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A Snapshot Of Telemedicine In One State: Clinical And Payer Implications

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 summation 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.

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.

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.

This is similar to the remarks of OPEN MINDS Advisory Board Member Richard Knecht about the importance of trauma-informed care and embracing the approach at all levels of the organization – through the organization’s culture, policy, procedures, staff, and screening tools. Managers of provider organizations should note that turning trauma-informed knowledge into practice is a complex endeavor but adopting an integrated approach can enhance the trauma-informed network in better supporting this under-served population.

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. Office of Management and Budget classification. Visit rates were calculated using annual U.S. Census Bureau estimates. The goal was to determine urban and rural differences in emergency department use over a 12-year period by demographic characteristics, payers, and characteristics of care, including trends in ambulatory care–sensitive conditions and emergency department safety-net status.

Additional findings include:

  1. During the time studied, overall rural emergency department visit estimates increased nearly over 50%, from 16.7 million to 28.4 million. During this time, overall urban visits increased an estimated 20%, from 98.6 million to 117.2 million overall. This equates to nearly one-fifth of all emergency department visits which occurred in the rural setting in 2016 (28.4 million of 145.6 million).
  2. Rural emergency department visits increased about 66.7% for non-Hispanic white individuals, from 13.5 million to 22.5 million during this time.
  3. Rural emergency department visits increased about 120.5% for Medicaid beneficiaries, from 4.4 million to 9.7 million.
  4. Rural emergency department visits increased about 74.0% for those aged 18 to 64 years, from 9.6 million to 16.7 million.
  5. Rural emergency department visits increased about 25.9% for those without insurance, from 2.7 million to 3.4 million).
  6. Overall rural emergency departments categorized as safety-net status increased about 26.75%, from 769 per 2009 total hospitals, 1,187 out of 1,855 total hospitals.

The researchers concluded that rural emergency departments are increasingly serving a larger proportion of traditionally disadvantaged groups. Increased visits by young to middle-aged white rural patients—particularly Medicaid beneficiaries and those without insurance—may indicate an increased burden of illness or challenges in access to alternative care sites. This places greater financial pressure on rural emergency departments, especially for those with safety-net status because they generally operate in the traditional fee-for-service mode. Rural areas may require tailored and innovative payment and delivery model strategies to achieve improvements in the access to and availability of health care in their communities.

The full text of “Trends in Emergency Department Use by Rural and Urban Populations in the United States” was published April 12, 2019, by JAMA Open. A copy is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730472 (accessed April 29, 2019).

PsychU last reported on this topic in “Can A New Reimbursement Model Stabilize Rural Hospitals?” which published on May 20, 2019. The executive briefing is available at https://www.psychu.org/can-a-new-reimbursement-model-stabilize-rural-hospitals/.

For more information, contact: Margaret B. Greenwood-Ericksen, M.D., MSC, Department of Emergency Medicine, University of New Mexico, 700 Camino de Salud, Albuquerque, New Mexico 87109; Email: mgreenwoodericksen@salud.unm.edu.

On May 2, 2019, Shatterproof announced that West Virginia would be joining Delaware, Louisiana, Massachusetts, and New York as the fifth and final state to participate in a pilot of a new quality rating system for addiction treatment programs.  The Shatterproof Rating System is intended to standardize the evaluation of addiction treatment across all levels of care, settings, and types of treatment.

Starting in August 2019, all specialty addiction treatment programs in the five pilot states will be asked to respond to an online survey developed by Shatterproof. When possible, information will be pre-populated in order to reduce the programs’ reporting burden. The pilot states are implementing varying participation requirements. Programs that do not respond to the survey will still be included in the system, but with a note that quality data is not available. To validate the treatment program survey, there will be an attestation as well as random checks in the form of additional questions or documentation review. When feasible, data from alternative sources will also be used to validate self-reported information.

The Shatterproof rating program will rate any residential, outpatient, and intensive outpatient programs that are licensed, certified, or otherwise approved by the state to provide substance use disorder (SUD) treatment; as well as facilities that the state does not fund, license, or certify. The evaluation will also include programs operated by federal agencies, such as the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service. It will not examine individual clinical professionals or prescribers. Shatterproof is working with its state partners and with commercial payers on strategies that incentivize and reward participation in the Rating System. These may include highlighting early adopters and using the Rating System to deploy technical assistance and support. In some cases, payers have also committed to requiring reporting to the Rating System in their payment contracts. While completion of the survey is the only mandatory requirement for participation set by Shatterproof, programs may choose to engage further with the pilot and learn more through monthly provider organization roundtables during the pilot.

The Rating System website is slated to go live as early as April 2020. It will include information on all of the programs in the five pilot states. The ratings primarily focus on process or structure quality measures recommended by an expert committee convened by the National Quality Forum (NQF). In addition to the self-reported treatment program survey responses, the ratings will also incorporate data from insurance claims and consumer experience surveys evaluating treatment. The ratings will be available for use by the public, private payers, states, and referral sources. The treatment programs will have a preview period to review their data before it is posted publicly.

The Rating System website will display each program’s rating, and will also display its accreditation or certifications, if provided during the data collection process. Ratings for treatment programs in the pilot states will be free and publicly available on the Rating System website. The Rating System website will not post aggregate outcomes across all states; although the website may include benchmarking information to compare quality of a given treatment program to similar programs within that state or region. States will have access to the treatment program rating data, and may choose to publicize aggregate data for the programs in their state.

The goal is to provide ratings for treatment programs in each state that are helpful to those in need of care and their families. The ratings reflect how consistently the programs delivers care that aligns with Shatterproof’s “National Principles of Care.” These principles of care include:

  1. Routine screenings in every medical setting
  2. A personal plan for every health care consumer
  3. Fast access to treatment
  4. Disease management rather than a current 28-day treatment standard approaches to drug and alcohol rehabilitation
  5. Coordinated care for every illness
  6. Behavioral health care from legitimate provider organizations and clinical professionals
  7. Medication-assisted treatment
  8. Recovery support services beyond medical care

Funding for the pilot totals $5 million in contributions by the Laura and John Arnold Foundation; the Robert Wood Johnson Foundation; and health insurers Aetna, Anthem, Beacon Health Options, Cigna, Magellan Health, and UnitedHealth Group. According to Holly Jespersen, senior communications manager at Shatterproof, after analyzing the pilot outcomes, Shatterproof anticipates expanding the rating system nationwide.

PsychU last reported on this topic in “Shatterproof Launching Addiction Treatment Rating System,” which published on February 25, 2019. The article is available at https://www.psychu.org/shatterproof-launching-addiction-treatment-rating-system/.

For more information, contact:

  • For Shatterproof: Holly Jespersen, Senior Communications Manager, Shatterproof, 135 West 41st Street, New York, New York 10036; 646-334-1024; Email: RatingSystem@Shatterproof.org.
  • For Massachusetts: Alison Cohen, Communications Director, Massachusetts Department of Public Health, 250 Washington Street, Boston, Massachusetts 02108; 617-624-6000; Email: alison.b.cohen@state.ma.us.
  • For New York: Evan Frost, Assistant Director, Communications & Public Information, New York State Office of Alcoholism and Substance Abuse Services, 1450 Western Avenue, Albany, New York 12203; 518-473-3460; Email: communications@oasas.ny.gov.
  • For Louisiana: Karen Stubbs, Assistant Secretary, Office of Behavioral Health, Louisiana Department of Health, Post Office Box 629, Baton Rouge, Louisiana 70821-0629; Email: Karen.Stubbs@la.gov.
  • For Delaware: Elizabeth Romero, Director, Division of Substance Abuse and Mental Health, Delaware Department of Health and Social Services, 1901 North Du Pont Highway, Main Building, New Castle, Delaware 19720; 302-255-9399; Fax: 302-255-4427 or Jill Fredel, Communications Director, Office of the Secretary, Delaware Department of Health and Social Services, 1901 North Du Pont Highway, Main Building, New Castle, Delaware 19720; 302-255-9047.
  • For West Virginia: Bill J. Crouch, Cabinet Secretary, West Virginia Department of Health and Human Services, One Davis Square, Suite 100 East, Charleston, West Virginia, 25301; 304-558-7899; Fax: 604-558-7075; Email: DHHRCommunications@wv.gov.

The good news: 84% of specialty provider organizations have an electronic health record (EHR). The bad? Hardly any specialty provider organizations have health information exchange (HIE) capabilities—at last count, less than half could exchange data (see IT Spending Follows The Money).

Why is this bad news? Our team has written before why HIE is essential for specialty provider organization survival. It’s the key for participating in integrated care, whole person care, social determinants initiatives, and much more. But, HIE and more data sharing flexibility may become mandatory. Last year, the Centers for Medicare & Medicaid Services (CMS) final rule for the Medicare and Medicaid Promoting Interoperability Programs emphasized measures that require the exchange of health information between provider organizations and consumers (see CMS Finalizes ‘Promoting Interoperability’ Rule For Hospitals and CMS Shifting Data Control To Consumers: Are You Ready To Share?).

Now the other shoe has dropped: In February CMS issued another proposed rule that requires health plans to provide members with immediate electronic access to medical claims data and other electronic health information (EHI), such as diagnoses, procedures, tests, and the provider organizations/clinical professionals seen, by 2020. The rule affects Medicare Advantage organizations, Medicaid managed care plans, state Medicaid agencies, state Children’s Health Insurance Program (CHIP) agencies and CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) in the federally-facilitated health insurance marketplace exchange (FFE). The proposed rule requires that organizations do the following:

  • Implement an openly-published Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) application programming interface (API). This will make patient claims and other health information available to patients through third-party applications and developers.
  • Support electronic exchange of data for transitions of care as consumers move between plan types (Medicare, Medicaid, CHIP, QHP issuers in the FFEs). This data includes information about diagnoses, procedures, tests, and the provider organizations/clinical professionals seen.
  • Use an API to display and facilitate member search of the health plan provider organization network.
  • Participate in a trusted exchange network with other health plans and with provider organizations which would allow them to join any health information network they choose and be able to participate in nationwide exchange of data.

What this means for stakeholders is a need to commit to finding a common understanding of what they are measuring and what measurements will provide value in the exchange of data. Most health plans already have mechanisms in place to provide this information electronically and chances are that this information could be made available to other health plans, health information exchanges, or other data sharing applications. OPEN MINDS Senior Associate Sharon Hicks noted that long-term success relies on reaching this common market definition of “value”:

The issue is less a technical data sharing issue than it is a question about what information is meaningful and useful. Paid claims information is not clinical information, it is simply a record of a clinical service that was delivered and proof of payment for same. It’s utility for medical decisionmaking has not been tested and may in fact be limited. We need to assure that we have a common language before we assume that sharing information will help improve health care.

To prepare, what should your management team do? OPEN MINDS Senior Associate Chris Williams explained that provider organizations need to start with an assessment of their current data sharing capabilities and a comprehensive review of the organizations they should be exchanging consumer data with in their market. In the new market realty, organizations need to understand who they need to connect with specifically and find the tech tools that enable that data sharing capability. He explained:

Which entities will you be required to connect with and share information—health plans? State payers? Other provider organizations? How will that process work? Understand at a deep level, how your reimbursement model functions within information exchange model. This is critical because under these new regulations, health plans will need to provide consumers access to every one of their claims. (Let that sink in for a moment.) Your starting point is to assess and understand the technology you have, compared to the technology you’ll need to comply, execute, and exchange information within your immediate network of payers and other provider organization partners—and potentially beyond.

EHRs, HIEs, and EHI are all critical to provider organization participation in the evolving health and human service system-critical for long-term sustainability. For more on meeting that challenge, check out these resources from the PsychU Resource Library:

  1. Is Your Organization Data Reactive – Or Data Predictive?
  2. Moving EHR Investments From ‘Must Do’ To ‘Must Have’
  3. IT Spending Follows The Money
  4. You Have An EHR, But Can You Share Data?
  5. Data Exchange Via Mail & Fax? In Today’s Market?
  6. Moving Out Of Your Comfort Zone: The VBR Technology Continuum
  7. Are You Strategically Interoperable?

Background

Burnout – measured in terms of emotional exhaustion, cynicism, and sense of professional efficacy – continues to be an issue among health care providers. Mental health providers are believed to be at a high risk for burnout due to the very nature of their jobs; they are often exposed to traumatic material and must withhold emotions and reactions while providing services. The Veterans Health Administration (VHA) is the largest single provider of mental health services, with a high percentage of the population they treat seeking services for posttraumatic stress disorder (PTSD).

There are many factors that may contribute to provider burnout at the VHA – a heavily monitored and highly public agency governed by bureaucratic and political oversight. Quality and performance of the agency is regulated by a vast number of administrative performance metrics alongside a myriad of rules and policies. On top of the sheer amount of evaluative metrics, care at the VHA must constantly live up to public scrutiny, as VHA performance is often reported to Congressional Oversight Committees and through national media outlets. Lastly, political pressure to provide specific diagnoses and treatment options to patients under their care may be a unique experience among providers at the VHA. Accessing benefits and treatment, or continuing treatment, is a major and highly-publicized concern amongst beneficiaries – and the pressure to conform to specific diagnoses or treatment against independent judgement may exist, as providers don’t want to be labeled “anti-veteran.”

A recently published article in Mental Health & Prevention, “Occupational burnout among PTSD specialty clinic providers in the Veterans Health Administration: Perceptions of bureaucratic and political oversight,” written by Hector A. Garcia, Justin K. Benzer, Elizabeth Haro, and Erin P. Finley, attempts to measure the impact of such pressures amongst VHA staff providing services through PTSD specialty clinic teams (PCTs). Specifically, the authors investigated the burnout risk and protective variables presented in Figure 1.

Background & Purpose

Unfortunately, for many individuals living with serious mental illness (SMI), presentation of their illness may include experienced lethargy, leaving them less active than their otherwise healthy peers. Additionally, some antidepressant and antipsychotic medications can place patients at a higher risk for metabolic disorder, which is associated with poorer physical health and comorbid physical health conditions like cardiovascular disease. Physical health problems can in turn depress patient mood, affect psychosocial functioning, and negatively impact other lifestyle outcomes. There is a plethora of research indicating that increased physical activity and changes to diet can positively impact patient quality of life (QoL). However, populations included in these studies have mostly been recruited from or treated in outpatient programs. Due to the limited population, findings may not be generalizable to patients living with SMI receiving treatment within an inpatient setting.

Recently, a program aimed at improving sedentary lifestyle and metabolic health was implemented amongst a patient population with SMI in an inpatient setting. This Multidisciplinary Lifestyle Enhancing Treatment For Inpatients With SMI (MULTI) demonstrated overall improvements in the physical health of patients over the long-term. If improving QoL for patients with SMI is one of mental health treatment’s key outcomes, professionals cannot ignore the benefits of physical activity and healthy lifestyle habits. However, more intangible factors of improved patient lifestyle – like psychosocial functioning and QoL – are also important, though less well-studied. Jeroen Deenik and colleagues examine the improvements in these factors amongst the MULTI participants in a secondary, cohort analysis of the program’s findings. Their study results were released in, “Improved psychosocial functioning and QoL in inpatients with severe mental illness receiving a multidisciplinary lifestyle enhancing treatment. The MULTI study II,” published in October 2018 in Mental Health & Physical Activity. In addition to investigating whether MULTI improved other lifestyle factors for inpatients with SMI, the authors also examine if physical health improvements have an amplifying effect on demonstrated positive outcomes.

In December of last year, the Centers for Medicare and Medicaid Services (CMS) released guidance to state Medicaid programs on how to better serve consumers who are dually eligible for Medicare and Medicaid. The guidance recommended that states leverage managed care models to better ingrate care for dual eligible populations, including existing dual eligible special needs plans (D-SNPs) and Programs of All-Inclusive Care for the Elderly (PACE). The guidance also referenced new opportunities for states to improve data exchange and streamline the enrollment.

But the general direction of these recommendations seems to run counter to the market numbers. One example is PACE, a program that has been part of Medicare in some form since the 1990’s. Though PACE programs have been able to show some positive results, in 2019, there were about 49,000 consumers enrolled in PACE programs in 31 states—that’s just 0.04% of the 12 million consumers who are dual eligibles. PACE programs in many states only have a few hundred enrollees.

Another example: enrollment in the much-touted dual eligible demonstration projects are not growing. Started in 2012, 13 states tested integrated financing models for their dual eligible populations through a waiver program. Though several states extended their original demonstration programs and shown some positive outcomes, only three states have been extended their projects through 2020—Massachusetts, Minnesota, and Washington. The other states have opted to end their programs, and there is little comprehensive data about the return on investment for these models (see Dual Eligible Demonstrations: Where Are We 4 Years Later?).

Why does this matter? The dual eligible population is one of the most expensive populations to serve. The dual eligible population represent 20% of all Medicare enrollees and accounted for 34% of all Medicare spending. In Medicaid, the dual eligible population represented 15% of all Medicaid enrollees and 32% of all Medicaid.

It appears that the path forward for provider organizations serving the dual eligible population will continue to involve navigating separate health plans for the same consumer, with separate health plans for Medicare and for Medicaid long-term services and supports. For provider organization administrative and clinical team members, this was simpler when both Medicare and Medicaid were fee-for-service plans. But we now have an increasing number of consumers in Medicare managed and of the 21 states with Medicaid managed long-term services and supports (MLTSS), 19 have included dual eligibles in their population.

If your organization serves dual eligible consumers—whether you are with a provider organization, a care coordination entity, a health plan, or a government agency—there will likely be more administrative complexity for more consumers. There are three administrative competencies that will become more critical as we see fewer dual eligible consumers in a single integrated health plan and more of the services for these consumers in separate managed care plans. First, there is the ability to “braid” services at the consumer level—making services paid by different health plans a seamless consumer experience. Second, there is the ability to participate in multiple approval processes for the same consumer—from prior authorizations, to care coordination, to coordination of benefits and more. Finally, organizations with health information exchange capabilities with the multiple organizations financing or delivery services for dual eligible consumers have a distinct advantage—clinically, financially, and in consumer experience.

Psychiatric facilities in the United States spend about $1.7 billion annually to comply with Medicare Conditions of Participation (CoPs) set by the Centers for Medicare & Medicaid Services (CMS). The cost of compliance represents about 4.8% of an average facility’s annual revenue for all inpatient psychiatric services from all sources. Key sources of compliance costs include the following:

  • Federal regulatory domains attached to participation in the Medicare program: standards for consumer screening and evaluations, medical records and treatment plans, and director qualifications for inpatient psychiatric facilities. These are called B-Tag requirements.
  • The burden of standards focused on “ligature risk points” in the facility physical environment. These standards are intended to help prevent self-strangulation.
  • The burden posed by the Emergency Medical Treatment and Labor Act (EMTALA) requirements to screen all consumers for emergency medical conditions, and, if an emergency condition is identified, involuntary admission to stabilize the individual before the individual may be discharged or transferred. The services must be provided without regard for whether or not the consumer can pay for the services.

There were 1,738 inpatient psychiatric hospitals in 2016, which included 580 freestanding psychiatric hospitals and 1,158 general acute hospitals. In fiscal year 2019 psychiatric hospitals provided 25.4 million inpatient days, and received an estimated $35.4 billion in all-payer net revenue according to data collected by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). The cost of compliance with the Medicare CoPs in the three domains was based on survey responses provided by 62 inpatient psychiatric facilities. Overall, the 62 facilities reported their annual per-day cost of complying with the CoPs, and the share of revenue represented by that cost. On average, the responding facilities devoted 4.84% of revenue to cover the CoPs. Using the 4.84% cost of compliance reported by the survey participants, across all 1,738 inpatient psychiatric facilities, with revenue estimated at $35.4 billion the total cost of complying with the CoPs was estimated at $1.7 billion. The estimated per-facility cost was $985,822. The estimated per-bed cost was $18,362.

These findings were reported in “The High Cost of Compliance: Assessing the Regulatory Burden on Inpatient Psychiatric Facilities” by researchers with Manatt Health for the National Association for Behavioral Healthcare (NABH). The researchers worked with members of NABH’s Regulatory Overload Task Force. A total of 62 inpatient psychiatric facilities were surveyed. The goal was to determine the level of financial resources required to fulfill the Medicare CoPs in three domains: regulatory (B-Tag requirements), physical environment and monitoring to mitigate/abate ligature risk, and screening and stabilization requirements of Emergency Medical Treatment and Labor Act (EMTALA).

B-Tag Requirements

  • National annual costs for regulatory burden are estimated at $622 million, representing 1.8% of all-payer revenue. The average annual cost per bed is estimated at $6,698.
  • About 77% of freestanding psychiatric hospitals report at least one B-tag citation in their most recent three compliance surveys.
  • B-tags produce frequent citations and impose large costs on providers, mostly through low-value documentation requirements.
  • Neither the rules nor the guidance for psychiatric patient evaluations, medical records, and staffing have been meaningfully updated since they were issued in 1966. Most believe these requirements are no longer appropriate in today’s environment of care.

Ligature Risk

  • National annual costs for ligature risk regulatory burden are estimated at $880.4 million, representing 2.5% of all-payer revenue. The average annual cost per bed for the most recently complete fiscal year was $9,422.
  • On average, provider organizations spent more than $15,600 per psychiatric bed on physical plant and equipment costs to address ligature-related issues over the past five years and is projected for the next fiscal year.
  • About 61% of respondents reported a ligature-related citation in the last two years.
  • Some surveyors demand major changes to psychiatric facilities’ infrastructure or staffing to address perceived issues that carry only minimal risk for consumers in that setting.

Emergency Medical Treatment and Labor Act (EMTALA)

  • National annual costs for EMTALA regulatory burden are estimated at $209.6 million, representing 0.6% of all-payer revenue. The average annual cost per bed is estimated at $2,243.
  • Some regulators have begun interpreting EMTALA in a manner that imposes new requirements on psychiatric facilities that goes above and beyond. These include raising the baseline licensure requirements for “qualified medical persons” (QMPs) who may screen patients for emergency medical conditions; and requiring all inpatient psychiatric facilities with an emergency department to accept involuntary commitments,  even if properly trained staff are not available to handle a particular individual.

The researchers recommended that CMS rationalize these regulations to minimize the burden on provider organizations, especially in areas where provider organization compliance costs could be reduced without significantly affecting consumer care. Consumers may also benefit from these strategies because health care professionals can shift more of their attention and resources from compliance to care. Specifically the researchers recommended the following for each domain:

  • For B-tag requirements, CMS should remove unnecessary documentation requirements, and direct surveyors to limit their review to whether a provider has adopted a reasonable approach to compliance.
  • For ligature risk, CMS should issue updated guidance to standardize survey practices for ligature risk, minimize the risk of redundant renovations related to ligature risk, and clarify the level of ligature-resistant physical spaces that are actually required.
  • For EMTALA, CMS and the U.S. Department of Health & Human Services Office of Inspector General (OIG) should ensure that surveyors respect EMTALA’s clear direction that each provider’s medical staff may decide for itself which clinical professionals are competent to screen for emergency medical conditions, subject to applicable state licensure laws that define clinical scope of practice; EMTALA should not be used to address the shortage of facilities that treat involuntarily committed consumers; and Federal regulators should respect state procedures for involuntary commitment, including state arrangements for facility designation and consumer transfer.

The full text of “The High Cost of Compliance: Assessing the Regulatory Burden on Inpatient Psychiatric Facilities” was published on March 19, 2019 by the National Association for Behavioral Healthcare. A copy is available online at https://mazusw1wa001.azurewebsites.net/getattachment/e788505e-5485-409c-b24f-efa19144dfd2/attachment.aspx (accessed April 9, 2019).

PsychU last reported on this topic in

For more information, contact: Jessica Zigmond, Director of Communications, National Association for Behavioral Healthcare, 900 17th Street Northwest, Suite 420, Washington, District of Columbia 20006; 202-393-6700; ext. 101; Email: jessica@nabh.org.

Clinical practice patterns in the U.S. have always had great variance. Over the past 35 years, since The Dartmouth Atlas Study, research has documented great geographic variations in health care practices. These variances do not necessarily correlate with quality of care. These issues are magnified for consumers with complex care conditions and chronic conditions—with often unstudied complications of comorbid conditions and unmet social support needs.

This variance, and how actual service delivery varies from clinical guidelines, has always been of concern to policymakers—because of the implications for quality of care and cost. Two recent changes in the health and human service delivery landscape are bringing new attention to clinical practice patterns and clinical guidelines. The first is the move to include financial risk in the reimbursement contracts of health plans, health systems, and provider organizations—particularly risk that is focused on reducing duplicative and unnecessary care delivery. The second is the addition of consumers with behavioral and cognitive conditions, and consumers with more complex social support needs, to these risk-based and value-based contracting models.

The challenge is one of incentives. In fee-for-service (FFS) and cost-based reimbursement models, while there was significant variance in clinical practices, there was only a financial incentive to provide too many services to consumers. As we move to more financial risk borne by health plans and provider organizations, the financial incentives skew to providing too few services. While “over treatment” is not great for consumers, “under treatment” can be life threatening.

I think this means we can’t continue to separate clinical practice guidelines from risk-based and value-based reimbursement models. When the management team of an organization develops rates for any type of alternate payment model, they make assumptions about the needs of the consumers they will serve—and the number and types of services those consumers will use. Essentially, the clinical practice guidelines become part of their pricing methodology. And, if the payers don’t specify the clinical guidelines to be used, the organization will use their own clinical guidelines as assumptions in that rate development.

The results of the disconnect around clinical guidelines are bubbling up in press coverage and lawsuits (see To Improve Consumer Care In Medicaid & Beyond: Define Value & Make It Public and Judge Rules United Behavioral Health Medical Necessity Criteria More Restrictive Than Accepted Standards). I think this conflict will continue and grow more acute. The Patient Protection & Affordable Care Act (PPACA) requires health plans to publish their clinical guidelines. Are they easy to understand or specific enough about clinical decisionmaking? Take a look at these examples:

  • UnitedHealthCare’s clinical guidelines for the treatment of bipolar disorder refer clinical professionals to the American Psychiatric Association’s practice guidelines.
  • Aetna’s clinical policy for the treatment of Autism Spectrum Disorders (ASD) relies on information from the American Academy of Child And Adolescent Psychiatry and the National Academy of Sciences and outlines specific services that may be included in treatment and assessment.
  • Cigna’s clinical practice guidelines for the treatment of depression refer clinical professionals to the American Psychiatric Association’s practice guidelines for the treatment of depression and the U.S. Preventive Services Task Force guide for screening for depression.

The question is how to get clinical practices in sync with the emerging VBR models. When I asked my colleagues, the consensus was the financial incentives that go beyond cost reductions are critical—as well as public performance data that is available to consumers, advocates, and clinical professionals. OPEN MINDS Senior Associate, David Young noted:

States and sometimes the Feds talk about quality care but in reality, health plans and provider organizations provide ‘legally’ acceptable care; they meet the terms of the contracts. Despite what that means to end users, that care is what we get.

OPEN MINDS Senior Associate Ken Carr went on to talk about incentivizing consumer outcomes and quality of care. He noted:

I agree that commonly accepted standards of care, or those standards included in contracts, may not represent “best practice” outcomes, especially for unique situations. With most politically charged issues like this, understanding the root causes of what causes unacceptable results is key. It is easier to blame bad people and organizations—and they do exist. But the issues are often a result of how resources flow, who has the power to make decisions, and whether fair, efficient processes (with an element of compliance) have been established.

The question is what the best approach for is driving results—implementing strict regulatory controls or aligning funding with incentives to motivate and empower results.

From a value-based perspective, aligning how resources flow to motivate health plans and provider organizations to achieve agreed upon results—care coordination, integrated services, consumer access, for instance—has been shown to deliver results. There are many examples of how this incentivized approach has increased quality services and driven down service costs. I like the concept of making health plan and provider organization results public because transparency addresses the compliance element. While we will always need regulations and compliance committees for those who lack ethical behavior, transparency of results motivates most of us (health plans and provider organizations alike) who really want to do the right thing for the consumers that we serve.

“Standards of care”—medical necessity, clinical appropriateness, social/legal necessity, consumer entitlement, community standards—are certainly not agreed upon across the health and human service field. But, even with agreement on a set of clinical guidelines doesn’t end the challenges for consumers. Published guidelines don’t necessarily change clinical practice patterns and the clinical decision support tools needed to do just that are not in common practice. As we see more “pay for performance” across the health and human service systems, managers of every organization will be looking for tools to measure clinical practice variance in their own organizations—and tools make the use of “best practices” the rules, rather than the exception.

A series of news stories released over the past year out of Texas has caught my attention—and the attention of legislators and advocates in Texas. Last year The Dallas Morning News published a series of investigative reporting articles, Pain & Profit, on the services delivered under the state’s Medicaid health plans. The series is extensive, but the overall theme was that the state’s Medicaid consumers suffer from “poor state oversight” allowing “companies to skimp on essential care for sick kids and disabled adults” and that “8,000 and 14,000 people were probably not receiving the care they needed.”

