should be standardized across managed care plans, the pros and cons of standardizing functions, potential barriers and ideas for addressing them.
  2. Communication about policy updates: Ideas for improving managed care plan communication with network providers about updates and changes to plan policies.
  3. Support for administrative requirements: How could managed care plans could help provider organizations navigate the plans’ administrative requirements, such as submitting clean claims and resolving billing issues.
  4. Data sharing: How could data sharing between the state, managed care plans and providers be improved? What data do provider organizations want access to that they do not have access to today; how would provider organizations use that data? What is the most effective way of providing data to provider organizations? Are there barriers to providing the requested data; how could those barriers be overcome? How could data be shared and used by provider organizations that have limited resources and technology?
  5. Supporting primary care provider organizations: How could managed care plans could support primary care providers in integrating care for individuals enrolled with them. What kind of primary care infrastructure may be needed? What kind of training or coaching may be needed? How could the state/managed care plans incentivize primary care providers to improve access to care? What kind of primary care models should be encouraged by the state/managed care plan?
  6. Workforce development: How could the state/managed care plans support workforce development for different types of professionals and provider organizations, including dentists, pediatric psychiatrists, primary care professionals, in-home caregivers and licensed or unlicensed behavioral health professionals?
  7. Payment innovation: What are some ways the state/managed care plans could prepare and assist providers to move through the continuum of shared accountability models that reward providers for quality and improved health care outcomes? How could the state or managed care plans support and increase the establishment of comprehensive primary care practices and/or accountable care organizations? Are there other payment innovations that the state should consider incorporating into the Medicaid managed care program?

For more information, contact: RFI response, Ohio Department of Medicaid, 50 West Town Street, Suite 400, Columbus, Ohio 43215; Email: MCProcurement@medicaid.ohio.gov; Website: https://medicaid.ohio.gov/FOR-OHIOANS/Managed-Care-Procurement; or Melissa Ayers, Director of Communications, Ohio Department of Medicaid, 50 West Town Street, Suite 400, Columbus, Ohio 43215; 800-324-8680; Email: Melissa.Ayers@medicaid.ohio.gov; Website: https://medicaid.ohio.gov/.  

On May 26, 2019, Wellpath, formerly known as Correct Care Solutions, announced that the City of New Orleans, Louisiana had renewed its contract for jail medical and mental health services at the Orleans Justice Center and the Temporary Detention Center. The Mayor’s Office agreed to a 90-day contract extension, with the goal of later signing a long-term contract. The contract is valued at $15 million annually. Since May 2018, the parish had issued two other short-term renewals of the Wellpath contract. As of June 26, 2019, no further information has been released about the status of the pending long-term contract.

In 2013 the jail and the Orleans Parish Sheriff’s Office (OSPO) entered a consent decree to settle Independent Monitors for LaShawn Jones, et al, and the United States of America v. Marlin Gusman, Sheriff. The parish agreed to improve conditions at the jail, and the OSPO agreed to ensure constitutionally adequate intake, assessment, treatment, and monitoring of prisoners’ mental health needs, including, but not limited to, protecting the safety of and giving priority access to prisoners at risk for self-injurious behavior or suicide. In October 2014, Wellpath (then Correct Care Solutions) began managing jail medical services, including mental health. Due to the terms of the consent decree, the quality of care at the jail has been monitored.

In the most recent monitors’ report released on March 18, 2019, the team cited meaningful improvements since August 2018 in safety, medical, and mental health care and the environment conditions of inmates held in both the Orleans Justice Center and the Temporary Detention Center. While the trend is positive, the monitor’s report said more work is needed to properly staff the facility, curb violence, and improve medical and mental health care.

Combined the consent decree and stipulated agreements have 207 provisions. The monitors said that OPSO has achieved compliance or partial compliance with 94% of the provisions. Substantial compliance has been achieved for 37% of the provisions; and 56% are in partial compliance. The OPSO is out of compliance on eight of the remaining 173 provisions, less than 6%. In August 2018, OSPO was in substantial compliance on only 24% of the provisions, and was out of compliance on 23%. The monitors reported that OPSO has begun to examine its strategies to obtain and sustain compliance. The monitors also noted that Wellpath has improved in its development and implementation of a “clear path forward with measurable benchmarks” for medical and mental health care initiatives.

PsychU last reported on this topic in “One-Third Of New Orleans Jail Inmates On Behavioral Health Medications; Service Provision Uneven,” which published on July 18, 2017. The article is available at https://www.psychu.org/one-third-new-orleans-jail-inmates-behavioral-health-medications-service-provision-uneven/.

For more information, contact:

  • Beau Tidwell, Communications Director, City of New Orleans, 1300 Perdido Street, New Orleans, Louisiana 70112; 504-658-4000; Email: communications@nola.gov; Website: https://www.nola.gov/mayor/communications-department/
  • New Orleans Parish Sherriff’s Office, 2800 Perdido Street, New Orleans, Louisiana 70119; 504-202-9339; Email: contactus@opso.us; Website: http://www.opcso.org/
  • Press Office, Wellpath, 1283 Murfreesboro Road, Nashville, Tennessee 37217; 1-800-592-2974; Email: corpcomm@wellpath.us; Website: https://wellpathcare.com/
  • Orleans Parish Jail Monitors, 1880 Crestview Way, Naples, Florida 34119; Email: nolajailmonitors@nolajailmonitors.org; Website: http://www.nolajailmonitors.org/  

The Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide) provides information and insights into the multi-layered United States behavioral health system. The Guide includes an in-depth view of current statistics, prevailing issues, and emerging trends in order to inform the discussions, debates and decision-making of policy-makers, payers, providers, advocates and consumers. The Guide addresses current behavioral health care trends topics, including:

    • A look at the national policy that is shaping the U.S. health and human services market
    • A view of the state behavioral health delivery systems that were created by a combination of historical practices, federal and state policy, and market factors over recent years
    • An examination of the practices of 1,265 health plans that manage both physical and behavioral health care for the vast majority of the U.S. population
    • A deep-dive into behavioral health care access and delivery of care from the consumer perspective

Suicide rates have increased by 33% between 1993 and 2017. It is the tenth leading cause of death in the United States, and the second leading cause of death among Americans aged 15 and 34. For every person who takes their own life, there are 30 suicide attempts (see American Foundation for Suicide Prevention).

These are stark statistics that paint a complicated picture of a fragmented system. During The 2019 OPEN MINDS Strategy & Innovation Institute, Carol Clayton, Ph.D., Translational Neuroscientist and Christopher Reist, M.D., MBA, Chief Population Health Strategy for Relias discussed the key issues driving some of these statistics and offered some potential solutions in the session, Beyond Suicide Risk Assessment: Adopting A Comprehensive Solution To Rising Suicide Rates.

It is known that there are risk factors commonly associated with suicide—and screening tools that can help provider organizations and clinical professionals prevent suicide. One huge challenge with assessment tools is that assessment protocols are not standard across organizations and not practiced consistently across providers. The session reviewed two models for identifying those consumers using data to predict risk instead of relying only on assessments—the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), and the Mental Health Research Network (MHRN) Suicide Risk Calculator Project. Common to both programs are components that ensure a review of treatment and an intervention if indicated for those individuals most at risk, and studies are under way to determine if these approaches reduce suicide attempts or deaths.

In 2017, the Department of Veterans Affairs’ (VA) launched (REACH VET)—the model analyzes data from veterans’ health records to identify individuals with an elevated risk for suicide, hospitalization, or illness (see VA REACH VET Initiative Helps Save Veterans Lives: Program Signals When More Help Is Needed for At-risk Veterans). Over 100 variables have been identified, including demographics, prior suicide attempts, diagnoses, VHA utilization, medications, and interactions.

In 2018, the Mental Health Research Network and Kaiser Permanente conducted the Mental Health Research Network (MHRN) Suicide Risk Calculator Project, which combined data from electronic health records (EHR) with results from standardized depression questionnaires to predict suicide risk in the 90 days following either a mental health care visit, or a primary care outpatient visit (see Suicide Prevention: Research Network Finds New Way To Predict Risk). The study was conducted in seven health systems (HealthPartners, Henry Ford, KP Colorado, KP Hawaii, KP Northwest, KP Southern California, KP Washington) using information from eight million members, and identified 150 predictors. These predictors included demographics, mental health and substance use diagnoses, mental health inpatient and emergency department utilization, psychiatric medication dispensing, co-occurring medical conditions, and PHQ8 and item 9 scores.

But while we have the information needed to identify those consumers most at risk for suicide and effective screening tools, those assessments don’t happen routinely. This is proven by the statistics that within one month of a suicide attempt, 63% of individuals had a health care visit of any type and 44% of individuals had a mental health visit.

The reasons for this gap between science and practice are many. There is an absence of standardized assessment protocols across provider organizations. Non-mental health clinical professionals are concerned about their ability to find treatment services for consumers who are at risk. There is also a general lack of awareness and acknowledgement of “critical assessment windows,” which are the time periods when consumers are the most at-risk of suicide ideation. These time windows include the week after a visit to the emergency department for substance abuse, the week after discharge from psychiatric hospitalization, and the first weeks after starting an antidepressant. These are crucial time periods but there is no standardization of screening practice—which results in missing the opportunity to intervene.

For health and human service executives, there is a lot to take in when assessing suicide assessment capabilities. Do you have a screening protocol in place? Do you have data analytics tools to recognize risk factors and build a population health management strategy? Do you understand how to build, find, and/or adopt evidence-based practices for treating consumers with suicide ideation? Answering these strategic questions is essential to building a comprehensive suicide prevention program within your organization and across the market.

For more on bringing standardized decision support models to your organization, check out these resources in the PsychU Resource Library:

  1. The ‘Best Practice’ Challenge
  2. Your Organization Is Ready For VBR When.
  1. Challenges In Changing To A Culture Of Value (Or Making Any Culture Change)
  2. Building A Workforce For Value-Based Reimbursement = Advice From Four Executives
  3. ‘Virtual Psychiatrist’ Telemedicine Decision Support System Effective In Diagnosing Mental Disorders
  1. Preparing For Your ‘Augmented’ Workforce

And for more on leveraging your data, join OPEN MINDS Senior Associate Deb Adler on August 12 for her seminar, How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating, & Contracting With Health Plans.

If you or someone you know are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741.

In 2018, 95% of prescriptions in the United States were handled by six prescription benefit management (PBM) organizations: CVS Health (including Caremark and Aetna), Express Scripts, OptumRx (including UnitedHealth), Humana Pharmacy Solutions, Medimpact Healthcare Systems, and prime Therapeutics. Three of these – CVS Health, Express Scripts, and OptumRx – handled 76% of all U.S. prescriptions. This concentration helps plan sponsors and payers to maximize negotiations by combining their prescription volumes within a small number of PBMs. The concentration also maximizes profits to these PBMs.

These findings were reported in “2019 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers” by Adam J. Fein, Ph.D. Chief Executive Officer of Drug Channels Institute. Researchers from Drug Channels Institute completed a comprehensive analysis of U.S. pharmacies, benefit managers, and prescription revenues though both internal data and a number of publicly available external reports and data sources. The goal was to create a comprehensive report of the PBM Market.

Through their analysis, the researchers identified four trends in the industry that dictate, and will dictate in the future, how PBMs make money. These trends include:

  1. Vertical integration of PBMs into companies that offer health insurance, as well as operation of specialty pharmacies. This integration is partly motivated by the continued growth in specialty drugs which treat a small number of consumers, but account for a large share of payers’ drug spending. For example, the CVS/Aetna partnership, and the Express Scripts/Cigna/Accredo pharmacy partnership. This integration will encourage insurers and PBMs to compete more aggressively on their bundled services.
  2. PBMs will continue to reduce reliance on rebate profits. The largest PBMs have announced approaches that adapt compensation into a system that features low (or no) rebates.
  3. PBMs will depend more on profits from specialty drug dispensation. A large percentage of PBMs and insurers operate the largest pharmacies that provide mail service and specialty handling. These profits results from a difference between the reimbursement to the pharmacy, and the pharmacy’s net acquisition cost for product purchase. Absorption of these costs internally allows PBAs to operate the pharmacies from within. PBMs now earn more than 50% of their profits through dispensing activities and look to increase these profits in the future.
  4. PBMs’ ability to capture network spreads will lessen due to payer and government pressure. Payments for drugs go through the PBM from plan sponsors to pharmacies that dispense the prescriptions. The difference between what goes in and what goes out is the spread. Spread pricing occurs when a company marks up the difference between the amount they reimburse pharmacies for a drug, and the amount they charge consumers. This practice is controversial in Managed Medicaid programs, which are run by PBMs and account for most Medicaid prescriptions and spending.

The full text of “2019 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers” was published in March 2019, by Drug Channels Institute. A copy can be purchased online at https://drugchannelsinstitute.com/products/industry_report/pharmacy/ (accessed June 18, 2019).

PsychU last reported on this topic in “CVS Health Completes Aetna Acquisition,” which published on January 7, 2019. The article is available at https://www.psychu.org/cvs-health-completes-aetna-acquisition/.

For more information, contact: Adam J. Fein, Ph.D., Chief Executive Officer, Drug Channels Institute, 1515 Market Street, Suite 960, Philadelphia, Pennsylvania 19102; 215-523-5700; Fax: 215-523-5758 Email: afein@drugchannels.net; Website: https://www.drugchannels.net/

On April 29, 2019, the National Association of Addiction Treatment Providers (NAATP) announced the release of a foundational set of resources to raise the standards for addiction treatment. The 3 documents form the foundation of NAATP’s Quality Assurance Initiative. The resources include:

  • The Addiction Treatment Provider Quality Assurance Guidebook
  • The NAATP Addiction Treatment Outcomes Measurement Toolkit
  • The NAATP Code of Ethics Version 2.5

The NAATP Quality Assurance Initiative (QAI) was created in 2018 to establish standards for addiction treatment service delivery.

The Addiction Treatment Provider Quality Assurance Guidebook

The guidebook was created to set a strong standard for treatment service delivery. It identifies the core competencies of addiction treatment service through various categories of operations. Within these categories are 32 specific guidelines, each accompanied by an explanatory commentary from an industry expert, followed by a list of resources referenced to develop the guideline. Overall, the focus is that provider organizations should operate programs, and maintain and use their facilities in a way consistent with zoning and intended use of the property, to enhance the therapeutic environment, convey a safe and professional setting, and integrate within the surrounding community. The guideline address the following operational areas:

  1. Admissions and consumer screening: The purpose of this section is to provide guidelines for admissions and patient screenings at addiction treatment facilities. Provider organizations should follow a written admissions process that governs admission criteria, decision making, and intake procedure at the facility. The process should provide information on the anticipated length, intensity, and cost of treatment, as well as what services are provided at the facility. Standardized screenings should be conducted before admission, at intake, and throughout treatment to determine if the facility is equipped to treat the consumer, assess the consumer’s needs, inform treatment planning, and measure progress throughout treatment.
  2. Employment, training, and credentialing: The purpose of this section is to provide guidelines that assist treatment provider organizations in developing and enhancing systems for employment, staff training, and credentialing. All personnel should receive training on their roles, responsibilities, and organizational expectations. Provider organizations should employ professional, credentialed/licensed staff. Salaries and benefits should be competitive enough to recruit and retain competent staff. In the event that a provider organization hires a former consumer, the organization should have a written policy that protects the consumer from exploitation, and ensures that the facility and treatment staff are not placed in a position of dual relationships with former consumers.
  3. Billing: The purpose of this section is to provide guidelines that assist provider organizations in developing policies, procedures, and best practices for billing, receiving, and collections from consumers. Provider organizations should have a methodology for calculating the cost of services, and use this cost in contracting and forecasting. The rates should reflect “reasonable” profit margins consistent with other health care sectors. Provider organizations should consider usual and customary rates when developing billing policies, and be prepared to justify billing amounts that significantly differ from usual and customary. Provider organizations should develop and adhere to a written policy regarding balance billing that complies with state law, network contracts, and insurance policy documents. Written policies should be developed for the use of and billing for toxicology provided at the facility; the type and frequency should be decided based on disease severity, best practices, and clinical need, and billing should be related to the actual cost of the service. Provider organizations should collect all deductibles and copayments in alignment with the consumer’s health insurance policy; routinely waiving the consumer’s financial responsibility is prohibited. Financial hardship waivers must be based on written objective criteria.
  4. Discharge and continuing care: The purpose of this section is to provide guidelines on effective utilization of the continuum of care and best practices for discharge planning. Addiction treatment provider organizations should offer treatment along a continuum of care that recognizes addiction as a chronic illness requiring ongoing bio-psycho-social treatment. Provider organizations offering only specific levels of care should have resources to help consumers access the full continuum. Discharge planning should focus on supporting consumers and their goals through the continuum of care and community reintegration. Provider organizations should develop policies and procedures for atypical discharges to prevent consumers from being discharged to the street.
  5. Outcomes measures: The purpose of this section is to provide guidelines for the implementation of validated outcomes measurement at addiction treatment facilities. Provider organizations should collect, analyze, and publish consumer outcomes to inform program development, enhance service quality, and inform the public.
  6. Community engagement, public relations, and public policy: The purpose of this section to provide guidelines for effective community engagement, public relations activities, and public policy advocacy. Addiction treatment provider organizations should integrate into and engage with the communities in which they serve and operate; this includes establishing collaborative collegial relationships with other addiction treatment provider organizations and other medical professionals. The public relations strategy should focus on communicating the provider’s mission, values, and treatment philosophy; promoting a positive relationship with the community. Public policy conditions should be guided by organizational vision, values, and treatment philosophy, but should frame addiction disorder as a chronic health condition best treated in an integrated and comprehensive continuum of care that addresses the bio-psycho-social-spiritual needs of the individual, uses best practices, and integrates within the larger health care field.
  7. Marketing, advertising, and visibility: The purpose of this section is to provide effective guidelines for the development and implementation of ethical and transparent marketing, branding, and advertising practices. Marketing practices should promote transparency, foster trust, support consumer confidence, and focus on the best interest of the consumer. To promote transparency and brand integrity, marketing materials should clearly identify the actual corporate identity of the program being promoted, and accurately reflect the provider organization’s clinical competence, location, amenities, staff, and staff credentials; the materials should not infringe on the recognition or integrity of a third brand. The provider organization should not provide or receive payment—financial or otherwise—for referrals made to or by the provider organization. Third parties can be used for some marketing activities, but that third-party must adhere to all other provisions of the NAATP Code of Ethics, and Marketing, Advertising, and Visibility standards of the NAATP Quality Assurance Guidebook.
  8. Ethics: The purpose of this section is to provide rationale for and guidance in implementation of professional ethics. Addiction treatment provider organizations should, and NAATP members must, adopt and adhere to the NAATP Code of Ethics.