The article ends with a series of recommendations, including pushing state policymakers to address the problems with capitated funding (specifically medical loss ratio requirements), mandating care coordination, addressing access issues, approving medical guidelines, standardizing the appeals process, providing opt outs of bad health plans for vulnerable populations, and tracking performance. As is common in the wake of investigative journalism that publicizes problems, there is now a bipartisan groundswell to revamp the Texas Medicaid system, with more than a dozen bills.

I think there are two issues at play here: One, there needs to be some standards of care that are uniformly agreed to by policymakers, payers, health plans, and provider organizations. And two, it is important to have standardized systems for incentivizing health plans and provider organizations to meet and exceed those standards of care.

The first issue comes down to the challenge of defining what constitutes “good care.” One of the ubiquitous challenges across the U.S. health and human service system is in definitions. This is not limited to Medicaid health plans. Determining what is “legally acceptable care” is one issue—this relates to the contract terms when states and counties buy health care systems and services from health plans, ACOs, provider organizations, and individual professionals. Less clear is what the “commonly accepted standards of care” are and whether these “commonly accepted standards of care” are what we want. Finally, there is the question of what “guidelines” (for medical/clinical necessity, appropriateness, and/or entitlement) should be incorporated in service contracts. These issues are some of the most fundamental to health and human service policy, budgeting, operations management, and consumer experience. Performance cannot be measured until it is defined.

The second issue is about incentives and accountability. I’m all for incentivizing health plans and provider organizations to deliver “value”, however it is defined. But the usual caveats apply: Aligning measures to performance objectives is key. The cost of tracking and measuring performance must be taken into consideration. And, incentives (particularly financial incentives) do change behavior, which means states, counties, and health plans must “choose wisely” when it comes to those incentives. Our team has designed enough value-based contracting systems that we have created a standard development process that starts with objectives, focuses on priorities and feasibility testing, and requires structured implementation testing. Measuring performance should be a given—and paying for that performance should be incorporated in contracting plans.

In addition, states and counties buying health and human services should move beyond measuring and paying for performance—and introduce consumerism into the equation with public performance reporting. Making performance metrics public—in a format that allows easy comparisons between health plans or provider organizations by both consumers and professionals—is key to creating a continuously improving delivery system. Even if the state, county, or health plan doesn’t pay financial incentives, public performance data is powerful. I once worked for a state Medicaid director who created a public performance dashboard for mental health service provider organizations in his state. When I asked why he did this, since he wasn’t allowed to pay penalties or bonuses, he said it changed the behavior of the worst performers. His exact phrase: “No CEO wants to be on the bottom of the list for more than one quarter.” That lesson has stuck with me.

I’m not hopeful that there is an easy path to resolving the issue of health and human service “best practice” guidelines. There is great work going on for some disease states, in some geographies—but there appears little agreement about how best to make decision support a reality across the system of care. I do think that payers can agree on some minimum metrics of what constitutes good performance. And, I think that the payers can speed the discussion of “best practices” by making their performance data comparable and public. I believe that most people working in the health and human service field—at every level, in most types of organizations—want to do well for the consumers they serve. Making performance data available (for their own organization and others) is a fundamental piece of making that happen.

For more on public performance reporting in the health and human service field, check out our coverage of these performance-based programs:

  1. CMS To Resume Terminating Medicare Advantage Plans With Low Quality Star Ratings
  2. ACOs Saved Medicare $660 Million Over Four Years
  3. CMS Awards 7 Agreements For Performance Measure Development For Medicare’s Quality Payment Program
  4. Nearly 11,000 Skilled Nursing Facilities Receive Medicare Rate Cut Due To Hospital Readmission Rates
  5. New Hampshire Medicaid Implements MCO Capitation Rates Linked To Performance
  6. New York Medicaid Releases Revised 2019 Health & Recovery Plan VBP Quality Measure Set

Denver’s pay-for-success, supportive housing social impact bond (SIB) has seen an 85% success rate from its creation in January 2016 through December 2017. During that period, the five-year program had served 285 individuals experiencing chronic homelessness, and 241 (85%) of these individuals had successfully retained their housing from the time that they signed their lease.

The Denver SIB program was created in a partnership of the City and County of Denver and Denver PFS LLC, an entity established by the Corporation for Supportive Housing and Enterprise Community Partners. The program’s goal is to assist those in a homelessness-jail cycle by providing them with supportive housing and accompanying services. Individuals are referred to the SIB through the Colorado Coalition for the Homeless (CCH) and Mental Health Center of Denver (MHCD) by the Denver Police Department (DPD). CCH and MHCD then go through a location process to offer individuals the chance to take part in the SIB program. If individuals elect to participate, assistance is given to locate a housing option and submit a housing application. Once an individual’s housing application is approved, they can choose to start a lease and continue to fully participate in the program. The housing stability outcomes are based on a measure of total adjusted days in housing. Success is achieved when the participant remains in housing for at least 365 days without any episodes away from housing for greater than 90 days or has a planned exit from housing at any point.

The SIB combines two assistance methods to help those with permanent supportive housing (PSH) needs:

  • Housing First: a homeless assistance approach that prioritizes providing permanent housing to people experiencing homelessness. The approach combines immediate housing with supportive services to both offer a sense of security, and the ability to pursue personal goals and improve their quality of life. A Housing First approach can benefit both homeless families and individuals with any degree of service needs.
  • Assertive Community Treatment (ACT): a mental illness assistance approach that aims to eliminate or reduce the symptoms of severe mental illness and to enhance the individual’s quality of life. ACT offers education about an individual’s illness; individualized treatment in either health care facilities, or an individual’s own home; long-term services; vocational assistance, and integration into the community.

Specifically, the Denver SIB program provides the following services:

  1. Subsidized housing
  2. An Assertive Community Treatment (ACT) team
  3. Behavioral health services, including psychiatric services, individual and group therapy, and substance use treatment
  4. Links to community resources (e.g., food resources, legal referrals and advocacy) and to integrated health services (e.g., medical, dental, vision, and pharmacy services)
  5. Transportation assistance and referrals

These findings were presented in “From Homeless to Housed: Interim lessons from the Denver Supportive Housing Social Impact Bond Initiative,” by the Urban Institute, The Evaluation Center at the University of Colorado Denver, and The Burnes Center on Poverty and Homelessness at the University of Denver. The evaluators used a randomized, controlled trial design, assigning eligible individuals to a treatment group and a 361-person control group. Analysis is restricted to the treatment group so that engagement patterns can be tracked for the six months after referral. To measure outcomes and impact for these individuals, the evaluators collected administrative data from a number of sources of interest, such as jails, courts, detox units, homeless shelters, and hospitals. The goal was to determine the success of Denver’s SIB.

Additional findings of the report include:

  • Between January 2016 and December 2017, 363 individuals were referred to supportive housing.
  • During this time, it took an average of 20 days to engage participants in the program. This includes locating those referred to the program, and the time it took for the individuals to agree to participate in the program.
  • Within six months of referral, 68% of individuals had approval to move forward with supportive housing. About 63% of individuals signed a housing lease within these six months.
  • During the three years before referral to the program, individuals in the program had an average of 14 arrests per person between 2013 and 2015: on average, 12 of these arrests happened when the individual identified as transient.

The social impact bond was created after the discovery that the cost of providing safety-net services to 250 of Denver’s homeless individuals is approximately $7 million per year. This includes 14,000 days in jail, 2,200 visits to detox facilities, 1,500 arrests, and 500 emergency room visits. These services add up to an average yearly cost to taxpayers of $29,000 per individual served. The SIB program was put in place through a $23.7 million total investment. About $15 million of this investment was from federal resources, while the other $8.7 million was provided by eight local organizations, which have received repayments totaling $1,025,968 from the city, based on the program’s outcomes so far:

  1. The Denver Foundation
  2. The Piton Foundation
  3. Ben and Lucy Ana Walton Fund of the Walton Family Foundation
  4. Laura and John Arnold Foundation
  5. Living Cities
  6. Nonprofit Finance Fund
  7. The Colorado Health Foundation
  8. Northern Trust Company

In launching the program, the City and County of Denver developed an agreement with Denver PFS LLC, an entity established by the Corporation for Supportive Housing and Enterprise Community Partners, to execute the Denver SIB. In the first year, CCH provided supportive housing services. Along with CCH, Mental Health Center of Denver (MHCD) provided supportive housing services in the second year of the program. Denver Crime Prevention and Control Commission provided staff for the program referral process, and the Denver Police Department (DPD) provided administrative data for the evaluation. The Urban Institute is conducting a five-year randomized controlled trial evaluation and implementation study in collaboration with partners from the Evaluation Center at the University of Colorado Denver and the Burnes Center on Poverty and Homelessness at the University of Denver.

The full text of “From Homeless to Housed: Interim lessons from the Denver Supportive Housing Social Impact Bond Initiative” was published in November, 2018 by the Urban Institute. A copy is available online at https://www.urban.org/research/publication/homeless-housed-interim-lessons-denver-supportive-housing-social-impact-bond-initiative/view/full_report (accessed April 2, 2019).

PsychU last reported on this topic in “Denver Supportive Housing Social Impact Bond Initiative Earns The First ‘Success Payment’ For Project Investors,” which published on June 13, 2018.

For more information, contact:

  • Cathy Alderman, J.D., MSPH, Vice President of Communications and Public Policy, Colorado Coalition for the Homeless, 2111 Champa Street, Denver, Colorado 80205; 303-312-9638; Email: calderman@coloradocoalition.org
  •  Kiki Turner, Communications Associate, Department of Finance, City and County of Denver, 201 West Colfax Avenue, Denver, Colorado 80202; 720-913-1589; Email: Kiki.Turner@denvergov.org
  • Dan Fowler, Senior Media Relations Manager, Urban Institute, 2100 M Street NW, Washington, District of Columbia 20037; 202-261-5554; Email: DFowler@urban.org

Where do mandated staffing ratios fit in value-based care? Do lower staffing ratios for clinical professionals improve the quality of care? The data isn’t clear about the benefits of lower staffing ratios and there is a wide range of state-specific regulations related to clinical staffing ratios.

Across the health and human service market, staffing ratios play a big role, but look very different depending on the type of organization, type of program, and the state where the program in operating. For residential and inpatient care for behavioral health and intellectual and developmental disability (I/DD) services for children and adults, staff ratios are a historically integral component to program description and design. There are no federal regulations, and these ratios are outlined by each states as a part of their licensing and operations standards. Ratios are found for 24-hour residential sites and inpatient psychiatric care, but not for outpatient-based care.

In community-based behavioral health residential care, the compliment of staff by education and experience is what is mandated through state regulation (i.e., one BA-level staff for each eight-hour awake shift and one master’s level clinical professionals for every 24-hour period). This is the states’ oversight activity to insure public safety and presumably provide a minimum standard of care. Broadly across the industry—including nursing homes, 24-hour behavioral health facilities, and 24-hour I/DD facilities—ratios exist as determined by the type of facility license issued. This is determined by acuity of population served, number of beds, age of consumers, and environment of care. Formulas vary by state but generally follow a 1:5 (staff-to-consumer) ratio during waking hours. For example, sampling the category of community-based residential care in three states (New Jersey, Illinois, and Texas) shows:

  1. New Jersey—On awake hours, a 1:6 ratio must be met. On overnight hours a 1:12 ratio must be met.
  2. Illinois—A 1:5 ratio must be met, or a 2:6 for six or more consumers.
  3. Texas—No minimum ratios.

In each of these examples staff is defined as a direct care support worker with a high school education. In looking across state regulations for community-based residential care the phrase, “Minimum staffing required to meet the needs of the population” is common along with definition of qualifications to fill roles such as manager, social worker, psychiatrist, and residential care worker.

Contrast this to the health care field where, though not standardized or regulated at the federal level, some states do require specific nurse staffing ratios for inpatient hospitals and inpatient rehabilitation facilities. A total of 14 states have some form of nurse staffing regulations. Of these states, California is the only one that has both mandated and implemented staff-to-consumer ratios.

In nursing homes and skilled nursing facilities, there are some basic federal discipline-specific requirements related to nurse staffing. The Centers for Medicare and Medicaid Services (CMS) guidelines for skilled nursing facilities and nursing homes that accept Medicare and Medicaid require facilities to provide licensed nurses 24 hours a day, which are “sufficient” staff to meet the needs of each resident and a registered nurse (RN) a minimum of eight consecutive hours per day, seven days a week. Most states have additional staffing requirements addressed through regulations and licensing standards. These staffing requirements are more often in the form of discipline-specific requirements for a specified number of hours. For example, there may be state regulations for skilled nursing facilities that must be staffed by a full-time master’s level social worker for 100 or more beds. For less beds, social work functions can be carried out by a variety of staff.

With this variety of regulations and lack of clear definitions, staffing ratios have become a political issue. There are two bills at the federal level, one in the House of Representatives and one in the Senate mandating nursing ratios in acute care settings including skilled nursing care facilities, psychiatric facilities, and rehabilitation facilities. Most recently we saw a ballot initiative placing limits on the number of consumers that a nurse would have responsibility for, fail to pass with voters after a record-breaking $25 million was spent by the Massachusetts Health & Hospital Association to defeat it. According to the MHA, the initiative would have reduced access to services and significantly increased cost of health care. In contrast, the Massachusetts Nurses Association spent $12 million to advocate in favor of the ballot initiative. This is just one example of the opposing forces that are continuously at odds when it comes to staff-to-consumer ratios. The reasoning of the opposition is that if staffing ratios are mandated and unable to be met, units will “limit” the number of consumers admitted, causing a negative cascading effect on care, while those in favor of mandated ratios say that it will enable better quality consumer care.

One issue is whether the use of technology is going to change how we view staffing ratios. We’ve written about how technology is replacing some health care service functions and making workers more “efficient” (Workforce Problems? Technology As Strategy; The Staffing Equation For Community-Based Services). Technology can bridge some of the gaps in staffing by augmenting the delivery of care. Remote monitoring of consumer conditions, medication monitoring systems, electronic appointment reminders, online cognitive therapy, and telehealth are all virtual care options that create efficiencies and can help to amplify staff. As we move into a more value-based financing systems, there is a much bigger bang for your buck by spending health care expertise on innovation and virtual care than simply adding more staffing.

For many executives of provider organizations, standards around staffing issues don’t represent a value-add, but rather another strategic and administrative challenge to overcome—particularly when faced with no increases in fee-for-service (FFS) rates and workforce shortages. As we have discussed before, knowing your numbers and understanding your drivers of cost are critical. Leading and managing by well-defined key performance indicators help drive your strategy for sustainability and growth. This squeeze is part of the formula of strategic decisionmaking for the future and how to achieve the size and scale to sustain an organization with programs that have a design based in a FFS world.

The cost of mandated staffing levels is one of many reasons behavioral health care provider organizations have been slower to jump into value-based care arrangements—fixed costs aren’t correlated with value added. Executives of provider organization are somewhat squeezed between the state regulatory requirements to operate a facility and the costs that are not necessarily compensated in newer reimbursement rates and models. Prescribed staffing ratios serve a purpose, but are best compensated in an FFS model.

Regulation of health care provider organizations is necessary to assure public safety. Reexamining what should be regulated based on the phasing out of FFS reimbursement models and the growth of value-based care models is worth exploration. This brings us back to the question—do mandated staffing ratios add value? I think in terms of timeliness and safety the answer is yes. I think in terms of improving care outcomes the answer is less clear. The compliment of care inputs drive quality and that is reflected by diverse care teams and innovative treatment offerings augmented by technology. Outcome measures should be defined by providers that directly correlate to the delivery of positive outcomes versus prescriptive input such as staffing ratios. In a value-based care environment, mandated staffing ratios hold less relevance.

The question for executive teams to answer is about balance—is it quality versus quantity? Or is it a little bit of both? In a market focused on value and driven by consumerism, it might be beneficial for provider organizations to ramp up their staffing ratios to deliver a more positive consumer experience. Consumers don’t do well with long waits for service, whether waiting for care while on an inpatient unit or waiting for an appointment as an outpatient. Consumer satisfaction, engagement, and progress declines the longer the consumer waits for a positive outcome. Clearly adequate staffing to provide care is necessary; that is not a question. Quality care is experienced when a consumer has a positive outcome as a result of the input, or efforts, of staff to provide care. Quality care is not experienced just because of the numbers of staff seen by a consumer.

A key to creating reasonable staffing levels is giving health care provider organizations input into defining those numbers based on acuity levels, environmental factors, staff skill, technology augmentation, and measured outcomes of care. Offering care that prioritizes safety, compassion, and individuality as the core components drive far better outcomes than administering programs by the numbers.

While staffing levels do play a role in operations of health care and need to remain a part of standards of care, without clear reasoning for the levels they are just numbers to be dealt with.

On March 7, 2019, the California Department of Health Care Services (DHCS) released draft Medi-Cal value-based payment (VBP) performance measures. The measures are grouped into four domains, and each domain has five measures. The Governor’s budget for fiscal year 2019 -2020 proposed that DHCS implement VBP through Medi-Cal managed care health plans (MCPs) to provide incentive payments to provider organizations for meeting specific measures aimed at improving care for certain high-cost or high-need populations. These risk-based incentive payments will be targeted at physicians who meet specific achievement on metrics targeting areas such as behavioral health integration; chronic disease management; prenatal/post-partum care; and early childhood preventive care. To address and consider health disparities, DHCS proposes to pay an increased incentive amount for events tied to beneficiaries diagnosed as having a substance use disorder or serious mental illness, or who are homeless.

In the draft VBP notice, “California Medi-Cal Value Based Payment Program Performance Measures, March 2019: Proposal For Comment,” DHCS noted that the final set of VBP measures may include some or all of the proposed measures. DHCS also sought comment on additional measures that should be considered for inclusion. When determining these draft measures, DHCS took into consideration several factors including: whether a measure aligned with other DHCS quality efforts; the number of affected beneficiaries; and whether or not the measure could be run administratively, among others. The four domains and the proposed measures eligible for incentive payments are as follows:

  • Prenatal/Postpartum Care, with five measures: prenatal pertussis vaccinations, first trimester prenatal visits, completion of two postpartum care visits, postpartum depression screening within 12 weeks after delivery, and provision of postpartum birth control methods or devices for women between three and 60 days after delivery.
  • Early Childhood, with five measures: Completion of eight well child visits by age 15 months, completion of four well child visits between ages three and six years, completion of full vaccinations for two-year-olds, blood lead screening for children up to age two, and applying dental fluoride varnish for children ages six months to five years.
  • Chronic Disease Management, with five measures: Each event of adequately controlled blood pressure for members ages 18 to 85 years being seen for a diagnosis of high blood pressure, each event of diabetes HbA1c glucose testing that shows better than poor control for members ages 18 to 75 years diagnosed with diabetes, control of persistent asthma for members between age five and 64 years, tobacco use screening provided to members age 18 and older, and influenza vaccine administered to members 19 years and older for individuals with a chronic disease diagnosis.
  • Behavioral Health Integration, with four measures: screening for clinical depression among members age 12 and older, antidepressant medication adherence among members age 18 and older diagnosed with major depression who take an antidepressant for at least 12 weeks, screening for unhealthy alcohol use among members age 18 and older, and member visits to co-located primary care and behavioral health services.

DHCS intends to release additional details about the proposed measure specifications after the measure set has been finalized. The Governor’s budget proposal funds the measure at $360 million annually. The VBP program is to be implemented for at least three years in the managed care delivery system. In the draft VBP proposal, DHCS did not propose dollar values for each program or measure. DHCS intends to set the value of incentive payments after finalizing the measure set and assessing projected achievement. Comments were accepted through March 22, 2019.

PsychU last reported on this topic in “California Revises Medi-Cal Managed Care RFP Schedule; Moves Release Of All RFPs To 2020,” which published on April 22, 2019.

For more information, contact: California Department of Health Care Services; Email: DHCS_PMMB@dhcs.ca.gov.

A Blue Cross Blue Shield of Massachusetts Foundation report has identified emergency room use caused by gaps in the state’s behavioral health continuum. Between 2011 and 2016, the number of behavioral health-related emergency department visits for mental health disorders rose by 9%; the number of emergency department visits for alcohol use disorders rose by 40%; and the number of visits for other substance use disorders (SUD) rose by 54%. Between 2011 and 2015, the share of emergency department visits for behavioral health disorders with length of stay (LOS) lasting 12 hours or more rose from 17.4% in 2011 to 22.8% in 2015. For non-behavioral health-related emergency department visits, the share with LOS lasting 12 hours or more rose slightly from 1.3% in 2011 to 1.4% in 2015. For emergency department visits, the median LOS for those visits with a primary behavioral health diagnosis was 5.4 hours. For visits with a non-primary behavioral health diagnosis, the median LOS was 3.4 hours. For non-behavioral health visits, the median LOS was 2.6 hours.

These statistics and others documenting unmet need and barriers to care in the existing system were reported in “The Massachusetts Behavioral Health Care System: Strengths, Gaps, And Opportunities For Improvement” chartpack released by the Blue Cross Blue Shield of Massachusetts Foundation. The chartpack was issued to accompany the Foundation’s “Ready for Reform: Behavioral Health Care in Massachusetts” report prepared by Stephanie Anthony, Patricia Boozang, Benjamin Chu, and Adam Striar from Manatt Health for the BlueCross BlueShield Foundation of Massachusetts. On behalf of the Foundation, the researchers analyzed the Massachusetts Health Policy Commission’s Annual Cost Trends Report, interviewed behavioral health experts, facilitated discussion groups, and analyzed the Massachusetts behavioral health care system (inclusive of mental health and SUD). The goal was to document and describe the current behavioral health care system for children, adolescents, and adults in Massachusetts, including its strengths and weaknesses; describe a vision for behavioral health care in the Commonwealth; and develop recommendations to strengthen the system to address gaps in the state’s behavioral health continuum that create access problems.

The researchers identified gaps across the behavioral health care service continuum. Some of these include (but are not limited to): training for health care professionals, SUD treatment, emergency service programs, outpatient programs, acute settings, and consumer and data transitioning. Additional details about each were as follows:

  • Primary Care/Screening/Early Intervention: Primary care and other physical health care professionals lack training on techniques for identifying individuals with behavioral health needs, treating those who can be managed in a primary care setting, and providing appropriate referrals for more complex cases.
  • Community-Based Treatment/Recovery Supports: Wait times for outpatient mental health and SUD treatment are long, and the supply of evidence-based treatment (including medication-assisted treatment for addiction) is inadequate. Clinical professionals lack expertise in treating co-occurring mental health and SUD and co-occurring behavioral and physical health conditions.
  • Emergency Services/Crisis Intervention/Urgent Care: Mobile crisis interventions, emergency services programs, and other urgent care programs are underfunded and struggle to hire qualified staff. Commercial insurers do not widely cover emergency services programs. Emergency services programs have historically focused on treating those with mental health conditions, as opposed to SUDs or co-occurring conditions.
  • Intermediate Care Settings: Wait times for partial hospitalization and intensive outpatient programs are long. Financial viability for outpatient programs remains a challenge; this is driven in part by burdensome staffing and licensure requirements.
  • Acute Inpatient Mental Health/SUD Treatment: Capacity is lacking for specialized beds for children with autism and individuals of all ages with intellectual and developmental disabilities. The lack of capacity is driven in part by difficulty hiring and retaining adequate clinical staff.
  • Care and Case Management: Consumers are often “lost” in navigating the transition between settings. Lack of interoperability and ability to exchange data across entities hinders seamless care management.

The full text of “The Massachusetts Behavioral Health Care System: Strengths, Gaps, And Opportunities For Improvement” chartpack was published in January 2019 by the Blue Cross Blue Shield Foundation of Massachusetts. A copy is available online at https://bluecrossmafoundation.org/sites/default/files/download/publication/MA_Behavioral_Health_System_Chartpack_Jan2019_FINAL.pdf (accessed March 20, 2019).

The full text of “Ready for Reform: Behavioral Health Care in Massachusetts” was published in January 2019 by the Blue Cross Blue Shield of Massachusetts Foundation. A copy is available online at https://bluecrossmafoundation.org/sites/default/files/download/publication/Model_BH_Report_January%202019_Final.pdf (accessed March 4, 2019).

Additional information on the Blue Cross Blue Shield of Massachusetts Foundation’s “2018 Massachusetts Health Reform Survey” can be found at https://bluecrossmafoundation.org/publication/2018-massachusetts-health-reform-survey (accessed March 20, 2019).

PsychU last reported on Massachusetts behavioral health services in “Massachusetts Rebids One Care Plans For Duals Demonstration,” which published on March 25, 2019.

For more information, contact: Kaitlyn Kenney Walsh, Ph.D., Senior Director, Policy and Research, Blue Cross Blue Shield of Massachusetts Foundation, 101 Huntington Avenue, Suite 1300, Boston, Massachusetts 02199-7611; 617-246-6116; Email: policy@bluecrossmafoundation.org.

Physicians generate an average of $2,378,727 (per physician) in annual revenue for hospitals. This includes $2,133,273 generated by each primary care physician; and $2,446,429 generated by each specialist physician. This is an increase of about 52% over average annual net revenue generated by all specialties in 2016. Primary care is defined as family practice, general internal medicine, and pediatrics. Specialist care is defined as care in a specific field of medicine.

Revenue generation generally came from direct hospital admissions, procedures performed, lab tests and treatments ordered, and prescriptions written. Indirect revenue that primary care physicians may have generated from patient referrals to specialists utilizing the hospital was not included in the study. While the study collected no solid evidence regarding the large increase from 2016 numbers, researchers propose that the increase may be from:

  • The growing number of employed physicians.
  • The growing volume and cost of hospital services, many of which are provided by physicians or are ultimately derived from physician activities (such as hospital admissions).

These findings were reported in the “Merritt Hawkins’ 2019 Physician Inpatient/Outpatient Revenue Survey.” Merritt Hawkins emailed the 2019 Physician Inpatient/Outpatient Revenue Survey to approximately 3,000 hospital chief financial officers (CFOs) and other financial managers in the U.S. The survey for this report was conducted to track the average annual net revenue that physicians generate for their affiliated hospitals. A total of 62 completed surveys were returned, which provided data on 93 separate hospitals. The goal was to offer benchmark data for hospitals to use to analyze their physician recruiting programs.

Additional findings for the 2019 survey include:

  • The specialty in which physicians generate the most average net annual revenue generated by physicians for their affiliated hospitals is cardiovascular surgery ($3,697,916), followed by invasive cardiology ($3,484,375) and neurosurgery ($3,437,500).
  • The specialty in which physicians’ average annual salaries are highest is neurosurgery ($687,000), followed by invasive cardiology ($590,000), and orthopedic surgery ($533,000).
  • In 2018, 49.1% of physicians were employed by a hospital, a hospital owned group, or physician owned group; 31.4% were independent employment, and 19.5% identified themselves as having “other” employment. No information was given about what constituted “other” employment.

The full text of “Merritt Hawkins’ 2019 Physician Inpatient/Outpatient Revenue Survey” was published February 25, 2019, by Merritt Hawkins. An abstract is available online at https://www.merritthawkins.com/news-and-insights/thought-leadership/survey/2019-physician-inpatient-outpatient-revenue-survey/ (accessed March 8, 2019).

For more information, contact: Phillip Miller, Vice President, Communications, Merritt Hawkins and Staff Care, 8840 Cypress Waters Boulevard, Suite 300, Dallas, Texas 75019; 469-524-1420; Fax: 972-983-0707; Email: phil.miller@amnhealthcare.com.

About 35.7% of psychiatrists accepted appointments for new consumers covered by Medicaid, compared to 70.8% of physicians overall. Psychiatrists accepted appointments for new consumers covered by Medicaid at a much lower rate (35.7%) than they did for Medicare beneficiaries (62.1%) or consumers with private insurance (62.2%). Overall, physicians were less likely to accept appointments for new consumers covered by Medicaid (70.8%) than those with Medicare (85.3%) or private insurance (90.0%).

These findings were reported in, “Physician Acceptance of New Medicaid Patients” by Kayla Holgash and Martha Heberlein. The Medicaid and CHIP Payment Access Commission (MACPAC) contracted with the State Health Access Data Assistance Center (SHADAC) to explore physician acceptance of new Medicaid patients. SHADAC assisted in the analysis of data points collected by the National Ambulatory Medical Care Survey (NAMCS), a survey used to collect data on ambulatory services provided by office-based physicians. The NAMCS represents physicians’ answers of whether their offices were accepting appointments for new consumers, and among those that were, which payment sources they accepted (Medicaid, Medicare, or private insurance). The researchers assessed state factors that could affect acceptance of Medicaid beneficiaries. These factors included managed care penetration rates in 2015, state Medicaid expansion status, and state Medicaid payment rates in comparison to Medicare. The researchers conducted a multivariate analysis to control for state share of the population in poverty, state share of population with Medicaid coverage, state physician supply, physician demographics, and physician employment characteristics.

Pediatricians (78.0%), general surgeons (88.4%), and obstetrician/gynecologists (81.1%) all accepted new Medicaid beneficiaries at a higher rate than physicians overall (70.8%). However, pediatricians accepted new Medicaid beneficiaries at a lower rate (78.0%) than they did consumers with private insurance (91.3%). Additional findings were as follows:

  • Physicians overall in states with high managed care penetration rates were less likely (66.7%) to accept new consumers covered by Medicaid than physicians in states with low managed care penetration rates (78.5%). However, psychiatrists in states with high managed care penetration rates were only slightly less likely (35.4%) to accept new consumers covered by Medicaid than psychiatrists in states with low managed care penetration rates (36.1%).
  • As of January 2015, there was no difference between expansion and non-expansion states in overall rates of acceptance of new consumers covered by Medicaid. Before and after the Patient Protection and Affordable Care Act went live on January 1, 2014, acceptance rates for Medicaid beneficiaries in both expansion and non-expansion states remained the same.
  • Physicians overall in states with a high Medicaid-to-Medicare payment ratio were more likely (81.1%) to accept Medicaid beneficiaries than physicians in states with a low Medicaid-to-Medicare payment ratio (64.5%). Psychiatrists were only slightly more likely (37.4%) to accept Medicaid beneficiaries than psychiatrists in states with a low Medicaid-to-Medicare payment rate (35.3%).

Based on their analysis of other factors that might affect acceptance rates, the researchers found that state Medicaid expansion status and managed care penetration rates were not associated with physician decisions to accept new consumers covered by Medicaid. Medicaid acceptance was associated with the Medicaid-to-Medicare fee ratio. Overall, each one percentage point increase in the ratio increased physician acceptance of new Medicaid beneficiaries by 0.78 percentage points.

For more information, contact: Kathryn Ceja, Director of Communications, Medicaid and CHIP 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.

On February 15, 2019, the New Hampshire Department of Health and Human Services (DHHS) announced the next New Hampshire Medicaid Care Management (MCM) managed care organization (MCO) contracts with AmeriHealth Caritas, New Hampshire Healthy Families, and Well Sense. The plans will be at-risk for physical and behavioral health, as well as pharmacy services, and will feature capitation rates linked to performance. The state’s performance measures seek to ensure MCO accountability for results in addressing addiction disorder, integrating physical and behavioral health, providing robust care management, and reducing unnecessary use of high-cost services.

As of March 19, 2019, the contracts were still pending approval. Once signed, the four-year contracts are collectively valued at $924.1 million over the contract term. The contracts are slated to begin July 1, 2019 and run through June 30, 2024.

The contracts will feature performance measures and a withhold and incentive program; several measures are focused on behavioral health. According to “New Hampshire Medicaid Care Management Program 2020 Withhold & Incentive Guidance,” during the first year the MCOs’ performance will be assessed in three performance categories: Quality Improvement (six measures), Care Management (three measures), and Behavioral Health (two measures).

New Hampshire DHHS Medicaid Care Management Program 2020 Withhold & Incentive Performance Measures
Quality Improvement Care Management Behavioral Health
Frequent (4+/year) emergency department users age 6 and older The percent of MCM members that received a health risk assessment within 90 days of enrollment The percent of community mental health program eligible MCM members that receive Assertive Community Treatment (ACT) services consistent with a fidelity score of 85 or more
Timeliness of prenatal care (HEDIS PPC) The percent of newborns diagnosed with neonatal abstinence syndrome (and parents) who receive care management from the MCO directly, or via a designated local care management entity The percent of MCM members in an emergency department or a hospital setting that are awaiting psychiatric placement for 24 hours or more
Percent of members with polypharmacy who completed a comprehensive Medicaid review and counseling The percent of MCM members that received care management from the MCO directly, or via a designated local care management entity
Adolescent well-care visits (HEDIS AWC)
Follow-up after emergency department visit for alcohol and other drug abuse or dependence – 7 day (HEDIS FUA)
Follow-up after hospitalization for mental illness – 7 day (includes members discharged from NH hospital) (HEDIS FUH modified to include unreimbursed NH hospital stays)

The state intends to withhold 2% of the MCO capitation rate that the MCOs can earn back. The withhold percentages will not be applied to directed payments, such as the MCO capitated payments to community mental health programs. The incentive program, based on the MCO’s performance, will provide an additional payment of up to 5% of the MCO’s qualifying capitation revenue. The MCO performance against the measures in each performance category will be assessed based on the following:

  • The minimum performance standard, which is used to determine whether the MCO is eligible to earn back the withhold payment. The 2020 Withhold & Incentive Guidance document reports the performance measures but does not report the minimum performance standards.
  • The earned withhold performance standard, which will be used to determine the earned withhold amount. To qualify for an earned withhold, the MCO must meet all the minimum performance standards for all measures within a performance category. Failure to meet the minimum performance standards will disqualify the MCO from receiving any earned withhold for the contract year in the relevant performance category. Each performance measure will be score from 0 to 3 points; the measure points will be weighted by performance category and totaled across all measures. The MCOs will be scored relative to the maximum possible points. The earned withhold will be calculated as the total withhold amount in dollars times the percent of possible total points.
  • The incentive payment performance standard, which will be used to determine if the MCO is eligible for any incentive payment. If any MCO does not meet any of the minimum performance standard or all the earned withhold performance standards, DHHS will use the unearned withhold funds to fund an incentive pool through which each MCO that met all the minimum performance standards can earn an incentive payment. The incentive payment will be calculated based on the MCO’s performance relative to its peers in each performance measure for measures where the MCO exceeded the earned withhold performance standard.

PsychU last reported on this topic in “New Hampshire Medicaid Selects Three Health Plans – AmeriHealth Caritas, New Hampshire Healthy Families & Well Sense,” which published on March 25, 2019.

For more information, contact: Public Information Office, New Hampshire Department of Health and Human Services, 129 Pleasant Street, Concord, New Hampshire 03301; 603-271-9389; Fax: 603-271-4332; Email: PIO@dhhs.nh.gov.

Between 2006 and 2014, emergency department visits attributed to International Statistical Classification of Diseases and Related Health Problems, ninth edition (ICD-9) codes related to opioids rose 217% among those aged 65 and older. The adjusted emergency department visit rate for opioid-related ICD codes from 37.8 per 100,000 population in 2006 to 119.9 visits per 100,000 in 2014. Opioids were associated with an increased number of chronic conditions, greater injury risk, and higher rates of alcohol dependence, and mental health diagnoses for this group.

These findings were reported in “Increasing Rates of Opioid Misuse Among Older Adults Visiting Emergency Departments” by Mary W Carter, Ph.D.; Bo Kyum Yang, Ph.D., RN;  Marsha Davenport, M.D., MPH; and Allison Kabel, Ph.D. The researchers analyzed data from the Nationwide Emergency Department Sample, specifically for adults aged 65 years and older with diagnostic codes related to opioid misuse disorder. A total of 28,167 unweighted (126,931 weighted) observations were identified as opioid-related emergency department visits by older adults. The goal was to determine factors associated with opioid misuse-related emergency department visits among older adults changes in outcomes associated with these visits.

Over time, the number of adults aged 65 to 84 years per 100,000 population who visited the emergency room due to opioid misuse was at least double that of the rate for those aged 85 or older. The rate rose 218% among adults ages 65 to 84, and rose 203% among those age 85 and older.

Number Of Older Adults With Emergency Room Visits Due To Opioid-Related ICD-9 Codes Per 100,000 Population
Age 2006 2009 2011 2014
65 to 84 40.5 63.4 89.1 129.0
85 and older 20.0 26.9 44.6 60.6

Additional findings about older adults with emergency room visits due to opioid-related reasons include:

  • The percentage of these visits that resulted in hospitalization decreased from 71.2% in 2006, to 66.0% in 2014 (with a slight increase to 72.3% in 2009).
  • The percentage of these visits that resulted in death remained constant (averaging about 1.4%) for all years.
  • Medicaid and self-pay rates were higher among opioid-related emergency department visits than Medicaid and self-pay rates for emergency department visits that were not opioid related. Medicaid was the primary expected payer for 3.3% of opioid-related visits. Self-pay was the expected payer for 6.7% of opioid-related visits compared to 1.1% of other visits. Medicare was the primary payer for 87.2% of opioid-related visits and other emergency department visits. Other payers (such as commercial health insurance) were the primary payer for 2.9% of opioid-related visits and 10% of other visits.

The researchers concluded that emergency department visits due to opioid misuse by older adults increased from 2006 through 2014. They said the rise indicates the need to better understand the scope and impact of opioid misuse among older adults. It also indicates a need to better inform policy responses to meet the needs of this age group.

The full text of “Increasing Rates of Opioid Misuse Among Older Adults Visiting Emergency Departments” was published March 7, 2019, by Innovation in Aging. A copy is available online at https://academic.oup.com/innovateage/article/3/1/igz002/5369972?preview=true (accessed March 18, 2019).

PsychU last reported on this topic in “Opioid-Related Hospitalizations Among 65+ Population Increased 34% Over Five Years,” which published on November 5, 2018.

For more information, contact: Todd Kluss, Director of Communications, The Gerontological Society of America, 901 1220 L Street Northwest, Washington, District of Columbia 20005; 202-587-2839; Email: tkluss@geron.org; Mary W. Carter, Ph.D., Gerontology Program Directory, Towson University, 8000 York Road, Towson, Maryland 21252; 410-704-4643; Email: mcarter@towson.edu.

During its first year, a social determinants of health pilot project in Newark cut the participants’ total cost of care by 25%. The “Newark Initiative” launched in 2017 as a collaboration between Robert Wood Johnson Barnabas Health (RWJBH) and Horizon Blue Cross Blue Shield of New Jersey (Horizon). For the pilot, Horizon and RWJBH assembled a care team with a Horizon care transformation specialist, nurses, a personal health assistant, a health system-based social worker, and community health workers recruited from the target neighborhoods. The care team members met with the identified Horizon members to learn about the non-medical problems preventing the individuals from receiving care for their chronic health conditions. The team found barriers such as lack of transportation to appointments, pressing immediate problems such imminent eviction, and family members in crisis. The team worked to resolve the barriers facing the individuals by connecting them to health care professionals and to non-medical resources.

Horizon recently released the initial outcomes for the 1,000 “Newark Initiative” participants. In addition to reducing the overall cost of care by 25% as of October 2018, the participants had 20% fewer hospital inpatient admissions and 24% fewer emergency department visits. Their visits to behavioral health professionals increased by 35%.

The “Newark Initiative” identified Horizon members living in four Newark ZIP Codes who, based on Horizon claims data, were found to have gaps in care; chronic health conditions (such as diabetes, hypertension, or heart failure); and high utilization of emergency department services at RWJBH’s Newark Beth Israel Hospital. Horizon and RWJBH followed the population analysis model used by the Camden Coalition when it launched the Good Care Collaborative in 2014.

Horizon has not released information about the cost per person for the care team or whether the initiative paid for social services. The focus of the initiative was on connecting the participants to needed non-medical services provided by other community entities.

Horizon intends to work with more health care partners to turn the Newark Initiative from a pilot to a statewide program starting later this year. Horizon is planning to turn the Newark Initiative from a pilot to a statewide program starting later this year. As of March 20, 2019, no further details about the expansion have been announced. A Horizon spokesperson said that the expansion may involve more of Horizon’s partners in the OMNIA Alliance, which includes: AtlantiCare, Atlantic Health System, Hackensack Meridian Health, Hunterdon Healthcare, Inspira Health Network, RWJ Barnabas Health, and Summit Medical Group.

For more information, contact: Thomas Vincz, Public Relations Manager, Horizon Blue Cross Blue Shield of New Jersey, Post Office Box 820, Newark, New Jersey 07101; 973-466-6625; Email: Thomas_Vincz@horizonblue.com.

Following the Centers for Disease Control and Prevention (CDC) issuance of its opioid prescribing guidelines in early 2016, payers, provider organizations, and physicians misapplied the guidelines to the detriment of people with chronic non-cancer pain by requiring involuntary dose reduction or discontinuation. Among its recommendations, the CDC prescribing guidelines directed that opioids should rarely be a first option for chronic pain, that clinical professionals must carefully weigh the risks and benefits of maintaining opioids for people already taking them, and it directed that established or transferring consumers should be offered the opportunity to re-evaluate their continued use at high dosages, such as more than 90 morphine milligram equivalents (MME). However, many physicians and regulators incorrectly interpreted the guideline to believe the CDC established a threshold of 90 MME as a daily dose limit. Because of this interpretation, many payers imposed payment barriers, and pharmacies demanded medical charts or taper plans for opioid doses as a precondition for filling prescriptions. These actions caused many health care professionals to consider many health care consumers with chronic pain as institutional and professional liabilities to be contained or eliminated.

On March 6, 2019, a group of physicians called Health Professionals for Patients in Pain (HP3) sent a letter to the CDC calling for the CDC to clarify the opioid prescribing guideline issued in early 2016. The claim is that, due to misapplication of the guidelines resulting in opioid drawdown or discontinuation, health care consumers with chronic pain previously controlled by prescription opioids have experienced adverse effects such as unnecessary pain due to dose reduction; some may have begun illicit substance use, and others may have completed suicide due to uncontrolled pain. The letter was signed by 300 physicians and medical experts.

The HP3 letter noted that the CDC recommendations said that opioids should rarely be the first option for treating chronic pain. Clinical professionals must carefully weigh the risks and benefits of maintaining people on opioids, and that established consumers or those transferring to a new health care professional should be offered to reevaluate continued use if they were taking 90 MME or more per day. The CDC recommendations indicated that high prescribed MME doses pose risk for adverse events, and supported dose reductions when the reduction can be achieved without adverse effect. For this group of people, the guideline does not endorse mandated involuntary dose reduction or discontinuation because data does not support the effectiveness and safety of such actions.

HP3 requests that the CDC take further action regarding its goals to protect health care consumers. They urge that the CDC:

  • Follow through with the commitment to evaluate the impact of opioids by “consulting directly with a wide range of patients and caregivers; and by engaging epidemiologic experts to investigate reported suicides, increases in illicit opioid use and, to the extent possible, expressions of suicidal ideation following involuntary opioid taper or discontinuation.”
  • Issue a “clarification about the 2016 Guideline regarding what it says and what it does not say, particularly on the matters of opioid taper and discontinuation.”

For more information, contact: Stefan G. Kertesz, M.D., Professor, Division of Preventative Medicine, University of Alabama at Birmingham, 717 11th Avenue, Medical Towers 608, Birmingham, Alabama 35205; 205-996-2866; Fax: 205-934-7959; Email: skertesz@uab.edu; Sally Satel, M.D., Scholar, American Enterprise Institute, 1789 Massachusetts Avenue Northwest, Washington, District of Columbia 20036; 202-862-7154; Email: slsatel@gmail.com.

Over the past few years, payer and health plan interest in social support services—housing, transportation, nutrition, and more—has reached a new peak. A quick scan of the headlines illustrates the wave of health plan investments in social support services:

  1. Blue Cross Launches Food Delivery Program To Address Social Determinants
  2. Kaiser Permanente Invests In Affordable Housing Complex In Oakland, California For $5.2 Million As Part Of Initiative To Improve Community Health By Addressing Housing Insecurity
  3. Health Partners Plans Shows Positive Outcomes From “Food As Medicine’ Nutrition Program

In addition to these health plan-specific program examples, there are also more systematic approaches afoot. A recent reports show that 80% of health plans now use one or more methods to identify and address social determinants of health—with 42% of payers integrating referrals to community-based social service programs and resources; 33.7% integrating consumer medical information with consumer financial, census, and geographic data; 31.1% offering a “social needs” assessment along with health risk assessments; and 70% of payers are integrating awareness of social determinants of health directly into clinical processes. A good example of more systematic health plan initiatives include the recent announcement from UnitedHealthcare to expand its efforts to identify consumers who have non-medical needs considered social determinants of health (see UnitedHealthcare Expands Initiative To Use Diagnostic Codes To Capture Social Determinants Of Health).

But coverage of a recent conference on the issues surrounding social determinants put this interest in perspective for me—and solidified the challenge for provider organizations that are looking for long-term sustainable service opportunities addressing social determinants. The health plan presenters described their current initiatives as “a smattering right now” and “random acts of kindness.” They said that the current social determinant initiatives are “too fragmented” to have an impact and “a strategic challenge most health systems encounter is trying to build a business case showing a return-on-investment (ROI) based on reduced cost or improved health outcomes.”

This is a call to action for any provider organization management team that hopes that their social services-infused approaches to health care will become a long-term market. Without proof of ROI, these initiatives will become one-time public relations investments, rather than long-term programmatic approaches adopted by payers and health plans.

So, like any new service approach, management teams with a “great new idea” need to embrace the need for a proof of concept, a measure of ROI, and a plan to take the service to scale. There are a few basic steps:

  1. Assess your organization’s ability to deliver social support programs—services, geographic reach, consumers, and more
  2. Review health plan/ACO enrollment in your the geographic service area to identify target consumers
  3. Develop a concept statement about your social support services that are appropriate to the health plan consumers—services, costs, and performance metrics
  4. Meet with health plan/ACO managers to start the dialogue and present your service line concept
  5. Refine your concept statement based on the conversation with health plan/ACO managers
  6. Continue the dialog until you get to the demonstration pilot stage

But getting to the demonstration pilot stage is just the first step on this journey. The pilot project needs to be designed to measure performance and conduct an ROI analysis for your organization’s proposed approach. Without a solid ROI, your approach runs the risk of becoming another one-time interesting experiment without long-term adoption. This is a tall order—and one that I think will need to be led by entrepreneurial provider organization executives.

For more on ROI, check out For Telehealth, The ROI Is Where You Plan For It and More Tools For Tech ROI from the PsychU Resource Library.

The projected national health expenditure (NHE) for 2018 is $3.65 trillion, representing 4.4% growth over the $3.49 trillion NHE in 2017. Between 2018 and 2027, the annual NHE is projected to grow at an average of 5.5% per year to reach nearly $6.0 trillion by 2027.

Due primarily to higher projected enrollment growth, Medicare spending is projected to increase at a higher rate than Medicaid or private health insurance. Average annual Medicare spending growth is projected at 7.4%, compared to 5.5% for Medicaid and 4.8% for private health insurance. By 2027, the share of health care spending sponsored by federal, state, and local governments is projected to increase by two percentage points from 45% in 2018 to 47% in 2027. The increase is largely due to the projected rise in Medicare enrollments, from 58.7 million in 2018 to 73.5 million in 2027. Medicaid enrollment is projected to increase from 73.4 million in 2018 to 82.5 million in 2027.

These findings were reported in “National Health Expenditure Projections 2018 to 2027; Forecast Summary” by the Office of the Actuary in the Centers for Medicare & Medicaid Services (CMS). The Office of the Actuary published its full analysis of the data in “National Health Expenditure Projections, 2018-27: Economic And Demographic Trends Drive Spending And Enrollment Growth.” The CMS Office of the Actuary annually produces projections of health care spending for categories within the National Health Expenditure Accounts, which track health spending by source of funds, type of service, and sponsor. These projections begin after the latest historical year (2017) and go through 2027.

From 2018 through 2027, about 90% of the population in each year is projected to have insurance coverage. However, in 2019, the insurance rate is projected to start declining slightly, from 90.9% in 2018 to 90.6% in 2019 and by 2027 to 89.7%. The decline in 2019 is largely attributed to the Tax Cut and Jobs Act of 2017, which repealed the individual mandate penalty in the Patient Protection and Affordable Care Act. The repeal of the individual mandate is projected to contribute to a reduction in the number of people with private health insurance of 0.6%, but that drop will be partially offset by growth in other types of health coverage.

The uninsured population is projected to increase from 29.9 million in 2018 to 36.2 million in 2027. The total U.S. population is projected to grow less than 1% per year, from 327.9 million in 2018 to 352.7 million in 2027.

During 2019, national health expenditures are projected to rise by 4.8%. Medicare spending is projected to rise by 7.1%, largely due to higher fee-for-service payment updates. Expanded eligibility for Medicaid in five new states (Idaho, Maine, Nebraska, Utah, and Virginia) is projected to contribute to faster Medicaid spending growth, from 2.2% in 2018 to 4.8% in 2019.

Out-of-pocket (OOP) spending growth is projected to have grown by 3.6% in 2018, up from 2.6% in 2017, rising from $365.5 billion in 2017, to $378.6 billion in 2018. The growth was consistent with higher average deductibles for private health insurance enrollees with employer sponsored insurance. OOP is projected to grow by 4.8% in 2019 to reach $396.9 billion, in part because fewer people are projected to have private insurance coverage due to the effective repeal of the individual mandate in the Tax Cut and Jobs Act of 2017. Over 2020 through 2027, annual OOP spending growth is expected to average 5.0%, and reach $585.8 billion by 2027.

Prescription drug spending is projected to have grown by 3.3% in 2018, up from growth of 0.4% in 2017. The growth is driven by higher utilization, higher medication adherence rates, and new drug introductions. In 2019, prescription drug spending growth is projected to rise to 4.6% in 2019. From 2020 to 2027, prescription drug spending is projected to rise by an average of 6.1% per year.

Hospital spending is projected to have grown by 4.4% in 2018, down from growth of 4.6% in 2017. The growth is slower due to slower growth in Medicaid and private insurance hospital spending in 2018. In 2019, hospital spending growth is projected to rise to 5.1% in 2019 due to faster Medicare spending growth. From 2020 to 2027, hospital spending is projected to rise by an average of 5.7% per year.

Physician and clinical services spending are projected to have grown by 4.9% in 2018, up from 4.2% in 2017. The spending growth projection reflects price growth of 0.3 percentage points to 0.7% and higher utilization. In 2019, growth in this sector is projected to rise by 5.4%; this increase is primarily associated with higher use arising from the Medicaid expansion in five additional states. Between 2020 and 2027, spending in this sector is projected to grow by an average of 5.4% per year.

Medicare spending on the physician and clinical services sector is expected to be faster than growth in private health insurance spending for this sector as the baby-boom generation ages into Medicare eligibility. Prices are projected to increase due to anticipated rising wages growth related to increased demand from older adults.

The full text of “National Health Expenditure Projections, 2018-27: Economic And Demographic Trends Drive Spending And Enrollment Growth” was published in the March 2019 issue of Health Affairs. An abstract is available online at https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05499 (accessed March 4, 2019).

PsychU last reported on NHE projections in the following articles:

 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.

During 2017, 130 health insurers offering plans sold through the Health Insurance Marketplace denied an average of 19% of claims. These insurers denied 42.9 million of the 229.8 million in-network claims received for the 2017 plan year. The denial rates for in-network claims ranged from 1% for a Celtic Insurance Company plan in Indiana to 45% for a Celtic Insurance Company plan in Texas. About 30.7% of insurers had a 10% or lower denial rate, about 33.1% of insurers had denial rates between 11% and 20%; and about 36.2% denied more than 20% of in-network claims in 2017.

For the 2016 plan year, health insurers offering plans through healthcare.gov about 17% of in-network claims were denied. That year, denial rates across all issuers ranged from less than 1% to more than 65%. For 2015, about 19% of in-network plans were denied. That year, denial rates across all issuers ranged from less than 1% to more than 90%.

These findings were reported in “Claims Denials and Appeals in ACA Marketplace Plans,” by Karen Pollitz, Cynthia Cox, and Rachel Fehr for the Henry J. Kaiser Family Foundation (KFF). The researchers analyzed Affordable Care Act (ACA) Transparency Data for 2015, 2016, and 2017 from the Centers for Medicare & Medicaid Services (CMS). The researchers analyzed these public files, with a focus on major medical plans and issuers that primarily offered stand-alone dental coverage. They excluded plans and issuers with incomplete data. For the 2017 plan year, of the total 180 major medical issuers offering plans through healthcare.gov, 130 had complete data on in-network claims received and denied. The goal was to examine claims denials and appeals among issuers offering individual market coverage on healthcare.gov from 2015 through 2017.

Transparency data is periodic data reported by group health plans and by health insurance issuers in the individual and group markets to provide transparency on how coverage works in practice. The law requires this data to be available to state insurance regulators and to the public. Plans should report on:

  1. Claims payment policies and practices
  2. Periodic financial disclosures
  3. Data on enrollment
  4. Data on disenrollment
  5. Data on the number of claims that are denied
  6. Data on rating practices
  7. Information on cost-sharing and payments with respect to any out-of-network coverage
  8. Information on enrollee and participant rights under this title
  9. Other information as determined appropriate by CMS

In February 2019, CMS announced in a transparency data collection notice that it will require reporting of plan level (rather than issuer level) claims data beginning with the 2019 collection year. Issuers offering plans on healthcare.gov will be required to report six denial reason categories beginning with the 2019 data collection, as follows:

  1. Referral or prior authorization required
  2. Out-of-network
  3. Services excluded or not covered
  4. Not medically necessary, excluding behavioral health
  5. Not medically necessary, behavioral health
  6. All other

The researchers noted that the wide range in denial rates across the 130 issuers and markets in 2017 could be due to differences in the following factors:

  • The plan’s determination of medical necessity
  • The plans limits, such as day or visit limits on covered services
  • The degree to which issuers’ automated claims processing systems routinely deny certain claims
  • Provider organization knowledge about which claims will be covered and how to properly submit claims
  • Issuer reporting methods, for example, in how to count partial approvals

They further noted that the impact of a denial varies. For some, the consumer is held harmless and would not realize that a claim had been denied. For others, the consumer might not be held harmless and could face a large medical bill. Consumers rarely appealed a denied claim. During 2017, consumers appealed 200,000 (0.5%) of the more than 42 million denied claims. Data for 2015 and 2016 show even lower consumer appeal rates, at 0.1% and 0.2%, respectively.

Appeals have a low success rate, and in 2017, only 14% of the 200,000 appeals resulted in overturning the denial. Across 118 insurers whose appeals outcomes were reported, the overturn rate ranged from 1% to 88%. The data does not indicate reasons for the low appeals rate which could include: validity of an initial denial, the consumer was unable to pursue the appeal or deficiency in consumer notices. State Consumer Assistance Programs, created by the Patient Protection and Affordable Care Act are charged with helping consumers file appeals for denied claims. However, Congress has not appropriated funding for the programs since 2010.

The full text of “Claims Denials and Appeals in ACA Marketplace Plans” was published February 25, 2019 by the Henry J. Kaiser Family Foundation (KFF). A copy is available online at www.kff.org.

PsychU last reported on this topic in “Pennsylvania Fines Aetna $190,000 Over Coverage Violations Involving Autism & Addiction Treatment,” which published on March 11, 2019.

For more information, contact: Craig Palosky, Director of Communications, The Henry J. Kaiser Family Foundation, 1330 G Street Northwest, Washington, District of Columbia 20005; 202-347-5270; Email: cpalosky@kff.org.

Of the total U.S. resident population in 2017, Maine has the highest percentage (44.7%) of individuals of all ages with cognitive disability living in the community, followed by Rhode Island (44.0%), and Idaho (42.2%). The District of Columbia had the lowest percentage (31.8%) of individuals with cognitive disability living in the community, followed by South Dakota (33.3%), and Nevada (33.5%). In 2017, there were 40,675,305 individuals living in the community with disabilities, 15,378,144 of which were individuals with a cognitive disability (37.8%). For this survey, “disability” is defined as self-reported difficulty with activities, work, or social situations; and activities of daily living includes self-care disabilities and independent living disabilities.

These findings were reported in the “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” by the Institute on Disability at the University of New Hampshire. The researchers analyzed data from the U.S. Census Bureau’s 2017 American Community Survey. The survey classifies disability in terms of physical, cognitive, or sensory deficits. The data sources do not report rates of disability by primary diagnosis, so the researchers do not report on the prevalence of disability due to chronic conditions such as back pain, mental illness, addiction, or intellectual/developmental disability. The goal was to calculate statistics related to disability in the U.S.

Additional findings for 2017 include:

  • Of the 8,836,223 individuals with cognitive disabilities, ages 18 to 64 years and living in the community, 2,456,526 individuals were employed (27.8%).
  • The percentage of people with cognitive disabilities employed was highest in South Dakota (44.7%), followed by North Dakota (42.7%), and Minnesota (41.8%).
  • The percentage of people with cognitive disabilities employed was lowest in Puerto Rico (15.5%), followed by West Virginia (18.5%), and Mississippi (19.2%).

The full text of “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” was released in February 2019 by the Institute on Disability at the University of New Hampshire. Copies of each available online at disabilitycompendium.org (accessed March 4, 2019)

PsychU last reported on this topic in “23.4% Of Adults With Cognitive Disabilities Employed, Most Work 20 Hours Per Week,” which published on February 17, 2015.

For more information, contact: Sarah Boege, Policy Analyst, University of New Hampshire Institute on Disability, 10 West Edge Drive, Suite 101, Durham, New Hampshire 03824; 603-862-0165; Email: sarah.boege@unh.edu.

Is “unblackboxing” the key to reducing health care costs? The answer to that question was in part the focus of Bill Green, Chief Executive Officer of Homestead Smart Health Plans, in his 2019 OPEN MINDS Performance Management Institute keynote session, “Building A New System For Private Insurance: Innovations & Emerging Models For Employer-Sponsored Health Plans.”