The Addiction Treatment Outcomes Measurement Toolkit

The Outcomes Measurement offers a nationwide standard for provider organizations to collect data through common outcome measures. The Toolkit is a set of comprehensive protocols, checklists, surveys, and best practices for use at addiction treatment facilities. The toolkit was developed following an Outcomes Pilot Program study by NAATP and conducted by the OMNI Institute. They conducted a three-year study at eight facilities across the United States to test the data collection method and produce a standardized, uniform, and replicable methodology for outcomes tracking. NAATP members interested in more information and implementing the Toolkit should contact NAATP at outcomes@naatp.org or the OMNI Institute at omni@omni.org with the subject line “Outcomes Toolkit Implementation.”

The Code of Ethics Version 2.5

Updated in February 2019, the NAATP Code of Ethics is guidance for the adherence to the highest levels of professionalism and ethical conduct through the entire continuum and spectrum of clinical and business services. The code of ethics outlines those standards to which all NAATP members must follow. The standards cover issues related to treatment, management, facilities, and marketing.

The National Association of Addiction Treatment Providers (NAATP) is a non-profit professional membership association comprised of addiction treatment providers and entities that support addiction treatment. Founded in 1978, the mission of NAATP is to provide leadership, advocacy, training, and member support services to ensure the availability and highest quality of addiction treatment.

The OMNI Institute conducts social science research, evaluation, and capacity building with non-profits, foundations, and government agencies focused on addressing society’s most pressing social challenges. For over 20 years, OMNI has partnered with stakeholders and providers across the spectrum of substance use prevention, treatment, and recovery to conduct research and support implementation of best practices.

The full text of “The Addiction Treatment Provider Quality Assurance Guidebook” was published April 8, 2019 by the NAATP. A copy is available online at https://www.naatp.org/sites/naatp.org/files/NAATP%20QA%20Guidebook%20Beta.pdf (accessed June 18, 2019).

The full text of “NAATP Addiction Treatment Outcomes Measurement Toolkit” was published March 11, 2019 by the NAATP. A copy is available online at https://www.naatp.org/sites/naatp.org/files/NAATP_Newsletter_Outcomes_FINAL.pdf (accessed June 18, 2019).

The full text of “NAATP Code of Ethics” was published in February 2019 by the NAATP. A copy is available online at https://www.naatp.org/resources/ethics/code-ethics (accessed June 18, 2019).

For more information, contact: Marvin Ventrell, J.D., Executive Director, National Association of Addiction Treatment Providers, 1120 Lincoln Street, The Chancery Building, Suite 1104, Denver, Colorado 80203; 888-574-1008; Email: mventrell@naatp.org; Website: https://www.naatp.org/; Kayla Huett, Program Coordinator, National Association of Addiction Treatment Providers, 1120 Lincoln Street, The Chancery Building, Suite 1104, Denver, Colorado 80203; 888-574-1008; Email: khuett@naatp.org; Website: https://www.naatp.org/

A couple of months ago, we wrote about the lack of measurement-based care or the use of decision support tools and data to inform how consumers receive care. Measurement-based care is defined as the collection of quantifiable data using validated scales and then incorporating that data into the treatment planning process creating a feedback loop. Currently only 7% of psychiatrists use measurement-based psychiatric scales when consumer treatment planning (see Why So Little Measurement-Based Mental Health Care?), and only 11.1% of psychologists routinely administer symptom rating scales.

Where does measurement-based care “fit” in the move toward metrics-based performance management and value-based reimbursement (VBR)? Measurement-based care facilitates standardization of service delivery. And, going a step further, measurement-based care allows clinical managers to identify the most effective service models. By measuring care outcomes, managers of provider organizations can see what is and isn’t working, and adjust accordingly in real time these are essential skills in value-based reimbursement environments.

What does measurement-based care look like in practice? An example was given at The 2019 OPEN MINDS Strategy & Innovation Institute during the session, Grafton’s Journey Into Measurable Patient Success, presented by Scott Zeiter, Executive Vice President/Chief Operating Officer, and Jeremy Ulderich, Director of Educational Consulting at Grafton Integrated Health Network. In the Welligent-sponsored session, Mr. Zeiter and Mr. Ulderich talked about Grafton’s development of measurement-based care and what they learned from that experience.

Grafton’s strategy for investing in measurement-based care began with questions—what do payers want from services for children with complex, co-morbid intellectual/developmental disability (I/DD) and behavioral health conditions? And, how could the Grafton team deliver on that? Answering the first question started with market research on what payers and health plans are looking for. Mr. Zeiter explained that their research found that payers are looking for efficiency, empiricism, evidence of change, and expedited responses to lack of change.

The answer to the second question was to build a measurement-based care system that provided payers with these answers. To build the system, the Grafton team started with a goal mastery model that they had already developed. The model creates quantifiable goals for individuals and then tracked those goals to determine whether they are met. While this existing system identified the “what” of the desired outcomes, it did not recommend an appropriate clinical pathway, or provide decision support. Adding that functionality was key to having a working measurement-based care system.

How Grafton’s Model For Measurement Based Care Works

To implement their model for children with complex behavioral conditions, Grafton’s clinical professionals first select from nine broad categories of actions that result in the children they serve needing supportive services. These categories include physical aggression, self-injurious behavior, elopement, lack of safety awareness, disruption, property destruction, sexual acting out, threats of harm, and psychological impairment (Grafton identified these categories as team). These categories form the basis of Grafton’s analysis. For example, they may find that children with physical aggression and elope have better outcomes when they receive motivational interviewing compared to cognitive behavioral therapy (CBT). Any of the variables in the EHR, from demographics to diagnosis to treatment approach can be compared to seek correlations.

In step two, the clinical professional develops a goal to address each problem area. This is a structured process that must include data points such as how long the goal will take to complete, the current rate of behavior occurrence (baseline), and the target rate. In step three, the clinical professional chooses from a list of empirically-based practices This is a structured process that must include data points such as: how long the goal will take to complete,the current rate of behavior occurrence (baseline), and the target rate, such as antecedent-based interventions, reinforcement, and prompting that will be used to meet the goal. Finally, in step four, the clinical professional selects from a list of “intervention objectives” nested under each empirically-based practice. These intervention objectives are the individualized for each client.

Step five is focused on behavior tracking. The direct support professionals working with the children enter the behaviors into the EHR as the behaviors occur (or shortly thereafter). The frequency of the behavior is then updated in real-time on the graphs that Grafton uses to track changes in behavior. If the behaviors are more than three points off the planned trajectory than staff know that it may be time to intervene to meet the goals. In the future, Grafton is partnering with Welligent to set up alerts for when goals go off track.

The Grafton measurement-based care system is in its initial implementation. Over time, Grafton will be able to use and analysis this data to inform appropriate clinical pathways and decision support. Mr. Zeiter and Mr. Ulderich explained that this obviously isn’t an academically rigorous study, it does tell them what works in the “real world” and will be used to refine their service approaches over time.

Advice To Executives Embarking On The Measurement-Based Care Journey

Mr. Zeiter and Mr. Ulderich had much to share about their evidence-based care journey. Their advice to other executives – know when to compromise, be constantly vigilant about model fidelity, and ensure a consumer-driven care plan.

First, know when to compromise and when to hold your ground. Mr. Zeiter explained that the new system was specifically designed to be user friendly and as simple as possible. As part of this, Grafton leadership decided not to develop a user manual for the new EHR system. However, staff were uncomfortable with this and in the end, they compromised to come up with a series of videos that explain the system. One area where Grafton leadership chose not to compromise was when staff wanted to implement a complicated paper system to enter behaviors in the EHR. For the new system to work and be updated in (near) real-time, data needed to be entered directly into the EHR.

Second, ensuring the fidelity of the model takes vigilance. Initially, Mr. Zeiter was afraid that staff would not accurately track behaviors in the EHR and then the model wouldn’t work due to a lack of data. What they found was that ease of the system means that sometimes staff are over-tracking behaviors, or two staff members will enter the same behavior. Grafton is working to ensure that behaviors are accurately tracked in the system. Additionally, just because a clinical professional chooses a specific intervention for a child, it is difficult to ensure that a child is getting that intervention.

Third, using a measurement-based model means that organizations must be extra careful that they are offering a consumer-driven care plan. With the ability to choose from drop downs and a set number of options, there is the possibility that plans may not be individualized enough for payers. Mr. Zeiter explained that in order to maintain a consumer-driven organization, Grafton must ensure that this is an important part of their culture and that care plans are carefully monitored.

Implementing a measurement-based care model is a heavy lift, but for organizations who have the culture and the will, it is possible. Crucial to developing this model is the use of a technology platform that is easy for staff to use and can capture the needed data and show progress in near real-time.

The North Carolina state auditor says that for the past seven years the state has not provided adequate oversight of the seven local management entity-managed care organizations (LME-MCOs) that manage Medicaid behavioral health, addiction treatment, and disability support benefits. The auditor said the North Carolina Department of Health and Human Services (DHHS) failed to obtain reports needed to ensure that services were provided, costs were reasonable, or that performance standards were met. DHHS did not document how it conducted evaluations, the results of the evaluations, or the feedback provided to the LME-MCOs as a result of the evaluations. In case of noted deficiencies, DHHS did not compel the use of corrective action plans (CAPs) or assess penalties. Further, DHHS did not monitor or follow-up on CAPs identified by the DHHS external quality review (EQR) contractor during annual reviews.

The findings were reported in “North Carolina Department Of Health & Human Services, Division Of Health Benefits, Medicaid LME-MCO Contract Monitoring Performance Audit” by the North Carolina Office of the State Auditor. The purpose was to identify DHHS weaknesses in monitoring the LME-MCOs so that DHHS can make changes to better monitor the performance of integrated Medicaid managed care organization (MCO) plans, which are slated to go live in November 2019. The Medicaid managed care plans will be responsible for integrated physical health and pharmacy services, plus behavioral health care services. Following a competitive procurement, in February 2019 DHHS awarded $6 billion in contracts to five managed care entities. After the integrated Medicaid managed care plans go live they will serve most of the state’s 2.1 million Medicaid beneficiaries.

Based on the audit findings, the auditor expressed concern about DHHS’s ability to oversee the integrated Medicaid managed care organizations. The report did not address whether the lack of monitoring led to excess costs. Currently DHHS oversees $3.2 billion in funds managed by the LME-MCOs. The integrated plans at full enrollment will manage nearly $13.9 billion. The auditor recommended that DHHS develop a formal, centralized tracking mechanism to ensure the timely receipt and retention of all LME-MCO reports and data, create formal policies and procedures for evaluating MCOs, and assess penalties and compel the use of CAPs to hold LME-MCOs accountable for their performance. DHHS should monitor and follow-up on CAPs initiated through the EQR process prior to the next annual EQR review.

DHHS has reviewed the audit and is addressing the issues raised in several ways. It has created a new process for Medicaid managed care oversight that will also be implemented for the LME-MCOs. Additional staffing has been added, including an Assistant Secretary for Transformation and a Chief Operating Officer (with health plan oversight experience) and other staff with managed care and health plan experience. Additionally, DHHS has a contract management plan that involves both contract specialists and subject matter expertise, as well as a contract management system that will document the incoming requirements and the internal responses and external communications. DHHS is currently conducting detailed readiness reviews to ensure that DHHS and the health plans are prepared to launch in November 2019.

For more information, contact:

  • Brad Young, Press Contact, North Carolina Office of the State Auditor, 20601 Mail Service Center, Raleigh, North Carolina 27699-0600; 919-807-5700; Email: Brad_Young@ncauditor.net; Website: https://www.ncauditor.net/pub42/Default.aspx
  • Mandy Cohen, Secretary, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina 27699-2001; 919-855-4840; Email: news@dhhs.nc.gov; Website: https://www.ncdhhs.gov/

Editor’s note: this article was updated on June 24, 2019, to incorporate the state’s description of how it is responding to the audit.

Following the 2014 Medicaid expansion, the share of psychiatrists who accepted Medicaid declined from 47.9% in 2010-2011 to 35.4% in 2014-2015, as weighted by the National Ambulatory Medical Care Survey’s national weights and adjusted for practice ownership status. There was no similar change among primary care or other specialties.

These findings were reported in “Medicaid Acceptance by Psychiatrists Before and After Medicaid Expansion” by Hefei Wen, Ph.D.; Adam S. Wilk, Ph.D.; Benjamin G. Druss, M.D., MPH; and Janet R. Cummings, Ph.D. The researchers analyzed information from the 2010 to 2015 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of physicians who were not federally employed, were based in offices, and were primarily engaged in direct care of consumers; the research was limited to physicians who reported accepting new consumers for care. The goal was to determine trends in Medicaid acceptance over time. These estimates were weighted by the National Ambulatory Medical Care Survey’s national weights and adjusted for individual-level covariates.

The 11,521 NAMCS respondents who reported seeing new consumers for care included 584 psychiatrists; 4,400 primary care physicians; and 6,537 other specialists. Additional findings include:

  • In expansion states only, the adjusted difference for Medicaid acceptance increased 4.7% for other specialists, decreased 1.9% in primary care physicians, and did not change for psychiatrists.
  • In non-expansion states only, the adjusted difference for Medicaid acceptance increased 7.8% for psychiatrists, decreased 10.2% for other specialists, and did not change for primary care physicians.

The researchers concluded that consumer gains in insurance coverage under Medicaid expansion may not improve access to office-based treatment by psychiatrists. However, due to patterns discovered through different weighting mechanisms, Medicaid expansion did not have a large effect on differences in Medicaid acceptance for psychiatrists. They suggest further studies to determine reasons for the decline in Medicaid acceptance for psychiatrists after Medicaid expansion.

The full text of “Medicaid Acceptance by Psychiatrists Before and After Medicaid Expansion” was published June 5, 2019, by JAMA Psychiatry. An abstract is available online at https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2735109 (accessed June 18, 2019).

PsychU last reported on this topic in “35% Of Psychiatrists & 70% Of All Physicians Accept New Appointments For Medicaid Beneficiaries,” which published on April 15, 2019. The article is available at https://www.psychu.org/35-of-psychiatrists-70-of-all-physicians-accept-new-appointments-for-medicaid-beneficiaries/.

For more information, contact: Hefei Wen, Ph.D., Department of Health Management and Policy, University of Kentucky College of Public Health, 111 Washington Avenue, Lexington, Kentucky 40536; Email: hefei.wen@uky.edu; Website: https://cph.uky.edu/people/hefei-wen

Billing-related administrative costs in the United States health care system are estimated at about 8.3% of the $3.36 trillion total health care spending in 2016. During 2019, billing-related administrative costs are projected to reach $496 billion annually. Excess billing-related administrative costs are estimated at $248 billion annually for 2019.

The billing-related administrative cost estimate includes annual costs for health insurers and provider organizations to submit claims, reconcile claims, and process payments. The 2019 estimate of $496 billion for billing-related administrative costs excludes medical record-keeping; hospital management; initiatives that monitor and improve care quality; and programs to combat fraud and abuse.

Billing-related administrative costs that were categorized as “excess” are caused by inefficiencies. This includes the cost of handling duplicate intake forms, transferring medical records between provider organizations, and ensuring accuracy in insurance bills. The $248 billion estimate of excess costs excludes costs associated with retail sales of medical products, such as sales of prescription drugs and durable medical equipment.

Annual billing-related administrative costs for 2019 incurred by physicians, hospitals, and other provider organizations are estimated at $282 billion. Up to 50% may be excess administrative costs.

Annual billing-related administrative costs for 2019 incurred by private insurers are estimated at $158 billion. Up to 66% may be excess administrative costs. Annual billing-related administrative costs for 2019 incurred by public programs are estimated at $56 billion. For public programs, the share of excess administrative costs is unknown.

These statistics were reported in “Excess Administrative Costs Burden the U.S. Health Care System” by Emily Gee and Topher Spiro for the Center for American Progress. The researchers used recent projections of U.S. health expenditures from the Centers for Medicare and Medicaid Services (CMS), and 2015 and 2016 data from the Organisation for Economic Co-operation and Development to obtain spending information for other countries. They analyzed the National Academy of Medicine’s estimations of billing-related administrative costs (13% of physician care spending; 8.5% of hospital care spending; 10% of spending by other provider types; 12.3% of spending on private insurance; and 3.5% of public program spending, including Medicare and Medicaid). The goal was to provide an overview of administrative expenditures in the U.S. health care system, in the context of proposals to reduce administrative costs and/or implement single-payer health care.

With estimated billing-related administrative costs at 8.3% in 2016, the United States has a higher burden of administrative costs than other developed countries. Those with the next highest percentage of administrative costs are France (5.7%), Austria (4.8%), and Germany (4.2%). In contrast, Norway (0.6%), Finland (0.8%), and both Sweden and Japan (1.6%) have the lowest percentages of administrative costs.

The researchers presented analyses of proposals to reduce administrative costs through a variety of strategies, including implementing a single-payer program. They reported that the estimates of savings varied widely.

The researchers concluded that a large body of evidence shows that the United States has much higher health care administration costs than other countries and may be spending twice what is needed for governance, billing, and insurance. They noted that other nations have high quality health care systems and spend a fraction of what the United States spends. They recommended that a structural overhaul of how the United States finances and prices health care could include key features used in other countries. Simplifying the payment system should be a key focus on future health reform in the United States to make the system work better for taxpayers and for consumers.

The full text of “Excess Administrative Costs Burden the U.S. Health Care System” was published on April 8, 2019, by Center for American Progress. An abstract is available online at https://cdn.americanprogress.org/content/uploads/2019/04/03105330/Admin-Costs-brief.pdf (accessed June 3, 2019).

PsychU last reported on health plan administrative costs in “2018 National Health Expenditure Projected At $3.65 Trillion, Up 4.4%,” which published on April 8, 2019. The article is available at https://www.psychu.org/2018-national-health-expenditure-projected-at-3-65-trillion-up-4-4/.

For more information, contact: Colin Seeberger, Press Contact, Center for American Progress, 1333 H Street Northwest, Floor 10, Washington, District of Columbia 20005; 202-682-1611; Email: cseeberger@americanprogress.org; Website: https://www.americanprogress.org/

With all the discussion about “consumerism” in health and human services, there are many terms—old and new—floating around. We’ve covered the current thinking about customer service and consumer experience (see Consumers Know What They Need. Do We?, and Considering Cash—& Consumerism—In Service Line Planning). But the discussion of new service models for consumers with disabilities has added self-direction, self-determination, and self-advocacy to this lexicon.

There is a lot of reference to the importance of health plans and provider organizations to incorporate these concepts in their service delivery models. But, it is important to get clarity on exactly what these terms mean from an operational and performance perspective. How are they the same or are they different? What are the “best practice” in service models incorporating these principles? And how to you measure success?

These were the issues tackled by Dan Ohler, Vice President, State Government Programs, Optum Behavioral Health and Molly Murphy, President, Applied Self-Direction discussed this at The 2019 OPEN MINDS Strategy & Innovation Institute during their session, Self-Determination In The I/DD Market: Keys To Incorporating Consumer-Directed Care Into Your Services. From their perspective, each of these terms takes on a slightly different flavor and has different nuances.

Self-determination is the idea that individuals can control their life and make decisions about where they live, how they access supports, their goals, etc. There are four overarching principles to self-determination—freedom to plan their own lives, authority to control their resources, support to build a life in the community, and responsibility to be a valued member of the community.

Mr. Ohler explained that health plans are looking for organizations that can incorporate these principles into their service delivery model because these principles result in higher consumer satisfaction. He said that in order to incorporate self-determination, provider organization management teams need to take a hard look at their culture and how they deliver services. For case managers, the shift to self-determination can be difficult. It is a change from managing people to helping people managing themselves. To be successful with self-determination, management teams must embed the principles of self-determination into their policies, communications, and community outreach materials.

Self-direction is a more specific form of self-determination where individuals (or a designated person) are given the ability to design and direct their support services. There are two types of self-direction—budget authority and employer authority. Under employer authority, participants can recruit, supervise, and manage their support professionals. Under budget authority, individuals manage their support budget and make decisions about the goods and services to purchase.

Ms. Murphy talked about the trends in the adoption of self-direction. Over the past ten years or so, self-direction has gone from boutique pilot programs to statewide programs serving a wider population. Her organization’s research found that, in 2016 there were over 250 self-direction programs serving approximately one million self-direction recipients—a 30% increase over three years. Additionally, in 21 states, the adoption of managed long-term services and supports resulted in an increase in the use of self-direction.

Finally, there is self-advocacy, which is the ability to speak up about your feelings and ask for what you need. Self-advocacy is a critical component of both self-direction and self-determination. Without self-advocacy, true self-determination and self-direction cannot occur. Mr. Ohler spoke to the importance of creating an organizational culture that encourages and welcomes self-advocacy. He also noted that it’s important not to confuse “self-advocacy” with “family-advocacy.” While families can play an important role in an individual’s life, ultimately the wants and needs of the consumer are the most critical.

Over time these principles for changing the role of consumers in the service system are going to become increasingly important to the success of health and human service organizations. Both Ms. Murphy and Mr. Ohler noted that managed care program managers see self-determination and self-direction as important components of their new service offerings. Managers and service professionals need to allow individuals to make their own choices, even if this involves more risk and overcoming the instinct is to “save” them from failing.

Depression, alcohol dependency, risk of suicide, childhood trauma — clinical professionals and provider organizations employ a variety of assessment tools and standardized questions to screen consumers for the drivers of poor health care. These screening tools help to identify issues, standardize treatment planning, and uncover issues that influence a consumer’s whole health. One area where we’ve recently seen a greater interest in screening tools and assessments is social determinants of health (SDH).

As health plans and provider organizations are increasingly focused on value and consumer outcomes, the interest in addressing social determinants has increased. But there is a long path between identifying the correlation between social determinants and health care costs and developing social service interventions with a clear return-on-investment (ROI) for payers and health plans. This is especially difficult because the field hasn’t traditionally had great mechanisms for identifying SDH. And while screening for social needs is not yet standard in clinical practice, the ability to effectively screen for SDH continues to evolve.

In 2017, in an attempt to create a more standardized screening process, researchers with the Centers for Medicare & Medicaid Services (CMS) developed a 10-item screening tool to identify health-related social needs. The tool focuses on five domains that can be addressed through community-based services: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety. The tool was developed in coordination with the Accountable Health Communities model, a five-year program that will test delivery approaches for linking clinical and community services. The 32 organizations selected for participation in the program are utilizing the screening tool as a standardized resource (see CMS Develops 10-Item Screening Tool Focused On Social Determinants and CMS Accountable Health Communities Model Selects 32 Participants To Serve As Local Test ‘Hubs’).

Earlier this month, Boston Medical Center (BMC) announced it had implemented a SDH screener for primary care consumers in order to better identify and address their unmet social needs—the BMC THRIVE Screening and Referral Program; it is based on the BMC electronic health record (see Boston Medical Center Develops EHR Tool To Screen For Social Needs). Consumers complete the screener before an appointment, answering questions on housing, food insecurity, transportation, and employment, and the screener autogenerates ICD-10 codes that are added to the consumer’s medical record. Of those with a social need, the most prevalent concerns were employment (12%), food insecurity (11%), and problems affording medications (11%).

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) from the National Association of Community Health Centers (NACHC) continues to be a popular tool utilized by health care provider organization. PRAPARE’s evaluation tool asks social health questions in areas ranging from demographic data and housing status to social-emotional health and physical security (see About the PREPARE Assessment Tool). They also provide an implementation and action toolkit that is being used by providers nation-wide to gather data that will allow them to assess their patients’ social needs, so they can take measures to address them. And many other organizations are developing their own screening and assessment processes (see How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care).

Already, 80% of payers use some method to identify SDH (see Payers Approaches To Addressing Social Determinants Vary), which means that even if you aren’t contracting with health plans right now that are focused on assessing consumer’s social support, the chances of that requirement in the future are all but guaranteed. As health plans put a greater emphasis on social determinants of health in value-based arrangements, provider organizations will need to find new ways to address consumer’s social support needs. But before those needs can be addressed, organizations will need a standardized tool to assess what those needs are. There are already many existing screening tools to explore, the key will be building an infrastructure (including staff training, shifting workflows to make screening a standard practice, incorporating assessment tools into electronic health records, etc.) that can support a standardized approach to screening for social support needs.

For more information to get your team thinking about new programming integrating social services, check out these resources from the PsychU Resource Library:

  1. Addressing Social Determinants-The Measurement Challenge
  2. Social Determinants Today, Social Determinants Tomorrow
  3. Addressing The Social Determinants Of Health With Income Assistance
  4. Medicare’s Path To Incorporating Social Determinants Into Value-Based Payment
  5. Screening Humana Medicare Advantage Members For Social Determinants Of Health Reduced ‘Unhealthy Days’ By 2.7%

 

The Centers for Medicare & Medicaid Services (CMS) has finalized a rule to maintain its existing 2006 policies on prior authorization and step therapy for Part D protected medication classes. The Part D protected classes include antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, antiretrovirals, and antineoplastics. Effective January 1, 2020, Medicare Part D plans can establish prior authorization and step therapy for only members initiating treatment with five of the six protected classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants, and antineoplastics. Prior authorization and step-therapy will not be permitted for Part D members initiating treatment with antiretrovirals.

In the proposed rule, CMS presented three exceptions to the protected class policy. These exceptions would:

  • Implement broader use of prior authorization and step therapy for protected class Part D drugs, including to determine use for protected class indications
  • Exclude a protected class Part D drug from a formulary if the drug represents only a new formulation of an existing single-source drug or biological product, regardless of whether the older formulation remains on the market
  • Exclude a protected class Part D drug from a formulary if the price of the drug increased beyond a certain threshold over a specified lookback period.

In the final rule, “Modernizing Part D & Medicare Advantage To Lower Drug Prices & Reduce Out-of-Pocket Expenses,” CMS finalized the first provision of the three exceptions, with modifications. This final rule does not place additional limits on beneficiary access to medications. The exception will permit prior authorization and step therapy only for enrollees initiating therapy, and will apply to all Part D protected classes, except antiretroviral medications, for non-protected class indications only. As is required for all other Part D drug categories or classes, these formulary design and utilization management edits will be subject to CMS review and approval as part of the annual formulary review and approval process, which includes reviews of prior authorization and step therapy edits that restrict access, step therapy criteria, prior authorization outliers, and prior authorization criteria.

Estimated savings to enrollees due to reduced out-of-pocket costs for this step therapy are between $5 and $8 million for the 2020 to 2029 timeframe, resulting in an aggregate savings of $62 million over 10 years. The Medicare Trust Fund savings are between $145 and $240 million annually for the 2020 to 2029 timeframe, resulting in an aggregate savings over 10 years of $1.9 billion. There is a $1-to-$1.3 million cost to the government and its contractors for the 2020 to 2029 timeframe, due to a projected increased in appeals, resulting in an aggregate cost of $11.2 million cost over 10 years.

Under the rule, Part D plans will also be required to build a tool to provide drug pricing data. The tool must be operational by January 1, 2021. This tool should be able to integrate into electronic health records or electronic prescribing. Plan sponsors must also update their explanation of benefits for members to include pricing information and offer potential alternatives for expensive therapies.

PsychU last reported on this topic in “CMS Approves Prior Authorization & Step Therapy For Part B Drugs Under Medicare Advantage,” which published on October 29, 2018. The article is available at https://www.psychu.org/cms-approves-prior-authorization-step-therapy-part-b-drugs-medicare-advantage/.

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore 21244; Maryland; 202-690-6145; Website: press@cms.hhs.gov; Website: https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-and-part-d-drug-pricing-final-rule-cms-4180-f

Editor’s note: This article was revised on June 17, 2019, to clarify that the final rule codified existing Medicare Part D policies on prior authorization and step therapy for the six protected drug classes. In the proposed rule, CMS had presented three changes. 

Many specialty provider organizations are facing formidable strategic challenges as the result of the growing payer preferences for integration. Health plans are looking for best practice models that take a whole person approach to care delivery—integrating primary care, pharmacy, behavioral health, social services, and long-term services and supports. This leaves specialty provider organizations with strategic questions: Will hospital systems, primary care providers, or retail clinics become the new competition for the delivery of specialty services to complex consumers? Should we pursue some form of partnership with these types of organizations to deliver integrated care? Or should we develop our own primary care services to provide the full care continuum to our complex consumer populations?

There are many ways to leverage payer preference for integrated care to find a competitive advantage in this shifting market—co-location between primary care clinic and behavioral health care provider organization, health homes and specialty medical homes, embedding behavioral health clinical professionals in a primary care office, comprehensive integrated care delivery, and more. Last week at The 2019 OPEN MINDS Strategy & Innovation Institute, we learned about two different models for delivering integrated care to the complex consumer populations in the session, Building A Specialty Primary Care Program: New Models For Consumers With Complex Conditions, featuring Stephanie M. Murtaugh, Director of Clinical Services, Pittsburgh Mercy; and Tine Hansen-Turton, President & Chief Executive Officer, Woods Services.

While their models have many differences, both Pittsburgh Mercy and Woods use a health home model to delivery integrated primary care for complex consumer populations. And Ms. Murtaugh and Ms. Hansen-Turton shared similar advice for provider organizations considering an integrated care model—focus on performance measurement from the beginning and build your model around clinical quality outcomes. To do this, all members of the care team need access to real-time comprehensive clinical data. A common medical record allows clinical professionals to better coordinate care for consumers and allows the organization to utilize a population health management approach to managing care, while producing (and demonstrating) positive outcomes and value to payers.

The first model, Pittsburgh Mercy Family Health Center, is a person-centered health care home that integrates physical health, substance use disorder (SUD) treatment, mental health care, as well as social support services. They serve 7,000 consumers—40% of which are considered to be a “very high risk” population. They are a certified community behavioral health clinic (CCBHC), and their integrated care model utilizes a person-centered, team-based approach, focused on whole-person care. Their primary care team has access to real-time behavioral and psychiatric consultation and consulting psychiatrists are on-site to do warm hand offs with primary care physicians. They also employ five embedded specialty care managers.

The goal with this consumer population is to move consumers from the most restrictive level of care, to community-based and home-based care. Ms. Murtaugh explained to do that, the team assesses and discusses consumer risk and functioning according to biological, psychological, social, and engagement factors. This assessment allows for risk stratification and enables to team to determine the needs of the consumer population. The team conducts weekly, population-based “high risk” meetings to discuss a comprehensive care plan for highest risk consumers. The meeting includes the entire primary care team and clinical professionals operating in the community. They also have six assertive community treatment (ACT) teams, which review 100 people every morning.

The second model, Woods, is a population health management non-profit organization that supports children and adults with developmental disabilities, complex medical needs and genetic disorders, behavioral and other challenges. Last year Woods opened an expanded medical center, featuring a Patient-Centered Medical Home (PCMH) program for Keystone First members with intellectual and developmental disabilities (I/DD) and complex medical challenges (Keystone First is a Medicaid managed care plan, an affiliate of Independence Blue Cross, in five southeastern Pennsylvania counties – see A Patient-Centered Medical Home For The I/DD Population—The Woods Services Model). Woods and its 6,000 staff offer 200+ health and human service programs in Pennsylvania and New Jersey for 18,000+ children, adolescents, and adults, with referrals from 175 school districts and 23 States.

Population health management includes Woods’ “Care for the Whole Person Model” that addresses all the needs of the people it serves by coordinating social determinants of health, providing physical and behavioral health care and medication management directly or in partnership with health systems, all essential care to achieve positive health outcomes. At Woods a Nurse Navigator coordinates all the health care related services and a Care Coordinator coordinates access to all the services addressing social determinants of health, including housing services, long-term supports, job training and coaching, education, etc.

Two key points stood out from both case study presentations. First, access to comprehensive clinical data is essential. In both of these models, the organizations took a metrics-driven approach to assessing consumer risk and integrating information across the care team. To succeed in this, provider organizations need to build a pathway to capture claims data for analysis, access external records such as hospital records, criminal justice etc., share that information, and (ideally) integrate the behavioral health and physical health record.