What is “blackboxing?” It’s the practicing of hiding information that would otherwise let you know how something works. Unblackboxing means bringing transparency to that information – or put another way, seeing inside the black box.

In health care, the focus of “unblackboxing” is in two areas – hospital chargemasters and rebates for pharmaceuticals. Together, spending on hospitals and pharmaceuticals account for 43% of total U.S. health care costs.

The hospital chargemaster is a comprehensive listing of items billable to a hospital consumer or a consumer’s health insurance provider. And traditionally, chargemaster information has not been available to the public, including consumers of hospital services. Tina Rosenberg explained the imbalance in this arrangement in her The New York Times article, “Revealing a Health Care Secret: The Price,” as:

Chargemaster prices are set by the hospital alone and reflect what the hospital would like you to pay. They are the basis for calculating the discounts given to insurers, and they are generally what’s billed to people without insurance. These charges are commonly three times the Medicare price or more.

As of January 1, 2019, hospitals are required by the Centers for Medicare & Medicaid (CMS) to post their chargemaster fee data. Consumers can now compare the price of services across different hospitals. But how useful this data is remains to be seen. The ruling has largely been touted as symbolic. Critics say that the newly-posted chargemaster rates are hard to understand (see Medicare To Require Hospitals To Post Standard Charges Online).

Then there are the rebates for pharmaceutical purchases. The rebates are pricing discounts paid by the pharmaceutical company to payers and health plans when they purchase a medication. The actual amount of these rebates is largely unknown (part of the reason for the debate). There are many critics of the rebate system. Dr. Sarah Sachs explained in a Health Affairs blog post that pharmacy benefit managers and payers often negotiate with pharmaceutical companies to receive rebates on drugs after point-of-sale. This means that pharmaceutical companies can raise their list prices, but increase the rebate for better formulary placement. Since consumers often pay cost-sharing on the actual list price of the drug, the higher list price can make many drugs unaffordable.

On February 1, 2019, the U.S. Department of Health and Human Services (HHS) proposed a new rule that will eliminate prescription drug rebates between pharmaceutical companies and Medicare Advantage and Medicaid health plans (and/or their pharmacy benefit managers). Instead, those rebates would have to be passed directly to the consumer at point-of sale, who often pays out-of-pocket costs based on the list rate and not the price with the rebate applied. The goal of the new rule is to lower the price of prescription drugs to consumers, to slow increases in drug prices year-over-year, and to make pharmacy benefit management more transparent.

One reimbursement solution to the challenges of the chargemaster and of pharmaceutical rebates proposed by Mr. Green is a concept called reference-based pricing According to the Commonwealth Fund in “Pharmaceutical Reference Pricing: Does It Have a Future in the U.S.?,” reference-based pricing is:

An emerging health insurance benefit design aimed at reducing health costs. In this model, an insurer establishes a maximum payment that it will contribute toward covering the price of a product or service in situations where there is wide price variation for therapeutically similar drugs, diagnostics, or procedures. 

Reference-based pricing is most often pegged to Medicare pricing – but not always, as some services are not covered by Medicare. To address this, prices are often pegged to average commercial costs.

I think we’ll see more reference-based pricing. Donald Trump specifically talked about reference-based pricing and cost transparency in his state of the union. Research also shows that employers are beginning to see reference-based price as a solution to high health benefit costs, even if they have not yet adopted this model.

But reference-based pricing doesn’t solve all of the health care cost drivers. It doesn’t address some of the core issues in health care spending like overutilization and lack of care coordination. Mr. Green explained that while reference-based pricing can help bend the cost curve, plans need to consider other benefit plan design changes, utilization review, and other cost containment programs in an overall strategy. In tandem, a multi-faceted approach is more likely to bend the needle.

For more of our recent coverage on health care costs, check out:

  1. Per-Employee Health Care Costs Expected To Increase 4.4% In 2019
  2. 14% Of Families Had Out-Of-Pocket Health Care Expenses Exceeding $2,500 In 2015
  3. Spending For Consumers With Comorbid Medical & Behavioral Conditions At 34% Of Total U.S. Health Care Spending
  4. Long-Term Care Costs Rise 4.5% Between 2016 & 2017
  5. U.S. National Health Spending Grew At A Rate Of 3.9% In 2017
  6. U.S. Health Care Expenditures Expected To Grow 5.5% Annually Through 2026

On February 6, 2019, the Centers of Medicare & Medicaid Services (CMS) announced that an 18-month moratorium on its ability to terminate Medicare Advantage (MA) organization contracts based on low star ratings in the Five-Star Quality Rating System has ended. Contracts may be terminated if they fail to receive at least a three-star drug or health plan Summary Star Rating for three consecutive years. The 2020 Star Ratings for MA and Part D plans, which are slated for release in the fall of 2019, will be the first set of ratings where performance below three stars would be counted toward qualification for termination. The first contract terminations would occur after the 2022 Star Ratings are released.

The Star Ratings system is intended to help people with Medicare, their families, and their caregivers compare the quality of health and drug plans being offered. Medicare Advantage and Part D prescription drug plans are given a rating on a 1- to 5-star scale, with 1 star representing poor performance and 5 stars representing excellent performance.

According to the “Medicare Advantage Part C & Part D 2019 Star Ratings Fact Sheet,” for the 2019 plan year, about 3.27% of the 376 Medicare Advantage plans with prescription drug (MA-PD) coverage in 2019 achieved a rating of less than three stars. In 2018, about 3.64% of the 385 MA-PD plans were rated below three stars. In 2017, about 2.48% of the 363 MA-PD plans were rated below three stars. In 2016, about 2.98% of the 369 MA-PD plans were rated below three stars. In each year, more than 70% of enrollees were enrolled in a MA-PD that achieved four or five stars.

The 21st Century Cures Act of 2016 prohibited CMS from terminating MA organization contracts through December 31, 2018. The Medicare Part C and Part D regulations allow CMS to terminate an MA contract for failing to achieve a Part C summary rating of at least three stars for three consecutive years. The Part D sponsor contract can be terminated for consistently low Part D summary ratings.

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.

Approximately 90.1% of those with disabilities (about 39.1 million), ages 18 to 64 years and living in the community, have health insurance coverage, as of 2017. In contrast, 87.5% of those without disabilities, ages 18 to 64 years and living in the community, had health insurance coverage. This equals a health insurance coverage gap between those with and those without disabilities of 2.6 percentage points. In other words, 2.6% more individuals with disabilities had health insurance than individuals without disabilities.

These findings were reported in the “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” by the Institute on Disability at the University of New Hampshire. The researchers analyzed data from the U.S. Census Bureau’s 2017 American Community Survey, and the Center of Disease Control and Prevention’s (CDC’s) 2009-2016 Behavioral Risk Factor Surveillance Survey. For this survey, “disability” is defined as self-reported difficulty with activities, work, or social situations. The survey classifies disability in terms of physical, cognitive, or sensory deficits. The data sources do not report rates of disability by primary diagnosis, so the researchers do not report on the prevalence of disability due to chronic conditions such as back pain, mental illness, addiction, or intellectual/developmental disability. The goal was to calculate statistics related to disability in the U.S.

Additional findings for 2017 include:

  • About 45.8% of individuals with disabilities, ages 18 to 64 years and living in the community, had private health insurance. Puerto Rico (28.1%) had the smallest percentage of people with private health insurance, followed by West Virginia (37.1%); Hawaii (57.8%) had the largest percentage of people with private health insurance.
  • About 55.8% of individuals with disabilities, ages 18 to 64 years and living in the community, had public health insurance (some had both public and private). Utah (40.2%) had the smallest percentage of people with public health insurance; Puerto Rico (71.9%) had the largest percentage of people with public health insurance, followed by New Mexico (68.8%).
  • About 9.9% of individuals with disabilities, ages 18 to 64 years and living in the community, did not have health insurance. Massachusetts (2.8%) had the smallest percentage of people with disabilities without health insurance coverage, while Oklahoma (20.2%) had the largest percentage of people with disabilities without health insurance coverage.

The full text of “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” was released in February 2019 by the Institute on Disability at the University of New Hampshire. Copies of each available online at https://disabilitycompendium.org/ (accessed March 4, 2019).

 For more information, contact: Lindsay Allsop, Communications and Information Coordinator, University of New Hampshire Institute on Disability, 56 Old Suncook Road, Suite 2, Concord, New Hampshire 03301; 603-228-2084; Email: lindsay.allsop@unh.edu.

On February 11, 2019, the U.S. Department of Health and Human Services (HHS) issued proposed rules about the standards for application programming interfaces (APIs) for (EHI) sharing across health plans, provider organizations, and acute and post-acute care settings. The rule, issued by the HHS Office of the National Coordinator for Health Information Technology (ONC), to adopt Health Level Seven’s (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standards as the standard to which developers must certify their 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 EHI.

The ONC proposed rule, “21st Century Cures Act: Interoperability, Information Blocking, & The ONC Health IT Certification Program,” would update the existing 2015 Edition certification criteria. It also implements the information blocking provisions of the 21st Century Cures Act, and identifies activities that will not be considered information blocking. Additionally, ONC seeks comments on how pricing information could be included as part of EHI so that the public could better understand the cost of their health care.

The goal is to ensure that certified health information technology (IT) systems can do the following:

  • Send and receive EHI in a structured format.
  • Make EHI available without special effort using APIs. ONC believes this approach could lead to industry standard interfaces—interfaces where app developers can develop effective apps that use API technology without special effort to access a patient’s data.
  • Export a single consumer’s or multiple consumers’ EHI from the health IT system to a location designated by the consumer.

Information blocking is defined as any action of a health care-related entity that is likely to interfere with, prevent, or materially discourage the access, exchange, or use of EHI. Under the proposed rule, certain actions of a health care professional or provider organization, developer of certified health IT, health information network, or health information exchange that interfere with the access, exchange, or use of EHI would not be considered information blocking under certain circumstances. The proposed exceptions to information blocking are as follows:

  1. Engaging in practices to prevent consumer harm.
  2. Engaging in consistent, non-discriminatory practices to protect the privacy of electronic health information.
  3. Implementing practices to promote the security of EHI.
  4. Recovering costs reasonablly incurred to allow for the access, exchange, and use of EHI.
  5. Responding to a request to provide access, exchange, or use of EHI that is infeasible because the request would impose a substantial burden that is unreasonable under the circumstances.
  6. Licensing of interoperability elements on reasonable and non-discriminatory terms.
  7. Performing maintenance or improvements to health IT performance with the agreement of the user.
  8. Maintaining and improving health IT performance with the agreement of the user.

Comments on the proposed rules will be accepted through May 3, 2019. Don Rucker, M.D., National Coordinator for Health IT at ONC, said, “We encourage everyone – patients, patient advocates, health care providers, health IT developers, health information networks, application innovators, and anyone else interested in the interoperability and transparency of health information – to share their comments on the proposed rule.”

For more information, contact:

  • Attention: 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Proposed Rule, Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, Mary E. Switzer Building, Mail Stop: 7033A, 330 C Street Southwest, Washington, District of Columbia 20201; or Michael Lipinski, Office of Policy, 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.
  • 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.

People with disabilities, aged 18 to 64 years and living in the community, comprised about 13.2% (nearly 43 million) of the total U.S. resident population in 2017. About 35.5% of this population with disabilities were unemployed.

These findings were reported in “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” by the Institute on Disability at the University of New Hampshire. The researchers analyzed data from the U.S. Census Bureau’s 2017 American Community Survey, and the Center of Disease Control and Prevention’s (CDC’s) 2009-2017 Behavioral Risk Factor Surveillance Survey. For this survey, “disability” is defined as self-reported difficulty with activities, work, or social situations. The survey classifies disability in terms of physical, cognitive, or sensory deficits. The data sources do not report rates of disability by primary diagnosis, so the researchers do not report on the prevalence of disability due to chronic conditions such as back pain, mental illness, addiction, or intellectual/developmental disability. The goal was to calculate statistics related to disability in the U.S.

Additional findings include:

  • The state with the largest number of individuals with disabilities was California, with 4,151,044 individuals; while the state with the smallest number of individuals with disabilities was North Dakota, with 75,801 individuals.
  • The state with the highest percentage of the population with disabilities was West Virginia at 20.2%; the lowest was Utah at 9.6%
  • The employment-to-population ratio of people without disabilities was 76.5%. This is nearly double that of people with disabilities and amounted to an employment gap of 41.0 percentage points.
  • Between 2016 and 2017, the employment-to-population employment gap of those without disabilities versus those with disabilities decreased 0.4 percentage points from 41.4%.
  • Since 2008, the employment-to-population employment gap of those without disabilities versus those with disabilities increased a total of 1.5 percentage points.

The full text of “The Annual 2018 Disability Statistics Compendium, Report, and Supplement” was released in February 2019 by the Institute on Disability at the University of New Hampshire. Copies of each section are available online at https://disabilitycompendium.org/ (accessed March 4, 2019).

For more information, contact: Lindsay Allsop, Communications and Information Coordinator, University of New Hampshire Institute on Disability, 56 Old Suncook Road, Suite 2, Concord, New Hampshire 03301; 603-228-2084; Email: lindsay.allsop@unh.edu.

The focus on consumerism and the consumer experience in health and human services is increasingly important—and our work with provider organizations over the years has found that it will require a new perspective on service line development (see Considering Cash—& Consumerism—In Service Line Planning). But for all that talk, how often do provider organizations—even those that are talking with consumers to find out what is necessary for a great consumer experience—ask those same consumers what would be necessary for great services? Have you, for example, thought of asking your consumers what it would take to keep them out of the emergency room (ER)—one of the primary drivers of avoidable health care costs?

A recent survey of high-need, high-cost (HNHC) health care consumers, with chronic health conditions, did just that, and found that this group believes five solutions would help them avoid unnecessary ER use. These five solutions were (and they should sound familiar): care management; readily available at-home physical therapy and nursing services; home delivery of prescription medications and easier refills; telemedicine; and more after-hours clinics.

It’s interesting to me that this study produced such “elemental” recommendations—but in truth, these system features are not there in any consistent kind of way. Why not? I think part of the issue is that many provider organizations are too focused on the “low hanging fruit” of the consumer experience, like improving wait times, or ease of appointment scheduling, or the friendliness of staff. It would be a mistake not to include these in consumer service efforts—but for a truly consumer-centric business model, provider organizations need to re-engineer whole service lines and service resources to meet a much broader demand: consumerism—the understanding that consumers understand that health care costs and quality are important and will making purchasing decisions to achieve it.

Or put it another way: Most of the managers at provider organizations don’t know how to think in terms of “what consumers want,” and even if they try, many fail to translate that into a service line design that delivers on the above basics. Considering how much consumers are now paying for health care—the average annual deductible for single adults with employer-sponsored health insurance was $1,077 and out-of-pocket (OOP) payments where at $656  (see The Challenges Of Rising Consumer Spending On Health Care and Out-Of-Pocket Health Care Costs – Down For Most, Up For Some)—this is a mistake. Additionally, health plans are focused on better and quicker access in a drive to lower wait times and produce both better consumer engagement and more satisfied consumers, as measured by the Centers for Medicare & Medicaid Services (CMS) STARS ratings and HEDIS scores (see ‘Rapid Access’ Might Just Be Your Next Health Plan Conversation and Oh, Those Consumer Reviews).

The key to really leveraging this trend isn’t to just give consumers a choice of the services you already have, it’s to build service redesigns that offer the options that you should already know that consumers want.

For more, check out these resources from the PsychU Resource Library:

  1. Making Consumer-Centricity A Reality For Medicaid Consumers With Complex Needs
  2. Integration, Interoperability & Consumer Engagement
  3. Get Your Price List Ready!
  4. Consumer Sovereignty As Success Strategy

Approximately 7.8 million direct care support positions will need to be filled by 2026. For all states, there were 4.52 million direct care jobs in the United States as of 2016 — and a projected 5.85 million will be required by 2026. In that intervening period, an estimated 6.4 million direct care workers will leave the labor force either for retirement or for positions in another field. This creates about 7.8 million new direct care positions in the health care field.

These findings were reported in “New Research: 7.8 Million Direct Care Jobs Will Need to Be Filled by 2026” by Stephen Campbell, a data and policy analyst at PHI. The author analyzed job growth and occupational separations data from the Bureau of Labor Statistics Employment Projections Program’s 2016 to 2026 Occupational Separations and Openings. Aggregate figures for the period reported were determined by multiplying annual average occupational separations by 10. The goal was to determine expected employment trends for direct care occupations through 2026. Direct care workforce will add the greatest number of new jobs (as compared to other occupations) in 38 states.

Direct care employment positions include:

  • Personal care aides are responsible for light cleaning, cooking, running errands, and doing laundry, as well as assisting clients with bathing, showering, grooming, and other personal hygiene tasks. They also engage clients in activities like reading, talking, and playing games.
  • Home health aides care for people who have disabilities, chronic illnesses, cognitive impairments, or age-related problems, who have the need or desire to still live in their own home. The home health aide provides basic services that include assisting medications, changing bandages, and checking vital signs like temperature, and pulse and respiration rates.
  • Nursing assistants work in nursing homes, home care, assisted living, hospice, hospitals, community based long-term care, correctional institutions, and other long-term care settings. Nursing assistants help patients of all ages perform the most basic daily tasks.

Additional findings include:

  • Direct care job growth through 2026 will be highest in California (about 274,700 positions); New York (190,550 positions); and Texas (126,140 positions).
  • Direct care job growth through 2026 will be lowest in Wyoming (about 1,000 positions); South Dakota (1,230 positions), and Alaska (1,800 positions).
  • The direct care workforce will grow the fastest in Arizona, with 59% job growth rate and 154,700 total job openings in 2026.
  • The direct care workforce will grow the slowest in Maine, with 8% job growth rate and 37,400 total job openings in 2026.
  • Personal care aide positions are projected to make up the largest overall personal care occupation need through 2026.

Occupations with the Most Projected Total Job Openings, 2016 to 2026 (Courtesy of PHI).

Mr. Campbell concluded that both the long-term care sector, and potential employers, can take steps to mitigate the effect of large number of projected job openings in direct care. The long-term care sector should reduce unnecessary turnover through steps such as: improve the quality of jobs through higher wages, better training, and opportunities for advancement. Employers should consider expanding the labor pool for the direct care workforce. This might be accomplished through education campaigns that increase awareness of direct care workers; targeted recruitment of new populations (including men, younger workers, and older workers, among others); and partnerships with community institutions such as schools, churches, and workforce development agencies.

The full text of “New Research: 7.8 Million Direct Care Jobs Will Need to Be Filled by 2026” was published January 24, 2019, by PHI. An abstract is available online at phinational.org

For more information, contact: Stephen Campbell, Data and Policy Analyst, Paraprofessional Healthcare Institute, 400 East Fordham Road, 11th Floor, Bronx, New York 10458; Email: scampbell@PHInational.org.

Knowing how to develop bundled payments and case rates is an executive team skill set that will become more important as value-based reimbursement models mature. While the majority of VBR contracts remain in fee-for-service models with a bonus or penalty, the use of case rate reimbursement is on the rise, and this brings a new level of financial risk to provider organizations (see VBR @ Scale—Changes Required).

As we learned at a recent institute, these reimbursement models are not “one size fits all”—the models require new approaches in both developing the rates and managing them successfully. That was the primary message from the session, Rate Setting For Value-Based Reimbursement: A Guide To Developing Capitated Payment Models, featuring Debbie Cagle Wells, Chief Marketing Officer at Centerstone, and Maggie Labarta, Ph.D., President and Chief Executive Officer at Meridian Behavioral Healthcare.

The panelists both have working experience with VBR. Centerstone—a large non-profit behavioral health provider organization—currently has 97 contracts in negotiation and 17 that are value-based. The contracts include pay-for-coordination (upside risk only), pay-for-performance, bundled payments, and shared savings (upside and downside risk). Dr. Labarta provided a brief review of Meridian Behavioral Healthcare, which has clinics in 11 Florida counties, covering a combined 500,000 consumers in a high-health disparity population.  Meridian is currently negotiating VBR, after its most recent capitated contract ended last year. Meridian has had several capitated arrangements under carve-in and carve-out scenarios, and the contracts covered the range of behavioral health services.

They offered five key pieces of advice developing case rates, and then managing to those rates.

Develop a “roadmap to capitation”—In a lot of ways, adopting risk comes down to understanding revenue predictability and a clear understanding of the scenarios that will help the organization sustain the necessary work under VBR contracts. This means understanding the “roadmap” that will let you build on a payer relationship, and work through the process to develop the necessary contract and then manage to that contract. Ms. Wells shared this roadmap:

Figure 1. Threnhauser, S. Developing Case Rates? Better Find Your ‘Single Source Of Truth’ [PowerPoint Slide] Retrieved from www.openminds.com

Start ahead and stay ahead—Managing VBR contracts effectively means that you must hit the ground running as effectively and efficiently as possible. This is not a scenario where you can figure out your services, costs, performance, or process as you go. All these things need to be balanced within the “risk corridor” that the organization needs to operate within. Dr. Labarta explained:

You must start ahead and stay ahead if you are going to manage these contracts effectively. You can’t provide too many services, or you are spending more than you bring in, but you also can’t offer too few if you want to meet the contract requirements and achieve the needed outcomes.

The data needs to be agreed upon—This is the “single source of truth” that the provider organization and the payer will agree upon. This means coming together to select and/or develop key performance indicators (KPI) that will best reflect the outcomes needed to achieve cost savings and population health management. Dr. Labarta explained.

What we discovered was that the data can’t be siloed in separate IS systems. You need to get to a place where there is a single source of truth that everyone agrees on. Pull all the data into a ware house. From there, develop the KPIs. Then make decisions about who needs access to what. The line staff, management staff, and executive staff will need something different, and the data must be available to you to help make decisions, in almost real time.

Internal champions are key—When Ms. Wells thinks of VBR success, she doesn’t immediately think of operations, or incentive bonuses, or quality outcomes. Those are all important, but the first thing that comes to mind are the people on the team who are leading those initiatives. Having commitment and support from both the leadership, as well as the staff who are leading those programs is mandatory. Ms. Wells noted:

Are you ready? I can talk about processes, but really you must be honest with yourself on your staff capabilities so that together you can be successful. And you must recognize that this is a new culture that touches both the staff and the consumers. I think of success, and I see the faces of the people who lead this.

Every cost counts—The new approach to finances means putting much greater importance on costs, including a focus on cost accounting, cost management, understanding population-based payment mechanisms, and unit costs. This is all about managing each service line, and each of these service line costs needs to be factored into risk in a very granular way (as detailed as possible). Ms. Wells explained:

You must take a good hard look at every cost that goes into your model. You need to stratify risk for the kinds of services and benefits you will manage. You can’t manage risk if you can’t manage the services and benefits you are at risk for. An example of a key incentive measurement that we control is every treatment plan contains a health care goal, and we document to that goal. Sounds easy? It is not easy.

Consumer engagement is top of mind for many reasons. Engaged consumers are consumers who have a better “experience.” Engaged consumers are activated consumers who take part in managing their health. Engaged consumers give provider organizations a significant edge over their competitors.

For many provider organization management teams, it’s not clear how to best go about achieving better consumer engagement. The executive got some words of wisdom about consumer engagement in the session Keeping Consumers In The Equation: Best Practices In Consumer Experience and Engagement, featuring Blake A. Martin, Executive Vice President and Chief Development Officer at Monarch; Chief Operations Officer at Monarch; and Philip O. Toal, Ed.D., Senior Vice President, Residential Services at Aspire Health Partners.

What does consumer engagement look like in practice? The panel shared five keys that will help provider organizations provide better consumer service, faster services, and better outcomes.

Invest in an up-to-date electronic health record—No strategic plan can be successful without the resources and infrastructure to support it. To properly manage consumer engagement and experience, you can’t just focus on the consumer’s experience when they are in the same room as a clinical provider. True engagement means tracking consumer data so that you can determine what they want or need and are prepared to provide that in real time. Mr. Martin explained that you can’t keep telling your payers and consumers that they have to wait for the data and the information they need to make decisions about care.

Expand and improve access—Contractual agreements drive consumers to your door, but if they can’t get in the door, or don’t like their experience when they do, they will be neither engaged nor likely to come back. Mr. Thompson explained that old-fashioned appearance and amenities can really help the consumer experience, noting:

We gave our facilities a face lift, including free Wi-Fi and phone charging. We made sure our front desk staff are welcoming and that our clinical staff understood customer service. We also focused on waiting room aesthetics and process components. We brought in a centralized call center with nine operators trained on mental health first aid and customer service. All calls go to corporate office and our team will transfer the consumer to where they need to go.

Provide stages of change education—Mr. Toal explained these as “motivational enhancement services” that are designed to convince staff that they want to change and take a greater role in providing a consumer-centered approach. Organizations need to ask themselves if they have a consumer-centered approach that isn’t being properly demonstrated. It’s not just about looks, it’s about core values

Comprehensive assessment that includes social determinants of health—It’s hard to know how best to engage with any given consumer if you don’t really know a lot about them. From a consumer services standpoint, it’s worth spending time on assessments. This also means investing in things like telehealth that can help you ask consumers about their goals, their environments, as well as get their feedback on your services.

Care coordination—Care coordination and case management are key and essential to achieving the kinds of consistency across systems that lead to greater consumer experiences in the short-term, and better consumer engagement in the long-term. Mr. Toal noted that organizations need to be available 24/7, 365 days a year because that brings consumer health satisfaction.

Last month I took on a difficult question—why has there been so little adoption of measurement-based care (see Why So Little Measurement-Based Mental Health Care?)? Response rate to treatment is 87% when measurement-based care is used, compared to 63% when the standard of care is used. Even more startling, measurement-based care results in a 74% remission rate, compared to 29% when the standard of care is used. Yet, measurement-based care is an exception rather than the rule in the field.

That piece sparked a lot of reader feedback, including a few interesting perspectives from Scott Zeiter, Executive Vice President, Chief Operating Officer, Grafton Integrated Health Network. Mr. Zeiter spoke about the challenges—and rewards—of making Grafton a “measurement-based” organization when it comes to planning services for children, adolescents, and adults with complex behavioral health challenges.

I sat down with Mr. Zeiter to learn more about why and how Grafton implemented measurement-based care. He explained the “why” this way:

Instead of stories that make us feel good, and feedback from families and referral sources, we wanted to be more data driven. And we wanted to answer the simple question, how do we know this is effective? The oncoming freight train of value-based reimbursement (VBR) means we need to know how to make good judgments as we will now be assuming financial risk for defined outcomes—we need a better idea of what worked and what didn’t work.

His description of the “how”—the journey to measurement-based care—was even more interesting. He had four key elements on how Grafton arrived at data-informed service planning for consumers: creating a culture around outcomes, determining which evidence-based practices (EBP) Grafton would adopt, implementing the right technology to implement this model, and choosing a partner to analyze the data.

Creating a culture around outcomes—After the decision to use data for consumer treatment planning, the next step is getting your clinical team to embrace the concept. Mr. Zeiter was surprised how easily the clinical professional staff agreed to the model and were willing to at least to see if it could work. Mr. Zeiter attributes this to the fact that the organization already has a culture focused around outcomes as a result of their ten-year-old goal mastery initiative, which requires clinical professionals to create actionable, measurable goals for consumers. He explained further:

I was expecting clinicians to say, “don’t tell me what to do.” What we got was the feedback, “let us give this a shot.” The biggest challenge is doing our best to ensure the behavioral data tracking that ends up falling on the people who are very busy and very stressed doesn’t overwhelm them. We needed to make sure the data entry is as simple as it could be.

Determining which EBPs to include—My key question for Mr. Zeiter was how Grafton selected measurements, and evidence-based practices, to include in their decision support model. His answer was that, based on their own data, Grafton developed service models that were “most effective” for consumers; an approach referred to as practice-based evidence. Mr. Zeiter said:

First, you must understand how “evidence” makes its way into EBPs. The first path is to a controlled experimental approach that is conducted in an academic setting to identify the effect of a treatment; this approach is long, costly, and often hard to apply in a treatment setting. The second path, and the one that offers the clearest path forward for organizations that make a commitment to measuring data and then using that to inform their practices, is a practice-based evidence approach that allows organizations to analyze their own “real world” practices.

We have a new clinical model that forces the clinician to choose the evidence-based practice they are using. And under that, there are “intervention objectives”—broad statements of method for that evidence based practice. Our hope is to link these approaches with outcomes data, so we can say that the most effective methodology was “X.” Our whole treatment process is methodologically driven. Choose a behavior to attack, clearly express the target of the goal in good behavioral terms, choose the evidence-based practice you will use, and then show how good you did.  We can then correlate all of the data in our EHR with those outcomes to drive practice-based evidence.

Implement the right technology—In order to implement a measurement-based model of care at scale, technology is essential. Grafton is implementing a new electronic health record (EHR) and has customized the EHR to both collect the consumer data they need for clinical decision making and facilitate the selection of preferred clinical pathways for each consumer.