And second, focus on outcomes and performance measurement. For these models to be successful at scale, there needs to be some form of bundled payment model. To gain capitated payment models with health plans, organizations need to demonstrate their value in outcomes. Specialty provider organizations can be at an advantage when it comes to integrated care delivery for the complex consumer population. The wider health care field usually does not understand how to serve complex consumer populations—people who are dually diagnosed with developmental disabilities and behavioral health challenges or behavioral health and addiction issues. Specialty provider organizations can utilize their expertise to deliver quality care and produce positive outcomes that demonstrate their value to payers.

There is no one, “right” model for integration. But as the market continues to move in this direction, now is the time for specialty provider organizations to consider what is the best model to serve their complex consumer populations. For more on identifying and responding to the disruptors in your market, check out these resources from the PsychU Resource Library:

  1. Can You Teach A Fish To Climb A Tree?
  2. David Versus Goliath?
  3. Innovation Isn’t Enough
  4. Don’t Let The Big Disruptors Out Of Your Sight
  5. What Does It Take To Outlast The Disruptors?
  6. Will Health Plan Backward Integration ‘Remake’ Specialty Care?

It is estimated that the United States will see up to a 12.8% shortage in physicians by 2032. Estimated physician demand in 2032 is about 953,100. This total equals approximately 283,400 primary care physicians; and 669,700 non-primary care physicians (165,200 medical specialty physicians; 177,200 surgery physicians; 38,000 hospitalists (dedicated in-patient physicians who work exclusively in a hospital); and 289,300 “other” physicians, such as pathologists, neurologists, radiologists, and psychiatrists.

These findings were reported in “The Complexities of Physician Supply and Demand: Projections from 2017 to 2032. The report was written for the Association of American Medical Colleges (AAMC). The AAMC engaged IHS Markit to conduct a new study, incorporating the latest modeling methods and available data on trends and factors affecting the physician workforce. Working with the AAMC Center for Workforce Studies, IHS Markit identified key trends likely to affect the supply and demand for health care services and physicians over the next decade and projected future national adequacy of physician supply through 2025 under multiple scenarios. The scenarios account for workforce growth in non-physician clinicians and new payment and delivery models such as patient-centered medical homes (PCMH) and accountable care organizations (ACO). They applied a microsimulation model, supply model, and demand model to develop supply and demand data.

This study used a microsimulation approach to project the supply of and demand for health care services and physicians. The projection models have been used for health workforce modeling for federal and state governments, and for trade and professional associations for physician and other health occupations. Although the modeling took place at the detailed specialty level, projections for individual specialties were aggregated into four broad categories for the final report: primary care, medical specialties, surgical specialties, and “other” specialties. To reflect future uncertainties in health policy, care use and delivery patterns, the projections are presented as ranges rather than a specific number. All supply and demand projections are reported as full-time equivalent (FTE) physicians, where an FTE is defined for each specialty as the average weekly consumer care hours for that specialty. The supply model, under a Status Quo scenario, simulated the likely career decisions of physicians taking into consideration current numbers, specialty mix and demographics of new entrants to the physician workforce, retirement and mortality patterns, and patterns of patient care hours worked. The demand model simulated the implications of changing demographics due to population growth and aging. This model accounts for projected changes in disease prevalence and other health risk factors among the population if health care use and delivery patterns remained unchanged.

Additional findings include:

  • The 12.8% shortage reflects a shortage of between 46,900 and 121,900 physicians by 2032. This includes a shortage of about 21,000 (at the 25th percentile) to 55,200 (at the 75th percentile) primary care physicians; and 24,800 to 65,800 specialists.
  • Of the projected shortage of specialists, 14,300 to 23,400 will be surgical specialists; and between 20,600 and 39,100 will be other specialists.
  • The projected demand for physicians in 2032 by region of the country is as follows: South (375,500), West (233,100), the Midwest (186,600), and the Northeast (157,900).

IHS is a publicly traded company providing comprehensive economic modeling and forecasting services covering more than 170 industries in over 200 countries. The Life Sciences team at IHS Markit conducts health economic and workforce studies for federal and state governments, trade and professional associations, for-profit life sciences companies, hospital systems, and non-profit organizations.

The full text of “The Complexities of Physician Supply and Demand: Projections from 2017 to 2032” was published in April 2019 by the Association of American Medical Colleges A copy is available online at https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf (accessed June 3, 2019).

PsychU last reported on this topic in “Top Recruiting Targets Of Rural Behavioral Health Provider Organizations – Occupational Therapists, Pharmacists & Nurse Practitioners,” which published on April 8, 2019. The article is available at https://www.psychu.org/top-recruiting-targets-of-rural-behavioral-health-provider-organizations-occupational-therapists-pharmacists-nurse-practitioners/.

PsychU also reported on this topic in “Nurse Practitioners May Represent 27% Of The Family Practice Workforce By 2025,” which published on May 23, 2019. The article is available at https://www.psychu.org/nurse-practitioners-may-represent-27-family-practice-workforce-2025/.

For more information, contact: Katherine Smith, Director, Public Relations, IHS Markit, 55 Cambridge Parkway, Boston, Massachusetts 02142-1201; 781-301-9311; Email: katherine.smith@ihsmarkit.com; Website: https://ihsmarkit.com/; or Association of American Medical Colleges, 655 K Street Northwest, Washinthe fgton,  District of Columbia 20001-2399; 202-828-0400; Website: https://www.aamc.org/

As of February 2019, about 71% of North Carolina Medicaid beneficiaries participating in a supportive housing program for people with serious mental illness (SMI) have remained in housing for two years. The program is called Transitions to Community Living Initiative (TCLI); it was launched by the North Carolina Department of Health and Human Services (DHHS) in 2013. Each of the state’s local management entities-managed care organizations (LME-MCOs) operate TCLI programs that provide Medicaid-eligible adults with SMI long-term housing, community-based services, supported employment, and community integration. At the end of February 2019 of the total 2,677 who have been housed through TCLI, 71% (1,900 people) were currently housed.

DHHS launched TCLI to help the state comply with a 2012 settlement agreement with the federal Department of Justice (DOJ) to increase the state’s capacity to provide supportive services in the least restrictive appropriate setting for individuals with SMI. The settlement featured an eight-year plan to gradually add 3,000 community-based supportive housing slots for adult Medicaid beneficiaries with SMI. DHHS also agreed to invest in job training and employment assistance for the class members and to launch a comprehensive, 24/7 crisis care program for people with SMI.

Specifically, the goal of TCLI is to ensure that people with SMI have access to safe and affordable housing plus community support, to help them become responsible renters. TCLI also teaches the participants, their friends, and their families about recovery, and about activities to control symptoms and promote wellness. The TCLI participants receive up to $2,000 in funding to assist with transition (household items, food, application fees, etc.), and an additional $3,000 if needed.

DHHS reported the TCLI retention rates in the “January 2019 Monthly Report On North Carolina Transition To Community Living Initiative.” Parallel data was also reported by Cardinal Innovations Healthcare (Cardinal Innovations) in “TCLI Performance Dashboard” on April 15, 2019. Cardinal Innovations is one of the state’s seven LME-MCOs that manage public mental health, developmental disability services, and substance use disorder services at the community level. The state DHHS also reported on the TCLI in both the “2017-18 Annual Report on North Carolina Transition to Community Living Initiative.”

The TCLI housing retention rates for the seven LME-MCOs ranged from 65.3% to 75.4%, as follows:

  • Alliance Behavioral Healthcare: 350 TCLI participants have been housed, with 264 remaining in housing, 75.4%
  • Cardinal Innovations: 780 TCLI participants have been housed, with 573 remaining in housing, 73.5%
  • Eastpointe: 251 TCLI participants have been housed, with 164 remaining in housing, 65.3%
  • Partners Behavioral Health Management: 358 TCLI participants have been housed, with 244 remaining in housing, 68.2%
  • Sandhills Center: 286 TCLI participants have been housed, with 204 remaining in housing, 71.3%
  • Trillium: 351 TCLI participants have been housed, with 243 remaining in housing, 69.2%
  • Vaya Health: 301 TCLI participants have been housed, with 208 remaining in housing, 69.1%.

For more information, contact:

  • Mandy Cohen, Secretary, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina 27699-2001; 919-855-4840; Email: news@dhhs.nc.gov; Website: https://www.ncdhhs.gov/
  • Mike Bridges, Director, Transitions to Community Living, Cardinal Innovations Healthcare, 2929 Crouse Lane, Suite B, Burlington, North Carolina 27215; 336-714-9344; Website: https://www.cardinalinnovations.org/

Greetings from New Orleans, where on the first day of The 2019 OPEN MINDS Strategy & Innovation Institute; we had the opportunity to hear from a lot of great organizations that are implementing new innovative programs such as specialty primary care programs at Woods Services, Intermountain’s social determinants of health, Compass Health’s on-site pharmacy program, and SummitStone’s medication adherence program.

But while we heard from these “‘ahead of the curve” organizations, the big question is how widespread is the adoption of innovations in specialty provider organizations? This question was answered with the release of The 2019 OPEN MINDS National Innovation Survey: 2019 Innovation Adoption Among Specialty Provider Organizations. The survey results were presented today by Monica E. Oss, OPEN MINDS Chief Executive Officer, at the opening of the institute. Some of the key findings include:

  1. Peer support was the top innovation adopted by specialty provider organizations. Fifty-four percent of organizations currently offer peer support. However, as more organizations offer peer support, we may be reaching a saturation point. The use of peer support only increased one percentage point over 2018.
  2. Telehealth/telepsychiatry remains the second most adopted innovation at 50% of organizations. The use of telehealth increased slightly more than peer support from 2018 – five percentage points.
  3. The innovation that saw the biggest increase between 2018 and 2019 was medication adherence technologies and programs. The use of this innovation increased 21 percentage points.

From a strategy perspective, there were a couple developments that caught our attention. The first was the new innovations among providers of intellectual/developmental disabilities (I/DD) and long-term services and supports (LTSS) services. As a group, these provider organizations had the largest increases in telehealth use and medication adherence programs. This market segment also reported an 18% increase in establishing “center of excellence” contracts with payers.

The second was the adoption of innovations by primary care provider organizations. This market segment had a 45% increase in co-location programs providing behavioral health services and an 18% increase in offering medication assisted treatment (MAT) for addiction treatment. Primary care organizations also reported 25%+ increases in offering medical home programs and readmission prevention/hospital diversion programs.

The challenge for health and human service organizations remains the slow implementation of innovations to scale. Specialty provider organization management teams are great at pilot programs but slow to take successful innovations from the pilot stage to scale. The keys to speeding this process are best practice change management processes and making sure there is buy-in at every level of the organization. Second, organizations need to have the data on the performance of innovative in order to respond to problems before it’s too late (see Five Rules For Building An Effective KPI System).

The Joint Commission requires accredited behavioral health organizations to adopt “measurement-based care” by assessing every consumer using a validated tool or instrument to track progress during treatment. The results of the assessments are to be used to inform the goals and objectives identified in individual plans of care, treatment or services as needed. Data from the tools may also be used to improve organizational performance. The revised behavioral health outcome measurement standard is CTS.03.01.09.

To assist organizations in finding an appropriate standardized tool or instrument, The Joint Commission has developed a list of measurement-based care tools and instruments that are currently available to behavioral health care organizations. There are currently 64 possible tools listed. Other tools may be used to meet the requirement, but the Joint Commission list was developed to assist accredited organizations in finding a tool that may be appropriate for their setting. Instrument developers, owners, vendors, and other stakeholders can submit additional behavioral health care tools or instruments to The Joint Commission using the process described on The Joint Commission’s Behavioral Healthcare Instruments Listing, posted online at https://manual.jointcommission.org/BHCInstruments/WebHome?_ga=2.8402421.1312718284.1558630339-1255441414.1558630339 (accessed May 28, 2019).

The background for the new requirement was reported in “Complying With Standard CTS.03.01.09 Behavioral Health Care Accreditation Program” by The Joint Commission. The requirement applies to both currently accredited organizations and those seeking accreditation. However, the requirement is not applied the same way for organizations that are seeking accreditation for the first time. These organizations would be expected to have selected (and be using) an instrument, but they would not be expected to already have a track record with aggregating the data and using it for quality improvement at the time of their initial survey. With that exception, the steps for demonstrating compliance are as follows:

  1. Use a standardized tool or instrument to monitor each individual’s progress in achieving his or her care, treatment, or service goals. These tools have well-established psychometric properties that consistently measure the same outcomes on the basis of reliability and validity, and they have documented sensitivity to distinguish what is normal from the statistically significant. They can be used as a repeated measure so as to not skew outcomes, and to evaluate established norms to determine a benchmark. Ideally the tool used will monitor progress from the individual’s perspective.
  2. Gather and analyze the data generated through standardized monitoring. Collect the data at routine, regular intervals during service delivery. Use the results to inform the goals and objectives of the individual’s plan for care, treatment, or services as needed. The data can be used to identify potential treatment failures, reduce the unintentional influences of provider organization bias, and justify changes in treatment plans and levels of service.
  3. Evaluate the outcomes of consumer care, treatment, or services provided to the population(s) it serves by aggregating and analyzing the data gathered through the standardized monitoring effort. The analysis can be used to inform goals and objectives, monitor consumer progress, and to make decisions related to changes in plans for care, treatment, or services to the consumer. This data should also be used to implement organization-wide improvements related to care, treatment, or service care quality improvement. The data should also be used to evaluate progress of organizational quality improvement efforts, and to evaluate the effectiveness of the services provided.

The new requirement is part of The Joint Commission Accreditation process for behavioral health organizations. The organization currently accredits 3,168 behavioral organizations. This category includes a range of inpatient, residential, and outpatient behavioral health settings including: addiction treatment, adult day care, behavioral health homes, case management, child welfare, corrections-based, crisis stabilization, day treatment, eating disorders, family preservation and wraparound services, forensic services, foster care or therapeutic care, partial hospitalization, prevention and wellness promotion, psychiatric rehabilitative services, residential/group homes, shelters, technology-based, therapeutic schools, transitional, supervised or supportive living, and vocational rehabilitation.

Note: The previous version of this article had not been reviewed by The Joint Commission (TJC). It was amended on June 6, 2019 to reflect TJC clarifications.

The full text of “Complying With Standard CTS.03.01.09 Behavioral Health Care Accreditation Program” was published March 1, 2019, by The Joint Commission. A copy is available online at https://www.jointcommission.org/assets/1/6/Rationale_CTS.03.01.09_Revised.pdf (accessed May 28, 2019).

PsychU last reported on this topic in “The Joint Commission To Add Measurement-Based Care Requirements To Addiction Treatment Accreditation In 2018” which published on August 3, 2017. The article is available at https://www.psychu.org/joint-commission-add-measurement-based-care-requirements-addiction-treatment-accreditation-2018/.

For more information, submit a question to The Joint Commission Standards Interpretation Group at: https://web.jointcommission.org/sigsubmission/sigquestionform.aspx.

A few weeks ago, we covered the announcement that the soon-to-launch Shatterproof Rating System for addiction treatment programs will go live in five states next year—Delaware, Louisiana, Massachusetts, New York, and West Virginia (see Five States To Pilot The Shatterproof Addiction Treatment Rating System). The system will provide a rating score for addiction treatment for all residential, outpatient, and intensive outpatient programs that are licensed, certified, or otherwise approved by participating states.

The Shatterproof Rating System website will display each program’s rating (which will reflect process or structure quality measures recommended by an expert committee convened by the National Quality Forum) and will also display its accreditation or certifications. Ratings for treatment programs in the pilot states will be free and publicly available on the website and will be searchable by commonly-sought treatment criteria (location, insurance, methods, etc.). The ratings will also be available on password-protected portals for treatment programs, payers, and states, providing more detailed information and data.

The new Shatterproof Rating System joins a growing list of ratings of health and human service stakeholders—health plans, state health systems, provider organizations, and individual clinical professionals. These range from the Centers for Medicare & Medicaid Services (CMS) Star ratings, ratings from accrediting organizations (NCQA, CARF, COA, CQL and others), private rating systems (the Commonwealth Fund, NAMI, World Health Organization, Consumer Health Ratings, HealthGrades, Leapfrog, A.M. Best), and consumer rating systems (RateMD, vitals.com, Yelp, ZocDoc, CareDash, Angie’s List).

Reactions to rating systems in health and human services (not specifically the Shatterproof Rating System) are mixed among provider organization executives. There are concerns about the validity of the rating systems and we have covered some of that criticism (see MedPAC Questions Validity Of CMS Hospital Star Ratings).

There are concerns that consumers aren’t aware of rating systems—including The 2019 HealthMine Medicare Survey that found that only 32% of Medicare Advantage plan members with chronic conditions are familiar with the CMS Star ratings system. And, critics point out that consumers don’t use rating systems even when they do know about them. The reasons are many, including an inability to understand the report cards or the systems used to deliver them; poor report card marketing; and the lack of “credible” report cards, as judged by consumers.

But, whether executives like these rating systems or not, or whether the ratings are completely valid, executives of health and human service systems ignore the many rating systems at their own risk. There are two issues. First, the rating systems become the “shorthand” for quality and value. For busy consumers and caregivers, it is a default selection process—think restaurant reviews on Yelp, hotel reviews on TripAdvisor, and movie reviews on Rotten Tomatoes. For payers, it is a means of differentiating between many competing options—and a proxy for quality that can be tied to reimbursement. From a market model perspective, the health and human service system is moving from a “commodity” market (all services by similarly licensed professionals or organizations are the same) to market driven by “value.” Value is a function of cost and performance. And, for better or worse, the rating systems represent the current proxy indicator for performance.

What we don’t know at this point is which of the rating systems will be here in the long-term or will have a lasting impact. But over time the dominant rating systems will shift market share and revenue. The shift in enrollment in the Medicare Advantage plans is an example.

We’ve covered a wide range of rating systems, ranking systems, and accreditation data over the past few years. For a quick look at the “state of the art,” check out this coverage:

  1. Medicare Advantage Star Ratings Create New Market Opportunities
  2. Consumer Star Ratings For Hospitals – It’s Only Going To Get Harder To Earn Those 5 Stars
  3. Succeeding In The Online Ratings Game – Second, You Need A Plan
  4. Performance Ratings In The Era Of Value-Based Purchasing
  5. Succeeding In The Online Ratings Game – First, Know The Score

Only four U.S. states (California, Minnesota, Oregon, and Rhode Island) have essential health benefits (EHB) benchmark plans that provide coverage for comprehensive addiction treatment that aligns with the parity standards established by the Patient Protection and Affordable Care Act of 2010 (PPACA) for individual health insurance marketplace plans. In the remaining states, the EHBs fail to address one or more elements of comprehensive addiction treatment at parity with medical and surgical benefits. Of the four states that offered comprehensive addiction treatment coverage, only Rhode Island offered comprehensive benefits for addiction treatment in two marketplace plans offered under the PPACA. California, Minnesota, and Oregon offered comprehensive coverage for addiction treatment in one marketplace plan.

The PPACA requires that health plans sold in the state’s individual health insurance marketplace offer a set of 10 EHBs, and the benefits in the EHB benchmark plan become the minimum level of coverage for PPACA plans sold in the state’s health insurance marketplace. The EHBs must include behavioral health benefits that must be provided at parity with medical and surgical benefits. Health plans sold in the individual health insurance marketplace must cover addiction and substance use disorder (including tobacco use) screening, treatment, counseling, and prescriptions. About 20% of states offered a marketplace plan that violated the Parity Act.

These findings were reported in “Uncovering Coverage Gaps II: A Review And Comparison Of Addiction Benefits In ACA Plans” by Center on Addiction. The researchers conducted a cross-state comparison of addiction treatment benefits within each state’s EHB benchmark plans sold in 2017. The analysis included all 50 states and the District of Columbia. Each plan was reviewed to evaluate the comprehensiveness of addiction treatment benefits and to determine whether the plan satisfied PPACA requirements regarding coverage of addiction treatment, and whether the plan complied with federal Mental Health Parity and Addiction Equity Act (Parity Act) requirements on coverage of services and medications without quantifiable or non-quantifiable treatment limitations. The goal was to determine whether PPACA plans sold in each state provide coverage for addiction benefits and comply with PPACA requirements. The researchers did not evaluate addiction treatment benefit coverage in other health insurance products, including Medicaid or employer-sponsored plans. The evaluation is limited to the benefits listed in plan documents; the researchers did not review requests for services or claims data.

Key findings about EHBs and benefits offered in individual marketplace plans were as follows:

  • Overall EHB coverage of comprehensive addiction treatment: About 66% of EHB plans did not provide comprehensive coverage, and 50% of states offered plans that did not cover comprehensive addiction treatment.
  • Tobacco cessation: 26 EHB plans were not in compliance, and plans sold in 28 states were not in compliance.
  • Medication assisted treatment: 45% of EHBs did not cover at least one medication used in MAT. Four plans did not cover medications used for tobacco cessation. Four states had plans that were in violation. Seven EHB benchmark plans exclude methadone for opioid use disorder.
  • Lifetime limits on behavioral health treatment: Two EHB plans set a lifetime dollar limit on addiction treatment benefits; no states offered a plan that imposed annual lifetime limits.
  • EHB addiction treatment services: Alaska covered only detoxification, and no other addiction treatment services. Louisiana had a possible exclusion for addiction treatment services. Thirteen EHB benchmark plans excluded residential treatment for addiction treatment.

The researchers analyzed transparency in EHB plan documents and documentation for marketplace plans to evaluate compliance with the PPACA addiction treatment benefits. The key findings were as follows:

  • EHB documents for 11 states lacked information to evaluate compliance; in four states they lacked coverage for smoking cessation; and in eight states they did not address coverage for either alcohol use screening for adults or alcohol and drug use screening for adolescents. In three states, the documents cover alcohol screening for adults but do not address coverage for alcohol and drug use screening for adolescents.
  • In 13 states, documentation for marketplace plans lacked sufficient information to evaluate compliance with the PPACA requirements for addiction treatment benefits. In four states, the plan documents did not address coverage for smoking cessation services. Documents for plans offered in seven states did not address coverage for either alcohol use screening for adults or alcohol and drug use screening for adolescents. Documents for plans offered in five states covered alcohol screening for adults but did not address coverage for alcohol and drug use screening for adolescents.

The researchers identified quantifiable parity violations or possible parity violations from “warning signs” for possible non-quantifiable treatment limitations (NQTL) violations in the plan documents as well unequal coverage of intermediate services. The review was limited to violations evidence from the plan documents. Additional findings about plan compliance with the Parity Act included the following:

  • Overall, nine EHB plan documents had omissions or limitations on benefits that violated the Parity Act, and 18 plans might violate the Parity Act with respect to coverage of intermediate services for behavioral health treatment. Ten states offered marketplace plans with parity violations, and 17 states offered plans with possible parity violations relating to coverage of MAT medications.
  • Quantifiable treatment limitations: Six EHB plans had quantifiable limitations or cumulative limitations that violated parity requirements. Five plans had violations because they imposed limits on the number of inpatient and/or outpatient visits for addiction treatment. Two plans are in violation because they impose lifetime limits on addiction treatment services. One state offered a plan containing a quantifiable treatment limitation that may violate parity requirements.
  • Cumulative financial requirements: Three EHB plans violated the Parity Act because the coinsurance on addiction treatment services does not apply to the out-of-pocket (OOP) maximum, but coinsurance for other medical/surgical services does apply to the OOP. No plans sold on in the insurance marketplace contained non-compliant cumulative financial requirements.
  • Intermediate services for addiction treatment (intensive outpatient, day/partial hospitalization and residential services), which are compatible with medical intermediate services (such as nursing homes): 18 EHB plans have possible violations because five have higher cost-sharing for addiction treatment intermediate settings, one plan has a restrictive visit limit, and 12 excluded addiction treatment intermediate settings but covered skilled nursing facility settings. Three states and the District of Columbia offered marketplace plans with possible parity violations due to disparate coverage of intermediate services for addiction. One state offered a plan that may have imposed a more restrictive limit on intermediate services for addiction than on intermediate medical services. Two states and the District of Columbia offered plans with possible parity violations because they covered intermediate medical services but excluded comparable intermediate addiction treatment services.

Non-quantifiable treatment limitations (NQTL) on behavioral health services evident in processes, strategies, evidentiary standards, and other factors, as compared to those used for medical/surgical benefits in the same classification. Key findings were as follows:

  • Two EHB plans contain language that appears to violate the Parity Act. Marketplace plans offered in 21 states and the District of Columbia contained apparent NQTL violations or warning signs of violations.
  • Plans offered in three states and the District of Columbia imposed treatment standards for addiction treatment that did not exist for medical/surgical services.
  • One state (Vermont) offered a plan that had a requirement for ongoing concurrent review for addiction treatment services that did not exist for medical services.
  • Five states offered plans that excluded coverage of court-mandated services for addiction treatment.

About 31% of the 2017 EHB benchmark plan documents do not provide comprehensive detailed information about the specific addiction treatment services that are covered. It was not possible to determine the degree of parity between addiction treatment and medical services. In 10 states, the EHB benchmark plans do not specify the addiction treatment services covered. In six states, the EHB benchmark plans do not address coverage for intermediate addiction treatment services. Documents for marketplace plans offered in 43% of states did not provide comprehensive information about the addiction treatment services covered.

The full text of “Uncovering Coverage Gaps II: A Review And Comparison Of Addiction Benefits In ACA Plans” was published in March 2019 by Center on Addiction. A copy is available online at https://www.centeronaddiction.org/addiction-research/reports/uncovering-coverage-gaps-ii-review-and-comparison-addiction-benefits-aca (accessed May 20, 2019).

PsychU last reported on this topic in “The Average Marketplace Health Plan Provider Network Includes 11% Of Mental Health Care Professionals,” which published on November 9, 2017. The article is available at https://www.psychu.org/average-marketplace-health-plan-provider-network-includes-11-mental-health-care-professionals/.

For more information, contact: Elizabeth Mustacchio, M.B.A, Senior Marketing and Communications Associate, Center on Addiction, 633 3rd Avenue, New York, New York 10017; 212-841-5293 ​; Email: emustacchio@centeronaddiction.org; Website: https://www.centeronaddiction.org/

Overdose deaths in California’s 36 correctional facilities increased by 160%, from 15 deaths in 2014 to 39 deaths in 2017. Emergency department visits and admissions for drug overdose increased 54% during this time, from about 310 in 2014 to about 500 in 2017. The number of persons in California correctional facilities decreased by 4%, from 135,484 in 2014, to 129,872 in 2017 during the same time period. During 2016, the overdose death rate was the fifth leading cause of death among inmates at California correctional facilities. California’s prison overdose death rates ranged from 5.3 deaths per 100,000 inmates in 2007 to a high of 22.5 deaths 100,000 inmates in 2016.

From 2001 to 2014, the California state prison system had 32% of all overdose deaths in state and federal prison systems in the country, although in 2014, California had only 8.7% of state and federal prison inmates. The national average overdose death rate from 2001 to 2014 was 3 per 100,000. From 2006 through 2016, the average overdose death rate in California prisons was 12.1 per 100,000.

These statistics were reported in “Treatment To Reduce The Burden Of Disease & Deaths From Opioid Use Disorder” by J. Clark Kelso, receiver for California Correctional Health Care Services (CCHCS) which provides health care services for the California Department of Corrections and Rehabilitation. This report includes data from “Substance-Use Disorder Treatment for Patients in the California Department of Corrections and Rehabilitation: An Evidence-Based Clinical Approach” by Renee Kanan, M.D., MPH, deputy director for CCHCS. Before 2016, CDCR and CCHCS provided addiction treatment counseling and behavioral therapies, but did not provide medication assisted treatment (MAT).

In 2016, CDCR’s mental health program started a small three-year pilot project to create, develop and implement a MAT program at one or more institutions. The medications are approved by the U.S. Food and Drug Administration (FDA) to treat AUD or OUD. The pilot was implemented in 2017 at the California Institution for Men (CIM), and at the California Institution for Women (CIW), and it is slated to end on June 30, 2019. The MAT program was expanded to the California Substance Abuse Treatment Facility in 2018; however, treatment outcome data for that facility is not yet available.

In March 2019, CDCR and CCHCS reported the pilot program outcomes in “California Correctional Health Care Services Medication-Assisted Treatment For Substance-Use Disorders, Final Legislative Report.” Since the launch, the MAT program has provided medication and psychosocial treatment to 246 individuals. Of these individuals, 79% (194 participants) continued with the MAT program during incarceration. The majority, 52%, reported opioids as their drug of choice, 29% reported alcohol, and 19% reported both alcohol and opioids. In total, 86 individuals were released on MAT during this time and all were linked to care. About 76% of those released attended their first post-release appointment.

To reduce the incidence of inmate overdoses, the revised 2020 state budget proposed by California Gavin Newsom includes a provision to offer MAT in prisons statewide. The proposal has three main components: MAT for inmates with OUD and alcohol use disorder AUD; a redesign of the current cognitive behavioral treatment curriculum; and the development and management of inmate treatment plans and substance use disorder-specific pre-release transition planning. The program would target three populations:

  • Inmates who were receiving MAT prior to entering prison
  • Inmates already in CDCR with high substance use disorder risk factors (such as a recent overdose)
  • Inmates scheduled for release within 15 to 18 months who have been assessed as having a high need for substance use disorder services

The program would offer MAT Medications; and would include enhanced cognitive behavioral therapy, post-release community-based treatment, peer support, education, and whole person care. An opioid overdose antidote medication would be distributed to at-risk inmates before release. The governor’s revised budget includes more funding for the program of than $71 million for the remainder of calendar year 2019, and nearly $162 million for 2020.

PsychU last reported on MAT in correctional facilities in “Corizon Health Expands Pilot Inmate Medication-Assisted Opioid Use Treatment Program,” which published on June 10, 2019. The article is available at https://www.psychu.org/corizon-health-expands-pilot-inmate-medication-assisted-opioid-use-treatment-program/.

For more information, contact: Vicky Waters, Press Secretary, California Department of Corrections and Rehabilitation, 1515 South Street, Sacramento, California 95811; 916-445-4950; Email: OPEC@cdcr.ca.gov; Website: https://www.cdcr.ca.gov/

Of individuals who have resolved a significant drug or alcohol problem in the United States, a median of two serious recovery attempts were needed for over half to achieve recovery. Compared to this median number of two, the average or mean number of recovery attempts to achieve recovery is 5.35. The number of attempts did not differ by primary addiction substance.

These findings were reported in “How Many Recovery Attempts Does it Take to Successfully Resolve an Alcohol or Drug Problem? Estimates and Correlates From a National Study of Recovering U.S. Adults” by John F. Kelly, Martha Claire Greene, Brandon G. Bergman, William L. White, and Bettina B. Hoeppner. The researchers analyzed data from the National Recovery Study to identify a nationally representative sample of 39,809 adults in the United States. Of the sample, 2,002 reported having overcome a significant drug or alcohol problem. The goal was to determine estimates of, and the factors associated with, needing fewer or greater attempts of serious recovery attempts made, based on medical history and demographics.

The researchers analyzed five quality-of-life indicators that may be associated with the success of recovery: quality of life (the degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events), happiness, self-esteem, psychological distress, and recovery capital (the volume of internal and external assets that can be brought to bear to initiate and sustain recovery from alcohol and other drug problems). Additional findings include:

  • The number of serious recovery attempts made among adults who have resolved a problem with alcohol or other drugs in the United States ranged from zero to 100 attempts.
  • Approximately 13% of those who reported having overcome a significant drug or alcohol problem also reported not making any “serious” recovery attempts.
  • Factors associated with needing a higher number of attempts to quit addiction included a history of depressive and anxiety disorders, prior use of treatment or recovery support services, and being single (rather than married or living with a partner).
  • Non-Hispanic black individuals were also associated with needing a higher number of attempts to quit their addiction.

The researchers concluded that while the mean and median number of recovery attempts are so different, the median figure of two attempts is the most appropriate measure to report: the difference in median and mean recovery attempts before achieving recovery is due to a a small group of individuals who need many more recovery attempts than most. The researchers hope this figure will offer hope to those struggling with an alcohol or drug use problem.

The full text of “How Many Recovery Attempts Does it Take to Successfully Resolve an Alcohol or Drug Problem? Estimates and Correlates From a National Study of Recovering U.S. Adults” was published May 15, 2019, by Alcoholism: Clinical and Experimental Research. An abstract is available online at https://onlinelibrary.wiley.com/doi/full/10.1111/acer.14067 (accessed May 28, 2019 2019).

For more information, contact: John F. Kelly, Ph.D., ABPP, Harvard Medical School, 151 Merrimac Street, Floor 6, Boston, Massachusetts 02114; Email: jkelly11@mgh.harvard.edu; Website: https://www.harvard.edu/.

One of the big cultural changes happening in health care is moving from “volume” to “value” in reimbursement. The volume of services is still the focus of provider organization management teams when it comes to profitability and sustainability. But, with the increasing use of value-based reimbursement models (VBR), the metrics for sustainability and profitability are shifting. Value-based reimbursement and other alternate payment models increase the “financial return” of achieving other goals—reduced total cost of care, reduce readmission rates, and reduced use of emergency rooms, to name a few.

This is a sea change in financial sustainability models, and it affects every aspect of the organization from the front desk, to clinical programming, to billing. And the effect is particularly pronounced for health systems and organizations with acute care and residential treatment beds—see The Future Has Arrived For VBR. If you’re a manager in an organization with a large amount of revenue (or profitability) tied to beds, the challenge ahead is making the shift from fee-for-service to value-based purchasing landscape-and surviving the transition period.

So, what do executives of these bed-based provider organizations need to do to map a successful trajectory from volume-based payment to VBR? For the answer to that question, we asked some executives with experience in these settings. They had four recommendations: Understand that hospitals play an important “short-term” role; develop a standards-based continuum of services; leverage unique services and expertise; and focus on quality and performance.