Select a partner to analyze the data—Finally, Mr. Zeiter said they hope to select an academic partner to help them ensure the fidelity of the model and do a deep dive into the data. While the Grafton team analyzes the data, an academic partner will add bandwidth and expertise. The academic affiliation also brings additional interest and credibility to any data that Grafton may choose to publish.

The Grafton model of measurement-based care is still in its infancy and Mr. Zeiter noted that they are certain the decision support model will change over time. This is not a small undertaking but one that Grafton—and other specialty provider organizations—need to optimize outcomes and standardize service delivery for success in a value-based environment.

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. Challenges In Changing To A Culture Of Value (Or Making Any Culture Change)
  3. Building A Workforce For Value-Based Reimbursement = Advice From Four Executives
  4. ‘Virtual Psychiatrist’ Telemedicine Decision Support System Effective In Diagnosing Mental Disorders
  5. Preparing For Your ‘Augmented’ Workforce

Last week, we spent the week taking a deep dive into the changing landscape of performance and its link to value-based reimbursement.

One of my big takeaways from the many discussions I had at the event is that the current landscape is creating a new role for chief financial officers (CFO). Best practice strategy development and planning for sustainability require robust internal performance metrics—and benchmarks to customer expectations and competitor performance. This changes the role of financial management to one with a broader and more strategic function.

How ready are CFOs for this new performance-driven landscape? If recent findings are any indication, there’s work to do. Only 13% of CFOs say their organizations are “very prepared” to manage evolving payment models and only 23% are very confident in their team’s ability to quickly and easily adjust strategies and plans. These were the findings of the recently-published “2019 CFO Outlook: Performance Management Trends and Priorities in Healthcare.” And, these statistics reflect a deterioration in CFO confidence from the last survey period.

I think some of the perceived problems result from a few new capability requirements that have been discussed before. First, “performance” is a broader concept and leadership teams should consider having all required information reside in one system accessed by all managers and leaders. In the survey, CFOs identified “financial health” as the most important (85%) performance measure. But consumer experience and quality outcomes followed closely.

Figure 1. Threnhauser, S. CFO Version 3.0. [Powerpoint Slide] Retrieved from www.openminds.com

Second, new cost accounting tools are a must. There is the need for new cost accounting tools and models to re-engineer service delivery. In addition, the field will need specialized cost accounting tools to re-engineer and manage service delivery within value-based payment arrangements that span across service continuums.

Third, budget processes need to change—allowing for more rapid budget development and the ability to adjust budgets within a shorter time frame. In the survey, 37% of CFOs reported having a budget process that takes six or more months from initial rollout to board presentation, up from 27% in 2018. And, 46% say their budgets cannot be easily adjusted when new strategic information or analyses are available.

Finally, CFOs need to lead the push for better performance reporting across their organization. This includes creating better dashboards and visuals (67%), pulling data from multiple source (64%); and accessing trusted data sources (52%).

Figure 2. Threnhauser, S. CFO Version 3.0. [Powerpoint Slide] Retrieved from www.openminds.com

About 15 years ago, we wrote about the need for “reinventing the CFO”. It’s probably time for CFO Version 3.0.

For more on the changes surrounding your CFO in response to the era of VBR and added financial pressures, check out these resources from the PsychU Resource Library:

  1. Income Statement Vs. Balance Sheet? The CFO Dilemma
  2. Can You Tell If Your Organization Is On The Financial Brink?
  3. ‘Surprise!’ A Word You Don’t Want To Hear From Your CFO
  4. Digital Transformations Demand Digital Dexterity
  5. Do You Have A Leadership Strategy For Tech ROI?
  6. Income Statement Vs. Balance Sheet? The CFO Dilemma
  7. The Art & Science Of Replacing Key Executives
  8. VBR @ Scale-Changes Required

In 2018 about 28% of American adults (ages 19 to 64) with employer-sponsored health coverage and 42% of those with individual coverage were underinsured in terms of the amount of their plan out-of-pocket costs compared to their household income. Since 2010, the greatest growth in the underinsured rate has occurred among Americans in employer-based health plans; in 2010 about 17% were underinsured compared to 28% in 2018. However, those who would purchase plans on their own through the individual market or the marketplaces were the most likely overall to be underinsured. In 2010 about 27% were underinsured, compared to 42% in 2018.

People who are underinsured are defined as:

  • Those whose out-of-pocket medical costs, excluding premiums, over the prior 12 months are equal to 10% or more of household income.
  • Those with income under 200% of the federal poverty level ($24,120 for an individual or $49,200 for a family of four) whose out-of-pocket medical costs, excluding premiums, over the prior 12 months are equal to 5% or more of household income.
  • Those whose deductible constitutes 5% percent or more of household income.

These findings were reported in “Health Insurance Coverage Eight Years After the Affordable Care Act (ACA); Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured” by Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty. The researchers presented facts from the Commonwealth Fund’s 2018 Biennial Health Insurance Survey. The telephone survey included a nationally representative sample of 4,225 adults ages 19 to 64 between June 27, 2018 and November 11, 2018. The goal was to summarize updates in the American health insurance population.

Additional findings include:

  1. The overall percentage of adults (45%) who are inadequately insured is about the same as in 2010, however there are shifts in the details surrounding the inadequate insurance.
  2. Compared to 2010, the duration of coverage gaps people experience has shortened significantly: the percentage experiencing a coverage gap of one year or more was 31% in 2016, compared to 39% in 2012.
  3. The 2018 adult uninsured rate was 12.4%, and statistically unchanged since the 2016 survey.
  4. The percentage of adults in 2018 who did not have long-term insurance coverage for more than two years was 54%, compared to 63% in 2010.
  5. People who are underinsured or spend any time uninsured report cost-related problems getting care and difficulty paying medical bills at higher rates than those with continuous, adequate coverage.

The researchers concluded that since 2010 when the PPACA became law, working-age adults are much more likely to have health insurance. However, the improvement in uninsured rates has stalled. More people are covered by health plans that fail to adequately protect them from high health care costs, and the erosion in cost protection has several possible sources, as follows:

  • Although the PPACA’s reforms—the essential health benefits package, cost sharing reductions for lower-income families, and out-of-pocket cost limits— have provided many consumers with greater protection against health care costs, the protections have primarily benefited consumers with incomes at or below 250% of the federal poverty level (FPL). Consumers earning more are not eligible for cost-sharing reductions on plans purchased through the Health Insurance Marketplace. Further, the PPACA reforms do not apply to plans purchased through an insurance broker.
  • The bans against insurers excluding people from coverage because of a preexisting condition and rating based on health status have meant that individuals with greater health needs, and thus higher costs, are now able to get health insurance in the individual market. Because they have health insurance, the population has higher costs because they are seeking care.
  • While plans in the employer market historically have provided greater cost protection than plans in the individual market, businesses have tried to hold down premium growth by asking workers to shoulder an increasing share of health costs, particularly in the form of higher deductibles.
  • Growth in Americans’ incomes has not increased at the same rate as the growth in health care costs.

The full text of “Health Insurance Coverage Eight Years After the ACA; Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured” was published February 7, 2019, by the Commonwealth Fund. An abstract with access to the full text is available online at www.commonwealthfund.org.

For more information, contact: Bethanne Fox, Vice President, Outreach and Strategy, Commonwealth Fund, 1 East 75th Street, New York, New York 10021; 212-606-3853; Email: bf@cmwf.org.

The prevalence of employer-sponsored health insurance did not change significantly after the Medicaid expansion provisions of the Patient Protection and Affordable Care Act (PPACA) of 2010 went into effect. A comparison of employer offers of insurance coverage, employee acceptance rates, and the amount employees paid for out-of-pocket premiums found little change that could be attributed to Medicaid expansion. There may have been an inverse relationship between expanded Medicaid eligibility and the share of employees who were eligible for employer-sponsored insurance.

These findings were reported in “The Impact Of Medicaid Expansion On Employer Provision Of Health Insurance” by Jean M. Abraham, Anne B. Royalty, and Coleman Drake. The researchers analyzed data from the 2010–2015 Medical Expenditure Panel Survey-Insurance Component for approximately 141,900 private sector employers that inluded all data for workforce characteristics. The goal was to detect change in four employer-sponsored insurance outcomes: offers of health insurance, eligibility, take-up, and the out-of-pocket premium paid by employees for single coverage. The researchers compared differences in the four outcomes between Medicaid expansion states and non-expansion states. The researchers merged information from the U.S. Bureau of Labor Statistics’ Local Area Unemployment Statistics file, and information about state minimum wage laws. They also controlled for a possible association between the employer shared responsibility requirement (ESRR) that applied to companies with 100 or more employees. Under the ESRR, companies were required to offer health insurance to full-time employees working at least 30 hours per week.

The researchers compared employer characteristics for 2010 to 2013, and for 2014 to 2015. Key findings were as follows:

  • The percentage of establishments (the physical locations of an employer, as opposed to the firm, which is the entirety of the employer’s operations) offering insurance declined from 49.13% to 44.19% between the two periods.
  • The percentage of workers eligible for insurance decreased from 80.57% to 79.53%.
  • The percentage of eligible workers who accepted the employer insurance decreased from 74.94% to 73.83%.
  • The share of establishment workforces that are low wage declined from 33.55% to 30.56%. Low wage is defined as the percentage of workers earning under $11.50 per hour.
  • Annual out-of-pocket premiums remained essentially the same after adjusting for inflation; they averaged $1,026.31 from 2010 to 2015 in 2015 dollars. However, establishments with higher percentages of low-wage workers have higher out-of-pocket premiums.

The researchers found no support for the hypothesis that expansion and non-expansion states exhibited significant differences in any of the four outcomes of interest. They concluded that the PPACA did not produce the large-scale changes in employer-sponsored insurance that some policymakers predicted. They noted that the PPACA provisions had incentives that encouraged employers to offer insurance and encouraged employees to accept, which may have countered the incentives to stop offering insurance and allow employees to seek Medicaid expansion eligibility or purchase Marketplace policies. The researchers also said that employers may have continued to offer insurance due to the legal challenges that created uncertainty about whether PPACA would remain law.

The full text of “The Impact Of Medicaid Expansion On Employer Provision Of Health Insurance” was published December 15, 2018, by International Journal of Health Economics and Management. An abstract is available online at link.springer.com.

For more information, contact: Jean Abraham, Ph.D., Wegmiller Professor and Master of Healthcare Administration Program Director, Division of Health Policy and Management, University of Minnesota, 420 Delaware Street SE, MMC 729, Minneapolis, Minnesota 55455; Email: abrah042@umn.edu.

More competition and more value-based reimbursement (VBR) are making performance management more important for health and human service management teams—they need to run business operations, track and correct staff performance, negotiate contracts—all the while out positioning other competitors in the market. The question is, does your management team have useful data available to make these decisions?

Creating a performance management system that reports metrics in a way that promotes action and performance improvement takes planning. Without a dashboard to display what data usable, answering that you have the data might not matter all that much. Data is great, but hardly useful without a good dashboard. You can measure and show outcomes, but they must be articulated in a way that the audience (your management staff) understands. That was my takeaway from the session, Building A New Performance Management Dashboard: How To Use KPIs To Manage Performance In A Value-Based Market, featuring Ashley Sandoval, Associate Chief Executive Officer, Emergence Health Network and Diana Salvador, Psy.D., Vice President, Quality Assurance and Risk Management, CPC Behavioral Healthcare.

The session called out five keys to building an effective KPI system:

  1. Prioritize high utilizers—The consumers using the most services are responsible for the highest spend, which isn’t a surprise to anyone in the field, but is where provider organizations need to focus their KPIs for maximum effect.
  2. Prioritize measurement of evidence-based practices— The performance expectations of value-based reimbursement will likely be demand that more provider organizations invest in standardized treatment protocols, meaning they need to measure evidence-based practices.
  3. Create infrastructure to share data—You need to be able to collect the data, analyze the data, exchange the data, and display the data in real-time. Otherwise, you have a file of information that no one internally, or externally, can use.
  4. Know the limits of technology—Technology won’t tell your value story. That takes staff that understands how to use the technology to extend the value-proposition that is critical to leveraging the power of data.
  5. Know the limitations of staff who use the technology—You can measure and show outcomes, but they must be articulated in a way that the audience understands. This isn’t necessarily a given, and the reports need to be built with staff understanding in mind.

Figure 1. Threnhauser, S. Five Rules For Building An Effective KPI System. [Powerpoint Slide] Retrieved from www.openminds.com

Ms. Salvador explained that CPC Behavioral Healthcare pursued KPIs in response to federal grants and a VBR pilot that forced the organization to reconsider what it would take to stay in business while telling their value story to different target audiences that included board members, payers, consumers, and staff.

Figure 2. Threnhauser, S. Five Rules For Building An Effective KPI System. [Powerpoint Slide] Retrieved from www.openminds.com

Ms. Sandoval explained that Emergence pursued KPIs as part of their three-year strategic plan to align service with the Certified Community Behavioral Health Clinic (CCBHCs) model which Texas doesn’t have yet but that Emergence has identified as the future of the market. As a result, Emergence chose 16 measures for their 1115 waiver funding, nine of which are attached to CCBHC core measures.

Figure 3. Threnhauser, S. Five Rules For Building An Effective KPI System. [Powerpoint Slide] Retrieved from www.openminds.com

Both expressed the need for organizations to move KPIs from the tactical to the strategic, or as Peter Drucker put it, “Management is doing things right; leadership is doing the right things.” Being strategic with your KPIs means choosing those KPIs that will most effectively define “truth” by reaching an internal consensus on what metrics will be the most valuable to know. The tactical work will then be how to display that data to the teams that need it.

A survey of high-need, high-cost (HNHC) health care consumers, with chronic health conditions, found that this group believes five solutions would help them avoid unnecessary emergency room use. The solutions are: care management, readily available at-home physical therapy and nursing services, home delivery of prescription medications and easier refills, telemedicine, and more after-hours clinics. HNHC is defined as the 5% of health care consumers who account for 50% of health care spending who have limited ability to perform activities of daily living, multiple chronic health conditions, and psychosocial needs.

These findings were reported in “High-Need, High-Cost Patients Offer Solutions for Improving Their Care and Reducing Costs” by Lala Tanmoy Das, MS, Erika L. Abramson, M.D., MSc; and Rainu Kaushal, M.D., MPH of Weill Cornell Medicine. The researchers led several focus group discussions with 21 high-need, high-cost consumers, as identified by clinical care coordinators at each site; and 3 primary caregivers. The participants represented an urban health care system in New York City, and a second one in Gainesville, Florida. The consumers were identified as having at least one chronic medical condition and either three or more emergency visits, or two or more inpatient admissions, during the six months prior to initiation of the study. Three consumers were too ill to participate, so their primary caregivers acted as proxies. The goal was to determine the best care and cost-reduction solutions for HNHC health care consumers, according to the consumers themselves.

In the year prior to the discussions, the participants had, on average visited their primary health care professionals six times, had visited the emergency department 16 times, and been hospitalized five times. Commonly reported medical conditions included arthritis, asthma, chronic obstructive pulmonary disease (COPD), depression , diabetes, epilepsy, heart disease, hypertension, and obesity.

Participants identified five solutions that they felt would help prevent overuse of hospital and emergency department services for symptoms and conditions, and would therefore reduce overall cost of care. The majority of the solutions relate to alleviating unnecessary and inconvenient travel for the consumer, especially in cases where means of travel do not easily exist for a consumer. These five solutions were:

  1. Care management, including appointment scheduling and reminders, and accessibility to health care professionals by telephone or internet chat to obtain professional advice.
  2. Readily available at-home physical therapy and nursing services to alleviate inconvenient and uncomfortable travel to health care locations following major surgery, and to allow the comfort of healing at home.
  3. Home delivery of prescription medications and easier refills to alleviate inconvenient (and sometimes impossible) travel to pharmacies.
  4. Telemedicine, including accessibility to health care professionals by telephone or internet chat to obtain professional advice about non-life-threatening conditions.
  5. More after-hours clinics in convenient locations for needed non-emergency assistance.

The researchers concluded that it is important to heed recommendations that come directly from HNHC health care consumers. Due to the consistent recommendations of this small sample, the group is likely an accurate representation of the HNHC consumer group as a whole. While almost all of the suggested solutions are being piloted in various settings across the country, the researchers recommended that health care systems consider expanding these solutions and offering education to HNHC consumers to continue lowering costs for this population overall.

The full text of “High-Need, High-Cost Patients Offer Solutions for Improving Their Care and Reducing Costs” was published February 5, 2019, by the New England Journal of Medicine (NEJM) Catalyst. A copy is available online at catalyst.nejm.org.

For more information, contact: Anna Sokol, Office of External Affairs, Weill Cornell Medicine, 1300 York Avenue, Box 314, New York, New York 10065; 646-962-9272; Email: ana2059@med.cornell.edu.

After three days of discussion about performance, my thoughts went to Peter Drucker and his leadership adage in The Effective Executive, “plan, organize, integrate, motivate, and measure.” I would just make one slight addition:” measure, plan, organize, integrate, motivate, and measure again.”

This afternoon in Monica E. Oss’s wrap up at The 2019 OPEN MINDS Performance Management Institute, Fit For Growth-Performance Management & The Growth Imperative, her focus was on the often broken link between performance, strategy, and growth in specialist health and human service organizations. For most organizations in the field, growth is an imperative-whether to achieve scale or just replace revenue streams that dry up due to changing customer preferences. But many of these organizations are not ready for growth and are missing the organizational characteristics that enable successful growth.

To spur growth in a turbulent market, our team encourages provider organization executive teams to use a four-step process: One, use market metrics and performance metrics to develop strategy; Two, use strategy to prioritize investment of both time and money; Three, focus the organization’s managers on executing strategy, with an emphasis on the strategic priorities; and Four, continually update market metrics and performance metrics in order to update strategy. This process is simple in concept and extremely difficult to actualize.

Figure 1. Oss, M. From Metrics To Action—Making Strategy A Reality [PowerPoint Slides] Retrieved from www.openminds.com

I’ve written before about the importance of performance metrics in management (see Putting Performance Into Compensation, and Performance Metrics Matter). But one of the big questions for managers is, how do you use metrics to create strategy? There are three very similar approaches that management teams can use:

  1. The blue ocean model
  2. The Amazon flywheel model (see The Amazon Leadership Principles & The Amazon Flywheel – What They Could Mean For Your Organization and Getting That ‘Preferred’ Role With Health Plans)
  3. The strategic quality model

What the three models share is a structured, metrics-based approach to increasing value to customers-by cost reductions and improvements in performance attributes-that result in superior market positioning and growth. The key is to develop a growth strategy that is both market-driven (identifying market opportunities) and capabilities-driven (identifying what the organization does better than its competition).

Once the strategy is written, the hard works begins. (Peter Drucker’s other adage that comes to mind is “strategy is a commodity, execution is an art”.) Executives need to create a budget that reflects the growth priorities—which may result in decreased funding of low-priority services and initiatives. And then executives need to hold their teams accountable for executing that strategy. The “art” is in that execution—which may involve new team members, new management styles, and new infrastructure. All these “new” elements equal big change within an organization.

I’ve found the greatest challenge in strategy execution for health and human service organizations is often about changing culture and tradition. “Unfunding” traditional programs and activities is hard. Assessing the ability of team members to execute plans and bringing in new talent when needed is a challenge. Assessing executives on their results alone, rather than their style, knowledge, or other contributions, can be problematic. For non-profit organizations, incorporating a concrete plan that funds mission-based activities, is often an uncomfortable exercise.

Figure 2. Oss, M. From Metrics To Action—Making Strategy A Reality [PowerPoint Slides] Retrieved from www.openminds.com

These are the building blocks of success for health and human service organizations—good strategy needs to be informed by data. I’m not saying that with data, strategy will magically write itself. Rather, good metrics provide leaders with the guideposts for great strategy. In the end, decisionmaking is the burden of executives and I’m reminded again of Peter Drucker: “There is nothing quite so useless, as doing with great efficiency, something that should not be done at all.”

Just a few years ago, most executives’ relationships with their team members took place in the same location—face-to-face meetings and working on problems side-by-side. But commerce has changed—larger multi-jurisdictional (and international) organizations with service locations and team members in many states (and time zones), more home-based and virtual services, more travel, and more virtual employee communication.

This evolving environment has affected work in health and human services in almost every way. Clinical professionals’ relationships with consumers, customer relationship management, supervision practices, and management roles are increasingly virtual. Virtual work environments also have important implications for leadership. How do leaders communicate a new vision and affect culture change in a virtual organization? That was the question posed to John Stupak, President & Chief Executive Officer, Sequel Youth and Family Services and Peggy S. Terhune, Ph.D., President & Chief Executive Officer, Monarch, by OPEN MINDS Senior Associate, Sharon Hicks in the session When Technology Becomes Integral To Strategy: Leading In A Virtual Environment.

The overall takeaway of the day was summed up by Mr. Stupak when he noted that both discipline and communication are vital in remote management situations. Team members who lack either of these skills are team members who won’t do well in a virtual environment. And, he had an observation that I found very interesting—the “risk” of virtual teams is much higher with your leadership team than your staff delivering consumer services. He said, “I don’t really worry about service providers, because there is service documentation, encounter and outcome data, and consumer satisfaction that reveals if one hasn’t done their job. It’s the leadership and managers where it may not be as apparent for a couple weeks or months down the road whether they have done their job or not. Not all managers and executives have the personal characteristics to be successful when not in an office environment. They can feel isolated and have trouble remaining focused. Solutions to those human issues must be part of your plan.”

During the discussion between leaders and participants, there were four best practices for virtual team leadership that emerged—in hiring, communication, employee operating process, and performance management.

Hire intentionally—Not all people can work in a virtual environment, either in your facility or remotely. Personality, work style, discipline, communication skills, and reliability are just as important as the specific skill sets you are looking for. Make sure that assessing these characteristics is part of your hiring processes.

Communicate clearly, deliberately, and quickly—When two team members work in the same location, the opportunities for communicating are much greater. This is particularly true for informal communication that uncovers problems and builds rapport. When team members are separated by distance and use virtual platforms for communication, this informal communication channel is lost. Leaders must both strengthen formal communication and find substitutes for informal communication. On the formal communication side, it is much more important to publish formal policies and procedures; to have regularly scheduled, structured team meetings, and one-on-one reviews.

But compensating for the informal communication is much harder and takes much more work on the part of managers. Managers need multiple communication channels (telephone, email, text, Twitter, LinkedIn, etc.) and need to be available and respond quickly to their team members. It is a big commitment from managers.

Understand Your Team Members’ Work Experiences—The introduction of the virtual work environment changes so much. Do team members who are physically distant from their managers have the same likelihood of promotion? Do managers understand the location-specific challenges of consumer service in a distant location? Do supervisors pay enough attention to virtual communication platforms? It is incumbent on executives to make sure these issues are addressed in virtual environments.

Additionally, people work best when they feel that they are part of team, and they feel most like a team when they can interact with one another in person. It’s hard to bond with a group of people that staff only knows through email and chat messages. To overcome this, leadership needs to plan and budget for events that bring the team together on a semi-regular basis.

Manage By Performance Metrics—When you can’t see what a team member is doing, it puts more pressure on supervisors and managers to manage their team using performance metrics. There are a few guidelines. Choose your performance measures wisely. Set clear performance and productivity benchmarks and communicate them frequently. Maximize the use of shared data to promote collaborative work approaches.

As I think about these best practices, I see the need for reorientation of managers who assume responsibility for virtual team members—and more thought to deliberate virtual team building. For more on digital challenges, check out these resources from the PsychU Resource Library: Digital Transformations Demand Digital Dexterity‘Going Digital’ For A Better Consumer Experience, and The Digital Revolution In Mental Health Hasn’t Happened Yet.

By the end of 2018, the uninsured rate rose to 13.7%, an increase of 2.8% since 2016. This represents a net increase of about seven million adults total without health insurance as of 2018. Prior to the 2014 implementation of the Patient Protection and Affordable Care Act (PPACA), 18% of U.S. citizens were uninsured, and while the percentage of women uninsured in 2018 was less than men, women showed a 3.9% increase since 2016, compared to a 1.6% increase for men.

These findings were presented in “U.S. Uninsured Rate Rises to Four-Year High,” by Dan Witters for the Gallup National Health and Well-Being Index (Gallup). Data for the report was collected as part of the Gallup National Health and Well-Being Index, based on Americans’ answers to the question, “Do you have health insurance coverage?” The researchers randomly surveyed approximately 28,000 adults per quarter in 2018 (a total of 115,929 adults) who lived in all 50 U.S. states and the District of Columbia. The goal was to determine the current rate, and trend, of those uninsured in the U.S.

Additional findings include:

  • While the uninsured rate increased in all age groups since 2016, those aged 18 to 34 years had the largest increase (4.8%), compared to those age 35 to 64 (a 2.7% increase), and those aged 65 and older (a 1.4% increase).
  • The increase in uninsured since 2016 was largest in households making between $24,000 and $48,000 per year (3.0%); followed by those making under $24,000 (a 2.8% increase); and those making between $90,000 and $120,000 per year (a 2.7% increase).
  • Those who live in the eastern U.S. states saw a 0.4% decrease in uninsured rates since 2016 (from 7.5% to 7.1%). In comparison, those who lived in the south saw a 3.8% increase; those who lived in the west saw a 3.6% increase, and those who lived in the Midwest saw a 3.2% increase in uninsured rates.

The full text of “U.S. Uninsured Rate Rises to Four-Year High” was published January 23, 2019 by Gallup. An abstract is available online at news.gallup.com.

PsychU reported on this topic in “12.2% Of U.S. Adults Are Uninsured, Up 1.3 Percentage Points From Record Low In 2016,” which published on February 21, 2018.

For more information, contact: Dan Witters, Research Director, Gallup National Health and Well-Being Index, Gallup, 1001 Gallup Drive, Omaha, Nebraska 68102; 402-951-2003; Fax: 888-500-8282; Email: Dan_witters@gallup.com.

On December 12, 2018, the New York Department of Health (DOH) issued a quality measure set for its Medicaid Health and Recovery Plans (HARP). The HARPs are specialized Medicaid managed care organization (MCO) plans that integrate physical health, behavioral health, and Medicaid waiver home- and community-based services (HCBS) for beneficiaries diagnosed with serious mental illness (SMI). The quality measure sets includes 38 measures, which will be reported by provider organizations to MCOs in 2019. The measures will be used to support value-based purchasing contracts between provider organizations and Medicaid managed care plans.

The quality measure sets are updated annually. For 2019, DOH added one measure to the 2018 measure set (Asthma Medication Ratio) and removed five measures related to diabetes care.

New York HARP 2019 Quality Measurement Set, Category 1 Measures

Measure Measure Steward Classification, Pay-For-Performance (P4P) or Pay-For-Reporting (P4R)
Adherence to Antipsychotic Medications for Individuals with Schizophrenia Centers for Medicare & Medicaid Services (CMS) P4P
Asthma Medication Ratio National Committee for Quality Assurance (NCQA) P4P
Breast Cancer Screening NCQA P4P
Cervical Cancer Screening NCQA P4P
Chlamydia Screening in Women NCQA P4P
Colorectal Cancer Screening NCQA P4P
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA P4P
Comprehensive Diabetes Care: Medical Attention for Nephropathy NCQA P4P
Comprehensive Diabetes Screening: All Three Tests (HbA1c, dilated eye exam, and medical attention for nephropathy) NCQA P4P
Continuity of Care from Inpatient Detox to Lower Level of Care NYS P4P
Continuity of Care from Inpatient Rehabilitation for Alcohol and Other Drug Abuse or Dependence Treatment to Lower Level of Care NYS P4P
Controlling High Blood Pressure NCQA P4P
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications NCQA P4P
Follow–Up After Emergency Department Visit for Alcohol and Other Drug Dependence NCQA P4P
Follow–Up After Emergency Department Visit for Mental Illness NCQA P4P
Follow–Up After Hospitalization for Mental Illness NCQA P4P
Initiation of Pharmacotherapy upon New Episode of Opioid Dependence NYS P4P
Maintaining/Improving Employment or Higher Education Status NYS P4R
Maintenance of Stable or Improved Housing Status NYS P4R
Medication Management for People with Asthma NCQA P4P
No or Reduced Criminal Justice Involvement NYS P4R
Percentage of Members Enrolled in a Health Home NYS P4R
Potentially Preventable Mental Health Related Readmission Rate 30 Days NYS P4P
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow–Up Plan CMS P4R
Preventive Care and Screening: Influenza Immunization American Medical Association Physician Consortium for Performance Improvement (AMA PCPI) P4R
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention AMA PCPI P4R
Statin Therapy for Patients with Cardiovascular Disease NCQA P4R
Statin Therapy for Patients with Diabetes NCQA P4R
Use of Pharmacotherapy for Alcohol Abuse or Dependence NYS P4R
Use of Spirometry Testing in the Assessment and Diagnosis of COPD NCQA P4R

There are no changes to the Category 2 HARP measure set for 2019. All Category 2 measures are classified as P4R in measurement year 2019.

New York HARP 2019 Quality Measurement Set, Category 2 Measures

Measure Measure Steward
Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder CMS
Asthma Action Plan American Academy of Allergy, Asthma & Immunology (AAAAI)
Asthma: Assessment of Asthma Control – Ambulatory Care Setting AAAAI
Asthma: Spirometry Evaluation AAAAI
Continuing Engagement in Treatment (CET) Alcohol and Other Drug Dependence NYS
Initiation of Pharmacotherapy upon New Episode of Alcohol Abuse or Dependence NYS
Mental Health Engagement in Care 30 Days NYS
Percentage of HARP Enrolled Members Who Received Personalized Recovery Oriented Services (PROS) or Home and Community Based Services (HCBS) NYS
Use of Opioid Dependence Pharmacotherapy NYS

To reimburse the MCOs for participating in the VBP, the state implemented a stimulus adjustment in the 2018 MCO rate setting process to increase the managed care capitation premium for those MCOs that have captured more provider-payment dollars in VBP arrangements at higher levels. The adjustment lasts for two years.

The state described the arrangements in “A Path Toward Value Based Payment: Annual Update November 2017: Year 3, New York State Roadmap For Medicaid Payment Reform,” which was released in November 2017. From 2018 on, based on the prior year’s VBP contracts, MCOs that fall behind the goals for VBP contracting as outlined in the Roadmap will receive a penalty. Additional details are as follows:

  • For 2018, MCOs were subject to a penalty if they had less than 10% dollars of total MCO expenditure captured in Level 1 or above VBP contracts as of April 1, 2018. The penalty was 0.5% on the marginal difference between 10% of Medicaid managed care expenditure and their total expenditure on Level 1 or above VBP contracts.
  • For 2019, fully capitated and non-fully capitated MCOs are both subject to penalties if as of April 1, 2019, their contracts fail to have at least 50% of the total MCO expenditures captured in a Level 1 or higher arrangement. The penalty is 1% on the marginal difference between 50% Medicaid managed care expenditure and the MCO’s total expenditure on Level 1 or above VBP contracts. Both types of MCOs are subject to penalties based on the share of expenditures captured in a Level 2 or higher arrangement. Fully capitated MCOs must have 15% in Level 2 or higher contracts; non-fully capitated MCOs must have at least 5%. Failure to meet the Level 2 target results in a penalty of 1.0% on the marginal difference between the contracting target and the total expenditure on Level 2 or above VBP contracts. If both penalties are incurred, then only the larger penalty will be applied.
  • As of April 1 2020, fully capitated and non-fully capitated MCOs are both subject to penalties, if their contracts fail to have at least 80% of the total MCO expenditures captured in a Level 1 or higher arrangement. The penalty for fully capitated MCOs is 1% on the marginal difference between 80% Medicaid managed care expenditure and the MCO’s total expenditure on Level 1 or above VBP contracts; for non-fully capitated MCOs, the penalty is 1.5%. Fully capitated MCOs must have 35% in Level 2 or higher contracts; non-fully capitated MCOs must have at least 15%. Failure to meet the Level 2 target results in a penalty of 1.0% (or 1.5% for the non-fully capitated MCOs) on the marginal difference between the contracting target and the total expenditure on Level 2 or above VBP contracts. For the fully capitated MCOs, if both penalties are incurred, both will be applied. For the non-fully capitated MCOs, only the larger penalty will be applied.

HARPs are a Medicaid Special Needs Plan (SNP) operated by New York’s Medicaid MCOs. The HARPs have a specialized staff with behavioral health expertise, and the plan provides all covered services available through Medicaid managed care, in addition to an enhanced benefit package that includes BH HCBS for eligible enrollees. HARP eligibility criteria has been determined by the state. Beneficiaries eligible for HARP cannot be dual enrolled (receiving both Medicare and Medicaid) or participating in a program with the New York State Office for People With Development Disabilities (OPWDD).

The state launched the first VBP pilot in the Fall of 2016. The long-term goal is that by April 2020, 80% to 90% of MCO payments to provider organizations will  be made using VBP methodologies. The VBP pilot lasted for two years to help create momentum in the transition from fee-for-service to a VBP environment and to provide data about the design of VBP. The pilot included six provider organizations and eight MCOs working together on 12 distinct contracts. The contracts pilot three types of VBP arrangements: HARP subpopulations, Integrated Primary Care (IPC), and Total Care for the General Population (TCGP). The HARP pilots included MCO Healthfirst PHSP, Inc. and provider organizations Maimonides Medical Center and Mount Sinai Health Partners. The pilot organizations helped evaluate the validity, feasibility, and reliability of quality measures for their respective arrangements, and they shared feedback on core aspects and best practices of the VBP process for statewide implementation. The 2018 performance results, in terms of penalties and bonuses, were not reported. The Measurement Year (MY) 2019 HARP Quality Measure Set was created in collaboration with the Behavioral Health/ HARP Clinical Advisory Group (CAG), as well as the New York State Value Based Payment (VBP) Workgroup. For measure year 2019, the quality measures in place for 2018 were reviewed by the VBP Measure Support Task Force.

The VBP Measure Support Task Force sorted the measures into three categories:

  • Category 1 measures are approved measures that are deemed to be clinically relevant, reliable, valid, and feasible. VBP contractors report Category 1 measures to the managed care organizations (MCOs). These measures are intended to be used to determine the amount of shared savings for which VBP contractors are eligible. VBP contracts must include at least one Category 1 pay-for-performance measure.
  • Category 2 are measures that are clinically relevant, valid, and reliable, but where the feasibility could be problematic. These measures were investigated during a 2017 and 2018 pilot program. These measures will be further investigated in the VBP Pilots. The state requires that VBP Pilots select and report a minimum of one Category 2 measure per VBP arrangement for measurement year 2019 (or have a state and plan approved alternative). VBP Pilot participants will be expected to share meaningful feedback on the feasibility of Category 2 measures when the CAGs reconvene. The state will discuss measure testing approaches, data collection, and reporting requirements with VBP Pilots as a part of the Measure Support Task Force.
  • Category 3 measures are those that were identified as unfeasible at this time, or as presenting additional concerns including accuracy or reliability when applied to the attributed member population for an arrangement. As a result, Category 3 are not included in the measure set.

PsychU reported on the HARPs in “New York Medicaid Releases RFQ For Adult Behavioral Health Benefit Plans Outside New York City,” which published on July 30, 2015.

For more information, contact: Delivery System Reform Incentive Payment (DSRIP) Program, New York State Department of Health, Empire State Plaza, Corning Tower, Albany, New York 12237; Email: dsrip@health.ny.gov.

Your organization has prepared. You’ve done your homework and built partnerships with health plans. You have the contract. The real question is, once you have the contract, then what? That was the topic of the session, Mapping Performance To Manage Value: The Clinical Data You Need To Manage The Risk Of Value-Based Reimbursement, featuring Luke Crabtree, J.D., MBA, Chief Executive Officer, Project Transition; Jason Turi, MPH, RN, Vice President of Population Health, Centerstone; and moderated by OPEN MINDS Senior Associate Joseph P. Naughton-Travers, EdM.

This question assumes that your executive team has done the obvious—made sure that the organization has “the basics” for value-based reimbursement (VBR) operations. Those basic competencies include the right technology-driven capabilities, the financial management skills, the clinical models, and more. For more on VBR competencies, see Four Ps For Leading A VBR Evolution (Or Any Change).

But once you “go live” with VBR, then what? Being ready and being successful are two separate issues. Mr. Crabtree and Mr. Turi shared their insights on VBR success and what is required to make those partnerships work. Their keys for success include:

Agree on what “value” means—Every payer and health plan are going to have a different definition of the “value” they are looking for from your services. Those value measures will have different priorities. Be sure you understand the many perspectives on value, perspectives that will vary by different executives in the same organization. And once you have that understanding, do another review to make sure that those “value priorities” are in sync with your VBR contract so your team spends their time on the right priorities. I am reminded of the Peter Drucker adage, “There is nothing so useless as doing efficiently that which should not be done at all.”

Define each performance measure—Defining a big concept like “value” is important, but that doesn’t outline a path for achieving that value. Value is all about quantifying performance and being able to show “how much” value is being produced, using measures that are important to the payer or health plan. If it’s not measurable, it really doesn’t count. Mr. Crabtree noted the use of data dictionaries and nationally recognized normed measurements.

Establish and maintain performance improvement initiatives—Once defined, your team needs to focus on metrics-based performance management. And, it is not enough to have a good dashboard. It’s all about using that data for on-going performance improvement.

Realize there is no “one” perfect software solution—What technology should your organization invest in, and which vendors are the best fit to partner with? For success with VBR, it is likely that your organization will need to have several software platforms—for EHRs, dashboards, care coordination, population health management, consumer engagement, clinical outcome measures, and more. The important part is understanding the functionality needs of your team.

Integrate “all” of your data—Beyond technology-facilitated functionality, in VBR arrangements your executive team needs a performance management tool that combines data from all sources to get the “big picture” of your organization’s performance (see Thinking About Partnering With A Tech Start-Up? and Preparing For The Very Glacial VBR Rollout In Some Markets). This is one of the most fundamental strategic issues for specialty provider organizations that want to participate in pay-for-performance initiatives. Health information exchange is an essential capability (see Are You Strategically Interoperable? and HIE 3.0?).

Engage consumers—Making consumers a partner in managing their wellness is critical to success in VBR arrangements. The data is clear: engaged consumers are activated consumers are healthier consumers (see Getting, & Keeping, Consumers Engaged With Technology).

Acknowledge that the transition is hard—It is unfortunate but there will be a long period of time for most organizations where there are both FFS and VBR contracts. This creates challenges in organizational structure, in performance management, and in hiring. And, it means that staff can easily be confused about priorities and often asked to perform extra work with two systems in place. Communicate this and engage your team in how best to optimize overlapping workflows (see The Future Has Arrived For VBR).

About 70% of Medicare Advantage members surveyed report having one or more chronic conditions, however 44% of respondents said their health care plan does not communicate with them about their chronic condition. Just 10% report that their health plan offers reminders about chronic conditions, but these reminders are often general reminders not tailored to their needs. Chronic conditions reported include:

  • Hypertension (65% of respondents)
  • Hyperlipidemia (37%)
  • Diabetes (22%)
  • Obesity (22%)
  • Asthma (11%)
  • Depression (11%)

These findings were based an analysis of the HealthMine Medicare Survey. During June and July 2018, the survey queried 781 Medicare Advantage-insured consumers, aged 65 and above. The goal was to give health plan sponsors insight into member attitudes and desires about health plan communication and help in informing and planning members’ health.

Members want communication from their health plan on several topics. These include:
Health Plan Communications By Topic

Topic Members Who Want Communication On This Topic Members Who Receive Communication On This topic
Chronic condition 28% 15%
Fees/coverage after service 43% 37%
How to lower health costs 47% 11%
Information from digital health tools 12% 12%
Recommended health screenings 53% 48%

About 86% of respondents believe that their health care provider knows best how to help manage their health care, while only 3% believe their health plan best provides health care. Additional findings include:

  • About 53% said they do not receive any follow up from their health plan after a health care provider visit. About 31% report follow-up regarding coverage, benefit, and bills only; while 16% report follow-up regarding quality of care.
  • About 48% report that their preferred communication method is by telephone; 31% prefer digital communication via email, text, web portal, or a mobile app; and 21% prefer communication via the U.S. mail.
  • About 47% are connected to their plan through a portal.
  • Approximately 52% say that their health care plan portal answers most or some of their questions. About 14% say the portal rarely answers their questions, and 33% said the portal never answers their questions.
  • About 31% report that they are informed when health care providers drop out of their health care network.
  • About 77% use digital health tools. These primarily include blood sugar monitors, physical health trackers, electronic health or electronic medical records, medication trackers, heart rate monitors, food or nutrition trackers, and sleep monitors.
  • About 57% of members know if their plan offers telemedicine; about 31% believe telemedicine is not offered.
  • About 79% do not have easy access to their electronic medical records.

The researchers concluded that getting correct information to health plan members in a timely manner is critical to the success of health care management. Follow-up can be important in better managing both physical health for the members, and cost-related factors for health plans.

Health Mine reported the top-line findings in “60 Percent of Medicare Advantage Beneficiaries Say Plan Does Not Incentivize Action to Improve Health”, which published January 6, 2019, as a press release at www.PRNewswire.com.

For more information, contact: Bryce Williams, President and Chief Executive Officer, HealthMine, Inc., 2911 Turtle Creek Boulevard, Suite 1010, Dallas, Texas 75219; 469-730-5320; Email: ITSupportTeam@healthmine.com.

“Unfit” organizations aren’t likely to be successful with growth. That’s a bold statement but one that I see as a growing problem among specialty provider organizations. Changes in the market and leadership inaction have let the fitness of many organizations atrophy—financially, operationally, and in terms of market positioning. In a market where successful growth strategies are both market-driven and capabilities-driven, organizational fitness is key. It’s hard to grow from a position of weakness.

So which organizations are “fit” and ready for the challenges of growth? These organizations have clear priorities, their investments and management team attention mirror those top priorities, they understand how their services stack up in terms of customer preference and the competition, and the focus of the management team is on improving those metrics. The big issue is that most organizations don’t have the performance data they need to set priorities, create services lines with competitive market positioning, and put forward a winning value proposition for customers.

Figure 1. Oss, Monica. Is Your Organization Fit For Growth? [PowerPoint Slides] Retrieved from www.openminds.com.

The right metrics are essential to understanding the distinctive capabilities that your organization has that can fill an “unfilled” gap in the market and continue to remain competitive. And, that’s not enough—managing the performance of your organization to hit the performance you promised is essential for the long-term. (For more, check out these resources from PsychU Resource Library What Does It Take To Outlast The Disruptors?Make Change Or Be Changed, and Innovation Success In Three Steps.)

This ability to identify unique capabilities—and keep ahead of the competition using data is the critical factor. The organization that is most successful in continually positioning and repositioning its service lines—and delivering on that positioning promise—will be the winner. The key is keeping your portfolio stocked with services that are relevant and competitive. While these are challenges of technology, they are also challenges of executive culture. For more on defining unique capabilities, check out these resources from the PsychU Resource Library:

  1. ‘Productizing’ Services For Competitive Success
  2. Consumer Sovereignty: Better Care = Financial Success
  3. The Enablers Of Competitive Advantage
  4. Health Plan Relationship Building Skills Key To VBR Success

For much of my career, provider organization executive teams have talked about performance management, but left the tough issues on the table with the thought that they would get to it at some point in the future. I think that future has arrived.

The late Peter Drucker said, “If you can’t measure it, you can’t improve it.”

I think that is a statement that most managers would agree with. So my question—raised by Roland Larkin, NP, Ph.D., MBA, Medical Science Liaison, Otsuka Neuroscience and Srikanth Gottipati, Ph.D., M.Phil, Associate Director, Think Team, Otsuka Pharmaceutical Development & Commercialization, Inc., in their session, Measurement Informed Treatment Assistant for Mental Health—why do only 7% of psychiatrists routinely use measurement based psychiatric scales when planning consumer treatment?

We know measurement-based care works. One study found that response rate to treatment is 87% when measurement-based care is used, compared to 63% when the standard of care is used. Even more startling, measurement-based care results in a 74% remission rate, compared to 29% when the standard of care is used. (For more, see The Moving Target—Best Practices In ‘Complex’ Care Management.)

So why the lack of adoption of measurement-based care? Especially now that digital technology gives provider organizations the decision support tools and ability to analyze data as they talk to consumers. Examples of these tools include mHealth sensors, digital interventions and assessments, and medication adherence technology.

A lot of it comes down to issues with digital tech adoption. First, both clinical professionals and consumers must accept the use of the technology and trust that it will improve care. There must be the infrastructure to support the technology and integrate it into clinical practice. Then there are the regulatory and privacy concerns. Finally, consumers must be comfortable with technology and engage with it. Many times, one (or more) of these elements isn’t present.

Figure 1. Mandros. A. Why So Little Measurement-Based Mental Health Care? [Powerpoint Slides] Retrieved from www.openminds.com

Another issue is the way in which the field approaches evidence-based practices. For example, of the 10 million adults in the United States who were living with serious mental illness (SMI), only 32% received medication management and only 19% received support for illness self-management (see Why Do Only A Third Of Consumers With SMI Receive Evidence-Based Treatment?). Culprits for this include not including EBPs as part of a clinical professional’s initial education and training, and a lack of continuing education around EBPs for front-line staff.

Also, there hasn’t traditionally been a lot of financial incentives (like value-based care) to drive this adoption. The performance expectations of value-based purchasing arrangements will likely be demand that more provider organizations invest in standardized treatment protocols—protocols that will need more digital tech to achieve the necessary scale, efficiency, and return-on-investment.

Whatever the challenges with measurement-based care and the use of digital tools in the treatment of mental illness, there will be increasing pressure to use these approaches as value-based reimbursement becomes more common. To be successful in VBR, there are a couple of steps organizations need to follow. The first is to set performance standards. In this stage, organizations decide what to measure and how to measure it. The second step is metrics-based management. This is where you develop the systems and processes to use performance measurement in management. The final step is creating a performance-driven culture. In this step, you use the metrics agreed upon and integrated into your management in the first two steps to make changes to the system as necessary. Without this your organization is much more likely to be surprised when reconciling your value-based reimbursement.

For the past year, in almost every meeting that I’ve attended that focused on provider reimbursement from health plans, the number one concern is the definition of “value.” The question—if we are going to reimburse some organizations more than others for a particular service based on the “value” of that service, who defines “value” and how is it measured?

As a reminder, the “value equation” is quite simple—”performance” for the “cost.” But while cost is easy to determine, defining “performance” is a continuing challenge in the health and human service field.

Where are we now? The big payers—Medicare, Medicaid, and employers—predominantly rely on either National Committee on Quality Health Assurance (NCQA) Healthcare Effectiveness Data Information Set (HEDIS) measures, or their own set of measures (like CMS STARS) to assess the quality of health plans and accountable care organizations (ACO). The health plans and ACOs—over 90%—are focused on improving those “big picture” payer metrics.

But one key question is whether those measures really work for consumers with complex conditions in general, and for behavioral health in particular. And even on the limited number of NCQA HEDIS and CMS STARS measures that might apply to this consumer population, the performance isn’t great. It’s a work in progress. According to the latest Centripetal reference guide, health plan performance on the behavioral health measures has been mixed, with some measures showing performance gains, and others showing performance declines (see Trends in Behavioral Health: A Reference Guide On The U.S. Behavioral Health Financing & Delivery System).

This issue—and how it affects the emerging value-based contracts between specialty provider organizations and health plans—was the topic of the session, What Do We Mean By “Value”? A Discussion Session On Defining, Measuring & Reporting Value. The session, facilitated by OPEN MINDS Senior Associate Joseph P. Naughton-Travers, brought together three health plan executives who are making this happen—Angie Costello, Assistant Vice President, Value-Based Payment Products, Beacon Health Options; Matt Miller, Senior Vice President, Public Sector, Magellan Healthcare; and Zoe Webb, Network and Contract Director, Cigna Behavioral Health-Northeast Region.

The panel discussed that at this point, there are few alternatives to the focus on HEDIS and CMS STARS measures. And their overall message was that in negotiations with health plans, it up to the executives of specialty provider organizations to “prove” how they can deliver “value” as currently defined. The panel offered four pieces of advice on this process.

Understand your impact on HEDIS measures—One of the primary and most important data sets that provider organization executives need to keep in mind are HEDIS measures (see ‘Rapid Access’ Might Just Be Your Next Health Plan Conversation and Solve The Problem, Gain A Partner.) Ms. Webb explained that provider organizations come with data and Cigna compares that with the HEDIS measures to designate who has have met those benchmarks.

Know what you are good at—Once a provider organization’s executive team understands the perspective of a potential health plan customer, the next step is for that team to know what they are good at today, and how incremental improvements can be made from a partnership built on the data (see Digital Transformations Demand Digital Dexterity). The panel was adamant that before a value-based discussion can happen, there needs to be a discussion about data and complete buy-in at all levels of the organization. Mr. Miller explained, “Two things jump out. The whole organization needs to be ready for change. And second, you need to understand what data you are being measured by. That needs to be transparent.” Ms. Webb also noted that this is incremental and starts with a partnerships, and building those partnerships has to happen on the data. Before there is even a value-based discussion, there has to be a discussion about the data.

Start the conversation with a value story—The data, both provider organization data and health plan data, is key to developing a contract. But a key is to put organizational performance in context and create a narrative of how the provider organization services can improve specific performance metrics and “value” to consumers. Ms. Webb explained that Cigna looks at member satisfaction outcomes as one of the primary measurements, and if providers want to begin to track what they think are the metrics for proving better quality of life, and what that means, that is a big positive. This will vary depending on the population and what their challenges are.

Ms. Costello added, “As a payer, we are focusing on VBPs with providers where membership attributions are high. Those relationships will yield great opportunities for us to recognize value to our members. Know your membership and how you can demonstrate your value to their total care.”

Be prepared operationally—As the field shifts away from fee-for-service (FFS) operations, provider organizations do need new operational processes for the wholeprocess of delivering and managing services within a value-based model. Mr. Miller explained:

We can write the contract that you need, but there must be someone who can administer it, for both the payer and provider. If we can’t play the claim, it won’t do any good. Most of the value-based reimbursement we’re participating in today is at the grass roots level and in partnership with the provider. It must be, “can we do this?”

Ms. Costello added, “No matter how solid your clinical expertise and performance, strong administrative and billing support at the payer/provider level is essential to a positive VBP relationship.”

The panel’s final takeaway for the day—approach this process with patience. This kind of transformation and contracting isn’t the kind of thing that will happen quickly, but will involve a lot of relationship building, time, and hurdles along the way. Mr. Miller noted, “It’s not going to be this monumental thing that happens tomorrow. It is happening, and we know it’s happening. It’s nothing to be frightened of. It’s something to be excited about.”

Ms. Costello added, “Establishing the right outcomes and payment model takes time. It’s a collaborative effort between the payer and provider. Be patient, as we build those VBPs together. We all are striving for the same primary outcome…better care for our members.”

About 54.7% of those diagnosed with major depressive disorder (MDD) stopped treatment after five months following their diagnosis. For those with MDD, a single treatment method (pharmacological or psychotherapy) of treatment was more common (58.5%) than treatment using both methods combined (36.2%).

These findings were reported in “Rates and Determinants of Use of Pharmacotherapy and Psychotherapy by Patients With Major Depressive Disorder” by Fraser W. Gaspar, Ph.D., M.P.H.; Catherine S. Zaidel, M.E.M.; and Carolyn S. Dewa, Ph.D., M.P.H. Through a data use agreement, researchers analyzed records from the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant IBM MarketScan Commercial Claims and Encounters database. This database contains records for over 260 employers and 40 health plans and is a convenience sample of employees with employer-sponsored health insurance: the data come mostly from large employers. The researchers identified 24,579 anonymous individuals with a diagnosis of major depressive order and focused on those individuals with a first diagnosis of “single-episode, major depressive disorder” and categorized as in remission, mild, moderate, or severe depression. The goal was to determine rates and factors of pharmacological and psychotherapy use after a diagnosis of MDD.

MDD is defined as having three phases:

  • The acute phase is when the individual is actively experiencing symptoms of depression. Successful treatment of the acute phase is the induction of remission. This phase has a minimum of six to eight weeks of time.
  • The continuation phase follows the acute phase, in which remission is preserved and relapse is prevented. This phase usually lasts 16 to 20 weeks.
  • The maintenance phase protects susceptible individuals against recurrence or relapse of subsequent major depressive episodes. Duration of this phase varies with the frequency and severity of previous episodes.

Antidepressant adherence is defined as having a proportion of days covered (PDC) by antidepressants of greater than, or equal to, 0.8 in the first 231 days following a diagnosis of MDD.

Most individuals were not receiving antidepressants or psychotherapy after the first five months following initial diagnosis of MDD, however the percentage of those with depression who received treatment was higher in this study then reported in previous studies. In the 12 months following diagnosis of MDD, 94.7% received either pharmacotherapy or psychotherapy, or both. Additional findings include:

  • For the 13,524 individuals prescribed antidepressants, 41.7% were adherent in the acute phase, while 32.0% were adherent during the continuation phase.
  • For initial antidepressant dosage prescriptions, 34.5% were outside guideline recommendations: 23.1% were below the recommendation, and 11.4% were above the recommendation.
  • When psychotherapy was initiated, the median number of visits in the year after a patient’s diagnosis was seven.
  • Initiating antidepressant treatment within 30 days of the first diagnosis of MDD was associated with increased odds of adherence. Adherence dropped similarly for all levels of diagnosed MDD as prescription time from the first diagnosis of MDD increased, with rates falling sharply after the first 30 days.

The researchers concluded that a shorter time from diagnosis to treatment, and a lower percentage of treatment costs paid by the health care consumer, were associated with increased antidepressant adherence and intensive psychotherapy use. Treatment guideline recommendations are not followed for a large group of those with MDD.

The full text of “Rates and Determinants of Use of Pharmacotherapy and Psychotherapy by Patients With Major Depressive Disorder” was published January 11, 2019 by Psychiatric Services. An abstract is available online at ps.psychiatryonline.org.

For more information, contact: Fraser W. Gaspar, Ph.D., M.P.H, Epidemiologist, MDGuidelines, 10355 Westmoor Drive, Westminster, Colorado 80021; Email: Fraser.gaspar@reedgroup.com

The National Quality Forum (NQF) recently endorsed two quality measures focused on consumer satisfaction of assisted living residents and their families. The resident satisfaction measure is focused on those living in an assisted living facility for two or more weeks. Satisfaction levels are based on responses to the four-item CoreQ: AL Resident Satisfaction questionnaire. The family (or designated responsible party) satisfaction measure is from the three-item CoreQ: AL Family Satisfaction questionnaire. The measure developer and steward is the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).

The CoreQ questionnaires measure individual experience with staff, care and overall satisfaction. Residents are also specifically surveyed on the food offered. Each measure calculates the percentage of individuals who are satisfied, thus yielding an overall score of satisfaction. AHCA/NCAL developed and released CoreQ in 2016 as part of the association’s Quality Initiative to ensure at least 90% of residents and/or family members are satisfied with their assisted living experience. CoreQ is a set of five measures for skilled nursing care centers (SNCC) and assisted living communities to use to assess satisfaction among residents, and their families. More than 15 customer satisfaction vendors offer CoreQ in questionnaires issued to assisted living customers, as well as automatically upload results on a member’s behalf into AHCA/NCAL’s quality and data tracking tool, LTC Trend Tracker. AHCA/NCAL member provider organizations may then monitor their customer satisfaction results over time and in relation to their peers.

NQF reported on the new measure endorsements in “Patient Experience and Function Final Report – Spring 2018 Cycle.” During the spring cycle of 2018, the NQF Patient Experience and Function Standing Committee evaluated the two newly submitted measures for assisted living settings against NQF’s standard evaluation criteria. Both new measures submitted for evaluation were endorsed. The NQF Patient Experience and Function measure topic area encompasses measures that address health-related quality of life and the many factors that influence it, including communication, care coordination, transitions of care, and use of health information technology.

The resident satisfaction measure (3420) and family satisfaction measure (3422) are not currently used in any accountability program. The Committee agreed that the resident satisfaction measure could be extremely helpful for quality improvement given the variability of performance in assisted living facilities. However, if the measure is used as a national benchmark, the Committee said the measure would need more constraints on how data are obtained to reduce gaming.

For the resident satisfaction measure (3420), the numerator is the sum of the individuals in the facility that have an average satisfaction score of =>3 for the four questions on the CoreQ: AL Resident Satisfaction questionnaire. The denominator includes all of the residents that have been in the AL facility for two weeks or more regardless of payer status; who received the CoreQ: AL Resident Satisfaction Questionnaire who responded within the two-month time window who did not have the questionnaire completed by somebody other than the resident, and who did not have more than one item missing. The denominator excludes residents with poor cognition, those receiving hospice, and those with a legal court appointed guardian.

For the family satisfaction measure (3422), the numerator is the sum of the family or designated responsible party for assisted living residents that have an average satisfaction score of =>3 for the three questions on the CoreQ: AL Family Satisfaction questionnaire. The denominator includes the family or designated responsible party members of a resident residing in the facility for at least two weeks. The denominator includes all the individuals in the target population who respond to the CoreQ: AL Family Satisfaction questionnaire within the two-month time window who do not meet the exclusion criteria. The denominator excludes court-appointed guardians; family of residents receiving hospice; family members who reside in another country, and family of residents who have lived in the assisted living facility for less than two weeks.

NQF is a non-profit, non-partisan, membership-based organization that works to catalyze improvements in health care. AHCA/NCAL represents more than 13,500 non-profit and proprietary skilled nursing centers, assisted living communities, sub-acute centers and homes for individuals with intellectual and development disabilities.