Understand that hospitals play an important “short-term” role—The days when hospitals were the undisputed center of the health care delivery experience are over and trying to use this resource as the main lever to meet the demands of value-based care and wellness focused population-based management simply won’t deliver the desired results. OPEN MINDS Senior Associate George Braunstein, noted:

While acute hospitals and residential treatment facilities are still a vital part of the health care continuum, they are no longer the center of gravity. They play an important short-term role and need to design their service system in that manner. If not, they will not only lose money, but will not be very effective at providing overall services and thus find it impossible to meet new standards and reimbursement realities in value-based health care.

Develop a standards-based continuum of services—Populations with complex health needs can’t get those needs met in one place. The solution is to build the provider organization relationships and infrastructure across the whole care continuum so that all those needs can be met with an agreed upon and shared standard of care. Mr. Braunstein, also noted:

Any hospital or residential facility not only needs to find effective community-based partners, they need to work with their partners to develop a standards-based continuum of services. Even if a hospital or residential facility has services available or has contracted partners, their team needs to work in a systematic way to address the service and care coordination needs of the various populations they serve. It is critical to have decision support tools to make these standards uniform across care coordinators in a system of care.

Brandon W. Danz, Director of Government Risk Programs at WellSpan Heath and OPEN MINDS Advisory Board Member, also explained the importance of partnerships across the continuum of care, noting:

Value-based reimbursement requires stronger partnerships across sites of care and across a consumer’s continuum of care – and especially when the consumer has complex medical needs. We are seeing new informal partnerships between hospitals and post-acute providers to institute seamless transitions of care and more importantly, meaningful coordination and communication surrounding patient-centered care. Health systems are recruiting preferred provider organizations who can meet these new population health opportunities. They’re looking for partners who offer solid care management, successfully manage medication adherence, and have in place continual performance improvement strategies to reduce infections and optimize length of stay.

Leverage unique services and expertise—In addition to great care coordination across the health care continuum, specialty services for specialty populations are critical for success in VBR arrangements. There should be a constant lookout for new models, innovations, or education to help maximize the effect these services can have on complex health needs. Mr. Danz explained:

Treatment facilities, skilled nursing facilities, and inpatient rehab facilities are well-positioned to leverage their unique set of services and expertise to succeed in value-based care. They should regularly monitor new models being developed by government and commercial payers. They can start by proactively addressing their organizational culture to be agile and ready to act on an opportunity when it is presented. Governing boards and leadership need to be educated and ready to adapt a value-based mindset. Thinking outside the box is critical here – these organizations must re-imagine their future in new ways. Under value-based models, post-acute facilities are seen as points of admission to divert consumers from hospitals when they can be better served by the unique expertise and set of services offered in the facility. This not only saves money and contributes to value-based success, but it also offers better care at a better location and often, with better outcomes for consumers and their caregivers.

Focus on quality and performance—Above all, the shift from volume to value must be about quality of care and performance of the service delivery system. Simply saving money isn’t good enough if the health outcomes aren’t also improved. When all competitors in a given market have shifted to value-based care and costs have come down across the board, the quality of care will also serve as a powerful market differentiator. Mr. Danz noted:

These types of facilities also need to keep an eye on quality. It is becoming more strongly tied to financial outcomes and is also being reported publicly. In competitive environments, being the second-highest quality provider organization in your region might mean being the second choice of well-informed consumers. It is only a matter of time until app developers commoditize on Medicare’s increased performance transparency data to provide consumers with transparency and choice.

For more on managing the shift from volume to VBR, check out these resources from the PsychU Library:

  1. How Do We Automate Population Health Management?
  2. No Whole Person Care Without Person-Centered Organizations
  3. Using Population Health Tools For Competitive Market Advantage
  4. Population Health Management Strategies – The Hospital Perspective & Beyond
  5. Leadership Evolution Needed For Successful Population Health Management
  6. Behavioral Health Evidence-Based Practices As Population Health Management Tools
  7. Improving Population Health Management With Public Health Approaches

Washington Governor Jay Inslee signed four bills into law on May 9, 2019, launching a transformation in Washington’s behavioral health system. The package includes two bills that affect community behavioral health services, one that will ensure timely court-ordered mental health competency evaluation and restoration services, and one to establish a behavioral health teaching hospital with the University of Washington. Of the two bills that directly affect community behavioral health, one will fully implement Medicaid behavioral health integration, and the other will support care in community-based facilities that are closer to an individual’s home and support network.

Behavioral Health Integration

The Medicaid behavioral health integration initiative, Senate Bill (SB) 5432, will go into effect by January 1, 2020. The provisions remove behavioral health organizations from law; clarify the roles and responsibilities among the Health Care Authority, the Department of Social and Health Services, and the Department of Health, and the roles and responsibilities of behavioral health administrative services organizations and Medicaid managed care organizations; and the bill makes technical corrections related to the behavioral health system.

In 2014, state legislation directed a transition to fully integrate the purchasing of medical and behavioral health services for Apple Health members through a managed care system no later than January 1, 2020. In each region, a behavioral health administrative services organization manages non-Medicaid services. Integrated managed care implementation began in 2016 with the Southwest Washington region (Clark and Skamania counties), and expanded in 2018 to the North Central region (Chelan, Douglas, and Grant counties). On January 1, 2019, integrated care went live in four more regions: Greater Columbia (Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla, Whitman, and Yakima counties); King (King County); Pierce (Pierce County); and Spokane (Adams, Ferry, Lincoln, Pend Oreille, Spokane, and Stevens counties). At that time, Klickitat County joined the Southwest Washington region and Okanogan joined the North Central region. In July 2019, the North Sound region (Whatcom, Skagit, Snohomish, Island, and San Juan counties) will move to integrated managed care; and on January 1, 2020, the last three regions will transition: Great Rivers (Grays Harbor, Pacific, Wahkiakum, Cowlitz, and Lewis counties); Salish (Clallam, Jefferson, and Kitsap counties); and Thurston-Mason (Thurston and Mason counties).

SB 5432 requires: the establishment of a work group to determine how to appropriately manage access to adult long-term inpatient voluntary care and to the children’s inpatient program; charges the director of the state behavioral health authority to assure that any behavioral health administrative services organization, managed care organization, or community behavioral health program provides medically necessary services to Medicaid recipients; and requires authorities to enforce requirements in managed care contracts to ensure coordination and network adequacy issues are addressed as well as submitting a report to the governor and legislature annually.

Community-Based Facilities

The changes in the system to support community-based facilities are through House Bill (HB) 1394. The bill concerns licensing for community-based facilities that are needed to ensure a continuum of care for behavioral health consumers. The bill acknowledges the need for bed space and smaller community treatment facilities. The secretary will license or certify mental health peer respite centers and work with community hospitals to enter into contract and payment evaluations for treatment facilities and hospitals choosing to provide long-term mental health placements. The bill also exempts any entity seeking to construct, develop, or establish a psychiatric hospital from Certificate of Need requirements if the proposed psychiatric hospital will have no more than 16 beds and dedicate a portion of the beds to providing treatment to adults on 90-or 180-day involuntary commitment orders. The bill is effective on July 28, 2019.

Competency Evaluation & Restoration Services

The changes to court-ordered mental health competency evaluation and restoration services are through SB 5444, which goes into effect on July 28, 2019. The provisions are intended to ensure that the state provides competency evaluations and restoration services consistent with the Trueblood settlement agreement. That agreement requires the state to provide court-ordered competency evaluation within 14 days and begin competency services within seven days after the evaluation. Within this time period, a court may appoint an impartial forensic navigator employed by the department to assist individuals who have been referred for competency evaluation. The forensic navigator will assist the individual to access services to diversion and community outpatient competency restoration. The forensic navigator will also be responsible for helping the individual defense attorney, prosecuting attorney, and the court to understand the options available to the individual.

The fourth bill in the package, HB 1593 establishes a behavioral health innovation and integration campus within the University of Washington School of Medicine. The bill utilizes the Medicine Department of Psychiatry and Behavioral Sciences at the University of Washington in creating a clinical inpatient and outpatient care center. The innovation and integration campus is required to serve individuals with behavioral health needs while training the behavioral health professional workforce through an interdisciplinary curriculum and programs. The bill is effective on July 28, 2019.

To launch the behavioral health transformation, the governor’s operating budget includes $404 million and his capital budget includes $271 million in investments during the next biennium, primarily in five key areas. These areas include:

Expanding Behavioral Health Treatment Options:

  • More than $40 million to expand community alternative placements and creates new facility types for individuals who no longer need inpatient treatment.
  • More than $30 million in invested in community services—such as intensive outpatient treatment, partial hospitalization and intensive wraparound services to make sure discharge placements are successful and to divert individuals from inpatient care.

Developing Housing Support

  • $35 million in rental assistance for permanent supportive housing services to an estimated 1,000 vulnerable people.
  • $20 million in capital funding in the Housing Trust Fund for permanent supportive housing for people with chronic mental illness.

Workforce Development

  • $4 million to address behavioral health workforce shortages.

Appropriate Community-Based Facilities

  • $35 million for community provider organizations to serve people committed under the Involuntary Treatment Act.
  • $110 million for grants to community hospitals and community provider organizations.
  • $31 million to begin work on state-operated civil behavioral health facilities.
  • $2 million to conduct a predesign of a behavioral health-focused teaching hospital at the University of Washington.

Continued Investment In State Hospitals

  • $56 million for building improvements and critical infrastructure at Western and Eastern State hospitals.
  • $47 million is provided to construct two new wards and a modern treatment space at Western State Hospital.

PsychU last reported on this topic in “Washington State Approves New 120-Bed Psychiatric Hospital In Tacoma,” which published on March 16, 2016. The article is available at https://www.psychu.org/washington-state-approves-new-120-bed-psychiatric-hospital-in-tacoma/.

PsychU last reported on this topic in “Washington Medicaid Moving To Integrated Care,” which published on April 11, 2018. The article is available at https://www.psychu.org/washington-medicaid-moving-integrated-care/.

 For more information, contact: Tara Lee, Deputy Communications Director, Communications Office, Washington Office of the Governor, Post Office Box 40002, Olympia, Washington 98504-0002; 360-902-4136; Email: Tara.Lee@gov.wa.gov; Website: https://www.governor.wa.gov/

As of March 2019, all 39 of Virginia’s local Community Services Boards (CSBs) and the Richmond Behavioral Health Authority (RBHA), which provide access to public mental health services had implemented same day access, a provision of the state’s larger System Transformation Excellence and Performance (STEP-VA). The Virginia Department Of Behavioral Health and Developmental Services (DBHDS) developed STEP-VA to provide easier access to public mental health services; ensure a uniform set of services across all CSBs, and ensure accountability across CSBs. STEP-VA requires CSBs to implement same day access, primary care screening, behavioral health crisis services, outpatient behavioral health, psychiatric rehabilitation, peer/family support services, Veteran’s behavioral health, care coordination, and targeted case management.

For same day access, the CSBs provide a clinical assessment that same day to any individual who comes to the CSB during open access hours. If the assessment determines that the person needs services, the first appointment will be offered within 10 days. The goal is to improve consumer satisfaction and engagement, as well as avoiding “no shows” in the assessment process. Before implementing same day access, people needing an assessment potentially waited weeks for their first clinical appointment, and some CSBs reported 40% no-show rate.

Now that all CSBs have implemented same day access, they will focus on implementing the next STEP-VA provisions: primary care screening and monitoring at all CSBs, phasing in a statewide expansion of outpatient services, and planning for more comprehensive crisis services at all CSBs.

STEP-VA is loosely based on the federal Certified Community Behavioral Health Clinic (CCBHC) model. Virginia was awarded a CCBHC planning grant, but in October 2016 opted not to submit a proposal for a demonstration grant due to cost and infrastructure concerns. The STEP-VA model was developed as a sustainable Virginia-specific solution. The CSBs began working on STEP-VA after the 2017 Governor and the General Assembly provided $4.9 million in general fund dollars for an initial group of CSBs to implement SDA. The General Assembly required the remainder of STEP-VA services to be implemented over the next two biennia, with additional funding to be allocated in the coming years. The 2018 Governor and the General Assembly provided $5.9 million for the second group of 22 CSBs to implement same day access in fiscal year 2019. Each CSB will receive $270,000 in ongoing state mental health funds. Eight CSBs had already implemented some form of same day access and received funding on July 1, 2018, to address their implementation costs. By the end of calendar year 2018, all but five CSBs had implemented same day access. The remaining CSBs were on-track to implement same day access in early 2019 and did so in March.

CSB progress on same day access was reported in March 2019 by the Virginia Association of Community Service Boards, Inc., a trade association for the CSBs. Additional information about same day access and STEP-VA was reported by the Virginia Department Of Behavioral Health and Developmental Services (DBHDS) in a December 2018 year-end report to the legislature, and was also mentioned in June 2018 in the CSB contract requirements for fiscal years 2019 and 2020. During fiscal year 2018, CSBs reported receiving more than $1.3 billion from all sources to provide community-based services for 218,894 individuals

For the fiscal year 2019 and 2020 CSB contracts, DBHDS implemented new reporting requirements that are focused on the continuity of care and utilization, as follows:

  1. Continuity of care for local psychiatric inpatient discharges: The population includes individuals for whom the CSB purchased or managed local inpatient psychiatric services from a private psychiatric hospital or psychiatric unit in a public or private hospital who keep a face-to-face (non-emergency) mental health outpatient service appointment within seven calendar days after discharge. The benchmark is 70%.
  2. Continuity of care for state hospital discharges: The population includes individuals for whom the CSB is the identified case management CSB and who keep a face-to-face (non-emergency) mental health outpatient service appointment within seven calendar days after discharge from a state hospital. The benchmark is 80%.
  3. Residential crisis stabilization unit utilization (RCSU): The measure focuses on the percent of all available RCSU bed days for adults and children utilized annually. The target annual utilization rate is 75%. This measure applies to CBS that operate an RCSU.
  4. Regional discharge assistance program (RDAP) service provision: The measure focuses on the share of total annual state RDAP fund allocations to a region obligated and expended by the end of the fiscal year. The benchmark: CSBs in a region shall obligate at least 95% and expend at least 90% of the total annual ongoing state RDAP fund allocations on a regional basis by the end of the fiscal year. The benchmark does not include one-time state RDAP allocations provided to support ongoing DAP plans for multiple years.
  5. Local inpatient purchase of services (LIPOS) provision: The measure focuses on the share of the total annual regional state mental health LIPOS fund allocations to a region expended by the end of the fiscal year. The benchmark: CSBs in a region shall expend at least 85% of the total annual regional state mental health LIPOS fund allocations by the end of the fiscal year.
  6. Program of assertive community treatment (PACT) caseload: The measure applies to the average number of individuals receiving services from the PACT team during the preceding quarter. The benchmark calls for CSBs that operate PACT teams to serve at least 75% of the number of individuals who could be served by the available staff providing services to individuals at the ratio of 10 individuals per clinical staff on average.
  7. Frequency of developmental enhanced case management (ECM) services: The percentage of individuals who receive Developmental Disability Waiver services who meet the criteria for receiving ECM who receive at least one face-to-face case management service monthly, with no more than 40 days between visits, and who receive at least one face-to-face case management service visit every other month at their residence. The benchmark: The CSB shall provide the face-to-face visits on time to at least 90% of individuals receiving DD Wavier services who meet the criteria for ECM.

The requirements were outlined in “Virginia Department Of Behavioral Health & Developmental Services Administrative Requirements For Community Service Boards For Fiscal Years 2019 & 2020.” The CSB Administrative Requirements include or incorporate by reference ongoing statutory, regulatory, policy, and other requirements that are not expected to change frequently. Reporting requirements are included for financial management; procurement; reimbursement; human resource management; information technology; planning; forensic services; interagency relationships, and access to services for those who are deaf, hard of hearing, late deafened, or deaf-blind. The document also outlines treatment block grant requirements for federal substance abuse prevention and treatment.

The VACSB notice, “All CSBs Have Implemented the Same Day Access Model,” is posted at https://vacsb.org/wp-content/uploads/2019/03/Same-Day-Access-at-CSBs-March-2019-.pdf (accessed May 14, 2019).

PsychU last reported on this topic in “Virginia Opts To Avoid CCBHC Demonstration,” which published on December 14, 2016. The article is available at https://www.psychu.org/virginia-opts-avoid-ccbhc-demonstration/.

For more information, contact:

  • Maria Reppas, Freedom of Information Act and Media Relations, Virginia Department of Behavioral Health and Developmental Services, Post Office Box 1797, Richmond, Virginia 23218-1797; 804-786-3921; Email: maria.reppas@dbhds.virginia.gov; Website: http://www.dbhds.virginia.gov/developmental-services/step-va
  • Hilary Piland, Public Policy Manager, Virginia Association of Community Services Boards, 10128 West Broad Street, Suite B, Glen Allen, Virginia 23060; 804-330-3141; Fax: 804-330-3611; Email: hpiland@vacsb.org; Website: https://vacsb.org/

Approximately 92% of Kaiser Permanente members report satisfaction with the convenience and quality of telemedicine visits with their primary care provider. Overall, 93% of members saying that the telemedicine visit met their needs, 92% felt that their provider was familiar with their medical history, and 90% were confident in the quality of their care via the telemedicine visit. Non-profit Kaiser Permanente provides health care services for more than 12.2 million members in eight states and the District of Columbia.

These findings were reported in “Patient–Provider Video Telemedicine Integrated With Clinical Care: Patient Experiences” by Mary E. Reed, DrPH; Jie Huang, Ph.D.; Rahul Parikh, M.D.; Andrea Millman, MA; Dustin W. Ballard, M.D., MBE; Irwin Barr, M.D.; and Craig Wargon, DPM. The researchers surveyed 1,274 adult (age 18 and over) health care consumers in Kaiser Permanente’s northern California region who scheduled a telemedicine visit from September through December 2015.

In 2014, Kaiser Permanente implemented new technology that allowed primary care providers to have video visits with their health care consumers. These telemedicine visits are provided through internet-connected and video-enabled computers or mobile devices. The primary reasons for Kaiser Permanente members to seek telemedicine visits included convenience, being able to see their primary care providers via telemedicine, and the perception that an in-person visit was not necessary. Additional findings for these Kaiser Permanente members include:

  1. About 89% of those who scheduled a telemedicine visit were interested in a future telemedicine visit.
  2. About 87% said that the telemedicine visit was more convenient than other ways of getting care.
  3. About 84% said that the telemedicine visit improved their relationship with their primary care provider.
  4. Telemedicine visits reduced office visits for 35% of members who would have otherwise needed to make other arrangements for in-person visits. For those who wouldn’t need to make other arrangements for in-person visits, telemedicine reduced office visits for 25% of these members.
  5. Of the 111 participants who scheduled a telemedicine visit but did not attend, about 26% reported technical difficulties as the reason for missing the appointment. Approximately 62% of those who did not attend their telemedicine visits communicated with the health care professional in some other way.

The full text of “Patient–Provider Video Telemedicine Integrated With Clinical Care: Patient Experiences” was published April 30, 2019, by Annals of Internal Medicine. An abstract is available online at https://annals.org/aim/article-abstract/2732082/patient-provider-video-telemedicine-integrated-clinical-care-patient-experiences (accessed May 20, 2019).

PsychU last reported on Kaiser Permanente in “Kaiser Permanente Invests $3 Million To Counter Homelessness,” which published on April 22, 2019. The article is available at https://www.psychu.org/kaiser-permanente-invests-3-million-to-counter-homelessness/.

For more information, contact: Mary E. Reed, Dr.PH, Research Scientist, Northern California Division of Research, Kaiser Permanente, 2000 Broadway Avenue, Oakland, California 94612; 510-891-3808; Email: mary.e.reed@kp.org; Website: https://divisionofresearch.kaiserpermanente.org/; or Janet Byron, Senior Communications Consultant, Northern California Division of Research, Kaiser Permanente, 2000 Broadway Avenue, Oakland, California 94612; 510-891-3115; Email: janet.l.byron@kp.org; Website: https://divisionofresearch.kaiserpermanente.org/

Hear from Jason Carter, Pharm.D., a Medical Science Liaison with Otsuka Pharmaceutical Development & Commercialization, Inc., as he explores the interrelation between chronic pain, opioid prescribing practices, and mental health conditions. Examine the Centers for Disease Control & Prevention (CDC) recommendations for opioid prescribing practices; prescription prevalence; the interrelated nature of mental health conditions and chronic pain for some patients, and assessment tools that can be utilized to screen for misuse risk and mental health conditions in this short presentation.

About 10% of law enforcement agencies’ total budgets in 2017 was spent responding to and transporting persons with mental illness. In total, law enforcement agencies spent an estimated $918 million on transport for people with severe mental illness (SMI). About 21% of total law enforcement staff time was used to respond to and transport individuals with mental illness, which accounted for 165,295 hours and 5.4 million miles. About 26% of all law enforcement transports of individuals with SMI were for people who had three or more law enforcement encounters in one month.

These findings were reported in “Road Runners: The Role and Impact of Law Enforcement in Transporting Individuals with Severe Mental Illness” by the Treatment Advocacy Center. The report was released in partnership with the National Sheriffs’ Association and the New York State Association of Chiefs of Police and funded by the Achelis and Bodman Foundation. The researchers surveyed sheriffs’ offices and police departments about the time and costs of transporting individuals with SMI. The report represents survey responses from 355 sheriffs’ offices and police departments in the United States. Law enforcement officers provide emergency and non-emergency transport for individuals with mental illness.

  • Emergency transport occurs in response to a 911 call, or a police response to a situation with a person at risk of immediate harm; destinations include: general hospital emergency department, psychiatric emergency room, inpatient facility, or jail. About 56% of all transports were emergency transports.
  • Non-emergency transport occurs in response to a court order or other planned event for a person with SMI who is not at immediate risk of harm resulting in transport between facilities such as an emergency department to an inpatient bed; destinations include: emergency department, inpatient facility, courtroom, or jail. About 44% of all transports were non-emergency.

Key Findings

  • The average distance to transport an individual in mental illness crisis to a medical facility was five times farther than the distance to transport them to jail.
  • Transporting a person with SMI to a medical facility required that law enforcement officers wait 2.5 hours longer than transporting the individual to a jail. The average wait was 37 minutes to transfer custody of an individual with SMI to jail. However, at a medical facility, law enforcement officers reported waiting with the individual as long as 72 hours before a bed became available and custody could be transferred.
  • The 355 survey respondents reported that more than $17.7 million was spent in 2017 transporting people with SMI, representing about 10% of the respondents’ budgets. At that spending level, nationwide spending on transport for people with SMI estimated at $918 million.
  • About 32% of emergency psychiatric encounters resulted in transport to a hospital emergency department, 22% to a psychiatric emergency department, 12% to an inpatient facility, and 15% to jail. In 19% of encounters no transport took place.
  • About 34% of non-emergency transports were to a hospital emergency department, 30% to an inpatient facility, and 16% to jail. About 20% were to a court.
  • For individuals with SMI transported by law enforcement to a medical facility, on average 55% were admitted for evaluation, 37% were evaluated and then released, and 8% were immediately released.

The survey analysis reported qualitative themes that emerged from the responses. The respondents expressed concerns about community treatment capacity, the criminalization of mental illness, the stress on law enforcement resources, the need for training law enforcement to respond to psychiatric crisis, and public safety. Additional details were as follows:

  • Time and resource issues caused by psychiatric transports are due to an inadequate supply of community-based psychiatric crisis beds, and that collaboration is needed between the criminal justice, health care, and social service systems.
  • Using law enforcement as the primary response and source of transportation for people in psychiatric crisis leads to criminalization of mental illness.
  • The time and funds required to provide psychiatric crisis response and transport creates difficulty in scheduling officers. The unpredictable nature of psychiatric crisis calls puts a disproportionate strain on operations, especially for small agencies, and takes officers away from regular public safety duties.
  • Law enforcement budgets often lack funding and staff availability to provide staff training on crisis intervention techniques and other forms of law enforcement training.

The survey respondents expressed an understanding of the positive effect of mental health training on an officer’s ability to interact with individuals with mental illness and keep them out of the criminal justice system. The respondents were willing to work with other agencies to improve outcomes for individuals with serious mental illness but expressed frustration with the health system’s lack of accountability in caring for people with SMI.

The full text of “Road Runners: The Role and Impact of Law Enforcement in Transporting Individuals with Severe Mental Illness” was published in May 2019 by Treatment Advocacy Center. A copy is available online at https://www.treatmentadvocacycenter.org/road-runners (accessed May 20, 2019).

For more information, contact: Matt Farrauto, Communications Director, Treatment Advocacy Center, 200 North Glebe Road, Suite 801, Arlington, Virginia 22203; 703-294-6003; Email: info@treatmentadvocacycenter.org; Website: https://www.treatmentadvocacycenter.org/index.php.

In creating proposed models for value-based reimbursement of specialty provider organizations, one of the goals of our team is to link specialty provider organization “performance” to the total cost of consumer care. This is a bigger goal—but also provides a bigger role for specialty provider organizations in the health care system since behavioral health and longterm
care services together are only about 15% of the total health care spend.

We were reminded of this while reading the recent article, “U.S. Economic Burden Of Chronic Diseases Reaches $3.7 Trillion,” about the cost of chronic health care conditions—of which the direct and indirect costs of chronic illness total $3.7 trillion, or about one-fifth of the 2018 gross domestic product of $20.50 trillion. The direct health care cost of those conditions is $1.1 trillion, about 33% of total U.S. health care spending. What was interesting to us was that this report found the costs for specific chronic diseases but didn’t discuss the costs of behavioral health disorders that commonly cooccur with the specific chronic diseases—and usually raise the costs significantly. We looked at a few of these conditions and found a robust set of research on the behavioral management as a solution.

Diabetes— The total annual cost of diabetes is estimated at $327 billion. Research shows that among adults with diabetes, 10.2% had unrecognized depression (for $2,872 in added cost), 13.6 % had asymptomatic depression ($3,347),and 8.9 % had symptomatic depression ($5,170). Successful interventions for behavioral management of diabetes include programs that prioritize frequency of feedback, problem solving, community support, personalized approaches, andscreenings for psychological.

Heart disease—The total annual cost of heart disease is estimated at $555 billion, but consider that the cost of care for health failure increases by 29% when the consumer also has depression; and women with depression have annual cardiovascular costs $1,550-$3,300 higher than consumers without depression. Successful interventions for behavioral management of heart disease are those that help consumers manage poor dietary habits, physical inactivity/low fitness, and smoking.

Arthritis—The total annual cost of arthritis is estimated at $304 billion in 2013, but the mean annual total health care costs for coexisting rheumatoid arthritis (RA) and depression are 7.2% higher than RA alone. In addition, consumers with osteoarthritis (OA) and depression have 38.8% higher direct health care expenditures as compared to those without OA. Successful interventions for behavioral management of rheumatoid arthritis include cognitive behavioral therapy.

Obesity—The total cost of care for obesity is estimated at $114 billion. Obesity makes it more likely that a consumer will become depressed, and that depression makes it more likely that a consumer will become obese; 43% of consumers with depression are obese. Successful interventions for behavioral management of weight include training in collaborative goal setting; accountability; nutrition consultation and meal planning; and self-monitoring food intake, weight, and activity.

Cancer—The total cost of cancer is estimated at $80 billion in 2015, and consumers with cancer and depression had total annual health care costs 113% higher ($235,337) than consumers with cancer but without depression ($110,650).  Successful interventions for behavioral management of cancer include cognitive behavioral therapy.

The high (and growing) costs of chronic disease—and the very real impact of behavioral health conditions and behavior management—are likely going to reshape care coordination programs and primary care. Payers will be looking for innovative approaches that can demonstrate a return-on-investment in the chronic disease management space.

California-based provider organizations sharing financial risk through a capitated payment model had better health outcomes and performance on quality measures than provider organizations reimbursed using a fee-for-service (FFS) model. In addition, average consumer out-of-pocket (OOP) costs were 60% lower for consumers under the care of a risk-sharing provider organization, at $268 OOP annually, compared to $672 OOP per year for those under the care of a FFS provider organization.

These findings were reported in “Health Care Cost & Quality Atlas” by the Integrated Healthcare Association (IHA). The researchers analyzed data from seven California health plans that cover 7.2 million lives via health maintenance organization (HMO), preferred provider organization (PPO), and accountable care organization (ACO) products, both fully insured and self-insured. The data set represents about 55% of the statewide commercial enrollment of 13.1 million, excluding Kaiser Permanente. The researchers excluded Kaiser Permanente data from the analysis, because its more than 6 million commercial lives would skew the results. The prevalence of provider organizations participating in risk-sharing varies from 24% in Northern California, 18% in Central California, and 45% in Southern California. The analysis compared three risk-sharing arrangements:

  • Full risk, which was defined as capitation for both professional and facility costs
  • Professional-risk only, which was defined as capitation for non-facility clinical professional and ancillary services such as outpatient lab tests
  • No risk, which was defined as FFS

Quality was defined as clinical quality scores based on a composite of eight measures, and on preventive screening rates. Provider organizations participating in a risk-sharing arrangement had higher scores than those in FFS. Quality scores for provider organizations in a full-risk arrangement had an average composite quality score of 67.1%. Provider organizations with professional risk only had an average quality score of 65.6%. Provider organizations paid FFS had an average quality score of 57.9%. Preventive screening rates were 11 percentage points higher for full-risk provider organizations compared to FFS provider organizations.

The total cost of care was up to 3.5% lower for risk-sharing provider organizations. The total cost of care for members under the care of a FFS provider organization averaged $4,589; the average cost was $4,428 for members under the care of a full-risk provider organization. The total cost of care averaged $4,501 for members under the care of a provider organization sharing professional services risk.

Pharmacy costs were up to 13% lower for risk-sharing provider organizations. Pharmacy costs per member per year (PMPY) averaged $970 for FFS provider organizations and averaged $840 PMPY for those under the care of a full-risk provider organization. Pharmacy PMPY averaged $882 for members under the care of a provider organization sharing professional services risk. The researchers noted that clinical risk was very similar across the three risk sharing levels (within 1% to 2% of the others) and did not account for the differences.

In each of the three geographic regions (Northern, Central and Southern), provider organizations participating in risk arrangements had higher clinical quality scores compared to FFS-only provider organizations. The researchers noted similar associations between risk sharing, quality scores, and cost of care in the 19 Covered California regions. They concluded that risk sharing is associated with higher value, defined as better clinical quality at lower cost. They proposed that the provider organizations participating in risk arrangements may be using the capitated payment to invest in care management programs and other infrastructure to support population health and quality improvement.

The full text of “Health Care Cost & Quality Atlas” was published April 11, 2019 by the Integrated Healthcare Association. A copy is available online at https://atlas.iha.org/story/risk (accessed May 3, 2019).

For more information, contact: Akhila Nanduri, Media Contact, Integrated Healthcare Association, 500 12th Street, Suite 310, Oakland,California 94607; 510-585-7422; Fax: 510-444-5842; Email: akhila.nanduri@ogilvy.com; Website: https://www.iha.org/

Medicaid expansion may have reduced the number of addiction-related deaths between 2014 and 2015. From 2002 through 2015, the national rate of addiction-related deaths was 21.15 per 100,000 population. During this period, the national addiction-related death rate rose by 71.9%, from 16.0 per 100,000 population to 27.5 per 100,000 population. Without the Medicaid expansion under the Patient Protection and Affordable Care Act of 2010 (PPACA), the addiction-related death rate would have been higher. In the 22 non-expansion states that had net contractions in their Medicaid eligibility thresholds between 2005 and 2015, there was an estimated increase of 570 addiction-related deaths. The number of deaths was lower than predicted in the 28 states that expanded Medicaid eligibility to at least 138% of the federal poverty level (FPL), as allowed by the PPACA. In these states, an estimated 1,045 addiction-related deaths may have been prevented.

These findings were reported in “Association Between State Medicaid Eligibility Thresholds and Deaths Due to Substance Use Disorders” by Julia Thornton Snider, Ph.D.; Margaret E. Duncan, M.D., Ph.D.; Mugdha R. Gore, Ph.D.; et al. The researchers conducted an economic evaluation using a retrospective analysis of state-level data between 2002 and 2015 for a total of 700 state-year observations. The goal was to determine the association between the Medicaid eligibility threshold and addiction disorder-related deaths. The analysis controlled for other relevant policies state socioeconomic characteristics, fixed effects, and a time trend. As controls, the researchers included state policies related to mental health, overdose treatment, and law enforcement of drug crimes.

During the period under analysis, the average Medicaid eligibility threshold increased from 87.2% to 97.1% FPL. By 2015, 58% of states had expanded Medicaid eligibility under the PPACA to at least 138% FPL. The average threshold was not higher because 22 states contracted their eligibility thresholds.

They ran two scenario simulations.

  • In the first, they predicted changes in national addiction-related deaths in 2015 if all states with eligibility thresholds below the median of 133% FPL had raised the threshold to the median in 2014. This scenario indicated a 2.67% reduction in addiction-related deaths, totaling 2,359 fewer deaths in 2015.
  • In the second, they predicted changes if all states raised their eligibility threshold in 2014 to match that of the state with the highest threshold (Minnesota, with a threshold of 205% FPL). This scenario indicated a 5.89% reduction in addiction-related deaths, totaling 5,207 fewer deaths in 2015.
  • Raising any given state’s Medicaid eligibility threshold by a 100-percentage point increase was associated with 1.373 fewer projected addiction-related deaths per 100,000 population, a reduction of 6.5%.

The researchers also compared their findings to an analysis issued by the federal Department of Health and Human Services (HHS) who reported that states that expanded Medicaid, experienced a greater increase in addiction-related deaths. The HHS analysis used a data set for 2010 through 2015. The researchers found that the longer data set for 2002 to 2015 resulted in outcomes different than the HHS outcomes. They said the HHS data set may have been too short in duration.