The full text of “Patient Experience and Function Final Report – Spring 2018 Cycle” was published in January 2019 by NQF. A copy is available online at www.qualityforum.org

More information about CoreQ is posted at www.coreq.org/

For more information, contact:

  • Media Relations and Online Communications, National Quality Forum, 1030 15th Street NW, Suite 800, Washington, District of Columbia 20005; 202-478-9326; Email: press@qualityforum.org
  • Rachel Reeves, Director of Communications, Press Office, National Center for Assisted Living, 1201 L Street NW, Washington, District of Columbia 20005; 202-898-2803; Fax: 202-842-3860; Email: rreeves@ncal.org; or American Health Care Association, 1201 L Street NW, Washington, District of Columbia 20005; 202-898-3165; Email: AHCAPressOffice@ahca.org

On December 18, 2018, Shatterproof announced plans to launch a rating system for addiction treatment programs; the ratings will be available for use by the public, private payers, states, and referral sources. The Shatterproof Rating System will standardize the evaluation of addiction treatment across all levels of care, settings, and types of treatment. The roughly $5 million project is supported by The Laura and John Arnold Foundation and the Robert Wood Johnson Foundation, as well as a group of health insurers: Aetna (a CVS Health business), Anthem, Inc., Beacon Health Options, Cigna, Magellan Health, and UnitedHealth Group.

The initiative will make the addiction treatment program’s ratings public –  showing whether or not each program offers services that align with proven, evidence-based best practices outlined in Shatterproof’s 2017 “National Principles of Care” for substance use disorder treatment. The National Principles of Care recommend that treatment be individualized, feedback-informed, and encompass the following eight principles:

  1. Routine screenings in every medical setting
  2. A personal plan for every health care consumer
  3. Fast access to treatment
  4. Disease management rather than inpatient treatment
  5. Coordinated care for every illness
  6. Behavioral health care from legitimate providers
  7. Medication-assisted treatment
  8. Support for recovery outside the health care professionals’ office

The Shatterproof rating program will rate any residential, outpatient, and intensive outpatient programs that are licensed, certified, or otherwise approved by the state to provide substance use disorder (SUD) treatment; as well as facilities that the state may not fund, license, or certify. The evaluation will also include programs operated by federal agencies, such as the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service, but will not examine individual clinical professionals or prescribers. The ratings will be based on data from insurance claims, provider organization surveys, and consumer experience to evaluate treatment, and will be based on recommendations by an expert committee convened by the National Quality Forum (NQF).

Publicly-available ratings will be reported on a single website with a public-facing dashboard, which 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. The password-protected information will include more detailed information and the ability to compare and examine the data in different cross sections.

The initial rating system will launch in a five-state pilot during 2019, and ratings are expected to be published in 2020. The five states will be announced in the first quarter of 2019. Shatterproof will invite all addiction treatment programs in the pilot states to be included in the rating system by self-reporting. Data collection portals for the pilot states will open from July 2019 through November 2019. Shatterproof will then analyze the data and will offer a provider organization preview period before the ratings are published online in 2020. Shatterproof anticipates sustained implementation in the pilot states before phased expansion begins in 2020, which will be based on lessons learned from the initial five states.

Shatterproof is a national non-profit organization dedicated to ending the devastation the disease of addiction causes families. Shatterproof is focused on one specific, urgent goal: To transform America’s broken addiction treatment system. The organization is working to ensure every American with a substance use disorder has access to treatment based on proven research. Shatterproof advocates for changes to federal and state policy, payer reform, and provider ratings, and provides public education through family and workplace programs.

The full text of “National Principles of Care” was published February 14, 2018 by Shatterproof. A copy is available online at http://shatterproof.prod.acquia-sites.com

PsychU reported on this topic in “16 Health Insurers Endorse Standard Principles For Addiction Treatment,” which published on January 3, 2018.

For more information, contact: Holly Jespersen, Senior Communications Manager, Shatterproof, 135 W 41st Street, New York, New York 10036; 646-334-1024; Email: info@shatterproof.org

I think that the executives managing Medicaid programs have one of the toughest jobs in the field. All the regulations, the state and federal political factors, the budget pressures, and the changing factors affecting health care costs and utilization make “success” a moving target.

Medicaid is of growing importance to the U.S. health care system—with 19% of the population covered under Medicaid. So, when Medicaid executives make big changes in their program, the impact is substantial—on consumers, families, advocates, professionals, provider organization executives, and health plan managers. So how do Medicaid directors think about the system change and about improving quality and managing budgets? To answer that question, we turned to Linda Zeller, currently the Senior Behavioral Health Fellow of the Michigan Health Endowment Fund and formerly Michigan’s Deputy Director for the Behavioral Health and Developmental Disabilities.

Her take? Decisions about Medicaid policy and practice are increasingly made using analytics. And, those analytics are changing along with the tools for analyzing large data sets that include capturing data, data storage, data analysis, search, sharing, transfer, visualization, querying, updating, and information privacy.

But even with data, we’ve seen organizations struggle to turn that information into a meaningful strategy or operational practice. Many organizations lack the digital dexterity to yield results, and when compared to other industries, health care struggles with preparedness for disruptive business models (see Crossing The Digital Health Chasm). What are the biggest impediments that Ms. Zeller has seen, to using data analytics to manage care for the complex consumer population? How has she seen state Medicaid plans, health plans, and provider organizations working to address these challenges?

The challenge is targeting what we need to look at and not being overwhelmed by the amount of data. It’s easy to lose sight of the purpose and focus. And now that so much of Medicaid coverage is managed by health plans, there is also a challenge at the health plan level of synthesizing Medicaid and Medicare data. Until Medicare and Managed Care Advantage Plan data is available in a parallel format to Medicaid data, we are going to have a really hard time using that data. You need both data sets to really understand what is happening at the consumer level.

There is a lot of investment going into innovation in health care space—both among traditional provider organizations and in new start-up organizations. The leaders of these organizations are trying to understand how State Medicaid directors look at innovation and new service delivery approaches. Ms. Zeller provided some insight into innovation at the state level:

I think we are going to see a move at the Medicaid program level to a real population health model. We’ll see more of a focus on prevention and early intervention. And a focus on specific targeted populations with a subset of strategies for different populations, including addressing the social determinants of health (SDH). This will shift the interest of Medicaid Directors to how systems of care can work better within Medicaid.

A great example is homelessness. We have continued to struggle to get our homeless management information systems to connect with the Medicaid claims data. When we did, we saw a high correlation of those without housing who also had psychiatric inpatient or addiction related residential inpatient. This is a nontraditional data source for a Medicaid Director to use, but that is something I think they increasingly want to happen.

To learn more about the specific Medicaid initiatives in every state, check our 50-state profile series—the PsychU Behavioral Health System State Profiles. Each profile includes detailed information about health care coverage; managed care programs and benefits; care coordination initiatives; health homes and medical homes; and dual eligible care management.

The costs of the 25 most frequently prescribed drugs in 2017 represented about 42.8% of the total $8.7 billion in total drug spending for California commercial health plans. These drugs represented 47.7% of prescription drugs dispensed through retail or mail order pharmacies and paid directly by commercial health plans. For the 25 most frequently prescribed drugs, enrollees paid 2.9% of the cost of specialty drugs and 56.6% of the cost of generics.

The California Department of Managed Care (DMHC) reported these findings in “2017 Prescription Drug Cost Transparency Report.” The report was compiled in response to state Senate Bill (SB) 17, which required health plans and health insurers that file rate information with the DMHC and/or the California Department of Insurance (CDI) to report specific data related to prescription drugs beginning October 1, 2018, and annually thereafter. In addition, SB 17 requires health plans that file annual large group rate information to the DMHC and CDI to also file specified information regarding plan spending and year-over-year cost increases for covered prescription drugs. Large group rate information will be included in the DMHC’s annual public meeting regarding large group rates but is not discussed in this report. The bill also requires that drug manufacturers provide advance notice for significant prescription drug cost increases; certain information in the notices will be public information.

According to a parallel report issued by CDI, costs of the 25 most frequently prescribed drugs in 2017 represented about 34.8% of the total $1.2 billion drug spending for nine commercial health plans that report to CDI. These drugs represented 39.9% of the 10.5 million prescription drugs dispensed through retail or mail order pharmacies and paid directly by commercial health plans. Members paid about 23% of the cost for the 25 most frequently prescribed drugs. For the 25 most frequently prescribed drugs enrollees paid 6.1% of the cost of specialty drugs and 58.5% of the cost of generics.

The data to be reported includes the proprietary drug names and therapy classes for generic, brand name, and specialty drugs. The number of prescriptions was measured in terms of units. DMHC and CDI are required to issue an annual report that summarizes how prescription drug costs affect health plan premiums; the data is aggregated to ensure that health plans’ specific data remains confidential. For 2017, DMHC analyzed data reported by 25 commercial health plans; and CDI analyzed data reported by 9 commercial health plans. Each reported the following information:

  • The 25 prescription drugs most frequently prescribed to health plan enrollees
  • The 25 most costly prescription drugs by total annual health plan spending
  • The 25 prescription drugs with the highest year-over-year increase in total annual plan spending

For this report, the DMHC and CDI considered the total volume of prescription drugs prescribed, and the total cost paid by health plans for these drugs, on both an aggregate spending level and a per member per month basis. The analysis focused on the impact on health plan premiums created by the 25 most frequently prescribed drugs, the 25 most costly drugs, and the 25 drugs with the highest year-over-year increase in total annual spending.

DMHC reported the following key findings:

  • Brand name drugs accounted for 10.6% of prescriptions and constituted 24.8% of the total annual spending on prescription drugs
  • Specialty drugs accounted for 1.6% of all prescription drugs and accounted for 51.5% of total annual spending on prescription drugs.
  • Generic drugs accounted for 87.8% of all prescribed drugs and accounted for 23.6% of the total annual spending on prescription drugs.
  • Overall, plans paid 91.2% of the cost of the 25 Most Costly Drugs across all three categories (generic, brand name and specialty).
  • Prescription drugs dispensed through retail or mail order pharmacies accounted for about 13.1% of total health plan premiums. Health plan prescription drug costs increased by 5.0% in 2017; medical expenses increased by 5.9%. Overall, from 2016 to 2017, total health plan premiums increased by 4.8%.

CDI reported the following key findings:

  • Brand name drugs accounted for 27% of all 10.5 million prescriptions, and constituted 13% of the total $1.2 billion annual spending on prescription drugs
  • Specialty drugs accounted for 3% of all prescription drugs and accounted for 52% of total annual spending on prescription drugs.
  • Generic drugs accounted for 84% of all prescribed drugs and accounted for 21% of the total annual spending on prescription drugs.
  • Overall, plans paid 88.7% of the cost of the 25 Most Costly Drugs across all three categories (generic, brand name and specialty).
  • The cost of prescription drugs (net of rebates) dispensed through retail or mail order pharmacies accounted for about 13.6% of total health plan premiums.
  • Health plan prescription drug costs increased by 6.1% in 2017; medical expenses increased by 7.6%. Overall, from 2016 to 2017, total health plan premiums increased by 4.6%.

Each report includes three separate lists of the 25 most frequently prescribed generics, the most frequently prescribed branded, and the most frequently prescribed specialty drugs. Neither released an aggregated list of the top 25 most frequently prescribed drugs across generic, branded, and specialty.

For more information, contact:

  • Stakeholder Relations, California Department of Managed Health Care, 980 9th Street, Suite 500, Sacramento, California 95814-2725; Email: stakeholder@dmhc.ca.gov.
  • Communications & Press Relations Branch, California Department of Insurance, 300 Capitol Mall, Suite 1700, Sacramento, California 95814; 916-492-3566; Fax: 916-445-5276; Email: cdipress@insurance.ca.gov.

It’s not uncommon to meet with an executive team and have them share that they think their organization is “underperforming.” Revenue are down, margins are down, productivity is down, performance bonuses are missed, plans aren’t implemented … the stated list of reasons for poor performance are many. Most often, I hear the “staff” isn’t performing. But what does that mean?

Beyond a list of lagging indicators, most managers I meet with can’t take the performance discussion much further. What are leading indicators that predict “poor performance” outcomes (leading indicators that allow manager intervention)? What are the causes of poor performance on those leading indicators? What supervisory interventions in process and practice would correct those causes of poor performance? And are supervisors willing and able to make those interventions? The answers to these questions are the “secret sauce” of metrics-based management.

With a more competitive market for health and human services—and a growing reimbursement focus on value—metrics-based management is more important than ever. Success with performance management was the topic of the session, “How To Adapt Your Organization To The Future: A Guide To Managing Data For A Performance-Driven Environment,” featuring OPEN MINDS Senior Associate Joseph P. Naughton-Travers along with the Kings View Corporation team including Anthony Prieto, Director of Health information Analytics; Leon Hoover, Chief Executive Officer; Alex Rocha, Quality Improvement Director; and Jim Rodriguez, Chief Financial Officer.

The Kings View team gave a great case study of metrics in action. And, in their presentation, they identified their four keys to creating a metrics-based, performance-driven environment.

Widespread cultural commitment—A performance-based culture demands commitment at all corners of the organization, and the baked-in ability to encourage staff to consider their performance in terms of value to both the organization and consumers. Mr. Hoover noted, “It takes a lot of people working together and focused on the mission. It’s ‘The One Team Culture.’ And it takes a lot of executive team effort to have the culture and the information.” Mr. Rodriguez noted that to do this, there needs to be cultural adoption across the system, and that value must be shown across the system. He explained that this is an organizational project—it’s not only an “IT” project. The dialog and the commitment of resources must be shared organization wide, with a commitment to the investment-money, time, and staff.

Set goals—Just like strategic plans, budgets, and new service lines, performance culture won’t implement itself. Building a culture of performance means just that. Take the time to deliberately build it, with achievable goals set along the way. Mr. Rodriguez gave examples of setting these goals, noting that organizations need to keep pace with the internal and external factors. They need to be good and cutting edge at analytics in a way that gives them an advantage. Organizations also need a standard and consistent reporting system that was compatible with other systems we may bring online.

See “all” the data—A performance culture really is a data-driven culture, and it’s built on measuring value for consumers and payers alike. Does everyone know what measures will reflect their job performance and how they can improve that performance? Do the necessary executives know, collect, and review all the available metrics as a standard way of managing? Mr. Prieto noted:

When we have the data we need, we are better prepared to have meaningful conversations with our staff. Having the data in a visual dashboard allows us to focus on executing our high-performance strategy without wasting time searching for data buried in spreadsheets. How do we solve the need for constant “follow up” questions? By having dashboards that pull data from all our systems.

Leadership must own the process—Staff at all levels comprehend and respond to cultural expectations based on how leadership communicates and acts on that culture. When an organization’s leadership reflects a performance-oriented, problem-solving approach, staff respond more positively. Mr. Hoover noted that when it comes down to people embracing this or not, your leadership really needs to have ownership of the process. Look at this in management meetings, and then drill down to find out how staff like it and are embracing it.

I couldn’t agree more with these four keys. And I have a few tips for making performance management a reality in health and human service organizations, based on my own experience. First, measure what you can now and build your performance management metrics over time. From your organizational strategy, do create an overarching “dream” set of metrics your management team needs. But, don’t put off measuring and using what you can now. The important part is creating management practices focused on performance. Second, transparency is your friend (in the long run). Organizational performance data shouldn’t be a secret-openness about performance and discussions about the validity of the performance data and the reasons for poor performance are critical to creating that culture. I have found that the initial push back to transparency of performance data is fierce for many reasons. But getting every team member, from the c-suite on down, to embrace an open review of performance is a critical cultural step. Finally, executive leaders have the obligation to make sure that every team is “positioned and prepared” for success—and that every team has a leader that can execute on managing by the metrics. This is a tall order, but it is the transition that successful health and human service organizations need to make to succeed in an environment if disruptive competition and margins dependent on customer-defined performance.

For more, check out these resources from the PsychU Resource Library:

  1. Becoming A ‘Blue Chip’ Provider Organization
  2. Using Consumer Experience Data As Management Tool
  3. The Five-Step Process To Demonstrate Your “Performance” To Health Plans

California behavioral health professionals in health plan networks scheduled at least 57% of urgent appointments within the standards set by the state’s 2010 Timely Access Regulation. At least 71% of non-urgent appointments were scheduled within the time set by the standards. Overall, individual behavioral health plan performance ranged between 64% and 83% of urgent and non-urgent appointments scheduled within the standards. This was the result of an analysis of six behavioral health plans conducted by the state Department of Managed Health Care (DMHC). For urgent appointments, the percentage of surveyed network professionals who had appointments available within the wait time standards ranged from 57% to 80%. For non-urgent appointments, the percentage of surveyed network professionals who had appointments available within the wait time standards ranged from 71% to 87%.

ValueOptions of California, Inc. (ValueOptions) had the highest overall rating at 83%, and OptumHealth Behavioral Health Solutions of California (OptumHealth) had the lowest overall rating at 64%. For urgent appointments, Holman Professional Counseling Centers (Holman) had the highest rating at 80% and Optum, had the lowest rating at 57%. For non-urgent appointments, Human Affairs International of California (HAI-CA), Managed Health Network (Managed Health), and ValueOptions had the highest rating at 87% and Optum, had the lowest rating at 71%.

California Behavioral Health Plan Timely Appointment Access Survey Findings, Measurement Year 2017

Plan Overall Urgent Non-Urgent
Cigna Behavioral Health of California, Inc. (Cigna) 75% 64% 85%
Holman Professional Counseling Centers (Holman)  77% 80% 78%
Human Affairs International of California (HAI-CA) 79% 71% 87%
Managed Health Network (Managed Health) 80% 72% 87%
OptumHealth Behavioral Health Solutions of California (OptumHealth)  64% 57% 71%
ValueOptions of California, Inc. (ValueOptions) 83% 79% 87%

The Timely Access Regulation, which became effective in 2010, requires that health plan networks be sufficiently large to meet a set of standards, which include specific timeframes under which enrollees must be able to obtain care. These standards include wait times to access urgent and non-urgent care appointments, as well as the availability of telephone triage or screening services during and after regular business hours. The wait time standards are as follows:

  • Urgent care (prior authorization not required by health plan): 48 hours
  • Urgent care (prior authorization required by health plan): 96 hours
  • Non-Urgent Doctor Appointment (primary care physician): 10 business days
  • Non-Urgent Doctor Appointment (specialty physician): 15 business days
  • Non-Urgent Mental Health Appointment (non-physician, including counseling professionals, addiction treatment professionals and qualified autism service providers): 10 business days
  • Non-Urgent Appointment (ancillary provider, including purposes such as lab work or diagnostic testing, such as mammogram or MRI, and treatment of an illness or injury such as physical therapy): 15 business days

DMHC reported the findings in “Timely Access Report Measurement Year 2017.” The DMHC required full service health and behavioral health plans to utilize external vendors to validate the health plans’ Timely Access data and conduct a quality assurance review of their compliance reports prior to submitting them to the DMHC, a requirement that was first implemented for measurement year 2016. The goal was to summarize California provider appointment availability data that health plans submitted to DMHC for 2017. The survey included non-physician mental health professionals, psychiatrists, and child and adolescent psychiatrists for both urgent and non-urgent appointments. The analysis focused on findings of an appointment wait time survey of network professionals’ participating in behavioral health plans’ Commercial, Individual/Family, and Medi-Cal products during 2017. All six plans offered a commercial product, but only two of the six plans offered all three products: HAI-CA and OptumHealth

Timely Access For Commercial Behavioral Health Plans, Overall, Urgent & Non-Urgent Appointments
Plan Overall Urgent Non-Urgent
Cigna 75% 64% 85%
Holman 77% 80% 78%
HAI-CA 80% 72% 88%
Managed Health 80% 72% 87%
OptumHealth 64% 57% 71%
ValueOptions 83% 79% 87%
Timely Access For Individual/Family & Medicaid Behavioral Health Plans, Overall, Urgent & Non-Urgent Appointments
Individual/Family Plans Overall Urgent Non-Urgent
HAI-CA 80% 72% 88%
OptumHealth 64% 57% 71%
Medicaid Behavioral Health Plans Overall Urgent Non-Urgent
HAI-CA 78% 70% 87%
OptumHealth 62% 54% 69%

PsychU reported on access standards in “State Medicaid Managed Care Access Standards Did Not Improve Access To Specialists,” which published on September 25, 2017.

For more information, contact: Rachel Arrezola, Communications and Planning, California Department of Managed Health Care, 980 9th Street, Suite 500, Sacramento, California 95814-2725; 916-445-7442; Fax: 916-322-2579; Email: media@dmhc.ca.gov.

On November 29, 2018, in a revision to its National Patient Safety Goal, The Joint Commission announced that it will require hospitals to screen individuals being treated or evaluated for behavioral health conditions for suicide risk using a validated tool. These revisions are effective starting July 1, 2019. However, the revised Goal does not require universal screening for all individuals. Organizations must develop a plan to mitigate suicide based on an individual’s overall level of risk, and organizations must follow written policies and procedures for counseling and follow-up care for individuals identified as at risk for suicide.

The Joint Commission explained the changes in “Approved: Revisions to National Patient Safety Goal Regarding Suicide Prevention.” The rationale is to provide specific instructions that align with current research and the recommendations of The Joint Commission’s Suicide Risk Reduction expert panel. The Goal was revised because there has been no improvement in suicide rates in the United States since the Goal was introduced in 2007, and suicide is the 10th leading cause of death in the country.

In addition to requiring screening at-risk individuals, the revised Goal calls for behavioral health care organizations, psychiatric hospitals, and psychiatric units in general hospitals to conduct environmental risk assessments to be ligature resistant. Non-psychiatric units in general hospitals are not expected to be ligature resistant; however, The Joint Commission requires that non-psychiatric units in general hospitals minimize risks in the environment for individuals identified at risk for suicide by removing hazards that can be removed without affecting a patient’s medical care, and by 1:1 monitoring for patients that are at high-risk for suicide.

The Joint Commission classifies suicide attempts and deaths by suicide as sentinel events, defined as any unanticipated event in a health care setting resulting in death or serious physical or psychological injury to a consumer or consumers, not related to the natural course of the consumer’s illness. Sentinel events signal the need for immediate investigation and response.

In 2016, The Joint Commission had issued an action alert focused on enhancing suicide prevention efforts by health care organizations. The goal was to help clinical professionals in emergency, primary care, and behavioral health settings detect suicide ideation and ensure that at-risk consumers receive an appropriate evaluation, evidence-based treatment, and follow-up care. The key focus is on care transitions for people with suicidal ideation, especially among those discharged from a psychiatric facility who are at a higher risk of suicide for up to four years after discharge.

Between June 2017 and March 2018, The Joint Commission held five technical expert panel meetings on the topic of suicide in health care settings. After reviewing the panel’s recommendations and research, The Joint Commission announced in March 2018 that it intended to revise the National Patient Goal for suicide screening in health care settings.

The full text of “Approved: Revisions to National Patient Safety Goal Regarding Suicide Prevention” was published November 29, 2018 by The Joint Commission. A copy is available online at JointCommission.org.

PsychU reported on this topic in “The Joint Commission Updates Suicide Prevention Guidelines, Recommends Greater Vigilance In Non-Acute & Acute Care Settings,” which published on June 13, 2016.

For more information, contact: Maureen Lyons, Corporate Communications, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181; 630-792-5171; Email: mlyons@jointcommission.org.

From December 10 to 14, 2018, the approximately 4,000 Kaiser Permanente behavioral health professionals represented by the National Union of Healthcare Workers (NUHW) held a strike at Kaiser facilities across California to protest staffing ratios. They say Kaiser’s ratio of one professional to 3,000 Kaiser members is inadequate to ensure that members making new and follow-up appointments, receive appointments within state timeliness standards. Kaiser Permanente is in contract negotiations with the NUHW for behavioral health professionals employed by Kaiser Permanente’s Northern and Southern California affiliates. The previous contract expired in September 2018.

The California Department of Managed Health Care (DMHC), which oversees health maintenance organizations (HMOs) such as Kaiser, requires that urgent appointments when prior authorization is not required must be scheduled within 48 hours of request. Non-urgent mental health appointments with a non-physician (psychologists, therapists, social workers, psychiatric nurses and addiction medicine specialists) must be scheduled within 10 business days of the member request.

The behavioral health professionals believe that the ratio of one professional to 3,000 members is inadequate because it is the same ratio that existed in the DMHC’s February 2015 Kaiser follow-up survey report, which found that 22% of Northern California members and 9% of Southern California members experienced excessive appointment delays. When NUHW settled the last contract in late 2015, Kaiser had committed to working with the NUHW to improve access and had agreed to contractual language in Northern California that was aimed at increasing staffing. However, due to turnover and growing membership, the ratio has remained unchanged. A NUHW spokesperson said some Kaiser members wait one to two months for follow-up behavioral health appointments.

The NUHW spokesperson said the behavioral health professionals have proposed that Kaiser require that for every new initial appointment with a patient, a therapist be able to schedule six return appointments. They believe this would reduce the wait for return appointments and set a mechanism for improving staffing. They also proposed that Southern California Kaiser commit to moving away from its model of outsourcing mental health care and bring the service in-house, just like Kaiser medical services. In press releases, NUHW said its contract proposals are intended to help Kaiser meet the DMHC appointment timeliness standards.

In a public statement released on December 9, 2018, Kaiser provided the following information about the dispute:

  • NUHW wants to reduce the amount of time clinical professionals spend seeing members to below the average of 75% of time, a performance standard NUHW agreed to in 2015. Kaiser believes doing so would mean fewer appointments for members.
  • NUHW has asked Kaiser Permanente to stop working with non-Kaiser community therapists that serve as extenders to ensure access to care for members.
  • Kaiser seeks no takeaways in its contract proposal and is offering wage increases.
  • Since 2015, Kaiser has hired more than 500 new behavioral health professionals in California, which increased its behavioral health staff by 30%,

In 2011, NUHW members reported Kaiser to the DMHC in 2011 for failing to meet the appointment timeliness standards. In 2013, the DMHC levied a $4 million fine on Kaiser for violating the California’s Mental Health Parity Act and state standards for timely access to care. In February 2015, the DMHC released a follow-up survey, which found that 22% of Northern California members and 9% of Southern California members experienced excessive appointment delays. In June 2017, the DMHC released results from a full survey of the Kaiser Health Plan, which found that Kaiser had not fully resolved member access issues for its mental health services. In July 2017, the DMHC and Kaiser announced a settlement agreement in which Kaiser agreed to a three-year program of outside monitoring of its mental health services by a state-approved firm with the authority to impose up to $1 million in additional fines against Kaiser if it fails to remedy access issues.

PsychU reported on this topic in “Kaiser Permanente In California Recruiting 350+ Mental Health Therapists By End Of Year,” which published on October 8, 2015.

For more information about the NUHW position, contact: Matthew Artz, Communications, National Union of Healthcare Workers, 5801 Christie Avenue, Suite 525, Emeryville, California 94608; 510-435-8035; Fax: 510-834-2019; Email: martz@nuhw.org.

For more information about Kaiser Permanente’s position, contact: Jessie R. Mangaliman, National Media Relations, Kaiser Permanente, 1950 Franklin Street, Oakland, California 94612; 510-301-5414; Email: National-Media-Relations@kp.org.

Meeting the management challenges for a health and human service workforce is one of the more challenging aspects that many provider organization executives must face: including recruiting for tough positions in remote markets (see Where Have All The Psychiatrists Gone?); the high turnover rate of these positions (see High Turnover, The Other Staffing Issue); and the compensation demands for both direct care workers (see Will Clinical Professional Compensation Drive Task Shifting?) and executives.

As if that weren’t enough, there is the shifting demands of staff performance in the face of value-based contracting requirements. This was the topic addressed in the session, “Best Practice Staffing Models For The New Value Equation: An Executive Discussion On Compensation, Retention & Productivity,” delivered by OPEN MINDS Senior Associate Ken Carr; Lori M. Schmidt, the former Director of Behavioral Health, HealthPartners; and Jeremy Gatto, LICSW, Clinical Manager, HealthPartners. The blueprint for the day—how to develop a performance-based compensation strategy and use productivity measurement to maximize revenue.

After you have decided that performance-based compensation at the staff level is a strategic imperative, there are three basic compensation models to see keep in mind—fixed salary, base plus incentive, and bonus pure productivity. But, beyond the model, managers need to develop a compensation model that is both metrics-driven (you can track and compare performance over time) and easily understood by staff (the staff member must be able to connect their performance with the reward). Our faculty identified four considerations to make sure a performance-based compensation plan works—build the infrastructure, populate a dashboard with the data, update financial forecasting models, and adopt a complete organizational philosophy.

Build the infrastructure necessary to implement an incentive-based compensation system—There are three critical infrastructure components that need to be in place before moving ahead—the ability to capture accurate data, implementation of a dashboard to make that data available to providers and supervisors on a weekly basis, and financial tools to forecast incremental revenue and expenses resulting from the incentive system. Mr. Carr explained:

The EHR will need to capture the units of service productivity—visits, charges or weighted relative value units (wRVUs). Visits and charges are standard measures of service activity that are easy to capture, but don’t consider the time and intensity of services. However, wRVUs, were created by CMS as a means of recognizing that some service activities time more time and have greater value. For instance, procedure code 90837, 60 minutes of psychotherapy, is one visit, but it is assigned a wRVU of 3.0. Some EHRs have the capability of capturing and reporting the wRVUs in addition to charges associated with procedure codes.

Populate a dashboard with the data—After capturing accurate service data, a system is needed to get that data into a timely dashboard. Providers need access to this information to inform them on their progress toward monthly or quarterly goals. Mr. Carr explained:

The data can be connected to a dashboard using business intelligence software or downloaded and distributed using spreadsheets. The key is to have staffing experience to summarize and analyze data, a tool that works, and a process to ensure that the data is used to drive results.

Update financial forecasting models— The financial forecasting model also needs to be updated to reflect the potential revenue and expense scenarios based on performance – and the impact on cash. Mr. Carr explained

Status quo budgets and business models are not effective when multiple performance factors can impact operating results. This includes tightening the revenue cycle process since incentives will need to be paid from incremental increases in cash collections.

Adopt a complete organizational philosophy—Ultimately, using productivity measurement to maximize revenue comes down to adopting a successful plan that is not just a model of payment, but offers a complete organizational philosophy for who gets paid how much, and tracks the performance to make sure those two things are aligned. Ms. Schmidt explained:

Focus on sustainable financial performance and developed a payment model for that. We worked to set a percentage target for that, and then when we have a clinical professional that isn’t meeting their goals, we work with them to adjust their scheduling template or their work style to help them reach their goals. Remember, the goal must be attainable. You don’t want to deflate your staff by making a goal that no one can attain.

The second thing is, know how you want to add your performance measure. In our case, we took the target salary and reduced it by two performance measures, so that gave us “the target salary of productivity.” For example, if your target salary is $90,000, and the incentives add up to $2,000, then the target salary of productivity is $88,000. But if you choose a productivity bonus on top of the salary, then your target salary with bonus could be $92,000.

For more on the staffing challenges facing today’s health and human service organizations, check out Aligning Clinical Compensation For The New Value Equation, Staff Vacancies Just Got A Little More Important & Complicated, The Staffing Equation For Community-Based Services, and How Do You Engage Employees & Improve Performance?.

Last week, we provided an update on the current state of credentialing of peer support specialists (PSS) and changes in reimbursement for their services. For most organizations, the question is not whether to add PSS to their service delivery team—but how. And how to bring those services to scale across a service location.

The article brought some interesting comments from my colleague and OPEN MINDS Senior Associate Sue Bergeson. She noted:

Provider organizations should leverage peers in the areas of activation, engagement, reduction of isolation/increase support, communication, and education. Involve peers as you would other staff in the organization’s decision-making process. Peers will see things differently and can give you feedback, and insights others will not see that can positively impact the effectiveness of your programs. Effectively on-board peers into the organization, supervise, and promote them as a part of the overall treatment team. Pay them a fair wage and offer them access to continuing education so they can continue to build skills and serve your clients.

Done right, she observed that this approach can improve consumer outcomes, including increased consumer empowerment, increased sense that treatment is responsive, and increased social support and social functioning. But she noted that there are six key issues that consistently diminish the effectiveness of peers in the workforce—role confusion, lack of integration, performance measures, management training, career paths, and specialties of focus.

Role confusion—Often job descriptions are unclear, and staff does not know what to do with peer staff. This can lead to peers used simply as extra hands to drive a bus, to do filing, or to clean. Its fine if peers are hired to do these roles specifically but they are not peer roles – they do not used the skills or leverage the experience of trained and certified peer specialists. It’s no more appropriate for peer specialists to drive the bus than it is for clinicians to drive the bus. Peer job descriptions and roles need to align with the core competencies or the system employing them is missing out on the benefits of adding peer support to the system of care – in short, they will not achieve the very benefits they were hoping to achieve by adding peers to the workforce.

Being treated as separate from the rest of the workforce—Because the staff team has usually not had any orientation to the work of peers, often peers are not invited to the table, not involved in committees, not involved in meetings, not informed or asked about organizational changes. Because peers have different experiences and can see things differently, the system misses important feedback if they do not involve peers as they create and implement new policies, programs and systems.

Not being held to the same standard—Peers are sometimes treated as fragile and the company might make special allowance for behavior not acceptable in other staff. This does the peer a disservice. Peers need to be held accountable for the same kind of professional behavior as other staff members. Sometimes hired peers are new to the workforce and so a mentor that helps them acclimate can be a great addition to the onboarding process

Training for supervisors—Because the role is often new to a system, supervisors often need additional support in learning how to effectively supervise this new role. It is not unusual for the peer to mistakenly be supervised as a “mini therapist” or “junior social worker” because that is the field the supervisor knows best. This diminishes the effectiveness of the peer worker.

Career paths—Hiring peers as supervisors is an effective way to ensure peer roles remain peer and are optimized for success. Successful peers should also be considered for other leadership and administrative roles as they demonstrate their effectiveness.

Areas of focus—We are seeing additional areas of focus emerging within the field, each with its with corresponding training. For example, peer support within later life populations, within transition age youth, within co-occurring health conditions like diabetes and depression.

Like any change in the service delivery system, planning for incorporating PSS demands planning. Managers of health and human service organizations will need to make this a priority to remain competitive in the coming years.

Opioids for chronic non-cancer pain provide small improvements in pain and physical function. Non-opioid medications were found to also offer similar outcomes.

These findings were reported in “Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis” by Jason W. Busse, DC, PhD; Li Wang, PhD; Mostafa Kamaleldin, MB BCh; et al. The researchers conducted a systematic review that included 96 randomized clinical trials, with 26,169 participants, to compare opioids with placebo and nonopioid alternative pain medications for the treatment of chronic non-cancer pain. The goal was to determine whether opioids are associated with greater benefits or harms compared to placebo and nonopioid alternatives for chronic non-cancer pain.

None of the studies provided rates of developing opioid use disorder. Another review by some of the authors, done to support the 2017 Canadian opioid guideline, found evidence suggesting that 5.5% of patients prescribed opioid therapy for chronic non-cancer pain develop addiction (opioid use disorder). Risk of developing opioid use disorder was not associated with opioid dose; however, higher doses of prescribed opioids were associated with increased risk of non-fatal and fatal overdose.

Of the 96 included studies, there were 25 trials of neuropathic pain (e.g. diabetic neuropathy), 32 trials of nociceptive pain (e.g. osteoarthritis), 33 trials of central sensitization (pain present in the absence of tissue damage), and 6 trials of mixed types of pain. Treatment effects did not differ across categories of chronic pain conditions. The review findings include:

  • Compared to placebo, opioids are associated with small improvements in pain, physical functioning, and sleep quality. Benefits for pain and sleep become smaller the longer opioids are used.
  • Compared to nonsteroidal anti-inflammatory drugs (NSAIDs), synthetic cannabinoids, and tricyclic antidepressants, low- to moderate-quality evidence suggested similar associations of opioids with improvement in pain and physical function. Opioids provided better pain relief, but similar functional improvement compared with anticonvulsants.
  • Opioids are associated with an increased risk of vomiting, compared to both placebo and nonopioid treatment.

The review found average pain improvement with opioids vs. placebo was below what consumers would consider important. However, some patients will experience more pain relief and some less with opioids; therefore, focusing on average effects alone has limitations. The researchers concluded that, versus placebo, an estimated 12% of patients living with chronic non-cancer pain will achieve important pain relief. Given the harms associated with opioids, health care providers should consider prescribing non-opioid alternatives that show similar efficacy (e.g. NSAIDs, tricyclic anti-depressants) before turning to opioids for chronic non-cancer pain relief.

The full text of “Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis” was published December 18, 2018, by JAMA Network. An abstract is available online at JAMANetwork.com

For more information, contact: Veronica McGuire, Communications for Corresponding Author Jason W. Busse, D.C., Ph.D., Faculty of Health Sciences, McMaster University, 1280 Main Street West, Chester New Hall, Room 111, Hamilton, Ontario Canada; L8S 4L9; 905-525-9140, ext. 22169; Email: vmcguir@mcmaster.ca.

As of 2016, the United States has among the highest average costs among wealthy countries for both inpatient and outpatient hospital visits. For inpatient stays, the average cost in the United States is $22,543 per person per stay; followed most closely by Switzerland at $15,670, and Maldives at $12,829 on average. For outpatient visits, the average cost in the United States is $478 per visit per person, topped only by Switzerland at $502, and followed by Norway at $459 on average. An outpatient visit is defined as a visit to a health facility that did not result in admission. Outpatient visits included four categories: curative visits, rehabilitative visits, facility-based preventive maternal and child care visits, and vaccination visits. Inpatient admissions included curative and rehabilitative.

These findings were reported in “Funding And Services Needed To Achieve Universal Health Coverage: Applications Of Global, Regional, And National Estimates Of Utilisation Of Outpatient Visits And Inpatient Admissions From 1990 To 2016, And Unit Costs From 1995 To 2016” by Mark W. Moses, MHS; Paola Pedroza, MPH; Ranju Baral, Ph.D.; Sabina Bloom, BA; Jonathan Brown, MAIS; Abby Chapin, BA, et al. The researchers analyzed surveys and administrative date from the Global Health Data Exchange, compiling outpatient utilization data from 130 countries, and inpatient data for 128 countries. The goal was to compile utilization and unit costs of both inpatient and outpatient visits to inform health care plans to achieve universal health coverage (UHC) in every country. UHC is one of the United Nations’ Sustainable Development Goals for 2030.

Additional findings for the 1990 to 2016 period include:

  • Outpatient admissions increased by nearly 59%, from about 24.80 billion in 1990, to 39.35 billion visits globally during 2016.
  • Of the 59% global increase in outpatient admissions 43.0% were due to population growth, 8.1% were due to population aging, and 7.6% were due to an increase in use rates.
  • Inpatient admissions increased 68.0%, from 0.42 billion in 1990, to 0.71 billion admissions by 2016.
  • Of the 68.0% global increase in inpatient admissions, 44.3% were due to population growth, 13.6% were due to increases in use rates, and 10.0% were due to population aging.

Other researchers commented that the quality of health care services is likely to differ substantially between countries, and inefficiencies in current health care systems should be considered when calculating UHC costs. In relation to implementing UHC for all nations, the effort would cost nearly $576 billion, and would result in a 49% increase in admissions and 27% increase in outpatient visits worldwide.

The full text of “Funding And Services Needed To Achieve Universal Health Coverage: Applications Of Global, Regional, And National Estimates Of Utilisation Of Outpatient Visits And Inpatient Admissions From 1990 To 2016, And Unit Costs From 1995 To 2016” was published December 12, 2018 by The Lancet Public Health. An abstract and article are available online at www.TheLancet.com.

For more information, contact: Marcia Weaver, Ph.D., Research Professor, Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Suite 600, Seattle, Washington 98121; Email: mweaver@uw.edu.

RAND researchers found that physician practices lack data management and analysis skills needed for value-based payments. Some medical practices report aversion to financial risk that include penalties for cost of care overruns, causing some organizations to renegotiated contracts with payers to reduce their downside risk or transfer some of that risk to partners.

These findings were reported in “Effects of Health Care Payment Models on Physician Practice in the United States: Follow-Up Study” by Mark W. Friedberg, Peggy G. Chen, Molly Simmons, Tisamarie Sherry, Peter Mendel, Laura Raaen, Jamie Ryan, Patrick Orr, Carol Vargo, Lindsey Carlasare, Christopher Botts, and Kathleen Blake. The study is a follow-up to a 2014 study that also assessed how physician practices were responding to alternative payment models. Researchers attempted to re-interviewed the same physicians and practice leaders that participated in the previous study. The project conducted interviews between January and June 2018, speaking with 84 people from 31 physician practices in six geographic markets (Little Rock, Arkansas; Orange County, California; Miami, Florida; Boston, Massachusetts; Lansing, Michigan; and Greenville, South Carolina). Researchers also spoke to leaders of eight health plans, 10 hospitals or hospital systems, 10 state and local medical societies, and four Medical Group Management Association chapters. The goal was to discover the effects of alternative health care payment models (APM) on those organizations.

Additional findings included:

  1. Payment models are changing at an accelerating pace— Physician practices, health systems, and consultants are struggling to keep up with the number of new models, which put additional pressure on them before they have adapted to the previous models.
  2. Payment models are increasing in complexity—Practices that have adapted to the complexity of APM report earning financial awards for preexisting quality of care without changing it.

Researchers provided three recommendations, including:

  1. Simpler APMs might help practices focus on improving consumer care—Many new APMs are confusing, causing provider organizations to avoid them. Simplifying the models “might help tip the balance back toward improving patient care as the preferred strategy for earning financial rewards.”
  2. Practices need new capabilities and timely data to succeed in APMs—Many survey respondents report that they lacked the internal skills and experience necessary to perform well in APMs. Helping them invest in those skill sets and supplying them with timely, understandable performance data is a critical contributor to success with APMs.
  3. Designing APMs to encourage clinical changes that individual physicians see as valuable might improve their effectiveness—Co- designing APMs with practicing physicians and other leaders of their practices might help improve physician engagement and the chances that APMs will produce real improvements in patient care.

The full text of “Effects of Health Care Payment Models on Physician Practice in the United States Follow-Up Study” was published on October 24, 2018, by RAND. A copy is available online at RAND.org.

For more information, contact: Warren Robak, Office of Media Relations, RAND Corporation, 1776 Main Street, Post Office Box 2138, Santa Monica, California 90401-2138; 310-393-0411; Fax: 310-393-4818; Email: media@rand.org.

On October 1, 2018, 10,976 (72%) of 15,306 skilled nursing facilities (SNFs) received cuts of up to 2% to their Medicare rates for high hospital readmission rates. Another 3,983 SNFs received a rate increase and 347 SNFs neither received a rate increase or decrease. The rates cuts and increases are part of the Medicare value-based purchasing (VBP) program for skilled nursing facilities (SNFs). The VBP measure focuses on improvement in all-cause 30-day hospital readmission rates, based on a baseline established with 2015 claims data and SNF performance during calendar year 2017. The baseline hospital readmission rate is 19%.

The total amount of incentive payments distributed to SNFs will be 60% of the total amount withheld from SNFs’ Medicare payments for that fiscal year. CMS estimated that during fiscal year 2019, the SNF VBP program would reduce aggregate Medicare payments to SNFs by $211 million.

The SNF VBP applies to hospital readmissions for fee-for-service Medicare beneficiaries discharged from a Medicare-participating hospital, a critical access hospital (CAH), or a psychiatric hospital. The program applies to freestanding SNFs, SNFs affiliated with acute care facilities, and all non-CAH swing-bed rural hospitals.

The program is initially using the Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM). However, in the final rule “Medicare Program; Prospective Payment System and Consolidated Billing For Skilled Nursing Facilities (SNF) Final Rule For FY 2019, SNF Value-Based Purchasing Program, & SNF Quality Reporting Program,” CMS noted that for later years it intends to transition to the Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure to replace SNFRM.

Individual SNF performance on the SNF VBP measures will be published on the Nursing Home Compare website. The information to be published will include SNF performance scores and rankings, the range of SNF performance scores, the number of SNFs receiving value-based incentive payments, and the range and total amounts of those payments.

Since October 2016, CMS has been providing SNFs with quarterly confidential feedback reports containing information regarding their performance on the readmission measure specified for the SNF VBP Program. These quarterly reports are disseminated to SNFs via the Quality Improvement and Evaluation System (QIES)/Certification and Survey Provider Enhanced Reports (CASPER) system.

PsychU reported on the final rule that included the SNF VBP in “Medicare SNF Final Rule Increases Skilled Nursing Rates By $820 Million,” which published on October 8, 2018.

For more information about the SNF VBP Program, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email: SNFVBPInquiries@cms.hhs.gov.

The value that peer support specialists (PSS)—a person who has lived-experience with mental illness and/or addiction recovery and combines that with training to deliver services in behavioral health settings—is well documented. These PSS provide a path to lower relapse rates, social support, social functioning, decreased psychotic symptoms, and reduced hospitalization rates (see Peer Support Groups In Addiction Treatment Boost Odds Of Long-Term Recovery). Currently, about 51% of health and human service specialty provider organizations have adopted PSS in their organization.

For managers of health and human service organizations looking to expand the role of PPS, there are two primary questions: Are the positions reimbursable and what are the credentialing criteria?

Reimbursement of peer support services—Medicaid is the primary payer for peer support services, although many state departments of behavioral health offer grant funding for these services as well. Currently 39 state Medicaid programs provide reimbursement for some form of PSS services. States have two options for funding the reimbursement of peer support services under their Medicaid program—either adding peer support services through a Medicaid state plan amendment (usually under the Medicaid Rehabilitation Option) or as part of a waiver program.

My colleague Athena Mandros looked at the reimbursement question earlier this year and determined who could be reimbursed and how reimbursement happens varies by state. If state Medicaid program covers peer support under the fee-for-service benefit, the health plans are also required to cover these services. Some states have special provisions that allow them to only cover peer supports for limited groups of individuals, such as those enrolled in managed care. Some states also allow peer support specialists to act as qualified health care professionals for certain types of behavioral health services, but do not allow for the specific reimbursement of peer support services. A review of selective states’ Medicaid fee for services (FFS) reimbursement found that group rates for a 15-minute period with a peer support specialist ranged from less than $2.00 to over $5.00. Individual billing by peer support specialists ranged from $6.50 to $24.36 per 15 minutes. Most of the states also use SAMHSA grants and state general funds to develop and sustain their peer support programs. In 2016, 32 states voluntarily reported that part of their block grants were used to fund peer recovery coaching activities for Medicaid—either training or service provision (see States Use Six Practices To Certify Competency Of Mental Health Peer Support Specialists).

Credentials of peer support team members—Peer support service credentialing also varies by state. A 2016 national overview of PSS done by The University of Texas at Austin found that 41 states and the District of Columbia have programs to certify PSS. The issue is that these certifications are just as unique to the states as the array of mechanisms the states use to reimburse for them. Most require some type of formal application process with references, training, and a competency exam. Some of these training programs are short (Kansas, five days) and include establishing healing relationships and understanding the role of trauma. Other programs are longer (Oregon, two weeks) and include core competency training that includes chronic disease management, health promotion, and health literacy. For example, in Florida, services provided by a certified peer specialist are billable to Medicaid. To become certified Florida requires a minimum of a high school diploma or GED, attestation of lived experience, 40 hours of training within the past  five years, 500 hours of supervised work or volunteer experience providing peer-to-peer recovery support services, and letters of recommendation—as well as passing the Florida Certified Recovery Peer Specialist Exam.

A recent review from the Government Accountability Office (GAO) highlights that as the PSS workforce grows, the is a need for “increased attention to standardizing the competencies of peer support specialists through certification” (see Mental Health: Leading Practices For State Programs To Certify Peer Support Specialists). To achieve this, the GAO looked at several states and identified six practices that researchers said should become a standard part of certifying PSS competency, including:

  1. Systematic and objective screening of the PSS’ understanding of recovery and the peer role.
  2. Ensure in-person core training to strengthen PSS interpersonal and relationship building skills.
  3. Incorporate physical health and wellness into PSS training or continuing education.
  4. Educate provider organization staff about the peer support role, and how to effectively use and supervise PSS.
  5. Require that PSS participate in continuing education specific to peer support.
  6. Engage PSS in the leadership and development of certification programs for applicants.

For more, we reached out to OPEN MINDS Senior Associate Bob Dunbar, who noted that while states have a primary responsibility for determining required competencies, best practices, and training needed to become certified as a peer support specialist, the fact that each state determines certification requirements means there will be a lot of variability. And that means, there is a lot of pressure on provider organizations to understand how to best prioritize peer recovery services as an “essential” component of a continuum of services. He noted:

This prioritization will be facilitated by an increased focus upon “recovery” and by the transition from a fee-for-service to a value-based payment system. Behavioral health professionals need to better understand and value the unique contributions of PSS. The development and operation of team-based models of care, including “health homes,” in which Peer Support Members are contributing equal “partners” would help. Also, behavioral health providers must avoid the temptation to hire PSS as a “cheap” alternative to other essential perhaps more “costly” staff. Behavioral health providers also need to increase their knowledge of “peer recovery” competencies, best practices, certification requirements, and funding sources.

If the decision is made to incorporate peer recovery as an essential service, behavioral health providers must identify the recovery needs of the target population to be served by PSS. Once these needs have been identified, the behavioral health provider must see that the PSS participate in training that assures the existence of competencies necessary to serve the identified target population in collaboration with their recovery team.

The likelihood that we will continue to see provider organizations adopt peer support is high, considering that value-based reimbursement models will focus on outcomes and make the return-on-investment (ROI) of peer support services a better deal. I suspect the market forces that are redefining every other aspect of behavioral health care will also alter the professional roles that allow provider organizations to expand access and reduce costs. We’ll keep you updated.

For more, check out these resources from the PsychU Resource Library:

  1. Will Clinical Professional Compensation Drive Task Shifting?
  2. Workforce Shortages As A Strategy Issue
  3. Wake Forest Baptist Medical Center Finds Addiction-Focused Peer Support Program Reduces Readmissions

The Illinois Medicare-Medicaid Alignment Initiative (MMAI) demonstration reduced inpatient utilization by 14.8% in the first year. Before the demonstration began, during the pre-demonstration comparison period (March 1, 2012 through February 28, 2014) dual eligible beneficiaries had an average of 0.0507 hospitalizations per person per month. During the first demonstration period (March 1, 2014 through December 31, 2015), beneficiaries enrolled in the demonstration had an average of 0.0434 hospitalizations per month.

Illinois and the Centers for Medicare & Medicaid Services (CMS) launched the MMAI demonstration in March 2014 to integrate care for Medicare-Medicaid beneficiaries in two regions: The Greater Chicago region, and the Central Illinois region. Under the demonstration Illinois and CMS contract with health plans to coordinate the delivery of and be accountable for all covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees. Eight health plans were competitively selected by the state and CMS to operate Medicare-Medicaid Plans (MMPs) under the demonstration: six in the Greater Chicago region and two in Central Illinois. The MMPs receive capitated payments from CMS and the state to finance all Medicare and Medicaid services. MMPs also provide care coordination and flexible benefits, depending on the coverage plan. As of December 2016, about 30% of eligible Medicare-Medicaid beneficiaries were enrolled in MMAI, representing about 46,000 enrollees of the more than 153,000 who were eligible.

The findings were reported in “Financial Alignment Initiative Illinois Medicare-Medicaid Alignment Initiative: First Evaluation Report” by RTI International for the CMS Center for Medicare & Medicaid Innovation (CMMI). The report includes findings from qualitative data for March 1, 2014 through February 28, 2017, and quantitative results for demonstration year 1 (March 1, 2014 through December 31, 2015). Data for the report comes from key informant interviews, beneficiary focus groups, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results, Medicare claims data, the Minimum Data Set nursing facility assessments, MMP encounter data, and other demonstration data. For admissions and visits, the report provides savings estimates for inpatient admissions, emergency room visits, physician evaluation and management visits, skilled nursing facility admissions, and probability of any long-stay nursing facility use. The demonstration and comparison groups were similar across many of the service utilization measures in each of the pre-demonstration years and the demonstration year.

Measured against the comparison group, the Illinois demonstration group had fewer monthly inpatient admissions, emergency room visits, and skilled nursing facility admissions. The demonstration group had a higher probability of any long-stay nursing facility use. There was no statistically significant difference in monthly physician visits between the demonstration and comparison groups. Results differed for beneficiaries with use of long-term services and supports (LTSS) and for beneficiaries diagnosed with serious and persistent mental illness (SPMI).

Summary Of Illinois Medicare-Medicaid Alignment Initiative Impact Estimates For First Demonstration Period (May 1, 2014, To December 31, 2015), For All, LTSS, & SPMI Beneficiaries (adapted from Table ES-1)

All LTSS SPMI
Inpatient admissions  Lower Not Statistically Significant (NS)  Lower
Probability of ambulatory care-sensitive condition (ACSC) admissions, overall  Lower NS NS
Probability of ACSC admissions, chronic Lower NS NS
All-cause 30-day readmissions  NS  Higher  NS
Emergency room (ER) visits  Lower  NS  Lower
Preventable ER visits Higher NS Lower
Probability of monthly follow-up after mental health discharges Lower  NS Lower
Skilled nursing facility (SNF) admissions Lower Higher  Lower
Probability of any long-stay nursing facility (NF) use Higher N/A  N/A
Physician evaluation and management (E&M) visits  NS Higher  NS

PsychU reported on this topic in “Illinois Medicaid Launches Redesigned Mandatory Managed Care Program Statewide,” which published on January 18, 2018.

For more information, contact: John K. Hoffman, Director of Communications, Illinois Department of Healthcare and Family Services, 401 South Clinton, Chicago, Illinois 60607; 312-793-4792; Email: John.K.Hoffman@illinois.gov.

During its first full year, the Ohio Medicaid MyCare demonstration project for people dually eligible for Medicare and Medicaid reduced inpatient utilization by 21%. The probability of inpatient admissions for ambulatory care sensitive conditions dropped by 14.3%. The probability of an inpatient admission for a chronic, but ambulatory care sensitive condition dropped by 13.2%. Skilled nursing facility (SNF) admissions were 15.3% lower. The probability of SNF stays longer than 90 days was also lower. However, the demonstration also resulted in a 10.3% increase in preventable emergency room visits.

These findings were reported in “Financial Alignment Initiative MyCare Ohio: First Evaluation Report” by the National Academy of State Health Policy and RTI International for the Centers for Medicare & Medicaid Services (CMS). CMS contracted with RTI International to monitor and evaluate the implementation of the MyCare Ohio capitated model demonstration, which began on May 1, 2014. The evaluation includes findings through December 2016 and quantitative results through December 2015, and looked at the demonstrations effect on beneficiary experience, quality, utilization, and cost.

MyCare Ohio is a capitated model demonstration in which five competitively selected Medicare-Medicaid Plans (MMPs), called MyCare Ohio plans, are paid a blended, capitated rate to provide Medicare and Medicaid integrated primary, acute care, behavioral health, and long-term services and supports (LTSS) to enrollees age 18 and older who live in one of the 29 demonstration counties. The five health plans are Aetna, Buckeye, CareSource, Molina, and United. Of the 100,000 Medicare-Medicaid dual enrollees eligible for MyCare Ohio, approximately 69,000 had enrolled in the capitated model demonstration as of December 2016. Approximately 43% of eligible MyCare beneficiaries had an diagnosis of serious and persistent mental illness (SPMI).

Results for the LTSS and severe and persistent mental illness (SPMI) populations, when compared with similar beneficiaries in the comparison group, varied somewhat from the results for all eligibles.

Summary Of MyCare Demonstration Impact Estimates For Demonstration Period (May 1, 2014, To December 31, 2015), For All, LTSS, & SPMI Beneficiaries (adapted from Table 22)

All LTSS SPMI
Inpatient admissions  Lower Lower  Lower
Probability of ambulatory care-sensitive condition (ACSC) admissions, overall  Lower Not Statistically Significant (NS) Lower
Probability of ACSC admissions, chronic Lower Higher Lower
All-cause 30-day readmissions  NS  Lower  NS
Emergency room (ER) visits  NS  NS  NS
Preventable ER visits Higher Higher Higher
Probability of monthly follow-up after mental health discharges NS  NS NS
Skilled nursing facility (SNF) admissions Lower Higher  Lower
Probability of any long-stay nursing facility (NF) use Lower N/A  N/A
Physician evaluation and management (E&M) visits  Lower NS  Lower

The demonstration reduced monthly inpatient admissions by 0.0112 admissions per beneficiary per month, which corresponds to 0.1343 fewer inpatient admissions per eligible beneficiary per year. The demonstration decreased physician evaluation and management (E&M) visits by 0.0728 visits per month; it decreased SNF admissions by 0.0022 visits per month. The likelihood of long-stay SNF use (101 days or longer) decreased by 1.59 percentage points. There was no statistically significant demonstration effect on emergency room visits.

Using a difference-in-differences (DID) approach to evaluate the impact of the demonstration on Medicare costs, RTI found that the predicted capitated rate of $1,498 when compared to actual fee-for-service (FFS) expenditures ($1,577) showed the potential for gross Medicare savings compared to the non-enrolled beneficiary population, but did not find “statistically significant Medicare savings or losses during the first 32 months of the Ohio demonstration.” Demonstration enrollees had lower expenditures in base year two ($1,280 for enrollees vs. $1,797 for non-enrollees).

The savings calculation was based on capitation rates paid by CMS to MyCare Ohio plans for enrollees, and the fee-for-service expenditures and Medicare Advantage capitation rates for eligible beneficiaries who did not enroll in the demonstration. The estimates do not take into account actual payments for services incurred by enrollees and paid by the MyCare Ohio plans. The researchers did not calculate Medicaid savings due to lack of data. They intend to rerun the analyses to calculate Medicaid savings when more data is available.

PsychU reported on this topic in “