They concluded that the Medicaid eligibility threshold increase, was the only policy that was significantly associated with lower rates of addiction-related deaths. Mental health parity, mandatory minimum sentencing, and Good Samaritan laws showed little evidence of association with addiction-related deaths. Increases in addiction-related deaths were associated with receipt of federal grant funding from the Substance Abuse and Mental Health Administration (SAMHSA), the number of drug courts, and the existence of a medical cannabis program. The researchers said the increases could be the result of reverse causality because states experiencing a more severe opioid epidemic would be more likely to implement addiction-specific policies. They noted that Medicaid policies are less responsive to the prevalence of addiction disorder or other events in the state.

The full text of “Association Between State Medicaid Eligibility Thresholds and Deaths Due to Substance Use Disorders” was published April 26, 2019 by JAMA Network Open. A copy is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2731689 (accessed May 3, 2019).

For more information, contact: Dana P. Goldman, Ph.D., Precision Health Economics, 11100 Santa Monica Boulevard, Los Angeles, California 90025; Email: dana.goldman@precisionhealtheconomics.com; Website: https://www.precisionmedicinegrp.com/phe/.

Humana’s Medicare Advantage members had an average 2.7% reduction in the number of “unhealthy days” during 2018, and the reduction was linked to an increase in screening for social determinants of health (SDOH), such as food insecurity and loneliness. The percentage change of “unhealthy days” ranged from a 3.6% increase in Broward County, Florida to a 9.8% decrease in San Antonio, Texas. “Unhealthy days” are defined as the overall number of days during the previous 30 days when the respondent felt that either his or her physical or mental health was not good.

These findings were reported the Humana Bold Goal 2019 Progress Report. Humana, along with community partners and physician practices, screened more than 500,000 members for food insecurity and loneliness, and connected those who screened positive to community resources. Humana’s Bold Goal is a population health strategy for primarily Medicare Advantage Members, launched in 2015.

The Bold Goal effort targets social determinants of health and community behavioral health to help the communities it serves become 20% healthier by 2020 and beyond. Bold Goal communities are those where Humana has a large presence, in terms of corporate offices or member enrollments. These include, but are not limited to, Baton Rouge, Louisiana; Broward County, Florida; Knoxville, Tennessee; Louisville, Kentucky; New Orleans, Louisiana; San Antonio, Texas; and Tampa Bay, Florida. Compared to those Humana members in Bold Goal communities, members in non-Bold Goal communities saw an average 0.6% increase in ‘unhealthy days.’ Results varied for Medicare Advantage members in each location (the report did not list the same percentage categories for each location):

  • Baton Rouge, Louisiana had an average 5.1% decrease in unhealthy days: members with disabilities saw a 5.8% reduction; low-income members (individuals whose taxable household income for the preceding year did not exceed 150% of the federal poverty level) amount saw a 4.9% reduction; and those living with diabetes saw a 3.7% reduction.
  • Broward County, Florida had an average 3.5% increase in unhealthy days: members with disabilities saw a 3.9% reduction, while those with depression saw a 12% increase.
  • Knoxville, Tennessee had an average 1.5% decrease in unhealthy days: low-income members showed a 2.9% reduction.
  • Louisville, Kentucky had an average 1.5% increase in unhealthy days: members with diabetes, depression, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) saw a significant reduction in unhealthy days, however exact figures are not available.
  • San Antonio, Texas had an average 9.8% reduction in unhealthy days: members with diabetes, disability, and low-income subsidies saw improvements, however exact figures were not available.
  • Tampa Bay, Florida had an average 3.8% reduction in unhealthy days: this is despite members living with depression seeing a 2% increase in unhealthy days.

Humana Inc. is a for-profit health insurance company that covers over 13 million members in the United States. Humana is committed to helping its millions of medical and specialty members achieve their best health.

The full text of “Bold Goal 2019 Progress Report” was published April 22, 2019 by Humana. A copy is available online at http://populationhealth.humana.com/wp-content/themes/humana/docs/Humana_2019_%20BoldGoal_ProgressReport.pdf (accessed May 10, 2019).

PsychU last reported on this topic in “Severe Loneliness Can Increase Health Care Costs By Over $300 Per Month,” which published on April 25, 2018. The article is available at https://www.psychu.org/severe-loneliness-can-increase-health-care-costs-300-per-month/.

For more information, contact: Marvin Hill, Jr., Corporate Communications Lead and National Public Relations Manager, Humana, 500 West Main Street, 8th Floor, Louisville, Kentucky 40202; 502-580-3950; Fax: 502-508-3493 Email: mhill1@humana.com; Website: https://www.humana.com/

In March the California Department of Health Care Services (DHCS) released draft value-based payment (VBP) performance measures for the state’s Medicaid managed care program (in California, the Medicaid program is called Medi-Cal—for more on the California Medicaid system, see California Mental Health System Guidebook. The measures are grouped into four domains: behavioral health integration; chronic disease management; prenatal/post-partum care; and early childhood preventive care. Each domain has five performance measures. These measures will be tied to risk-based incentive payments and are aimed at improving care for certain high-cost or high-need populations (see California Releases Proposed Medi-Cal Value-Based Payment Program Measures).

What is interesting about the draft VBP measures is that DHCS focused the measures on screening, prevention, and integration of physical health care and behavioral health. Many states and national measures have incentivized screening for depression or substance abuse in primary care settings, but these measures go one step farther. The measures include an additional incentive payment to provider organizations per visit for services delivered in an environment that has co-located primary care with behavioral health care.

Why do these measures matter if you’re not serving consumers in the state of California? Just keep in mind the adage: “As California goes, so goes the nation.” California is the most populous state in the country and has the largest Medicaid population of any state by far, at about 10.5 million total enrollees—or about 16% of the total Medicaid population. While they are not alone in requiring their Medicaid health plans to utilize value-based reimbursement (VBR) models, with such a huge portion of the Medicaid population they are often a bellwether for innovation in Medicaid and the results of their program changes can provide a significant data set for other states to analyze when making their own program modifications.

What do these measures tell us? First, primary care-led integration will continue to be a priority for payers and health plans. In California and elsewhere, performance measures related to behavioral health tend to be aimed at primary care—not behavioral health care provider organizations. Measures like screening for depression or alcohol use are about improving behavioral health, but they are intended for the primary care setting. With California adding additional incentives for services to be delivered in an integrated care setting, we will see health plans give priority in referrals to co-located programs. If so, this presents an incentive for provider organizations to form new partnerships with primary care practices and health systems. In a co-located system of care, behavioral health screening measures are easier to meet. The right changes in workflow ensure that consumers who may screen positive can see the right clinical professionals on site as needed.

Second, integration measures, particularly screening measures, are a new opportunity to use technology tools to streamline processes. Online or tech-based screening systems are a convenient and efficient way to ensure that every consumer has their screening either before they come into the office for their visit utilizing on online tool or in office while waiting for their appointment using a tablet device or kiosk. Studies have shown that online screenings can be just as effective as in-person screening (see Computer-Based Suicide Risk-Assessment Tool As Accurate As In-Person Psychiatric Assessment), and with screening being such a huge part of VBR performance measures, we can expect the use of these tools to grow.

California was accepting comments on their draft performance measures through the end of March, with the final measures expected this year. We’ll continue to monitor the effectiveness of California’s new performance measures and how other states are utilizing VBR to prioritize integration.

The Orange County, California Health Care Agency is preparing to launch an online addiction treatment registry by summer 2019; the system is currently in testing. The registry will require private addiction treatment programs in unincorporated Orange County to provide the program/ center name business address and state license number; services provided; accepted methods of payment for each location; the identity of each owner, director, partner and officer; and the identities of each organization’s affiliated entities. The stated purpose of the registry is to prevent industry fraud and to promote a coordination of effort in the county.

The registry was proposed by the District Attorney’s office but will be overseen by the county’s Health Care Agency. While compliance timelines and roll-out specifics are still being discussed, the target date for the ordinance to go into effect is July 1, 2019. Failing to register honestly and completely is scheduled to be a misdemeanor carrying fines of up to $1,000 and jail time of up to six months. The following provider organization must participate:

  1. Residential programs
  2. Drop-in centers
  3. Crisis telephone lines
  4. Free clinics
  5. Detoxification centers
  6. Narcotic treatment programs
  7. Chemical dependency programs
  8. Alcohol and other drug prevention programs
  9. Non-specific programs that provide or offer to provide, in whole or in part, for counseling, therapy, referral, advice, care, treatment, or rehabilitation as a service

Organizations affected by the new registry requirements will be notified by mail. Following roll-out, new rehabilitation centers will be required to register within 30 days of opening. The cost of the registry, and a source of funding, has not been released.

For more information, contact: Annette Mugrditchian, Chief of Operations, Behavioral Health Services, Orange County Health Care Agency, 405 West 5th Street, Santa Ana, California 92701; 714-834-5026; Email: AMugrditchian@ochca.com.

More than half of clinical health care professionals said they felt unprepared to provide behavioral health screening and brief intervention (SBI) during regular consumer visits. About 57% do not feel adequately prepared to provide screenings for substance use or mental health disorders, or to provide consumers with information about the impact of behavioral health disorders. About 64% feel inadequately prepared to use motivational interviewing to encourage consumers to change their behaviors or seek help. About 62% feel inadequately prepared to collaborate with consumers to create an action plan.

These findings were reported in “Are Healthcare Professionals Ready to Address Patients’ Substance Use and Mental Health Disorders?” by Glenn Albright, Ph.D., co-founder and director of research at Kognito, and Deborah S. Finnell, DNS, CARN-AP, FAAN, faculty consultant at Johns Hopkins School of Nursing. The authors surveyed 676 health care professionals (physicians, nurses, and nurse practitioners) from over 50 organizations. The participants completed the survey immediately prior to enrolling in one of Kognito’s online simulations on substance use and mental health screening and brief intervention, which were implemented by their organizations as a professional development activity. The researchers analyzed the participants’ health care competency in delivering clinical strategies for substance use and mental health, the likelihood that they would implement these activities as part of routine care, and the number of consumers for whom the health care professionals currently provided these activities.

Additional findings include:

  • About 84% are likely or very likely to provide a health screening, brief interventions, and referrals to treatment for substance use or mental health needs.
  • On average, each health care professional screened 17.6 individuals, engaged in brief intervention with 5.6 individuals, and referred 1.3 individuals to treatment for substance use or mental health needs.
  • On average, each nurse and nurse practitioner screened 8.5 individuals, engaged in brief intervention with 4.7 individuals, and referred 3.5 individuals to treatment for substance use or mental health needs.

The authors recommended better screening and brief intervention training for health care professionals. Because many health care professionals were educated prior to integration of screening and brief intervention training into standard curricula, they may not have been trained on this topic at all. Health care professionals therefore feel unprepared to offer these services to individuals that they treat.

The full text of “Are Healthcare Professionals Ready to Address Patients’ Substance Use and Mental Health Disorders?” was published in March 2019 by Kognito. A copy can be requested at https://go.kognito.com/Are_Healthcare_Professionals_Ready_Substance_Use-Mental_Health_Whitepaper.html (accessed May 3, 2019).

For more information, contact: Glenn Albright, Co-founder and Director of Research, Kognito, 135 West 26th Street, Floor 12, New York, New York 10001; 212-675-9234; Email: glenn@kognito.com.

The Illinois legislature is considering three bills to change the practices of managed care organizations (MCOs) operating under HealthChoice Illinois, the state’s Medicaid managed care program. The proposed legislation comes in response to news that during the first three months of the statewide HealthChoice Illinois implementation, January 2018 through March 2018, the MCOs denied 10.6% of Medicaid hospital claims.

The bills were introduced on February 15, 2019, to change MCO business practices and performance as a result of the denial rate. The bills address MCO rates, appeals processes, and timely payment. The MCO rates, and timely payment bills specifically concern medically necessary treatment that was provided without obtaining prior approval. The appeals process bill guarantees a third-party review of denials.

The denial rate was reported in “Illinois Medicaid MCO Hospital Denial Claims Report,” by the Illinois Department of Healthcare and Family Services (HFS) in November 2018. HFS analyzed the MCO claims processing and payment performance regarding hospital claims under the redesigned mandatory managed care program. HealthChoice Illinois expanded Medicaid managed care from just 30 counties to all 102 counties in the state. As of the end of fiscal year 2018, HealthChoice Illinois covered about two million people and cost the state about $10.7 billion during fiscal year 2018.

The 10.6% denial rate represented more than $630 million in denied revenue for the hospitals. About 43.6% of these were benefit denials; about 21.7% were denials for missing information; and about 17% were denials for not meeting the MCO’s authorization policy on provider network status, service limits, medical necessity, non‐emergency services, or missing/invalid authorization form/record.

As of May 1, 2019, all three proposed state senate bills were still in committee. The three bills currently in front of the state senate include:

Senate Bill 1697: The bill assures fair Medicaid managed care rates. The bill was first read in the Senate and filed on February 15, 2019. Specifically, the bill:

  • Requires MCOs to ensure that contracted provider organizations shall be paid for any medically necessary service rendered to any of the MCO’s enrollees, regardless of inclusion on the MCO’s published and publicly available roster of available provider organizations.
  • Requires that all contracted provider organizations are contained on an updated roster within seven days of entering into a contract with the MCO and that such roster be readily accessible by all medical assistance enrollees for purposes of selecting an approved health care provider.
  • Requires HFS to develop a single standard list of all additional clinical information that shall be considered essential information and may be requested from a hospital to adjudicate a claim.
  • Provides that a provider organization shall not be required to submit additional information, justifying medical necessity, for a service which has previously received a service authorization by the MCO or its agent.
  • Contains provisions concerning a timely payment interest penalty; an expedited payment schedule; a single list of standard codes to identify the reason for nonpayment on a claim; payments under the HFS fee-for-service system; a 90-day correction period for provider organizations to correct errors or omissions in a payment claim; service authorization requests; discharge notification and facility placement; and other matters.

Senate Bill 1703: The bill assures a fair appeal process for denied Medicaid claims. The bill was first read in the Senate and filed on February 15, 2019. Specifically, the bill:

  • Provides that a provider organization that has exhausted the MCO written internal appeals process shall be entitled to an external independent third-party review of the MCO’s final decision that denies, in whole or in part, a health care service to an enrollee or a claim for reimbursement to a provider organization for a health care service rendered to an enrollee of the Medicaid managed care organization.
  • Requires a MCO’s final decision letter to a provider organization to include: a statement that the provider organization’s internal appeal rights within the MCO have been exhausted; a statement that the provider organization is entitled to an external independent third-party review; the time period granted to request an external independent third-party review; and the mailing address to initiate an external independent third-party review.
  • Provides that a party shall be entitled to appeal a final decision of the external independent third-party review within 30 days after the date upon which the appealing party receives the external independent third-party review.
  • Provides that a final decision by the Director of HFS shall be final and reviewable under the Administrative Review Law. Contains provisions concerning fees to help defray the cost of the administrative hearings; the specific claims of services that are appealable; and the HFS rulemaking authority.

Senate Bill 1807: The bill assures timely payment by MCOs for any medically necessary service provided to health care consumers. The bill was first read in the Senate and filed on February 15, 2019. Specifically, the bill:

  • Requires HFS to require MCOs to ensure that any provider organization under contract with an MCO on the date of service shall be paid for any medically necessary service rendered to any of the MCO’s enrollees, regardless of inclusion on the MCO’s published and publicly available roster of available providers; that all contracted provider organizations are listed on an updated roster within seven days of entering into a contract with the MCO; and that the roster is readily accessible by all medical assistance enrollees for purposes of selecting an approved health care provider organization.
  • Requires HFS to require MCOs to expedite payments to provider organizations based on specified criteria (rather than providing that HFS may establish a process for MCOs to expedite payments to providers based on criteria established by HFS)
  • Contains provisions concerning discharge notifications and facility placements and other matters.

PsychU last reported on this topic in:

For more information, contact: John Hoffman, Director of Communications, Illinois Department of Healthcare and Family Services, 401 South Clinton Street, Chicago, Illinois 60607; Email: John.K.Hoffman@illinois.gov.

Between January 2005 and December 2016, rural emergency department visit rates increased by more than 50%, from 36.5 to 64.5 per 100 persons. At the same time, there was a 5% decline in the overall U.S. rural population. In urban areas, emergency department visits increased from 40.2 to 42.8 visits per 100 persons. The higher rate of increase in rural areas occurred among those aged 18 to 64 years, non-Hispanic white individuals, Medicaid beneficiaries, and individuals without insurance.

Rural Emergency Department Utilization Rates
Population Classification # Per 100 in 2005 # Per 100 In 2016
Non-Hispanic Whites 39.2 65.3
Medicaid Beneficiaries 56.2 112.6
Aged 18 To 44 Years 46.9 81.6
Aged 45 To 64 Years 27.5 53.9
Those Without Insurance 44.0 66.6

These findings were reported in “Trends in Emergency Department Use by Rural and Urban Populations in the United States” by Margaret B. Greenwood-Ericksen, M.D., MSc; and Keith Kocher, M.D., MPH. The researchers analyzed data from the National Hospital Ambulatory Medical Care Survey for January 2005 to December 2016. Emergency departments were categorized as urban or rural in accordance with the U.S